Individual/personal levelLimited understanding of sexual and reproductive physiology

At the individual level, some of the participants argued that many adolescents lacked comprehensive understanding of the adolescence period, especially the physical, biological, and emotional changes that occur during this period. Due to this lack or limited knowledge of the body’s mechanisms and evolving sexual development, some engaged in unprotected sex without mindful of the risks unintended pregnancy and STIs.

As a growing boy or girl, sometimes you get some ‘feelings.’ The desire for sex is innate; so, emotions are also a cause. (Adolescent Boy, 16 years, Offuman, Techiman North)

Parents and community leaders on the other hand argued that low risk perceptions associated with some sexual activities (e.g., kissing and fondling), which could trigger penetrative unprotected sexual intercourse, was a major challenge for adolescents. However, they recognised that emotional and biological changes associated with adolescence could increase the desire for sexual intercourse and in the absence of protection, lead to pregnancy. This group of participants did not attribute adolescent pregnancy to any socioeconomic factor(s) other than sexual maturation. A community leader concurred with this assertion:

I think naturally there are these feelings they get in their bodies that prompts them to do so (have sex). (Community Leader [Pastor], Kintampo South).

Misperceptions about contraceptives

The data also revealed negative perceptions around contraceptives, which discourages some adolescents and young people from use. For instance, there was a widespread belief that using contraceptives in adolescent years could cause infertility in the the adult years. From the data, some adolescents and parents expressed strong sentiments against use of contraceptives for fear of infertility. An example of such view is:

I would rather get pregnant than use contraceptives because those medicines can cause side effects for you. When you use it for so long there will be a time you will want a baby and you will not get. (Adolescent Girl, 18 years, Atebubu, Atebubu-Amantin District).

Interpersonal levelTechnical capacity of SRHR providers

Utilization of health services is a function of capacity of providers to offer what clients require. In situations where users have little confidence in the ability of providers, utilization is likely to be affected. We asked providers the types SRHR services they did not have capacity to provide. Principally, comprehensive abortion care and minimally invasive family planning methods were frequently mentioned as can be seen from the extracts below:

I cannot provide some family planning methods. I can give the injection but the other procedures, implants, and IUD, I cannot do it. (Midwife, Offuman, Techiman North)

I am not that good in family planning and so it is not everything that I can do, I must call someone to assist me so that if I am okay, when someone comes hereandIamtheonly one here I can do it … with the abortion care, I have no skills at all. (Midwife, Kintampo North).

Parental capability to provide resources and information/education

On the parental side, participants shared that adolescents who became pregnant often did not have the requisite parental care. Adolescents who participated in the study discussed that parents did not sufficiently connect with their children, especially girls. Parental failure appeared in different ways: 1) inability/failure to provide necessities (e.g., menstrual hygiene products and school supplies) for their children, and 2) failure of parents to provide children suitable guidance on sexual behaviours (i.e., home-based sexuality and reproductive health education). For many adolescents, there is no motivation to discuss their SRHR issues with their parents for fear of being judged as spoilt/bad. One boy intimated:

Because if you discuss such things (sex-related) with your parents, they will say you are a bad boy. So, we discuss it with our friends. Not our parents. (Adolescent Boy, 18 years, Offuman, Techiman North)

Another form of parental deficiency that adolescents lamented about was maltreatment and low parent–child connectedness or quality of relationship between parents and adolescents. For poor parent–child relationships, it was viewed as a push factor for adolescents to seek affection, love, and belonging through sexual relationships. When faced with an unconducive home environment, some adolescents may find solace in sexual relationships, which could result in unintended pregnancy. A participant noted:

Some of the guardians make the children uncomfortable. They are always in fear of these guardians.… You can clearly see that these children are unhappy all the time. Even when they do not intend to be in a relationship with the opposite sex, they end up being in a relationship. If they do not know how to protect themselves, they become pregnant in the end. (Adolescent Girl, 15 years, Kintampo South)

Discussions with some adolescent mothers showed that while none deliberately wanted to become a mother, the sexual intercourse that led to the pregnancy was intentional and that they were often led by some push factors. In many instances, they had some material and financial needs that were not provided by their parents. Adolescent mothers with such experiences blamed their parents’ inability or failure to adequately provide for their needs which pushed them into transactional sex and pregnancy consequently. A 17-year-old mother in Atebubu described:

When I got pregnant, I didn’t blame myself because when I am going to school, and I ask my mother for money she doesn’t mind me.

