Bad girl and unmet family planning need among Sub-Saharan African adolescents: the role of sexual and reproductive health stigma

Kelli Stidham Hall; Abubakar Manu; Emmanuel Morhe; Vanessa K. Dalton; Sneha Challa; Dana Loll; Jessica L. Dozier; Melissa K. Zochowski; Andrew Boakye; Lisa H. Harris

doi:10.4081/qrmh.2018.7062

Authors

Kelli Stidham Hall
kelli.s.hall@emory.edu
Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, United States.
Abubakar Manu School of Public Health, University of Ghana, Accra, Ghana.
Emmanuel Morhe University of Allied Health and Sciences, Ho, Ghana.
Vanessa K. Dalton University of Michigan, Women's Hospital, Ann Arbor, United States.
Sneha Challa University of Michigan, Women's Hospital, Ann Arbor, United States.
Dana Loll University of Michigan, Women's Hospital, Ann Arbor, United States.
Jessica L. Dozier University of Michigan, Women's Hospital, Ann Arbor, United States.
Melissa K. Zochowski University of Michigan, Women's Hospital, Ann Arbor, United States.
Andrew Boakye Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
Lisa H. Harris University of Michigan, Women's Hospital, Ann Arbor, United States.

Adolescent pregnancy contributes to high maternal mortality rates in Sub-Saharan Africa. We explored stigma surrounding adolescent sexual and reproductive health (SRH) and its impact on young Ghanaian women’s family planning (FP) outcomes. We conducted in-depth, semi-structured interviews with 63 women ages 15-24 recruited from health facilities and schools in Accra and Kumasi, Ghana. Purposive sampling provided diversity in reproductive/relationship/socioeconomic/religious characteristics. Using both deductive and inductive approaches, our thematic analysis applied principles of grounded theory. Participants described adolescent SRH experiences as cutting across five stigma domains. First, community norms identified non-marital sex and its consequences (pregnancy, childbearing, abortion, sexually transmitted infections) as immoral, disrespectful, and disobedient, resulting in bad girl labeling. Second, enacted stigma entailed gossip, marginalization, and mistreatment from all community members, especially healthcare workers. Third, young sexually active, pregnant, and childbearing women experienced internalized stigma as disgrace, shame and shyness. Fourth, non-disclosure and secret-keeping were used to avoid/reduce stigma. Fifth, stigma resilience was achieved through social support. Collectively, SRH stigma precluded adolescents’ use of FP methods and services. Our resulting conceptual model of adolescent SRH stigma can guide health service, public health, and policy efforts to address unmet FP need and de-stigmatize SRH for young women worldwide.

Singh S, Sedgh G, Hussain R. Unintended pregnancy: Worldwide levels, trends and outcomes. Stud Fam Plann 2010;41:241-250. DOI: https://doi.org/10.1111/j.1728-4465.2010.00250.x

Tsui AO, McDonald-Mosley R, Burke AE. Family planning and the burden of unintended pregnancies. Epidemiol Rev 2010;32:152-174. DOI: https://doi.org/10.1093/epirev/mxq012

Hindin MJ, Christiansen CS, Ferguson BJ. Setting Research Priorities for Adolescent Sexual and Reproductive Health in Low-and Middle-Income Countries. Bull WHO 2013;91:10-18 DOI: https://doi.org/10.2471/BLT.12.107565

Machiyama K, Cleland J. Insights into Unmet Need in Ghana. Step Up Research Report. 2013. London: London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.31899/rh4.1062

Adanu R, Seffah J, Anarfi JK, Lince N, Blanchard K. Sexual and Reproductive Health in Accra, Ghana. Ghana Med J. 2012;46(2): 58-65

Asamoah BO, Agardh A, Ostergen P. Inequality in Fertility Rate and Modern Contraceptive use Among Ghanaian Women from 1988-2008: Int J Equity Health. 2013;12(37):1-12 DOI: https://doi.org/10.1186/1475-9276-12-37

