University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH UNIVERSITY OF GHANA PSYCHOSOCIAL CHALLENGES OF PREGNANT ADOLESCENTS IN THE HO MUNICIPAL AREA OF THE VOLTA REGION BY EMMANUEL ARHIN (10600389) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2017 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that excluding precise references which have been duly acknowledged, this submission is my own work towards my Master of Public Health (MPH) dissertation and that, to the best of my knowledge, it contains no material published by another person nor material which has been accepted for the award of any degree of any University elsewhere. …………………………………. ……./…………/……………… EMMANUEL ARHIN DATE (STUDENT) ……………………………………….. …………/…………../…………. DR. ABUBAKAR MANU DATE (SUPERVISOR) i University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my wife Mrs. Theodora Klenam Humado-Arhin and my son Donald Kle Arhin for their support and encouragement. It is also dedicated to all pregnant adolescents who helped in diverse ways in making this research a success. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGMENTS My greatest appreciation goes to the Almighty God for giving me the Strength and knowledge to undertake this project work. My appreciation will be incomplete without me extending my profound gratitude to the various individuals for their enormous contributions. My profound gratitude goes to my supervisor, Dr. Abubakar Manu, who selflessly took me through this work. Dr. Manu showed my much love and care by offering me important comments on my work, advice and encouraged me at a point when I felt stressed and discouraged to complete this work. His calls and lectures right from writing my proposal to date made me master courage to complete this work. I will also like to extend my appreciation to the management and staff of the Ho Municipal Hospital as well as the pregnant adolescents who assisted me in gathering data for this research. To the staff of the Population, Family and Reproductive Health Department of the School of Public Health, I say a big kudos to you all for the knowledge imparted in me which enabled me to put this work together. Last but not the least, I express my gratitude to all and sundry who contributed in one way or the other to make this work a success. Thank you all and may God continue to bless and keep you all in good health. iii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS GHS : Ghana Health Service GSS : Ghana Statistical Service IDI : In-Depth Interview MDG : Millennium Development Goal P.A : Pregnant Adolescent UN : United Nations UNFPA : United Nations Population Fund WHO : World Health Organization iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ............................................................................................................ i DEDICATION ............................................................................................................... ii ACKNOWLEDGMENTS ............................................................................................. iii LIST OF ABBREVIATIONS .........................................................................................iv TABLE OF CONTENTS................................................................................................. v LIST OF TABLES ...................................................................................................... viii LIST OF FIGURES ........................................................................................................ix CHAPTER ONE ............................................................................................................. 1 1.1 Background to the study ......................................................................................... 1 1.2 Statement of Research Problem .............................................................................. 2 1.3 Conceptual Framework .......................................................................................... 4 Source: (Modified from Baafi, 2015). .......................................................................... 4 1.4 Justification ............................................................................................................ 5 1.5 Study Objectives .................................................................................................... 6 1.5.1 General Objective ............................................................................................ 6 1.5.2. Specific Objectives ......................................................................................... 6 1.6 Outline of the Dissertation ...................................................................................... 6 CHAPTER TWO ............................................................................................................. 8 LITERATURE REVIEW ................................................................................................ 8 2.0 Introduction .......................................................................................................... 8 2.1. Global Burden of Adolescent Pregnancy ............................................................... 8 2.2. Adolescent Pregnancy in Ghana ............................................................................ 9 2.3 Factors Contributing to Adolescent Pregnancy ....................................................... 9 2.4 Challenges of Adolescent Pregnancy .................................................................... 15 2.4.1 Psychological Challenges............................................................................... 15 2.4.1.1 Depression .................................................................................................. 16 2.4.1.2 Anxiety ....................................................................................................... 16 2.4.1.3 Violence ..................................................................................................... 16 2.4.1.4 Sadness ....................................................................................................... 17 2.4.1.5 Suicidal Tendencies .................................................................................... 17 2.4.1.6 Anger .......................................................................................................... 17 2.4.1.7 Loneliness ................................................................................................... 18 2.4.2 Social Challenges .......................................................................................... 18 2.4.2.1 Lack of Community and Family Support ..................................................... 18 2.4.2.2 Isolation ...................................................................................................... 18 2.4.2.3 Lack of Support by Partner ......................................................................... 19 2.4.2.4 Inadequate or Poor Self-care ....................................................................... 19 2.4.2.5 Stigmatization and Discrimination .............................................................. 19 CHAPTER THREE ....................................................................................................... 20 METHODOLOGY ........................................................................................................ 20 3.0 Introduction.......................................................................................................... 20 3.1 Research Design ................................................................................................... 20 v University of Ghana http://ugspace.ug.edu.gh 3.2 Sources of Data .................................................................................................... 22 3.2.1 Primary Data.................................................................................................. 22 3.2.2 Secondary Data .............................................................................................. 22 3.3 Study Area ........................................................................................................... 23 3.4 Study Population .................................................................................................. 24 3.5 Sampling Procedure ............................................................................................. 24 3.5.1 Selection of Participants .................................................................................... 25 3.5.2 Data Collection Procedure ................................................................................. 25 3.6 Data Processing and Analysis ............................................................................... 26 3.7 Data Storage ......................................................................................................... 26 3.8 Quality Control .................................................................................................... 26 3.9 Ethical Consideration ........................................................................................... 27 CHAPTER FOUR ......................................................................................................... 28 RESULTS ..................................................................................................................... 28 4.1 Introduction.......................................................................................................... 28 4.2 Background Characteristics of Participants ........................................................... 28 Table 4.1 Background characteristics of Participants .............................................. 29 4.3 Main Factors Contributing to Adolescent Pregnancy in the Ho Municipal Area of the Volta Region. ............................................................................................................. 29 4.3.1 Poverty .......................................................................................................... 29 4.3.2 Adolescent Sexual Behavior .......................................................................... 30 4.3.3 Age Discrepancy ............................................................................................ 30 4.3.4 Childhood environment ................................................................................. 31 4.3.5 Drugs and Alcohol ......................................................................................... 31 4.3.6 The Lack of Education on Safe Sex ............................................................... 32 4.3.7 Contraceptives ............................................................................................... 32 4.3.8 Influence of Family Structure......................................................................... 33 4.3.9 The Influence of the Media on Sexual Behavior of Adolescents ..................... 33 4.3.10 Peer Pressure ............................................................................................... 34 4.3.11 Cultural factors ............................................................................................ 34 4.4 The Psychosocial Effects of Adolescent Pregnancy in the Ho Municipality in the Volta Region of Ghana............................................................................................... 34 4.4.1 Psychological Challenges............................................................................... 34 4.34.1.1 Depression ................................................................................................ 35 4.4.1.2 Anxiety ....................................................................................................... 35 4.4.1.3 Anger and Violence .................................................................................... 35 4.4.1.4 Sadness ....................................................................................................... 36 4.4.1.5 Suicidal tendencies ..................................................................................... 36 4.4.2. Social Challenges.......................................................................................... 36 4.4.2.1 Lack of community and family support ....................................................... 36 4.4.2.2 Isolation ...................................................................................................... 37 4.4.2.3 Lack of Support by Partner ......................................................................... 37 4.4.2.4 Lack of proper Self-care .............................................................................. 37 4.4.2.5 Stigmatization and Discrimination .............................................................. 38 vi University of Ghana http://ugspace.ug.edu.gh 4.5 Summary of findings ............................................................................................ 38 CHAPTER FIVE ........................................................................................................... 40 DISCUSSIONS ............................................................................................................. 40 5.1 Introduction.......................................................................................................... 40 5.2 Main Factors Contributing to Adolescent Pregnancy in the Ho Municipal area in the Volta Region. ............................................................................................................. 40 5.2.1 Poverty .......................................................................................................... 40 5.2.2 Adolescent Sexual Behavior .......................................................................... 42 5.2.3 Age Discrepancy ............................................................................................ 42 5.2.4 Childhood environment ................................................................................. 43 5.2.5 Drugs and Alcohol ......................................................................................... 44 5.2.6 The Lack of Education on Safe Sex ............................................................... 44 5.2.7 Contraceptives ............................................................................................... 45 5.2.8 Family Structure and its influences on Sexual behavior of adolescents ........... 47 5.2.9 The Influence of the Media on Sexual Behaviour of Adolescents ................... 48 5.2.10 Peer Pressure ............................................................................................... 49 5.2.11 Cultural factors ............................................................................................ 49 5.3 The Psychosocial Effects of Adolescent Pregnancy in the Ho Municipal area in the Volta Region of Ghana............................................................................................... 50 5.3.1 Psychological Challenges............................................................................... 50 5.3.1.1 Depression .................................................................................................. 50 5.3.1.2 Anxiety ....................................................................................................... 50 5.3.1.3 Anger and Violence .................................................................................... 51 5.3.1.4 Sadness ....................................................................................................... 51 5.3.1.5 Suicidal tendencies ..................................................................................... 51 5.3.2. Social Challenges.......................................................................................... 52 5.3.2.1 Lack of Community and Family Support ..................................................... 52 5.3.2.2 Isolation ...................................................................................................... 52 5.3.2.3 Lack of Support by Partner ......................................................................... 52 5.3.2.4 Lack of proper Self-care .............................................................................. 53 5.3.2.5 Stigmatization and Discrimination .............................................................. 53 5.4 Adolescent Pregnancy Prevention Programs in the Ho Municipal Area ................ 