Disrespect and abuse of adolescents: when is it justified?

Further to these, we investigated the circumstances under which providers may be justified to disrespect and abuse adolescent clients. Two key circumstances emerged: when clients do not comply with appointments and instructions and when they refuse effective treatment.

On non-compliance to appointments and treatment instructions, – adolescent girls, mainly, justified abuse and disrespect. They viewed health workers as authorities in issues of health care and viewed non-compliance to well-meaning instructions as grounds for adolescent clients being treated harshly. Extracts from two adolescent girls are illustrated here:

Maybe you are asked to come for a scan at 3 months and you don’t go, as you don’t go for the scan it will be difficult for them to know what is going on, she will not be happy with you because you didn’t follow her orders. Let’s say you have all been asked to come to the facility at 7:30 and at 10:00 you are now coming; it angers the health workers. (Adolescent Girl, 18 years, Jema, Kintampo South).

It is not about their (health workers) attitude; when you are pregnant, you need to buy certain things for your delivery so if you come and you don’t bring anything at all then what will the put the baby on? You will give them the opportunity to mistreat you if you don’t do what is required of you. That’s what I am saying. If you don’t take the things needed for delivery and you also do not take money, they ask you to do this, you don’t do it, they give instructions, and you don’t follow so that is what will happen. (Adolescent Girl, 18 years, Atebubu).

Adolescent participants also argued that an adolescent who persistently refused a known effective treatment could be threatened or disrespected/abused. This view was underpinned by participants' notion that health providers were only interested in the wellbeing of their clients. Consequently, providers would be justified to threaten or abuse clients who do not adhere to specific therapeutic instructions. One provider narrated an experience:

Yes, I remember that I delivered one girl and after delivery I had to expel the products and she kept shifting herself. At a point she told me to leave it like that because it was paining her and I told her that if I leave it and she goes, it will still bring you back so for something like that you still have to do it. (Midwife, Kintampo South).

Some adolescent participants also discussed that in cases where providers judged a particular treatment to be the best option and there was threat to lifer, the provider could compel the client, failing which they could be called to undertake more difficult services. The following excerpt provide some context:

Yes, madam, for instance, family planning. A nurse might recommend it because they perceive that the girl cannot abstain from sexual intercourse, yet she is refusing to accept family planning. You (the health provider) must force her to do the family planning else she will get pregnant and come with another pregnancy. (Adolescent Girl, 15 years, Jema, Kintampo South).

Community and societal levelSocial safety, moral hazard and access to contraceptive education and services

The data generally showed acceptance to providing SRH education to adolescents. For instance, many participants including community approved educating adolescents on contraceptives. However, some participants discussed the need for age-appropriateness in SRHR education and services. For instance, on contraceptives and specifically condom education, most parents and community leaders (CLs) disapproved condom education for early adolescents (10–14 years). It was described as a moral hazard or perverse incentive to early adolescents. They argued that early adolescents lacked the maturity to process the information and education within the right context. They feared that early adolescents may experiment with what they have learned about contraceptives and condoms. However, CLs and parents supported educating older adolescents (15 – 19 years) on contraceptives, as they were deemed old enough to appreciate that form of education from different perspectives and contexts. An interaction with a male Pastor in Kintampo South is reproduced here:

Moderator: Now, we want to look at some of the SRHR services that will be accepted by leaders in this community. Will the community find it acceptable for children aged 10 to 14 years to be given sex education?

Participant: I will give it 100% support. I agree and we must accept it because we want to prevent this menace (adolescent childbearing). So, if this is going to help then I agree to it.

Moderator: What about education on contraceptive uses (e.g., condom) for children aged 10-14 years in the community?

Participant: No as for that one I don’t think it will help. When we teach them those things then we are telling them to go and do it. Rather, we should teach them to abstain. So, in my view we should not teach them those things.

Moderator: What about those who are 15-19 years?

Participant: I think 15-19-year-olds are of age to know those things. They could be taught that if they are not able to take care of a child, use these things (contraceptives) to protect themselves. But the smaller ones should be taught to abstain from these things [sexual intercourse].