Kelly DM. Stigma Stories: Four Discourses About Teen Mothers, Welfare, and Poverty. Youth Soc. 1996;27(4):421-49 DOI: https://doi.org/10.1177/0044118X96027004002

Fenton KA. Time for change: Rethinking and reframing sexual health in the United States. J Sex Med 2010;9:250-252. DOI: https://doi.org/10.1111/j.1743-6109.2010.02057.x

Sanfilippo JS. Teen pregnancy prevention: sexuality the magic bullets. J Pediatr Adolesc Gynecol. 2015;28:207-208. DOI: https://doi.org/10.1016/j.jpag.2015.05.009

Satcher D, Hook EW, Coleman E. Sexual health in America: Improving patient care and public health. JAMA. 2015;314(8):765-66. DOI: https://doi.org/10.1001/jama.2015.6831

Levandowski BA, Kalilani-Phiri L, kachale F, Awah P, Kangaude G, Mhango C. Investigating Social Consequences of Unwanted Pregnancy and Unsafe Abortion in Malawi: The Role of Stigma. Int J Gynecol Obstet. 2012;118(2):167-71. DOI: https://doi.org/10.1016/S0020-7292(12)60017-4

Atuyambe L, Mirembe F, Johansson A, Kirumira EK, Faxelid E. Experiences of Pregnant Adolescents-Voices from Wakiso District, Uganda. Afr Health Sciences. 2005;5(4):304-9.

Wienmann CM, Rickert VI, Berenson AB, Volk RJ. Are Pregnant Adolescents Stigmatized By Pregnancy. J Adolesc Health. 2005;36:1-7.

Glinski A, Sexton M, Petroni S. Understanding the adolescent family planning evidence base. International Center for Research on Women. Accessed August 25, 2015. Available at, http://www.icrw.org/publications/understanding-adolescent-family-planning-evidence-base-review-literature.

Langer A, Meleis A, Knaul FM, Atun R, Aran M, Arreola-Ornelas H, et al. Women and health: the key for sustainable development. The Lancet. Published online ahead of print, 5 Jun 2015. DOI: https://doi.org/10.1016/S0140-6736(15)60497-4

Hokororo A, Kihunrwa AF, Kalluvya S, Changalucha J, Fitzgerald DW, Downs JA. Barriers to access reproductive health care for pregnant adolescent girls: A qualitative study in Tanzania. Acta Paediatrica, 2015; 104(12):1291-7. DOI: https://doi.org/10.1111/apa.12886

Lince-Deroche N, Hargey A, Holt K, Shochet T. Accessing sexual and reproductive health information and services: A mixed methods study of young women’s needs and experiences in Soweto, South Africa. African J Reprod Health, 2015;19(1):73-81.

Hall KS, Kusunoki Y, Gatny H, Barber J. Social discrimination, mental health, and risk of unintended pregnancy among young women. J Adolesc Health. 2015;56(3):330-7. DOI: https://doi.org/10.1016/j.jadohealth.2014.11.008

Thorburn S, Bogart LM. African American women and family planning services: perceptions of discrimination. Women’s Health. 2005;42:23–39. DOI: https://doi.org/10.1300/J013v42n01_02

Goffman E. Stigma: Notes on the management of spoiled identity. New York: Prentice Hall. 1963.

Norris A, Bessett D, Steinberg JR, Kavanaugh ML, De Zordo S, Becker D. Abortion Stigma: A Reconceptualization of Constituents, Causes, and Consequences. Women’s Health Iss. 2011;21(35):549-54 DOI: https://doi.org/10.1016/j.whi.2011.02.010

Hatzenbuehler ML, Phelan JC, Link BG. Stigma as fundamental cause of population health inequalities. Am J Pub Health, 2013;103:813-821. DOI: https://doi.org/10.2105/AJPH.2012.301069

Link BG, Yang LH, Phelan, JC, Collins PY. Measuring mental illness stigma. Schizophrenia Bulletin, 2004;30:511–541. DOI: https://doi.org/10.1093/oxfordjournals.schbul.a007098

Turan JM, Hatcher AH, Medema-Winjnveen J, Onono M, Miller S, Bukusi EA, et al. The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya: A Prospective Mixed-Methods Study. PLOS Med. 2012;9(8):1-12 DOI: https://doi.org/10.1371/journal.pmed.1001295

Nyblade L, MacQuarrie K. Can we measure HIV/AIDS stigma and discrimination? Current knowledge about quantifying stigma in developing countries. Washington, DC: ICRW, USAID; 2006.

Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: The internalized AIDS-related stigma scale. AIDS Care, 2009;21:87–93. DOI: https://doi.org/10.1080/09540120802032627

Garnets L, Herek GM, Levy B. Violence and Victimization of Lesbians and Gay Men: Mental Health Consequences. 2003. In D. C. Kimmel & L. Garnets (Eds.), Psychological perspectives on lesbian, gay, and bisexual experiences. New York: Columbia University Press.

Van Brakel WH. Measuring health-related stigma--A literature review. Psychol Health Med. 2006;11(3):307–334. DOI: https://doi.org/10.1080/13548500600595160

Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatric Res, 2003;121:31-49. DOI: https://doi.org/10.1016/j.psychres.2003.08.008

Sartorius N. Iatrogenic stigma of mental illness. BMJ. 2002;324:1470-71. DOI: https://doi.org/10.1136/bmj.324.7352.1470

Cockrill K, Upadhyay UD, Turan J, Foster DG. The stigma of having an abortion: development of a scale and characteristics of women experiencing abortion stigma. Persp Sex Reprod Health 2013;45:79-88. DOI: https://doi.org/10.1363/4507913

Shellenberg KM, Hessini L, Levandowski BA. Developing a scale to measure stigmatizing attitudes and beliefs about women who have abortions: Results from Ghana and Zambia. Stigma, Research and Action. Women’s Health. 2014;54:599-616. DOI: https://doi.org/10.1080/03630242.2014.919982

Challa S, Manu A, Morhe E, Loll D, Dozier JL, Zochowski MK, Adanu R, Dalton,VK, Hall KS. Multiple levels of social influence on adolescent sexual and reproductive health in Ghana. Women & Health, 2018;58:434-450. DOI: https://doi.org/10.1080/03630242.2017.1306607

Rajapaksa-Hewageegana N, Salway SM, Piercy H, Samarage S. A quantitative exploration of the sociocultural context of teenage pregnancy in Sri Lanka. BMC Preg Childbirth 2014;14:394. DOI: https://doi.org/10.1186/s12884-014-0394-y

Tanner AE, Jelenewicz SM, Ma A, Rodgers CR, Houston AM, Paluzzi P. Ambivalent messages: adolescents’ perspectives on pregnancy and childbirth. J Adolesc Health. 2013;53(1):105-11. DOI: https://doi.org/10.1016/j.jadohealth.2012.12.015

Creswell JW, Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, second ed., Thousand Oaks, CA: Sage Publications, 2003.

Strauss A, Corbin J. Basics of qualitative research: Grounded theory procedures and techniques. Thousand Oaks CA: Sage Publications Inc. 1990.

Supporting Agencies

Society of Family Planning Research Fund #SFPRF8-1, National Institute of Child Health and Human Development (NICHD) #1K01HD080722-01A1, NICHD #K12HD001438.

Hall, Kelli Stidham, Abubakar Manu, Emmanuel Morhe, Vanessa K. Dalton, Sneha Challa, Dana Loll, Jessica L. Dozier, Melissa K. Zochowski, Andrew Boakye, and Lisa H. Harris. 2018. “Bad Girl and Unmet Family Planning Need Among Sub-Saharan African Adolescents: The Role of Sexual and Reproductive Health Stigma”. Qualitative Research in Medicine and Healthcare 2 (1). https://doi.org/10.4081/qrmh.2018.7062.