53 5.5 Conclusion ........................................................................................................... 54 5.6 Study Limitations ................................................................................................. 54 CHAPTER SIX ............................................................................................................. 56 CONCLUSIONS AND RECOMMENDATIONS.......................................................... 56 6.1 Introduction.......................................................................................................... 56 6.2 Conclusions ......................................................................................................... 56 6.3 Recommendations ................................................................................................ 57 REFERENCES .............................................................................................................. 59 APPENDICES............................................................................................................... 64 APPENDIX 1 ................................................................................................................ 64 APPENDIX 2 ................................................................................................................ 79 vii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4.1 Background characteristics of Participants……………………..……………...29 viii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1.1: Conceptual Framework of Psychosocial Challenges of Pregnant Adolescents. 4 Figure 3.1: Map of Ho Municipal Area ........................................................................... 24 ix University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Adolescent pregnancy is considered to be high risk. The psychosocial challenges of these adolescents are enormous. This study therefore seeks to explore the psychosocial challenges of pregnant adolescents in the Ho Municipal area of the Volta Region in order to help inform policy on the appropriate psychosocial interventions. The scope of this study focused predominantly on the menace of adolescent pregnancy in the Ho Municipal area in the Volta Region of Ghana. Therefore, the central objective of the study was to explore the psychosocial challenges of pregnant adolescents in the Ho Municipal area of the Volta Region. Methodology: The study is purely qualitative and relies primarily on literature review and interviews for data collection and analyses. Results: Findings from the study revealed that the major causes of teenage pregnancy in the Ho Municipal area includes poverty, influence of alcohol and drugs on sexual behavior, influence childhood environment, the lack of education on safe sex or contraceptive usage, family structure and its influences on sexual behavior of adolescents and peer pressure. It was also revealed that the psychosocial effects of adolescent pregnancy in the Ho Municipal area in the Volta Region of Ghana includes depression, anxiety, anger and violence, sadness, lack of community and family support, isolation, lack of proper health and stigmatization and discrimination. Conclusion: Pregnant adolescents in the Ho Municipality encounter various psychosocial challenges. Multiple factors such as poverty, alcohol and drug abuse and lack of adequate knowledge on the use of contraceptive contribute significantly to the menace in the study area. It is therefore imperative that working strategies be implemented to reduce x University of Ghana http://ugspace.ug.edu.gh unplanned adolescent pregnancies, and to support pregnant adolescents in realizing their right to continue with their education, during pregnancy and following childbirth. xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.1 Background to the study Adolescence is a transitional phase of growth and development between childhood and adulthood, usually between the ages of 10 and 19 years (WHO, 2014). Adolescent pregnancy is therefore the gestation in women before having reached the full somatic development (WHO, 2014). Pregnancy in this age group is generally considered to be risky (Ayuba et al, 2014). However youth sexual activity continues to increase globally with a trend towards early onset (Grimes et al, 2006; WHO, 2015) resulting in the overall burden of adolescent pregnancy (WHO, 2016). It is estimated that about 20-50% of adolescents have had their first sexual intercourse within the ages of 14-18 years (Yen & Martin, 2013). It is therefore not surprising that 16 million of adolescents within the age group 15–19 years old give birth each year representing about 11% of all births worldwide (WHO, 2016). It is however estimated that over 90% of these births occur in women living in developing countries, particularly sub-Saharan Africa (WHO, 2016). The emergence of this public health challenge associated with adolescents has been attributed to various factors including peer pressure, substance abuse, denied access to and failure of contraceptive options, increased access to negative media and internet images that promote irresponsible sexual behavior and unhealthy childhood environment (London et al, 2013) coupled with early marriage and traditional gender roles, low educational status of female children and poverty in the developing countries (Dare et al, 2016). Adolescent pregnancies constitute major socio-medical, socio-economic and psychosocial problems. Psychological effects of pregnancy on adolescents include, denial, depression, withdrawal, anxiety, suicide attempts, aggressiveness, fighting, frustration and fear of 1 University of Ghana http://ugspace.ug.edu.gh rejection by peers and parents (Babafemi & Adeleke, 2012). Compounding this however is the interruption of the developmental tasks of these adolescents. This creates a huge psychological burden (Dare et al, 2016). However, in Ghana, it has been recorded that 24% of all births are untimed, 16% of all births to adolescents are unwanted and 40% are unplanned (GSS, GHS & ICF Macro, 2009). On the average, urban women within the ages of 25-49 years had the median age of 18 years first sexual intercourse, with most giving birth before attaining age 20 (GSS, GHS, 2008). The Ho Municipal area is the most populous district in the Volta Region with the prevalence of 44.1% unintended pregnancy (Birhanu, 2010). However, no study has been done to ascertain the psychosocial challenges facing the young adolescents in the Municipal area. The purpose of this study is to explore the psychosocial challenges of pregnant adolescents in the Ho Municipal area of the Volta Region to help develop psychosocial interventions to curb the menace. 1.2 Statement of Research Problem The medical challenges of pregnant adolescents are enormous. These include spontaneous abortions, preterm labor and delivery, anemia from malaria, pre-eclampsia and eclampsia, infection and inadequate nutrition, antepartum hemorrhage, obstructed labor and its complications notably genital fistulae and fetal pelvic disproportion with its attendant risks of high operative intervention rates (Dare et al, 2016). Moreover, there is inadequate comprehensive care to pregnant adolescents causing significant environmental and psychosocial stressors and risk that can affect them and their children (Hodgkinson et al, 2010). 2 University of Ghana http://ugspace.ug.edu.gh These culminate into high psychosocial challenges resulting in depression, social isolation, stigma, being dropped out of school, drug use, poor educational attainment, poverty, absence of job opportunities and repeated pregnancy (Beers & Lewin, 2009; Paranjothy et al, 2009). Adolescent pregnancy continues to increase especially in Ghana. Out of all births registered in 2014, 30% were by adolescents and 14% of these adolescents aged between 15 and 19 years had begun childbearing (GHS, 2016, p.2). Moreover, it has been reported that 16%, 40% and 24% of all births in Ghana are unwanted, unplanned, and mistimed respectively (GSS, GHS & ICF Macro, 2009, p.3). Additionally, the median age at first sexual intercourse among urban women age 25-49 years in Ghana is 18.8 years. The Volta Region of Ghana has the highest percentage adolescents aged 15-19 years who are pregnant with their first child or percentage who have begun childbearing in Ghana (GSS, GHS and ICF International, 2015). Additionally, the Ho Municipal area is the most populous district in the Volta Region with the prevalence of 44.1% unintended and teenage pregnancy (Birhanu, 2010). Although several studies have been conducted on adolescents in the Volta Region, many of them looked at family planning, unsafe abortions, teenage pregnancy, determinants of early sexual activity, and contraception among teenagers in Ghana. For example, Birhanu, 2010 looked at unintended pregnancy in the Ho Municipal area whiles Nabila et al, (1998) also looked at problems of teenage pregnancy in the Nkwanta District of Volta Region. Till date, very little empirical evidence exists regarding the psychosocial challenges of pregnant adolescents go through. Therefore, this study seeks to explore the psychosocial challenges of pregnant adolescents in the Ho Municipal area of the Volta Region in order to help inform policy and the development of appropriate psychosocial interventions. 3 University of Ghana http://ugspace.ug.edu.gh 1.3 Conceptual Framework PSYCHOLOGICAL CHALLENGES Depression, anxiety, violence, sadness, suicidal tendencies, anger, loneliness DEMOGRAPHIC CHARACTERISTIC S Age, Religion, Educational level, PSYCHOSOCIAL CHALLENGES Parity OF PREGNANT ADOLESCENTS SOCIAL CHALLENGES Lack of community / family support, isolation, lack of partner support, lack of proper self-care and stigmatization and discrimination Figure 1.1: Conceptual Framework of psychosocial challenges of pregnant adolescents. Source: (Modified from Baafi, 2015). The above conceptual framework suggests the cause of adolescent pregnancy and its attendant psychosocial challenges faced or suffered by pregnant adolescents are largely based on their demographic characteristics including age, religion, educational level, family background, among others. Also, the framework suggests that the extent to which a pregnant adolescent girl may suffer or deal with psychosocial challenges that characterizes her pregnancy is largely dependent on her demographic characteristics. Some of the social challenges that may be suffered by a pregnant adolescent mother include lack of community / family support, isolation, lack of partner support, inadequate self-care and 4 University of Ghana http://ugspace.ug.edu.gh stigmatization and discrimination whilst the psychological challenges include depression, anxiety, violence, sadness, suicidal tendencies, anger, loneliness, among others. Therefore, this particular study will adopt the conceptual framework shown in Figure 1 to explore and analyze the psychosocial challenges of pregnant adolescents in the Ho Municipal area of the Volta Region in order to help inform policy and development of appropriate psychosocial interventions. The framework was adopted from Baafi (2015) with modifications. The modified conceptual framework shows the various psychosocial challenges of the pregnant adolescent. Psychological factors such as depression, anxiety, violence, sadness, suicidal tendencies, anger, and loneliness characterize pregnant adolescents‟ challenges. Additionally, factors such as lack of community and family support, isolation, lack of partner support, inadequate self-care, stigmatization and discrimination are some of the social challenges that these young females face. Moreover, these psychological and the social factors in turn influence each other. However, the severity of these psychosocial challenges depends on the demographic characteristics such as age, parity, marital status, religion, maternal educational level, and ethnicity. 1.4 Justification Assessment of the level of knowledge with respect to causes of teenage pregnancy in the Ho Municipality would unravel the knowledge gaps among these young women. This would enable specific areas which need awareness creation and policy formulation to bridge these gaps. 5 University of Ghana http://ugspace.ug.edu.gh Additionally, when the psychological and social challenges pregnant adolescents face are identified, pertinent underlying factors will be addressed. Addressing these challenges would contribute to the overall quality of life of the pregnant adolescents. Lastly, the findings of this study will contribute to the existing literature on the psychosocial dimension of adolescent health since very little is known about studies on the psychosocial challenges of pregnant adolescents. The findings of the study could inform policy and international programs; and could also be replicated in other communities and municipalities. 1.5 Study Objectives 1.5.1 General Objective The general objective of the study is to explore the psychosocial challenges of pregnant adolescents in Ho Municipal area of the Volta Region. 1.5.2. Specific Objectives The specific objectives were to: 1. Explore the psychological challenges of pregnant adolescents. 2. Identify the social challenges of pregnant adolescents. 3. Determine the level of knowledge with respect to causes of teenage pregnancy in the Ho Municipal area. 1.6 Outline of the Dissertation The dissertation is presented under five chapters. Chapter one presents the introduction to the study. Background, problem statement, conceptual framework, justification, general objective, specific objectives and research questions are presented. Chapter two presents the literature in relation to the study. Chapter three contains the methods used for the 6 University of Ghana http://ugspace.ug.edu.gh study. Chapter four presents the data analysis and interpretation of data and finally Chapter five presents the summary of findings, conclusions and recommendations. 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter reviewed literature on the subject matter and important published studies by other researchers relevant to this study. The literature review is structured around the objectives of this study and research process. 2.1. Global Burden of Adolescent Pregnancy Youth sexual activity continues to increase globally with a trend towards early initiation of sex (Grimes et al, 2006; WHO, 2015) leading to the overall burden of adolescent pregnancy (WHO, 2016). It has been estimated that about 20-50% of adolescents have had their first sexual intercourse within the ages of 14-18 years (Yen & Martin, 2013). Additionally, about 16 million females between the ages of 15–19 years give birth each year representing about 11% of all births worldwide, this results in 23% of the overall burden of disease (disability- adjusted life years). Further, more than 90% of these births occur in adolescents living in developing countries (WHO, 2016) with the highest rate occurring in sub-Saharan Africa, at 143/1000 (WHO, 2016). This resulted in an estimated 1.3 million deaths of adolescents in 2015 (WHO, 2016). However, most teenage pregnancies in both the developed and developing are unplanned (Birhanu, 2010). These are caused by peer pressure, substance abuse, denied access to and failure of contraceptive options, increased access to negative media and internet images that promote irresponsible sexual behavior and unhealthy childhood environment (London et al, 2013) coupled with early marriage and traditional gender roles, low educational status of female children and poverty in the developing countries (Dare et al, 2016). The 8 University of Ghana http://ugspace.ug.edu.gh socio-medical, socio-economic and psychosocial problems caused by adolescent pregnancy are enormous. Ghana is however not an exception from this burden of pregnant adolescents. 2.2. Adolescent Pregnancy in Ghana Adolescents are sexually active (Sedgh et al, 2014; Dick & Ferguson, 2015) thus putting a significant number of the world population at risk for getting pregnant unintentionally. In Ghana, “a rise in adolescent pregnancies among those aged 15 to 19 years was recorded from 43,465 in 2009 to 83,917 in 2013, representing 12.3% of all pregnancies in the country” (GHS, 2013, p.3). For instance in the Upper East Region of Ghana, 21.7% of adolescents aged 15 to 19 years have begun childbearing in 2014 (GSS; GHS; ICF International, 2015). Moreover, “it is on record that 16% of all births in Ghana are unwanted, 40% are unplanned, and 24% are mistimed (GSS, GHS & ICF Macro, 2009).” Additionally, the median age at first sexual intercourse among urban women age 25-49 years in Ghana is 18.8 years. Further, “one- fifth of Ghanaian women age 25-49 years (22%) had given birth before age 18, while nearly two-fifths (39%) had given birth by age 20” (GDHS, 2014, p.1). However, the challenges of these pregnant adolescents are cannot be underestimated. 