However, while there was support for the education, providing the products (e.g., condom) was rejected, again, citing moral hazard. A parent with an adolescent child remarked:

When you come to teach them (adolescents) without giving them the condoms, that will be fine. However, when you expose them to condoms as children, they would want to try. (Mother, 43 years, Kintampo).

On the other hand, some CL rejected a universalist approach in providing SRHR services and education to adolescents, arguing that not all adolescents may be able to abstain from sexual activities. In effect, some CL had made personal efforts in making condoms available to adolescents after offering them sexuality education. One noted:

For me, after taking them through sexuality education I request for condoms and I tell them, if you can’t abstain and you don’t have money to buy certain things, I advise that you come so that we will get you some to protect yourself. (Community Leader, Kintampo North).

Among health workers and adolescents there were no exceptions to when adolescents could learn and access contraceptives. They asserted that abstinence and protected sex must not be treated as mutually exclusive; none must be prioritized over the other. This was needed to safeguard all adolescents due to the diversities of sexual responses during the maturation process. Some illustrative excerpts are:

I will say yes. We are all not the same, someone will listen, someone will not so by all means, she will have sex so if you want to have sex, the protective thing is to use condoms (Adolescent Girl, FGD participant, Kintampo South).

Some people will listen, and some will not. Now there are many diseases so if they use condoms, they can protect themselves from diseases. And she will not get pregnant (Adolescent Girl, FGD participant, Kintampo South).

With this recognition, health workers reported using a dual approach in working with adolescents—abstinence, and protection through contraceptives (including condom for dual protection against unintended pregnancy and STIs). One health provider remarked:

We teach them about abstinence. We also talk about protection against pregnancy and STIs. We try to make it clear to them that if they want to have sex, they must ensure that they are protected. (Health Worker, Kintampo South).

Adolescents, however, discussed the merits of knowing about methods of contraception and being able to access them. Adolescents generally viewed contraceptives as important in preventing adolescent pregnancy. They further argued that complete abstinence was not a realistic expectation during the adolescence period. Making contraceptives/family planning methods readily available for adolescents was described as a need. Participating adolescents also mentioned the added benefits of some contraceptive methods in protecting against STIs. Some illustrative quotes are below:

It is a concern. Maybe there is no money at home but as an adolescent the desire for sex is real, so you must be careful, you must protect yourself by using condoms. Family planning alone is not going to protect you from sickness. As a man you must protect yourself so that if the girl has any diseases, you will not be affected. (Adolescent Male, FGD participant, Atebubu).

On access to contraceptives, two views were noted from the data. One being that accessing contraceptives from pharmacies and chemical shops was less challenging. Adolescents who had accessed contraceptives from pharmacies and chemical shops expressed satisfaction with the services they received. Largely, these providers – mainly private—were described as non-judgemental in providing services. To some of them, the services they received were beyond their anticipation, as opposed to how adolescents were treated at some health facilities. That is participants shared that prior to their own personal experiences in accessing contraceptives, they worried about being judged and possibly turned away by providers. However, what they experienced was positive as shared below:

From the pharmacies I have gone to, it was normal to my surprise. The pharmacists didn’t raise an eyebrow; they don’t care about selling contraceptives to you (me). (Adolescent Boy, 19 years, Tuobodom, Techiman North).

However, accessing contraceptive/family planning products/services from health facilities was described as challenging on account of social safety. Here, the view was that some family planning outlets provided little-to-no privacy and confidentiality to patrons. Consequently, adolescents found it uncomfortable to access contraceptive/family planning services from health facilities. Adolescents and providers shared similar perspectives. The account below is an illustration:

I buy it (contraceptives) from the chemical shop. When I am entering a pharmacy or chemical shop, you don’t know what medicine I am going to buy; maybe it is my mother who has sent me to buy medicine for her. However, in the clinic, they have a particular room they do the family planning and once you enter that place everybody will be watching you and by the time you get home, your mother is even aware of what you went there for (Adolescent Girl, 18 years, Offuman, Techiman North).

Some adolescents reported being questioned by adult providers about the purpose of contraceptives they were purchasing. Even though providers are professionally required to provide guidance on dosage of medications/drugs, the manner and tone of inquiry can create discomfort for clients and discourage patronage of services. An adolescent recounted past experiences in line with this:

When I go there, and a male is not there how will I buy it? If there is an elderly person there, how can I buy it? They will ask what I am going to use it for at my age. I remember the last time someone asked me to buy a contraceptive for her, she wrote it on a piece of paper. When I got there, they were asking me what I was going to use it for. (Adolescent Girl, 18 years, Atebubu, Atebubu-Amantin District).