2.3 Factors Contributing to Adolescent Pregnancy In Ghana; about 22% of the total population of Ghana is adolescents as at 2012 (Viner et al, 2012). Also, about 16% of these adolescents give birth by age 18. Teenage pregnancies are reaching alarming proportions. It is reported that about 30% of all births in some communities are attributed to adolescent mothers (Viner et al, 2012). Below are some factors that contribute to adolescent pregnancy. 9 University of Ghana http://ugspace.ug.edu.gh 2.3.1 Poverty The current socio-economic status of most parents in Ghana means that poverty is likely to cause younger members of the family to be more likely exposed to be engaged in sexual activities of older members, especially in cases where both older and younger members of the family share the same room (Newman & Newman, 2017). Children who grow up under such circumstances are more likely to engage in sexual activities at the early stages of their lives which could result in pregnancy. Across the globe, especially in the advance world, adolescent pregnancy is more predominant and common among young people who have low expectation of education or the job market and who live under disadvantaged low standards of conditions. Research shows that female adolescents who live under poorer conditions have five times the chance of becoming pregnant (Viner et al, 2012). Therefore, socio-economic conditions play very significant role of influencing the rates of adolescent pregnancy. Most female adolescents see no wrong in having sex or becoming pregnant to survive, especially if they live under poor conditions. For some disadvantaged youth, sexuality become their cherished value, especially when they have low self-esteem in society. “Lack of opportunity and hope for future, have been identified as a driving force behind high rates of teenage pregnancy “(Viner et al, 2012). Poverty has become one major influential factor for increased rate of adolescent pregnancy across the globe. 2.3.2 Adolescent Sexual Behavior Sexual behavior is also another cause of adolescent pregnancy. Lack of information on pregnancy control measures makes most female adolescents become pregnant in early stages of their lives. For example, wrong use of contraceptive by inexperienced adolescents result in high adolescent pregnancy rates. Contraceptive failure is most predominant among girls from the poorer homes (Kirby, 2001). 10 University of Ghana http://ugspace.ug.edu.gh Tsebe (2012) explains that the teenager‟s sexual decisions which influence their sexual bahviours is contingent on several factors including ignorance of contraceptives, coping with boredom, catching up with modernity or fashion, influence by peers, parents or one‟s partner, desire to provide love and influence under drugs and alcohol. 2.3.3 Age Discrepancy According to Johnson (2016), “age-differential relationships in which the younger partner in the relationship is the female often results in situations where the male partner makes no room for negotiations on the use of contraceptives and sexual activities.” This male adult may pressure the younger female to engage in sexual activities as a way of proving her trust or fidelity. Older men in recent times tend to have sexual feelings for younger females. This places most young females under the risk of becoming pregnant. Also, the females are usually incapacitated to negotiate on sexual activities and options for contraceptive use due to financial assistance or promises they receive from older men (Johnson, 2016). There is lesser pressure and risk for becoming pregnant when adolescent girls date boys of their same age. Adolescent girls in relationship with older boys and in particular adult men, are more likely to become pregnant than when they are in relationship with someone of their age. This also reduce the incidence of rape and other sexual abuses which may result in pregnancy (Johnson, 2016). 11 University of Ghana http://ugspace.ug.edu.gh 2.3.4 Childhood Environment The environment in which an adolescent grows up has a high tendency of influencing the behaviour of the adolescent including sexual behaviour. There is high risk of great appetite for sex in an environment where the female adolescent has been introduced to sexual abuses at a tender age. However, adolescent girls who have not been exposed to sexual violence at an early stage of her life have higher tendency of remaining chaste till they mature before attempting sexual activities. According to Reyees (2015), “adolescent pregnancy can be greatly reduced by preventing sexual abuses on female adolescents, A third of teenage pregnancies could be prevented by eliminating exposure to abuse, violence and family early stages of their lives.” 2.3.5 Drugs and Alcohol Adolescents who come under the influence of drugs and alcohol are most likely to venture into other risky activities including having unprotected sex (Noller & Callan, 2015). This factor have largely contributed to a lot of adolescent pregnancies among females. When a female adolescent gets intoxicated with alcohol or drug, she could develop impaired judgements which may push her into unprotected sex, thereby becoming pregnant. According to Noller & Callan (2015, p.3), “the side effects of drugs and alcohol on an adolescent include “increase sexual arousal and desire, decrease inhibition and tenseness, diminish decision-making capacity, judgment and sense of responsibility, and generally disempowered women to resist sex.” Their study revealed that most adolescents forget or fail to use contraceptives during sexual intercourse when they are under the influence of drugs or alcohol. 2.3.6 Lack of Education on Safe Sex Buckingham (2013) explains that the absence of sex education by parents, teachers, religious leaders and peer educators have contributed significantly to female adolescents 12 University of Ghana http://ugspace.ug.edu.gh engaging in careless sexual activities which to a very large extent result in pregnancy. Many adolescents are deprived of knowledge on healthy sexual behaviour and pregnancy control measures due to lack of education on them. This is because most parents are too busy to engage their wards in such useful discourse, whilst some teachers and peer educators feel they may be promoting immorality among adolescents when they educate them on such topics (Borrero et al 2015). The consequences have been costly since it has contributed to the rampant adolescent pregnancy especially in developing countries. Chirkut (2016), “explain that the way girls dress and behave in society reflects the reciprocal treatments from boys and older men. So female adolescents who dress provocatively, stay out at nights for long hours and often visit places like night clubs and beaches attract men who will only be interested to have sex with them. This increases the tendency for such girls to become pregnant.” 2.3.7 Contraceptives Most adolescents have little knowledge about the types and use of contraceptives for preventing pregnancy among adolescents. However, most youth become sexually active and engage in sexual intercourses in early stages of their lives. As a result, adolescents are left to their fates to take their own decisions when it comes to sexual behaviours and practices. This land most adolescents in making wrong decisions regarding sexual activities, thereby resulting in high rates of adolescent pregnancy (Kao and Manczak, 2013). Family planning programmes also serve as birth control measures. However most of these programmes focus on older persons at the neglect of adolescents and teenagers. In addition, most rural areas where sexual activities have become source of entertainment 13 University of Ghana http://ugspace.ug.edu.gh have clinics which are not easily accessible due to long distances for the youth to visit to obtain knowledge on contraceptive use. 2.3.8 Family Structure and its Influences According to Tsebe (2012) “family characteristics contribute significantly in understanding and determining adolescent sexual behavior including pregnancy.” In families where there is absence of sex education, adolescent females in such families become pregnant as compared to families where such education exist. Also, female adolescents who live in a families where parents are permissive on pre-marital sex and also have negative conceptions about the use of condoms are more likely to become pregnant than in families with strict values on pre-marital sex or where parents are lenient or encourage the use of contraceptives among their wards in case they should venture into any sexual activity. Also, most female adolescents are most likely to become pregnant if they grow up in a family where older siblings or other relatives became pregnant at their youthful stages as compared to families where older siblings mature or even marry before becoming pregnant (Tsebe, 2012). This is because parents and older siblings, most often than not serve as role models to the younger members of the family. So, the behavior adolescents put up is largely influenced by the kind of life style she emulates from older siblings or parents. 2.3.10 The Influence of the Media The Media, both print and electronic, is a very strong force of socialization and has a high tendency of influencing the lives of adolescents including their sexual behaviour. Such influence by the media could induce adolescents into early sex than expected, which could result in pregnancy for most young females (Vandenbosch and Eggermont, 2013). Imageries and scenes portrayed on contemporary media sources such as Televisions, radio, internet, novel and some Newspapers and magazines portray sex as fashion or the order of 14 University of Ghana http://ugspace.ug.edu.gh the day. Most adolescents will try to catch up with fashion or blindly emulate sexual scenes they gain access to through the media. These contribute greatly to the increasing adolescent pregnancy in recent times. 2.3.11 Peer Pressure Aside parents and siblings, most adolescents spend more times with their peers and feel more comfortable to share their experiences and thoughts with their peers than parents and siblings. In this regard, where an adolescent fall in the midst of bad company or gang as his or her peers, the person is likely to engage in social vices which may include sexual activities (Shepherd et al, 2011). This has also contributed significantly to the high rates of adolescent pregnancy. 2.4 Challenges of Adolescent Pregnancy The effects of adolescent pregnancy are enormous and can be viewed from different perspectives. Teenage pregnancy is seen to have social, economic, psychological, medical spiritual, and physical effects on the teenage mother, the baby and the family as a whole. Moreover, the psychosocial challenges of these adolescents are high and may include: depression, social isolation, stigma, school dropout, poor education attainment, limited job opportunities, poverty, drug use and repeated pregnancy (Beers & Lewin, 2009; Paranjothy et al, 2009). These challenges are grouped into the following categories for the purpose of the study. 2.4.1 Psychological Challenges Adolescent pregnancy is associated with psychological problems. These may include anxiety, sadness, rejection, thoughts of abortion and suicidal tendencies. Mental health disorders are fairly common in adolescents with one in four or five teenagers suffering from this disorder (Merikangas et al, 2010). Pregnancy greatly affect not only the physical 15 University of Ghana http://ugspace.ug.edu.gh but also psychosocial wellbeing of adolescents (Assini-Meytin & Green, 2015). Some of these psychological challenges of the adolescents are categorized as follows. 2.4.1.1 Depression Adolescent pregnancy has been found to be associated with depressive symptoms. The teenagers have been reported to be “far from being emotionally, cognitively and socially ready for motherhood” (Assini-Meytin & Green, 2015). Furthermore, a wide range of psychiatric disorders, notably major depressive disorder and panic disorder remained associated with suicidal behaviour of pregnant adolescents (Dick & Ferguson, 2015). 2.4.1.2 Anxiety Studies have shown that pregnant adolescents often experience anxiety (Siegel & Brandon, 2014). Anxiety is an unexplained fear or uneasiness experienced by pregnant adolescents over issues related to their pregnancies (Amoah, 2013). These anxieties may be due to either changes in the body of the adolescent, behavior of family members or fear of labour. Other studies identified teenage pregnancy as psychologically stressful experience that is associated with conditions such as anxiety, insomnia, depression, social isolation and somatic symptoms (Beers & Lewin, 2009). 2.4.1.3 Violence Violence is a leading cause of death amongst adolescents, mostly in Africa. An estimated 180 adolescents die every day as a result of interpersonal violence. About one out of three deaths among adolescent males of the low- and middle-income countries in the WHO Americas Region is due to violence. Globally, some 30% of girls aged 15 to 19 experience violence by a partner. 16 University of Ghana http://ugspace.ug.edu.gh 2.4.1.4 Sadness This refers to the adolescents‟ sense of unhappiness about the behavior of their parents and significant others (Amoah, 2013). Several studies have shown that pregnant adolescents weep or become sad when they realize or are told they were pregnant (Amoah, 2013; Wilson-Mitchell et al, 2014). Pregnant teenagers with high social support showed less sadness prevalence ratios than those with low social support (Fergusson & Woodward, 2011). 2.4.1.5 Suicidal Tendencies Researches have shown that suicidal behavior is a relatively common feature in pregnant teenagers, frequently associated with psychiatric disorders (Fergusson & Woodward, 2011). However, with good parental support many of these adolescents will have better outcomes and quality of life (Beers & Lewin, 2009). Several studies have reported that pregnant adolescents had thoughts of taking their own lives when they realized they are pregnant (Amoah, 2013). This happens when the adolescents feel there is no hope in their situation and therefore it is useless to be alive. Some thought their parents would kill them upon hearing that they were pregnant, so they reckoned it would be better they do it themselves (Amoah, 2013; Fergusson & Woodward, 2011). 2.4.1.6 Anger Pregnant adolescents usually develop feelings of anger towards herself or her partner due to the unplanned pregnancy. Some of the adolescents get angry with themselves for allowing themselves to be pregnant. Others become angry at their partners for not taking up their responsibilities. This turmoil experienced by pregnant teenagers are caused by the overwhelming emotions they experience in related to their pregnancies such as breakdown in relationships with their parents, families and peers (James et al, 2012). 17 University of Ghana http://ugspace.ug.edu.gh 2.4.1.7 Loneliness As part of the coping strategies of pregnant adolescents to their situations, they isolate themselves from others or vice versa. This is as a result of the comments people make and the way people look at them (Amoah, 2013). Similar studies found that pregnant teenagers feel lonely and desperate leading to the isolation and despair in adapting to their new role as a parent (Higginbottom et al., 2006). 2.4.2 Social Challenges The social challenges faced by pregnant adolescents are grouped as follows: 2.4.2.1 Lack of Community and Family Support Pregnant teenagers experience a change in their relationships with significant others due to expectations that was not met (James et al, 2012). Studies have shown that parents experience overwhelming emotions due to the unexpected pregnancy of their girl child leading to loss of control as the pregnancy could not be reversed (Amoah, 2013). However, all these bad experiences are culminated in anger that hampers the necessary parental support for the pregnant teenager. Moreover, parents feel cheated and unappreciated when the teenagers become pregnant. Findings showed that all the parents and family members developed feelings of anger towards their pregnant adolescents (Assini-Meytin & Green, 2015). 2.4.2.2 Isolation Studies have shown that pregnant adolescents experience discrimination and unsolicited comments by the general public regarding their status (Higginbottom et al., 2006). Similar studies showed that, even though most of the pregnant adolescents try to talk to somebody, some were scared to tell their parents until the pregnancy is noticed by others (Kekesi, 2007). 18 University of Ghana http://ugspace.ug.edu.gh In other studies pregnant adolescents were thrown out of their home by their parents when they noticed that they were pregnant without even searching for them later (Amoah, 2013). 2.4.2.3 Lack of Support by Partner This refers to partners refusing to accept responsibility for the pregnancy of the adolescent girls. Studies have revealed that, some of the partners were married men with children, and they informed the adolescents only when they got pregnant (Higginbottom et al., 2006; Amoah, 2013). Similarly, most partners do not show responsibility or fail to take responsibility of their actions even though they are not married men. 2.4.2.4 Inadequate or Poor Self-care Younger pregnant adolescents aged less than 16 years old lack the ability to take care of themselves (Assini-Meytin & Green, 2015). The poor self-care is because they are just too young to take care of themselves and at the same time face emotional disturbances as older adolescents. 2.4.2.5 Stigmatization and Discrimination Pregnant adolescent suffer stigmatization and discrimination in society. This occurs in both the developed and developing countries (Ayuba et al, 2014) compounding this is the fact that apart from being stigmatized by parents and community members, they also face stigma and discrimination at school, leading them to leave school prematurely (Assini- Meytin & Green, 2015), as protection against stigma. To protect the adolescent from stigma and discrimination, parents of the adolescents became more controlling over their daughters‟ social life (Ayuba et al, 2014). 19 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter explains the methods that were employed to carry out the study. It discusses the research design, sources of data, study area, population, sample size, sample and sampling procedure. Others are data collection method, data analysis and ethical considerations. 3.1 Research Design This is an exploratory facility-based qualitative case study using narrative and phenomenological approach. The qualitative method involves in-depth interviews (IDIs). Exploratory design was employed because it is more flexible in allowing the use of other avenues of obtaining data for analysis. Exploratory design usually employs case studies, in-depth interviews and pilot studies (Dellinger & Leech, 2007). Explorative design helps a research to formulate a more precise statement of research problem (Shields and Rangarjan, 2013), and also helps in investigating a social phenomenon without prejudice (Dellinger & Leech, 2007). On the other hand, a case study research plays an important role in advancing a field‟s body of knowledge (Merriam, 2009). Miles and Huberman (1994) assert that a case study is a phenomenon of some sort occurring in a bounded context. Myers (2009) argues that the most significant aspect of case study research is its emphasis on „how‟ and „why‟ questions and therefore Mouton (2001) considers it appropriate for descriptive and exploratory studies. Stake (2005) points out that case study focuses on describing processes, individual or group action in a whole setting, and/or the sequence of events in 20 University of Ghana http://ugspace.ug.edu.gh which an action occurs. The case study approach supports both theory building, particularly where existing theoretical and conceptual frameworks are inadequate, and theory testing usually where no hypothesis is formulated but “general objectives” or “questions” act as a guide to the empirical research (Chetty, 1996; Mouton, 2001). Case study approach enables research to closely examine data within a specific context (Zainal, 2007). The choice of an exploratory qualitative case study is based on the foregoing factors. This study is subjective and multiplicity of reality from the opinions of the subjects in a study involving communication or interaction between the researcher and respondents to provide primary data through interviews. The study design is context bound, and therefore is necessary to conduct the study in its natural setting to enable the researcher find explanations for the various constructs and elements from the theoretical perspective of the study. The values ascribed by the participants need to be understood and are relatively personal. Decisions evolve and there is the need for a personal voice with a language typically informal. This study does not require any control group to investigate the phenomenon within the context of real life. Psychosocial challenges faced by pregnant adolescents in the Ho Municipality of the Volta Region of Ghana is set within a particular context. The idea of employing an exploratory qualitative case study is to unfold the challenges as pertains to the study area and recommend approaches to tackle the challenges faced. The data collected is varied, detailed and extensive using research questions. This research is neither focusing on discovery of a universal, generalizable truth, nor looking for cause effect relationships: Instead, it emphasizes exploration and description of the psychosocial 21 University of Ghana http://ugspace.ug.edu.gh challenges faced by pregnant adolescents in the Ho Municipal area in the Volta Region of Ghana. 3.2 Sources of Data 3.2.1 Primary Data Primary data is first- hand sources of data which have not been published. Such data according to Chan and Ahmed (2006) is more objective, reliable and accurate. Some few methods used to collect the primary data, include observation, interview and questionnaire. In this study, primary data was obtained through unstructured interviews at Ho Municipal Hospital. Some of the health practitioners including doctors and nurses of the hospital, as well as some few parents, friends and relative of pregnant adolescents in the Municipal Area were also interviewed. 3.2.2 Secondary Data The secondary data refers to data that has been obtained from other researchers and has been published. Normally, the secondary data is more easily accessible as it can be obtained from journals, books and the internet. The disadvantage for this secondary data is that data obtained may not accurate and may be outdated compared to primary data. The study utilized secondary sources including journal articles, books, news reports, newspaper articles, video documentaries and commentaries which contained relevant data to the topic under study. All these were synchronized to general literature on adolescent pregnancy with a key focus on Ghana. Online websites where relevant data pertinent to the topic could be obtained were also consulted. The document analysis and exploratory qualitative approach was the basis for drawing conclusions in this study. 22 University of Ghana http://ugspace.ug.edu.gh 3.3 Study Area The study will be conducted at Ho Municipal Hospital. The Municipality is located between latitudes 6o 20”N and 6o 55”N and longitudes 0o 12‟E and 0o 53‟E. The Municipality shares boundaries with Adaklu and Agotime-Ziope Districts to the South, Ho West District to the North and West and the Republic of Togo to the East. Its total land area is 2,361 square kilometers thus representing 11.5 percent of the region‟s total land area. The population of Ho Municipal Area according to the 2010 Population and Housing Census is 177,281 representing 8.4 percent of the region‟s total population. Females constitute 52.7 percent and males represent 47.3 percent. About 62 percent of the population resides in urban localities. The Municipality has a sex ratio (number of males per 100 females) of 89.7. Of the population 11 years and above, 90.3 percent are literate whiles 9.7 percent are not literate. About 64.5 percent of the population aged 15 years and older is economically active. Of the employed population, about 21.4 percent are engaged as skilled agricultural, forestry and fishery workers 26.8 percent are engaged in service and sales while 22.6 percent are into craft and related trade, and 15.8 percent are managers, professionals, and technicians. 23 University of Ghana http://ugspace.ug.edu.gh Figure 3.1: Map of Ho Municipal Area 3.4 Study Population The study population will be all pregnant adolescents (10-19 years) accessing health care at the Ho Municipal Hospital. 3.5 Sampling Procedure The study employed a purposive sampling method which is an example of non-probability sampling technique. Purposive sampling was selected because it is a time-effective sampling technique and is essential when a specific characteristic of study participants are being considered. The purposive sampling involved maximum variation sampling strategy. The maximum variation sampling strategy encompassed participants of different 24 University of Ghana http://ugspace.ug.edu.gh backgrounds in order to have a fair representative of the group. This will include the younger and the older adolescents, married and unmarried, educated and uneducated and people of different socio-economic backgrounds. 3.5.1 Selection of Participants Pregnant adolescents between ages 10-19 were recruited and in-depth interview (IDI) was carried out. The IDI was chosen because it gives more information on sensitive issues. The participants were included based on their acceptability, willingness to participate and provide information on the topics being studied. 3.5.2 Data Collection Procedure The interview was divided into two sections and lasted for about 60 minutes. Participants were asked questions related to demographics and risks of adolescent pregnancy. Participants described their psychosocial challenges as pregnant adolescents based on the main themes psychological challenges with the subthemes: depression, anxiety, violence, sadness, suicidal tendencies, anger, loneliness and social challenges with subthemes: lack of community / family support, isolation, lack of partner support, lack of proper self-care and stigmatization and discrimination. In order to minimize bias and the risk of reactivity, an interview guide was designed used for conducting the in-depth-interviews for participants. This enabled a full description of the challenges of adolescent pregnancy. All interviews were recorded using an audio recorder. Notes were also taken. Both the recording and the notes helped ensure accuracy of data and facilitated analysis. Most of the IDIs were carried out at the homes of participants and also within isolated areas of the Ho Municipal Hospital. There were tendencies of the interviews conducted being replete with biases. However to reduce these 25 University of Ghana http://ugspace.ug.edu.gh biases, a structured processes for recording observations and analyzing the data increased accuracy and reduced biases. 3.6 Data Processing and Analysis Data processing and analysis was started on the day of the in-depth interview. The analysis involved the following stages. Firstly, the audiotapes were transcribed. Secondly coding was done to identify informants‟ words or phrases and even sentences related and relevant to the psychosocial challenges. The third stage covered data categorization, in which the identified codes were sorted into relevant categories. Finally, the main themes were identified and the categories were brought together and rearranged under those themes. Significant statements were clustered under themes, to form the architecture of the findings (Padgett, 2008) and was used to describe the challenges the participants encountered and the context that influenced how the participants experienced the phenomenon. 3.7 Data Storage Audio tapes and transcribed data (soft copy) were locked on a computer using a password and only accessible to principal researcher. All hard copies of the research materials were stored under lock and key. 3.8 Quality Control Rigour and epistemological integrity was ensured in order to maintain methodological coherence by precisely representing participants‟ experiences. This was done using Thorne‟s (1997) guidelines as an evaluation criterion for qualitative design. Credibility was ensured by interviewing only people who have experienced the phenomenon, that is, 26 University of Ghana http://ugspace.ug.edu.gh pregnant adolescents. Representative quotations from transcribed words was submitted to experts to seek their agreement on whether audio-recording was the same as the transcribed information. Peer debriefing was done with those interested in adolescent health services. With regards to Interpretive Authority which represents the trustworthiness of the data interpreted, the researcher made sure feedback was obtained from the participants to check if he had the stories right. 3.9 Ethical Consideration 1. Ethical Clearance was obtained from Ghana Health Service Ethical Review Committee prior to data collection. 2. Consent was sort from all participants. Potential participants were made to understand that participation in this study was entirely voluntary and participants had the option not to participate or to discontinue their participation without any adverse consequence. 3. Participants were given sufficient information about the study to enable them decides whether to take part or not. Participants were assured of the fact that this work is for academic purposes and that no harm is intended. Also, participants who decide to discontinue the interview were not penalized or victimized. Those who successfully completed the interview were given refreshment at the end. 4. Permission was sought from the Authorities of the Ho Municipal Health Directorate and Municipal Hospital, Ho. 5. Confidentiality and anonymity was also taken into consideration. To provide further protection to participants, there were no identifiers linked to the information provided during the study. All information were not linked in any way to the respondents. 27 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Introduction In the previous chapter, the exploratory qualitative case study was discussed as the main methodology adopted for the conduct of this study. This chapter presents the findings of the research results of psychosocial challenges of pregnant adolescents in the Ho Municipal area of the Volta Region. The Chapter begins with the background characteristics of participants, presentation of the main causes of adolescent pregnancy in the study area. Subsequent section presents the results of the psychosocial challenges of teenage pregnancy in the study area. From field data, most of the pregnant adolescents interviewed were within the ages of 12-15 years. 4.2 Background Characteristics of Participants The background characteristics of the participants are presented in Table 4.1. About 70 percent of the respondents were older adolescents aged 15-19 years while about 60 percent had attained at least secondary education. With regards to religion, 35 percent were Christians and about 10 percent had no religion. Additionally, 40 percent of the respondents were in their early stage of pregnancy. 28 University of Ghana http://ugspace.ug.edu.gh Table 4.1 Background characteristics of Participants Variable Frequency Percent Age 12-14 years 6 30 15-19 years 14 70 Level of Education Primary 2 10 Junior High School 6 30 Senior High School 7 35 Tertiary 5 25 Religion Christianity 7 35 Islam 6 30 Traditional Religion 5 25 No religion 2 10 Duration of Pregnancy One month 8 40 2-6 months 7 35 7-9 months 5 25 Total 20 100 Source: Field work, 2017 4.3 Main Factors Contributing to Adolescent Pregnancy in the Ho Municipal Area of the Volta Region. 