Structural constraints

Among health providers, the data revealed structural barriers that were similar across all facilities. Among them was lack of adequate infrastructure, (i.e., the quantity and location). In the view of providers, the available infrastructure compromised the privacy of adolescents who needed certain SRH services. Some of the providers recounted instances where adolescents would make inquiries about certain services outside of facilities but would decline coming to the facilities for fear of being noticed by family relations or other acquaintances. An illustrative excerpt is shared here:

Last time I met a girl, I referred her, but she told me if she comes, her aunt who works here will see her. Here, the clinic is very open. Everyone can see you. And if the person is not pregnant, why will she enter a maternity building? So, if someone is sitting at the out-patient department (OPD), they can see you and so by the time you get home, your mother will start asking you questions. Where did you go to, that is what they do so it makes the adolescent reluctant to come. (Health Provider, Techiman North, Tuobodom)

Also, the accounts showed that some basic surgical equipment for family planning, safe termination of pregnancy and management of post-abortion complications were inadequate. This often led to delays in providing adolescents timely services; the turnaround time to transition from one client to other was longer as they had to make allowance for disinfection before re-using equipment and materials. A provided recounted:

We have the instruments we use but it is not many so after using it for this person you must disinfect it before you come and use it for another and that makes the work someway (awkward). (Midwife, Kintampo)

Another structural issue that healthcare providers faced which affected service delivery to adolescents is the lack or limited number of teaching and learning materials for adolescents. The expectation was that at adolescent corners, providers would have the materials and the equipment to support learning and interactions among adolescents. However, these learning materials were limited in all the facilities studied. This in turn discouraged many adolescents from patronizing the adolescent corners. A provider elaborated as follows:

If we have maybe games like ludu, dummy, cards, adolescent games…when those things are available, it will really help. … those things that will make people happy to come here always, if they come here and things are not here, they will not be happy to come here but if all those things are available then they will be happy to come here. (Health Provider, Atebubu, Atebubu-Amantin).

Satisfaction with maternal health services for adolescents

Two contrasting perspectives were noted about adolescents' satisfaction with maternal and child health services. On the one hand, adolescent mothers gave positive testimonies about the quality of provider–client interactions. They described providers as friendly, warm, and showed interest in their welfare. Adolescent mothers recounted positive stories about being given nutrition counselling and the importance of attending clinics on scheduled dates. Two adolescents narrated their recent experiences as follows:

They weigh the baby and teach you how to care for the baby. They tell us that every month we should bring the baby for weighing for them to take care of them. The nurse that attended to me when I had my first child did not mistreat. They will take care of you in the sense that they will direct you to where you are supposed to go, if you need a scan to show how the baby is lying in your womb, they will ask you to go for a scan and they will interpret the results to you. They take good care of you here and if you don’t understand anything and you ask them politely, they will explain things to you. (Adolescent Mother, 19 years, Atebubu).

They sit all of us down and talk to us about what foods are more nutritious for us currently (during pregnancy and breastfeeding). (Adolescent Mother, 18 years, Jema, Kintampo South).

Notwithstanding the positive accounts of some adolescent mothers, others held contrary perspectives. This group of participants had heard many stories abuse and disrespect of peer adolescent mothers at health facilities for different reasons. Such stories made some sceptical about accessing SRH services completely. And what was particularly striking about some of these stories is that they were narrated by adolescent boys, as illustrated in the following:

Because they are young, health workers sometimes tell them that they have rushed into motherhood and how they are treated before they get the care, they want is not the best. They get the treatment alright, but the adolescent mothers are shy to go to the facility because they are shy, and they will also be mistreated. (Adolescent Boy, 19 years, Tuobodom, Techiman North).

An adolescent mother also shared a third party’s account:

I know someone who from the time she was discharged with her baby, she has never been to the hospital for weighing. If you also don’t buy the things, they have prescribed for labor they will shout on you. They will ask you to bring Dettol, rubber (mackintosh) pad and other things so if you don’t take them, which patient’s birthing accessories do you expect to use at the hospital? (Adolescent Mother, 18 years, Atebubu).