4.3.1 Poverty Poverty was identified as the major cause of teenage pregnancy. It was revealed that most of the pregnant adolescents interviewed come from poor family backgrounds. Some of these adolescents share the same rooms with parents and elderly siblings. They become 29 University of Ghana http://ugspace.ug.edu.gh easily exposed to the sexual activities at tender ages. A pregnant participant reported her living conditions in the following comment: I come from a family of 11 members, 9 siblings and with both parents alive. Unfortunately, I share the same room with 5 elderly siblings of mine. I therefore became exposed to sex at a tender age due to the chats and relationships I observed from my older siblings. I started dating as early as 10 years and unfortunately, here I am today pregnant at age 15. [P.A 2, 15 years] 4.3.2 Adolescent Sexual Behavior The cause of adolescent pregnancy in the Ho Municipal Area could largely be attributed to the sexual behavior of adolescents in the area. A revelation by a pregnant adolescent indicated that: I usually have sex with my boyfriend in my safe periods, but do not know what went wrong for me to get pregnant. And the worst part of it all is that he is denying the responsibility for the pregnancy.[P.A 4, aged 18 years] 4.3.3 Age Discrepancy The age difference between female adolescents and their male partners sometimes weaken their abilities to negotiate „No Sex‟ or the use of contraceptives, especially when the female is the younger partner in the relationship. Consequently, most male adults or youths cajole and coerce female adolescents to having unprotected sex. From field data, most female adolescents in the Ho Municipality become vulnerable to such requests or pressure which subsequently result in pregnancy. As revealed by a participant aged 17, who was pregnant, she asserted that, My boyfriend who was 25 years usually mount pressure on me into participating in unprotected sexual activities as a way of proving my trust and fidelity in the 30 University of Ghana http://ugspace.ug.edu.gh relationship, and these sexual activities are what have landed me in me pregnancy today. The sad aspect of it all it that, he denied responsibility of the pregnancy explaining that I was not a virgin when he first made love to me. [[P.A 3, aged 17 years] 4.3.4 Childhood environment The study revealed that females who were exposed to some form of sexual abuse or domestic violence by male adults in their early stages of life are more likely than not to become pregnant as adolescents as compared to those who never experienced such circumstances. A specific revelation was made by an 18 year old pregnant adolescent who was not married. She pointed out that; My class six male teacher broke my virginity and ever since, my desire for sex has never diminished. [P.A 1, aged 18 years] 4.3.5 Drugs and Alcohol Some of the pregnant adolescent participants included in the study revealed that sexual abuses and non-use of contraceptives which usually resulted in their pregnancies was due to overdose of either alcohol or drug by male adults or the youths or they themselves. A respondent aged 15 years revealed that, My first sex with my boyfriend was at age 14, even though I had denied him on several attempts. However, our first sex happened after a party where I became very intoxicated and gave in so easily to his demands, which would not have happened if I was fully aware of my decisions. Sex with him has landed me in this pregnancy today, but unfortunately he denied responsibility because he was still a student and could not bear the extra challenge to father a child. [P.A 7, aged 15 years] 31 University of Ghana http://ugspace.ug.edu.gh 4.3.6 The Lack of Education on Safe Sex Notwithstanding the improved nature of sex education in contemporary Ghanaian society, in some urban areas like Accra, little strides has been made in the Ho Municipality. Data from the field revealed that most pregnant adolescents interviewed have never been educated on adolescent sexual behavior. This is due to busy work schedules of their parents to pay critical attention to that aspect of their children‟s lives or the absence of peer educators or inadequate health practitioners in the Ho Municipal area to provide education to the adolescents on healthy sexual behaviors. This situation was revealed by a pregnant participant, I have never heard anything on pertinent education with regards to adolescent sexual behaviour, till I got pregnant and came to the hospital to realize such education exists. I was a bit disappointed in my parents, especially my mother for not providing such education to me in the early stages of my life. I could have averted my current predicaments. [P.A 9, aged 13 years] 4.3.7 Contraceptives Education on the use of contraceptives is supposed to be a birth control measure or family planning to prevent the incidence of unwanted pregnancy, however this is lacking in most communities in developing countries. The result of the study show that, most parents and adults feel educating the adolescent about contraception encourages sexual activity. The assumption is that the absence of education on the types and use of contraceptives would prevent sexual activity, thereby reducing immorality and high incidence of adolescent pregnancy. A participant aged 15, stated her experience as follows; 32 University of Ghana http://ugspace.ug.edu.gh I got pregnant not because I was ignorant about the use of contraceptives but because my boyfriend threatened to quit the relationship if I insisted on that. So, I have to sacrifice for the sake of our relationship and this is what it landed me into, Unfortunately, he has relocated and no one has heard from him ever since I became pregnant. [P.A 5, aged 15 years] 4.3.8 Influence of Family Structure Family structural characteristics contribute to understanding and determining teenage sexual behaviour including pregnancy. A 15 year old pregnant adolescent participant asserted that, I was brought up under single parenting by my mum since they were divorced. This largely contributed to me becoming pregnant. This is because there was no proper supervision over me when my mother was not around, so I had the laxity to do whatsoever I preferred including sexual activities. The consequence of this is my pregnancy today. I do not regret becoming pregnant but regret becoming pregnant for someone I thought loved me so much who later denied responsibility for the pregnancy. [P.A 12, aged 15 years] 4.3.9 The Influence of the Media on Sexual Behavior of Adolescents Sexual scenes, videos and imageries that flood the phones of adolescents, coupled with opera soap series (telenovela) which adolescents gain access to, have higher tendencies of influencing their sexual behaviour. This factor has contributed significantly to adolescents engaging in early sexual behaviour in the Ho Municipal area, hence higher adolescent pregnancies as confirmed from field data. A 17 year old pregnant respondent, revealed that, 33 University of Ghana http://ugspace.ug.edu.gh I was not too much closer to the opposite sex till I became deeply engrossed in Telenovelas which influenced my decision to get a boyfriend and subsequently engage in sexual activities leading to my pregnancy. [P.A 10, aged 17 years] 4.3.10 Peer Pressure Peer pressure was also identified as one of the major causes of the increased rate of teenage pregnancy in the Ho Municipal area. As revealed by a participant aged 15, who was pregnant, in the following comments All my best friends are pregnant and was feeling very odd among them not being pregnant. So, I gave myself the chance to become pregnant to be able to solve the uncomfortable feelings I use to have, when I was not pregnant. [P.A 11, aged 15]. 4.3.11 Cultural factors Cultural influence also serve as a major factor in the alarming rate of adolescent pregnancy in the area. The increasing disregard for traditional cultural values on sexual restraints or control measures among adolescents in contemporary Ghanaian society has also contributed greatly to the prevalence of adolescent pregnancy in the Ho Municipal area. 4.4 The Psychosocial Effects of Adolescent Pregnancy in the Ho Municipality in the Volta Region of Ghana 4.4.1 Psychological Challenges Most pregnant adolescents in the Ho Municipality in the Volta Region are bedeviled with some psychological challenges due to their conditions. Paramount among them are elaborated below. 34 University of Ghana http://ugspace.ug.edu.gh 4.34.1.1 Depression Adolescent pregnancy has been found to be associated with depressive symptoms. There is a feeling of hopelessness and low-spiritedness among some pregnant adolescents interviewed. As revealed by a participant, this is due to their conditions, Ever since I became pregnant, it was as if, all hopes and aspirations for me has come to end. I feel so lonely in this world because my parents, friends and loved ones were so disappointed in me. I am now less self-motivated and feel nothing good again can happen to me in life, especially after my boyfriend denied responsibility for the pregnancy.[P.A 14, aged 15 years] 4.4.1.2 Anxiety Studies have shown that pregnant adolescents often experience anxiety (Siegel & Brandon, 2014). One of the participants described her feelings as follows, I feel like I will die before the ninth month. The pain and stress is too much for a single individual to bear. I also feel restless and experience sleepless nights most times, making life extremely unbearable. [P.A 15, aged 15 years] 4.4.1.3 Anger and Violence Field data revealed that most pregnant adolescents in the Ho Municipal area easily become angered or infuriated at the slightest provocation or joke. This has usually resulted in strife and fights which lead to severe consequences such as miscarriage and deaths. A participant remarked as follows; I nearly lost my pregnancy when it was about three months old because, a male friend of mine called me a deviant child. We engage in a fierce fight that it even escalated into tensions between our families. I really regret that day. This is 35 University of Ghana http://ugspace.ug.edu.gh because the two families which were initially having cordial relationship with each other are now at war all because of our fight. [P.A 16, aged 16 years] 4.4.1.4 Sadness Evidence from field that suggests that unwanted adolescent pregnancy bring unhappiness and sometimes sorrow to the adolescent females. A pregnant respondent who is aged 14, revealed that, “I have been crying for the past two months after realizing I was pregnant for a guy who used to confess and profer his love for me but later denied the responsibility for the pregnancy.”[P.A 8, aged 14 years] 4.4.1.5 Suicidal tendencies Researches have shown that suicidal behavior is a relatively common among pregnant teenagers, frequently associated with psychiatric disorders (Fergusson & Woodward, 2011). A nurse at the Ho Municipality Hospital, revealed that, More than 5 pregnant adolescents have committed suicides in the last 2 years due to the unbearable and unfavorable social conditions they find themselves as a result of their pregnancy. 4.4.2. Social Challenges The social challenges faced by pregnant adolescents are grouped as follows: 4.4.2.1 Lack of community and family support Lack of community and family support to pregnant adolescents in the Ho Municipality have social repercussions on their lives. A 14 year old pregnant respondent remarked that, 36 University of Ghana http://ugspace.ug.edu.gh I have to drop-out from school due to my condition and my parents also limited their expenses on me except it has to do with food. I now find it very difficult to meet some necessities aside food. [P.A 17, aged 14] 4.4.2.2 Isolation Most pregnant adolescents are sometimes thrown out from the home and discriminated against by friends and society. This cause them to segregate themselves from the society to void the persistent shame and embarrassment they face. A pregnant respondent aged 13 years identified that, “I now stay with a friend far away from home because I was thrown out by my father after finding out that I was pregnant.” [P.A 6, aged 13] 4.4.2.3 Lack of Support by Partner Lack of support by partners to pregnant adolescents in the Ho Municipality have social repercussions on their lives. A respondent who was aged 14 and pregnant asserted that, I used to say Dodzi was the best thing that ever happened to me. However, after my pregnancy he has become the worst thing that ever happened to me since he was bold enough to deny responsibility for the pregnancy and denied ever knowing me. [P.A 13, aged 14 years] 4.4.2.4 Lack of proper Self-care As revealed from field data, the poor self-care of most pregnant adolescents in the Ho Municipal area find themselves is due to the fact that they are just too young to take care of themselves during pregnancy, coupled with emotional disturbances they experience as older adolescents. 37 University of Ghana http://ugspace.ug.edu.gh 4.4.2.5 Stigmatization and Discrimination Most pregnant adolescent faced stigmatization and discrimination and these have been some of the major predicament which bedevil pregnant adolescents in the Ho Municipal area. As indicated by some respondents including P.A 6, P.A 14, P.A 11, P.A 16 and P.A 9 with ages 13, 15,15,16 and 13, they never live a day now without hearing nicknames they have been given at school and in the community due to their conditions. Some of the names include „Night Rider‟, „Chief Porter,‟ Silent Killer,‟ „Slow Poison‟ and „Marfia One.‟ This names according to them, make them feel so uncomfortable that they are sometimes unable to come out of their rooms, let alone talk about coming to mingle and integrate into society. 4.5 Summary of findings The following findings were made after analyzing the data collected: The majority of pregnant adolescents interviewed were within the ages of 12-15yrs and only few of these adolescents have had tertiary or vocational education. Information obtained from primary data (participants) was complemented by literature from secondary sources to provide a complementary analysis on the topic. Poverty was identified as a major contributor to adolescent pregnancy in the Ho Municipality in the Volta Region of Ghana, followed by single parenting or poor parental control, difficulty or inaccessibility to contraceptives, low or poor sex education and desire to have babies, among others. Also, the acceptability, accessibility and appropriateness of contraceptives were poor among most of the participants interviewed due to cultural and religious reasons. 38 University of Ghana http://ugspace.ug.edu.gh Teenage pregnancy has both psychological and social repercussions for most pregnant adolescents interviewed. The main psychological challenges discussed during interviews in the study included, depression, anxiety, anger and violence, sadness and suicidal tendencies. The main social challenges discussed in the study included the lack of community and family support, lack of support by partners, lack of proper self-care and stigmatization and discrimination. 39 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSIONS 5.1 Introduction The Ghana Health Service Report on Antenatal care registrants for 2016 indicated that 115 pregnancy cases were recorded among teenagers between the ages of 10-14, whilst 5,474 cases occurred among adolescents between 14-19 years, which was an increase from 5,518 and 5,564 adolescent pregnancy cases recorded in 2014 and 2015 respectively, (Citifm, 2017). According to the Report, majority of these adolescent pregnancies were recorded in the Upper East and Volta Regions of Ghana (Citifm online News, 2017). This shows that, the rate of teenage pregnancy in the country is alarming. It is in this vein that this chapter presents discussions on field data or results of research findings as evident in the Ho Municipal area of the Volta Region. The Chapter consists of discussions on the main causes and psychosocial challenges which bedevil adolescent girls in the Ho Municipality. This is done taking into consideration the conceptual framework as proposed in Chapter One. In addition, some Adolescent Pregnancy Prevention Programs which could be relied upon to tackle the alarming adolescent pregnancy in the Ho Municipality were also discussed. 5.2 Main Factors Contributing to Adolescent Pregnancy in the Ho Municipal area in the Volta Region. 5.2.1 Poverty Poverty was identified as the major cause of teenage pregnancy in the Ho Municipality. It was revealed from field data that most of the pregnant participant in the Ho Municipality area come from poor family backgrounds. Some of these adolescents share the same 40 University of Ghana http://ugspace.ug.edu.gh rooms with parents and elderly siblings and become exposed at tender ages to the sexual activities exhibited them. The current economic hardship in the country, coupled with insufficient revenue for people to afford decent and comfortable accommodation has forced most people, especially those with large family sizes to share rooms. This most often than not expose adolescents to sexual tendencies if practiced or discussed in their presence. With this, it could instigate unhealthy relationships which could result in adolescent pregnancies. This is because children who grow up under such circumstances could engage in early sexual activities immediately they reach puberty, hence increasing the tendencies of adolescent pregnancies as evident in the Ho Municipality. As compared to most developed countries, literature exist to show that adolescent pregnancy is pronounced among young people who live in abject poverty and have no hopes of better education or employment opportunities (Newman & Newman, 2017). Therefore, poverty plays a major role in the high rate of teenage pregnancies as evident in the Ho Municipal area. Female adolescents who live and survive under harsh economic conditions or abject poverty may not see the reason not to get pregnant if it brings relief to them. With such kind of adolescent girls, they develop low self-esteem and find attachment to the opposite sex to engage in sexual activity as a sure way of enhancing their confidence in society as revealed by this study. This is supported by the assertion of Viner et al (2012) who observed that over 83% of adolescent who are pregnant are from poor homes. It is therefore not surprising to know the assertion made by the Ghana Health Service Report on Antenatal care registrants for 2016 that Upper East and Volta Regions have the higher rates of adolescent pregnancy in Ghana. This is because these regions are considered part of the poorest in the country. 41 University of Ghana http://ugspace.ug.edu.gh 5.2.2 Adolescent Sexual Behavior Tsebe (2012) reveals that "the sexual behavior exhibited by others to a large extent influences the rate of adolescent pregnancy in the study area. He identifies that the teenager‟s sexual decisions may be influenced by: one is suffering from boredom and wants to be fashionable; one is ignorant of the consequences of sex; one is carried away by passion; one is coerced by one‟s partner and wants to prove one‟s love; one is under pressure and cannot say no; one is under the influence of drugs and alcohol.” Field data suggests that most adolescents in the Ho Municipal area, especially the girls have low control and adequate knowledge about proper sexual behavior and how best to cope or manage it. Adolescent pregnancy can therefore be caused by poor sexual behavior among adolescents as evident in the study area. This arise especially when the adolescent starts rebelling and downgrading religious and parental restraints, especially with regards to their sexuality, the desire for self-gratification or pleasure to escape boredom or loneliness, the disregard to virginity and virtues of chastity in contemporary world, among others. 5.2.3 Age Discrepancy The age difference between female adolescents and their male partners sometimes weaken their abilities to negotiate „No Sex‟ or the use of contraceptives, especially when they are in a relationship as a result of poverty. Consequently, most male adults or youths cajole and coerce female adolescents to having unprotected sex. From field data, most female adolescents in the study area become vulnerable to such requests or pressure which subsequently result in pregnancy. This situation is better elucidated by Johnson (2016). When he asserted that “in the age-differential relationships in which the female is the younger partner, male power and control may undermine the woman‟s ability to negotiate sexual intercourse and the use of contraception. An older partner may not pressure on the 42 University of Ghana http://ugspace.ug.edu.gh adolescents into participating in unprotected sexual activities, basing the encounter on ideas of trust and fidelity.” In contemporary Ghanaian society is becoming increasingly overwhelming that older men tend to develop erotic emotions towards female adolescents. These older men tend to make financial commitments which makes it very difficult for most female adolescents to turn down sex requests from their sponsors or such older men or youths making financial commitments to them. In cases where female adolescents try to decline offers to older men who usually make financial promises to them for sex, it results in abuses or cut-off of financial support to them as evident in the Asamoah Gyan and Kwasi Kyei Darkwah popularly called KKD, scandals which were reported in the media in recent times. These are top public figures who try to take advantage of their financial support to some female adolescent to have sex with them without their consents. The repercussion for these female adolescents is the contracting of Sexually Transmitted Infections (STIs) or becoming pregnant as evident in the Ho Municipal area. Age discrepancy, coupled with the respect for the elderly as a custom in the study area have become major contributor to the alarming adolescent pregnancy in the Municipality. 5.2.4 Childhood environment Females who were exposed to some form of sexual abuse or domestic violence by male adults in their early stages of life are more likely than not to become pregnant as adolescents as compared to those who never experienced such circumstances. This is because, such females are usually at the mercies of the male adults who usually abuse them including satisfying them sexually. This situation has contributed greatly to the alarming rate of adolescent pregnancy in the Ho Municipal area as confirmed by majority of the respondents. Some revealed that they have been one way or the other exposed to 43 University of Ghana http://ugspace.ug.edu.gh sexual abuses in their early stages in life which aggravated their sexual desires till becoming pregnant. This proves that female adolescents in such situation will find it very difficult to abstain from sex or practice safe sex, thereby increasing the tendency for which such female adolescents could become pregnant as confirmed by most of the respondents included in the study. 5.2.5 Drugs and Alcohol The use of drugs and alcohol may lead to impaired judgements when abused. This could cause adolescents to venture into risky behavior such as having unprotected sex. This assertion is supported by Noller, & Callan (2015); they point out that, “the psychoactive effects of alcohol and drugs use are taught to increase sexual arousal and desire, decrease inhibition and senses, diminish decision-making capacity, judgment and sense of responsibility, and generally disempowered women to resist sex.” In the Ho Municipality, some of the pregnant adolescent respondents included in the study revealed that sexual abuses and decreased use of contraceptives which usually resulted in their pregnancies was due to either abuse of alcohol or drugs by male adults or the youths or they themselves. 5.2.6 The Lack of Education on Safe Sex As stated by Buckingham (2013) the lack of education on safe sex, either on the side of the parents or the educators, may lead to teenage pregnancy. Efforts to keep with the current socio-economic status quo in Ghana had made it very difficult for some parents to get time for their children, let alone provide them with peer education including healthy adolescent sexual life and safe sex. Data from the field revealed that most pregnant adolescents in the Ho Municipality have never been educated on adolescent sexual behavior due to parent‟s busy work schedules to pay critical attention to the aspects of their lives or the absence of peer educators to educate to on healthy or decent adolescent 44 University of Ghana http://ugspace.ug.edu.gh sexual behaviors. Consequent to this, most female adolescents are left to their fate to make decisions on their own when faced sexual pressures or harassment from male adults or youth. This mostly result in female adolescents giving inn to sex demands upon pressure or coercion by male adults or youths. This is better explained by Borrero et al (2015) assert that most female adolescents usually dress and act like common prostitutes, when parents ignore attention to their sexual behaviors to provide meaningful and relevant education to them in that regard. As a result, such female adolescents easily kowtow to pressures from male adults which include having unsafe sex, thereby resulting in pregnancy It is pointed by Chirkut (2016) that most adults and parents feel that sex education, even in secondary school is dangerous and premature for impressionable adolescents and is likely to lead to indiscriminate promiscuity. He however concludes based on findings from his studies on adolescent pregnancy that most adolescents would love that sex education provided in formal education is not submerged under other subjects or disciplines such as Biology, but should be a course on its own. This to a very large extent will help minimize the alarming rate of adolescent pregnancy as evident in the Ho Municipality. 5.2.7 Contraceptives Similar to the previous point, most parents and adults feel educating the adolescent about contraception encourages sexual activity. The assumption is that the absence of education on the types and use of contraceptives would prevent sexual activity, thereby reducing immorality and high incidence of adolescent pregnancy. On the contrary, studies show that majority of adolescents are already sexually active due to contemporary media and peer group formation (Kao & Manczak, 2013). Education on the use of contraceptives is supposed to be a birth control measure or family planning to prevent the incidence of unwanted pregnancy. 45 University of Ghana http://ugspace.ug.edu.gh However, the reality in most areas in Ghana including the Ho Municipality is that education and family planning programmes, especially on the use of contraceptives have concentrated on older women at the neglect of adolescents for the fear of not promoting immorality among adolescents. This shows that there is poor cooperation among parents, peer educators, schools, clinics and adolescents on how to prevent unwanted pregnancies through the effective use of contraceptives. To compound this problem, most clinics are not easily accessible to adolescents in the Ho Municipal area; where they can easily visit especially for education on the use of contraceptive. This has created the misconception or notion among most of the adolescents in the Ho Municipality that the clinics and the hospitals in the region are only for adults to access, to later come and impact health education to the younger ones as revealed from field data. Kao & Manczak (2013) assert that most adolescents do not like using contraceptive frequently just because they do not know how to use them or have limited knowledge about their usage. This has contributed significantly to the alarming adolescent pregnancy as witnessed in the Ho Municipality in the Volta Region of Ghana. In addition, most female adolescents in the region feel they could ruin their relationships if they opt for the use of contraceptives against the wish of their partners. The inability of female adolescents to abstain from sex in their relationships, results mostly in unwanted pregnancies among the adolescents in the study area. Field data showed that some female adolescents in the Ho Municipal area are myopic about the dangers of engaging in unprotected sex without the use of contraceptives. Some also feel the use of contraceptives during sex reduces ecstasy, hence the non-use of contraceptives during sex. Also, it was revealed that, most adolescents especially the females have the misconception that the use of contraceptives may have negative or harmful effects on the biological and physical composition. Some of these misconceptions 46 University of Ghana http://ugspace.ug.edu.gh contribute significantly to the non-use of contraceptives with high adolescent pregnancy in the region. According to Chirkut (2016), “generally, young men consider the acquisition of contraceptive supplies and the use of contraceptives to prevent unplanned pregnancies as the responsibility of women.” So, where the ladies fail to do so, such young guys do not make any conscious effort to use them either or encourage their usage. The resultant effect is unwanted pregnancies witnessed in the Ho Municipal area. 5.2.8 Family Structure and its influences on Sexual behavior of adolescents According to Tsebe (2012) “family structural characteristics play a vital role in understanding and determining teenage sexual behavior including pregnancy.” In families where there is no education on healthy reproductive and sexual life by elderly siblings, parents or other relatives to younger ones, adolescent pregnancy is common as compared to a family where such education exist. Most often than not, fathers tend to be strict on their children so are more unlikely to discuss sexual and reproductive life issues with their children. Such strict parenting style is more likely to result in adolescent pregnancy as children would like to hide their feelings and take their own decisions on sexual behaviours which usually end in in pregnancies. Also, parents who have negative conceptions about the use of contraceptive due to religious and cultural reasons are more likely to have children having unsafe sex (Schalet, 2013), hence have high tendencies of resulting in adolescent pregnancy. It is also established from field data that female adolescents who live under single parenting or with their grandparents are likely to become pregnant as compared to those who live with their biological parents. Parental divorce during the early teenage years has also been associated with early onset and increased frequency of sexuality in females. 47 University of Ghana http://ugspace.ug.edu.gh These effects are mainly due to less monitoring and supervision of teenagers which typically occurs in single parent homes. “Teenagers who have older siblings (more especially sisters) who are sexually active or who have had a baby are more likely to begin having sex at a younger age (Killoren & Roach, 2014).” Therefore, a family structure where parents or older siblings and other relatives serve as a role model to younger ones, their sexual behavior are being imitated by the younger ones. 5.2.9 The Influence of the Media on Sexual Behaviour of Adolescents Both print and electronic media has been a great source of socialization in contemporary world. Where the media accessed by adolescents are usually full of sexual themes or imageries, they may turn to influence the thought patterns of younger ones which could instigate negative sexual behaviours including having unprotected sex. This assertion is supported by Vandenbosch & Eggermont (2015) who point out that, “media may function as a strong agent of socialization in putting pressure on teenagers into having sex earlier than expected.” According to Vandenbosch & Eggermont (2013), “contemporary media including televisions, newspapers, internet sites, magazines, advertisements and novels are full of love scenes and imageries.” The media often shows the glitzy aspects of sex in such a manner that teenagers perceive sex as something fashionable to practice. Most teenagers, especially girls, rely greatly on magazines as a vital source of information about sex, birth control and health related issues they ignore the consequences of sex such as unplanned pregnancy and sexually transmitted diseases. Vandenbosch & Eggermont (2013) identifies that “the media portrays sex as something exciting without risk. Heavy doses of television may accentuate teenagers‟ feeling that everyone is having sex except them. Messages from the media often convey the concept that abstinence is outdated. Coupled with the fact that teenagers seldom think of long-term consequences of their behavior, teenagers may engage in sexual behaviours to gain 48 University of Ghana http://ugspace.ug.edu.gh immediate feeling of acceptance and self-worth (Shulman et al, 2012). It is becoming almost indispensable to do away with social media in this technological age and dispensation. Sexual scenes, videos and imageries that flood the phones of adolescents, coupled with opera soap series (telenovela), have higher tendencies of influencing their sexual behaviours. This factor has contributed significantly to early sexual behaviours of adolescents in the Ho Municipal area, hence higher adolescent pregnancies. 5.2.10 Peer Pressure Adolescents most often spend more time with their peers than their parents and siblings. Peers just as the media serve as great force of socialization. As the saying goes, “show me your friend, and I will show you my character.” Parents nowadays work all day long as they focus mainly on making money to fend for the family. By so doing, their children‟s emotional and developmental needs are neglected. “This often leads to children spending more time with their peers and then copying them and older gang members or negative role models in the community (Shepherd et al, 2011).” Therefore, the sexual behaviors uphold and exhibited by one‟s peers have higher tendencies of influencing one‟s sexual behaviour. If an adolescent‟s peers are engaged in negative sexual behaviour or activities, they are likely to corrupt her. In this vein, peers serve as strong agents for transferring sexual signals or knowledge among adolescents. In this regard, peer pressure was also identified as one major force for the alarming incidence of adolescent pregnancy in the Ho Municipal area. 5.2.11 Cultural factors The increasing disregard for traditional cultural values on sexual restraints or control measures among adolescents in contemporary Ghanaian society has also contributed greatly to the prevalence of adolescent pregnancy in the Ho Municipal area. This is because most adolescents of today feel traditional sexual retrains are outmoded and do not 49 University of Ghana http://ugspace.ug.edu.gh have their relevance in contemporary times. This is led to indiscriminate sexual activities among adolescents which usually results in adolescent pregnancies in the Ho Municipality. In addition, cultural settings where maturity and womanhood is based on pregnancy and child birth, early unsafe sexual activities are encouraged, and pregnancies among adolescents are likely to occur as compared to cultural settings where early marriages or sexual activities are prohibited until one gets of age. Cultural factors therefore contributes greatly to the incidence of adolescent pregnancy in the study area. 5.3 The Psychosocial Effects of Adolescent Pregnancy in the Ho Municipal area in the Volta Region of Ghana 5.3.1 Psychological Challenges Many pregnant adolescents in the Ho Municipality in the Volta Region are bedeviled with some psychological challenges. Paramount among them are elaborated below. 5.3.1.1 Depression Adolescent pregnancy has been found to be associated with depressive symptoms. Some experience feelings of hopelessness and low-spiritedness due to their conditions. The assertion by the respondent P.A 11, in the previous Chapter suggests that adolescent pregnancy could destabilize the girl‟s emotional, social and cognitive stability and her self-image towards social and economic aggrandizement in society. 5.3.1.2 Anxiety Studies have shown that pregnant adolescents often experience anxiety (Siegel & Brandon, 2014). Some pregnant adolescents interviewed develop frequent uneasiness and fear of death due to sudden biological changes that take place in the body, coupled with poor treatments they receive from friends, parents, health practitioners, and other relative they might have disappointed. 50 University of Ghana http://ugspace.ug.edu.gh 5.3.1.3 Anger and Violence Many pregnant adolescents in the study area easily become angered or infuriated at the slightest provocation or joke. This has usually resulted in strife and fights which sometimes lead to severe consequences such as miscarriage and deaths. Sometimes, pregnant adolescents usually develop feelings of anger towards herself or her partner. Some of the adolescents get angry with themselves for allowing themselves to be pregnant. Others become angry at their partners for not taking up their responsibilities. These support the assertion made by James et al (2012) that the turmoil experienced by pregnant teenagers are caused by the overwhelming emotions they experience in relation to their pregnancies such as breakdown in relationships with their parents, families and peers. 5.3.1.4 Sadness Evidence from the field suggests that unwanted pregnancy bring unhappiness and sometimes sorrow to adolescent females. Field data supports the assertion made by Amoah (2013) that pregnant adolescents most often weep or become sad when they realize or are told they were pregnant. Some pregnant adolescents in the study area also cry a lot after realizing it will curtailed their enjoyment from all the social and family support they hitherto enjoyed before conception. 5.3.1.5 Suicidal tendencies Researches have shown that suicidal behavior is a relatively common feature in pregnant teenagers, frequently associated with psychiatric disorders (Fergusson & Woodward, 2011). This situation usually occurs when pregnant adolescents realize they are ostracized and mocked for their condition. To cope with their situation, they isolate themselves from others or vice versa, causing loneliness and tendencies for wilder thoughts including suicides as an option to end their predicaments and woes. 51 University of Ghana http://ugspace.ug.edu.gh 5.3.2. Social Challenges The social challenges faced by pregnant adolescents are grouped as follows: 5.3.2.1 Lack of Community and Family Support Adolescent pregnancy in the Ho Municipality usually denies most adolescent girls the community and family support they hitherto enjoyed before conception. Pregnant teenagers experience a change in their relationships with significant others due to expectations that were not met. This disappointment is one of the main factors that instigate suicidal thoughts among such pregnant adolescents. 5.3.2.2 Isolation Most pregnant adolescent are sometimes thrown out from the home and discriminated against by friends and society. This cause them shame and embarrassment. The research findings show that pregnant adolescents experience discrimination and unsolicited comments by the general public regarding their status (Amoah, 2013). Similar studies showed that, even though most of the pregnant adolescents try to talk to somebody, some were scared to tell their parents until their families realized that they are pregnant (Shaffer & Kipp, 2013). 5.3.2.3 Lack of Support by Partner Many adolescent males leave pregnant adolescent in distress and discomfort when they realize they cannot or are not ready to father a child. This lack of support by girls further worsen the woes and plights of the latter. This shows that neglect towards such pregnant adolescents could engender bitterness and hatred towards their partners in situation where they deny responsibility for the pregnancy. This is very common or evident in the Ho Municipality. 52 University of Ghana http://ugspace.ug.edu.gh 5.3.2.4 Lack of proper Self-care Younger pregnant adolescents aged less than 16 years old lack the ability to take care of themselves (Assini-Meytin & Green, 2015). The poor self-care is because they are just too young to take care of themselves and at the same time face similar emotional disturbances as older adolescents. According to Luttrell (2014), “mothering is a topic that has been thoroughly researched within psychology, sociology, social work etc. He further stated that teenagers found mothering to be difficult, be unclear about as to what their children‟s emotional needs are, and have irrational thoughts and feelings. Most teenagers display high levels of parenting stress and are less responsive and sensitive in interaction with their infants than adult mothers. This is caused by the lack parental skills.” Lack of proper care among pregnant adolescents is very common in the Ho Municipality. 5.3.2.5 Stigmatization and Discrimination Pregnant adolescent become stigmatized and discriminated against in societies. This occurs in both the developed and developing countries (Ayuba et al, 2014) compounding this is the fact that apart from being stigmatized by parents and community, the also face stigma and discrimination at school, leading them to leave school prematurely (Assini- Meytin & Green, 2015). This has been one major predicament that bedevil pregnant adolescent in the Ho Municipality in the Volta Region of Ghana. 5.4 Adolescent Pregnancy Prevention Programs in the Ho Municipal Area There are many teenage pregnancy prevention programs throughout the world since teenage pregnancy is an issue that confronts not only a single society but almost all societies of the world. Some of these programs include: The Aban Aya Youth Project (AAYP), designed to reduce risky behaviours such as violence, substance abuse, and unsafe sexual practices; Adult Identity Mentoring (Project AIM), designed to reduce sexual 53 University of Ghana http://ugspace.ug.edu.gh risk behaviours among low-income youth between the ages of 11 and 14 by providing them with the motivation to make safe choices; “All 4 You, designed to reduce the number of students who have unprotected sexual intercourse, which is associated with increased risk of HIV, other sexually transmitted diseases, and unplanned pregnancy;” “Draw the Line/Respect the Line, designed to promote abstinence by providing students with the knowledge and skill to prevent HIV, other STD and pregnancy.” 5.5 Conclusion This chapter presented the discussion of the results presented in the previous Chapter on the main causes and psychosocial challenges which bedeviled adolescent girls in the Ho Municipal area. This was done taking into consideration the conceptual framework as proposed in Chapter One. In addition, some Adolescent Pregnancy Prevention Programs which could be rely upon to tackle the alarming adolescent pregnancy in the Ho Municipal area were also discussed. The next chapter which is the final chapter presents, the conclusion and recommendations. 5.6 Study Limitations  It was difficult getting respondents since some pregnant adolescents in the Ho Municipality were not willing to participate in the study.  It was also a challenge meeting most of the adolescents at the Ho Municipal Hospital within the period of conducting the study since they were scheduled for antenatal services in different months.  Limited time to conduct the study did not allow for impact assessment of psychosocial challenges faced by pregnant adolescents in the Ho Municipality over certain periods to ascertain the changing trends or dynamics. 54 University of Ghana http://ugspace.ug.edu.gh  Financial constraint was one of the challenges faced during gathering of resources to conduct the study. 55 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS 6.1 Introduction This chapter covers the summary of all the findings of this research, the various conclusions drawn from the findings and suggested alternatives and recommendations to help teenagers avoid teenage pregnancy. 6.2 Conclusions  This study revealed that multiple factors contribute to the high levels of adolescent pregnancy in the Ho Municipal area and most pregnant adolescents go through a lot of psychosocial challenges. The results and findings shows that the canker of teenage pregnancy requires a multi-faceted approach at both structural and individual levels to tackle the challenge. Furthermore, poverty and low levels of living conditions in rural areas contributed greatly to high incidence of adolescent pregnancy as observed in the Ho Municipal Area.  On an individual level, although adolescents in the Ho Municipal Area reported having relatively high levels of basic knowledge of how to prevent unplanned adolescent pregnancies, it was evident that this knowledge is often superficial and many girls reported not really knowing how to apply the knowledge and subsequently not using contraceptives. In other words, correct and consistent contraceptive use was low. Furthermore, there were very low levels of knowledge around dual protection and limited understanding of fertility and conception.  While working on strategies to reduce unplanned adolescent pregnancies it is imperative that adolescents who do get pregnant are supported in realizing their right to continue with their education, during pregnancy and following childbirth. 56 University of Ghana http://ugspace.ug.edu.gh 6.3 Recommendations Our focus should be on comprehensive sexuality education, and not merely preventing adolescent pregnancy through a simple reproductive health or family planning lens. Comprehensive sexuality education and training  Ghana Education Service will need to revise its curriculum and enable teachers enhance their knowledge and skills in adolescent sexual health and values clarification sessions. Also, the education system must be revised so that female adolescents will be accepted and allowed to continue their education even when pregnant.  Churches and other religious bodies should educate their members about the effects of adolescent pregnancy and its impacts on children through counseling and also plan for activities that mostly involve marriage couples. These will let them know the long-term benefit of chastity, abstinence and the use of contraceptives.  The Ho Municipal Hospital should designate a day for antenatal services for pregnant adolescents only.  Parents, relatives and friends should not force or push young ladies into early sexual relationship, since it may lead to early pregnancies. Premarital sex is on the ascendency with lots of teenagers giving birth out of wedlock. Hence, there is very important for parents and educators to provide their teenagers with sex education and use of contraceptives. This is because most parents and adults hesitate to provide information about safe sex and contraceptive use because they perceive it to promote promiscuity. Meanwhile, the reality is that many teenagers are already sexually active and without these important information they may end up being pregnant. 57 University of Ghana http://ugspace.ug.edu.gh  Finally, children must always be counselled on how to cope with adolescent pregnancy when it eventually crops up. Assist pregnant adolescents in the Ho Municipal Area with childcare support  The evidence shows that the most critical intervention to assist a teenage mother to return to school following childbirth is providing her with childcare support during the day to enable her to attend school and study. This could be done through: maternal grandmothers, parenting support, increase access to child support grant. Early return following childbirth  Awareness creation to highlight the importance of returning to school quickly following childbirth. And adolescents who deliver must be given the opportunity to continue their education after childbirth. Academic support at school  Returning to school is the first step of continuing one‟s education, the teachers and principals need to recognize the particular experiences and needs of teenage mothers. Teachers need to provide additional support to teenage mothers; if they are absent due to childcare demands they should be provided with support to complete missed work.  Ghana Education Service (GES) should integrate the causes and effects of adolescent pregnancy on the adolescents, or a subject on reproductive and sexual behaviour as part of the syllabus to be studied from the basic level to the senior high to enable children know the gravity of psychosocial effects of adolescent pregnancy on adolescents. 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(2001). Emerging answers: Research findings on programs to reduce teen pregnancy (summary). American Journal of Health Education, 32(6), 348-355. Killoren, S. E., & Roach, A. L. (2014). Sibling conversations about dating and sexuality: Sisters as confidants, sources of support, and mentors. Family relations, 63(2), 232-243. Luttrell, W. (2014). Pregnant bodies, fertile minds: Gender, race, and the schooling of pregnant teens. Routledge. Merikangas, K.R., He, J., Burstein, M., Swanson, S.A., Avenevoli, S., Cui, L., & Swendsen, J. (2010). Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). J. Am. Acad. Child Adol. Psychiatry, 49, 980–989. Merriam, S. B. (2009). Qualitative research: A guide to design and implementation (2nd ed.). San Francis-co, CA: Jossey-Bass. Newman, B. M., & Newman, P. R. (2017). Development through life: A psychosocial approach. Cengage Learning. Noller, P., & Callan, V. (2015). The adolescent in the family. Routledge. Paranjothy, S., Broghton, H., Adapa, R., & Fone, D. (2009). Teenage pregnancy: Who suffers? Arch Dis Child, 94, 239–45. Reyes, J. W. (2015). Lead exposure and behavior: Effects on antisocial and risky behavior among children and adolescents. Economic Inquiry, 53(3), 1580-1605. Schalet. A., T. (2013). Not Under My Roof: Parents, Teens, and the Culture of Sex. University of Chicago Press. Sedgh, G., Finer, L. B., Bankole, A. M., Eilers, A., & Singh, S. (2014). Adolescent pregnancy, birth and abortion rates across Countries: Levels and recent trends. J Adolesc Health, 56(2), 223–30. 61 University of Ghana http://ugspace.ug.edu.gh Shaffer, D. R., & Kipp, K. (2013). Developmental psychology: Childhood and adolescence. Cengage Learning. Shepherd, J. L., Lane, D. J., Tapscott, R. L., & Gentile, D. A. (2011). Susceptible to social influence: Risky “driving” in response to peer pressure. Journal of Applied Social Psychology, 41(4), 773-797. Shields, P., & Rangarjan, N. (2013). A Playbook for Research Methods: Integrating Conceptual Frameworks and Project Management. Stillwater OK: New Forum Press, USA. ISBN 1-58107-247-3. Shulman, S., Zlotnik, A., Shachar-Shapira, L., Connolly, J., & Bohr, Y. (2012). Adolescent daughters‟ romantic competence: The role of divorce, quality of parenting, and maternal romantic history. Journal of youth and adolescence, 41(5), 593-606. Siegel, R.S., & Brandon, A. R. (2014). Adolescents, pregnancy, and mental health. J Pediatr Adolesc Gynecol, 27, 138. Speidel, J. J., Harper, C. C., & Shields, W. C. (2008). The Potential of Long- Acting Reversible Contraception to Decrease Unintended Pregnancy. Contraception, 78(3), 197–200. Stake, R. E. (2005). Qualitative case studies. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook of qualitative research (3rd ed.) (pp. 443-466). Thousand Oaks, CA: Sage. Tsebe, N. L. (2012). Factors contributing to teenage pregnancy as reported by learners at Mpolokang High School in the North-West Province (Doctoral dissertation, University of Limpopo (Medunsa Campus). Vandenbosch, L., & Eggermont, S. (2013). Sexually explicit websites and sexual initiation: Reciprocal relationships and the moderating role of pubertal status. Journal of Research on Adolescence, 23(4), 621-634. Vandenbosch, L., & Eggermont, S. (2015). The role of mass media in adolescents‟ sexual behaviors: Exploring the explanatory value of the three-step self-objectification process. Archives of sexual behavior, 44(3), 729-742. Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. The Lancet, 379(9826), 1641-1652. Wilson-Mitchell, K., Bennett, J., & Stennett, R. (2014). Psychological Health and Life Experiences of Pregnant Adolescent Mothers in Jamaica. Int J Environ Res Public Health, 11(5), 4729–4744. World Health Organization. (2015). Family planning/Contraception: Fact sheet. WHO, Geneva. 62 University of Ghana http://ugspace.ug.edu.gh World Health Organization. (2016). Adolescents: health risks and solutions. WHO, Geneva. Yen, S., & Martin, S. (2013). Contraception for adolescents. Pediatr Ann., 42(2), 21–25. Zanial, Z. (2007). Case study as a research method. Jurnal Kemanusiaan 9, 1–6. 63 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX 1 Participant‟s Consent Form SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA Project Title: PSYCHOSOCIAL CHALLENGES OF PREGNANT ADOLESCENTS IN THE HO MUNICIPALITY OF THE VOLTA REGION. Principal Investigator: EMMANUEL ARHIN, P.O.BOX MA 374, HO. TEL: 0209185742. EMAIL: earhin3@gmail.com General Information about the Study This is a research study being undertaken by Emmanuel Arhin, a student of the School of Public Health, University of Ghana, Legon; in order to explore the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region. Purpose of the Study This research is to explore the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region. Findings from this study will provide a better understanding of the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta Region and help develop informed policy on the appropriate psychosocial interventions. 64 University of Ghana http://ugspace.ug.edu.gh Procedures This is an exploratory facility-based qualitative study using narrative and phenomenological approach. The qualitative method involves In-Depth Interviews (IDIs) of selected pregnant adolescents aged 10-19 years leaving within the Ho Municipality. The participants will be included based on their acceptability, willingness to participate and provide information for this study. The interview will be divided into two sections. The first aspect of the interview will last for 15–30 minutes. Participants will be asked questions related to demographics and risks of adolescent pregnancy. This interview will promote the next interview by creating easiness and develop trust. Part two of the interview will take about 30–60 minutes. Participants will describe their psychosocial challenges as pregnant adolescents based on the main themes psychological challenges with the subthemes: depression, anxiety, violence, sadness, suicidal tendencies, anger, loneliness and social challenges with subthemes: lack of community / family support, isolation, lack of partner support, lack of proper self-care and stigmatization and discrimination. In order to minimize respondent bias and the risk of reactivity, open-ended questions will be arranged to follow the cues from participants. This will enable a full description of the challenges of adolescent pregnancy. All interviews will be recorded using an audio recorder. Notes will also be taken. Both the recording and the notes are to help ensure accuracy of data and to facilitate analysis. The IDIs will be carried out at the Volta Regional and Municipal Hospitals. The interview is expected to last for an average of 30 to 60 minutes. 65 University of Ghana http://ugspace.ug.edu.gh Possible Risk and Discomforts There is no possible risk associated with this study but we anticipate some discomfort during the interview process given the sensitivity of some of the questions. You may feel uncomfortable answering those questions or you may not know the answer to a particular question. You are free to skip any questions you are not comfortable answering. Possible Benefits There is no monetary benefit to the participants of this study. However, the information you will provide will contribute to the overall knowledge about the psychosocial challenges of pregnant adolescents and how to help overcome this challenges will be generated from this study. This information will help us identify the factors associated with the psychosocial challenges of pregnant adolescents within the Ho Municipality of the Volta region and Ghana at large. Voluntary Participation and Right to Refuse Your participation in this study is absolutely voluntary. During the interview, you can choose not to answer any answer any question that you do not want to answer. Additionally, you are at liberty to withdraw from the study or stop the interview at any time. However, we will encourage you to participate and complete the questions since your options are very important in helping us to understand the psychosocial challenges of pregnant adolescents. Confidentiality We would like to assure you that whatever information you provide will be handled with strict confidentiality, it will be used solely for research purpose and will never be used against you. Data analysis will be done at an aggregate level to ensure anonymity. Your 66 University of Ghana http://ugspace.ug.edu.gh name or personally identifying information will not be published in any report. Some members of the research team (principal researcher and research supervisors) may sometimes review the research records, but no unauthorised individual(s) will be able to access the information. Compensation There is no compensation for participants in this study. Contact for Additional Information If you have any questions about the study later, you may contact: (Emmanuel Arhin, Tel: 0209185742, Email:earhin3@gmail.com) Your Right as a Participant If you have any questions about your rights as a research participant, you can contact the Ghana Health Service Ethical Review Committee at the following address: Hannah Frimpong GHS-ERC Administrator GHS-Ethical Review Committee Research and Development Division Ghana Health Service P. O. Box MB 190 Accra-Ghana Office: 233(0)243235225 / 0507041223 Email: Hannah.Frimpong@ghsmail.org 67 University of Ghana http://ugspace.ug.edu.gh VOLUNTARY CONSENT I hereby declare that the above document describing the purpose, procedure as well as risks and benefits of the research titled “Psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region” has been thoroughly explained to me in English/Ewe language. I have been allowed to ask any question about the research which have been answered to my satisfaction. I hereby voluntary agree to participate as a subject in this study. ___________________ _____/______/______ (Participant‟s Signature (Date) Or Thumbprint) If the participant cannot read the form themselves, a witness must sign here. I, __________________________________________________ was present while the purpose, procedures as well as the risks and benefits were read to the participant. All questions were answered and the participant has voluntarily agreed to participate as a subject in this study. ___________________ _____/______/______ (Witness Signature (Date) Or Thumbprint) 68 University of Ghana http://ugspace.ug.edu.gh Parental Consent Form SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA Project Title: PSYCHOSOCIAL CHALLENGES OF PREGNANT ADOLESCENTS IN THE HO MUNICIPALITY OF THE VOLTA REGION. Principal Investigator: EMMANUEL ARHIN, P.O.BOX MA 374, HO. TEL: 0209185742. EMAIL: earhin3@gmail.com General Information about the Study This is a research study being undertaken by Emmanuel Arhin, a student of the School of Public Health, University of Ghana, Legon; in order to explore the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region. Purpose of the Study This research is to explore the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region. Findings from this study will provide a better understanding of the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta Region and help develop informed policy on the appropriate psychosocial interventions. 69 University of Ghana http://ugspace.ug.edu.gh Procedures This is an exploratory facility-based qualitative study using narrative and phenomenological approach. The qualitative method involves In-Depth Interviews (IDIs) of selected pregnant adolescents aged 10-19 years leaving within the Ho Municipality. The participants will be included based on their acceptability, willingness to participate and provide information for this study. The interview will be divided into two sections. The first aspect of the interview will last for 15–30 minutes. Participants will be asked questions related to demographics and risks of adolescent pregnancy. This interview will promote the next interview by creating easiness and develop trust. Part two of the interview will take about 30–60 minutes. Participants will describe their psychosocial challenges as pregnant adolescents based on the main themes psychological challenges with the subthemes: depression, anxiety, violence, sadness, suicidal tendencies, anger, loneliness and social challenges with subthemes: lack of community / family support, isolation, lack of partner support, lack of proper self-care and stigmatization and discrimination. In order to minimize respondent bias and the risk of reactivity, open-ended questions will be arranged to follow the cues from participants. This will enable a full description of the challenges of adolescent pregnancy. All interviews will be recorded using an audio recorder. Notes will also be taken. Both the recording and the notes are to help ensure accuracy of data and to facilitate analysis. The IDIs will be carried out at the Volta Regional and Municipal Hospitals. The interview is expected to last for an average of 30 to 60 minutes. 70 University of Ghana http://ugspace.ug.edu.gh Possible Risk and Discomforts There is no possible risk associated with this study but we anticipate some discomfort during the interview process given the sensitivity of some of the questions. Your daughter may feel uncomfortable answering those questions or she may not know the answer to a particular question. She is free to skip any questions she is not comfortable answering. Possible Benefits There is no monetary benefit to the participants of this study. However, the information she will provide will contribute to the overall knowledge about the psychosocial challenges of pregnant adolescents and how to help overcome this challenges will be generated from this study. This information will help us identify the factors associated with the psychosocial challenges of pregnant adolescents within the Ho Municipality of the Volta region and Ghana at large. Voluntary Participation and Right to Refuse Your daughter‟s participation in this study is absolutely voluntary. During the interview, she can choose not to answer any question that she does not want to answer. Additionally, she is at liberty to withdraw from the study or stop the interview at any time. However, we will encourage her to participate and complete the questions since her options are very important in helping us to understand the psychosocial challenges of pregnant adolescents. Confidentiality We would like to assure you that whatever information your daughter provides will be handled with strict confidentiality, it will be used solely for research purpose and will never be used against her. Data analysis will be done at an aggregate level to ensure 71 University of Ghana http://ugspace.ug.edu.gh anonymity. Her name or personally identifying information will not be published in any report. Some members of the research team (principal researcher and research supervisors) may sometimes review the research records, but no unauthorised individual(s) will be able to access the information. Compensation There is no compensation for participants in this study. Contact for Additional Information If you have any questions about the study later, you may contact: (Emmanuel Arhin, Tel: 0209185742, Email:earhin3@gmail.com) Your Right as a Participant If you have any questions about your rights as a research participant, you can contact the Ghana Health Service Ethical Review Committee at the following address: Hannah Frimpong GHS-ERC Administrator GHS-Ethical Review Committee Research and Development Division Ghana Health Service P. O. Box MB 190 Accra-Ghana Office: 233(0)243235225 / 0507041223 Email: Hannah.Frimpong@ghsmail.org 72 University of Ghana http://ugspace.ug.edu.gh VOLUNTARY CONSENT I hereby declare that the above document describing the purpose, procedure as well as risks and benefits of the research titled “Psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region” has been thoroughly explained to me in English/Ewe language. I have been allowed to ask any question about the research which have been answered to my satisfaction. I hereby voluntary agree that my daughter participates as a subject in this study. ___________________ _____/______/______ (Parent‟s Signature (Date) Or Thumbprint) If the parent cannot read the form themselves, a witness must sign here. I, __________________________________________________ was present while the purpose, procedures as well as the risks and benefits were read to the participant. All questions were answered and the parent has voluntarily agreed that her daughter participates as a subject in this study. ___________________ _____/______/______ (Witness Signature (Date) Or Thumbprint) 73 University of Ghana http://ugspace.ug.edu.gh ASSENT FORM FOR ADOLESCENTS BELOW 18 YEARS SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA Your parent has given permission for you to be in this project study. But first, we want to tell you all about it so you can decide if you want to be in it. If you don‟t understand, please ask questions. You can choose to be in the study, not be in the study or take more time to decide. Project Title: PSYCHOSOCIAL CHALLENGES OF PREGNANT ADOLESCENTS IN THE HO MUNICIPALITY OF THE VOLTA REGION. Principal Investigator: EMMANUEL ARHIN, P.O.BOX MA 374, HO. TEL: 0209185742. EMAIL: earhin3@gmail.com General Information about the Study This is a research study being undertaken by Emmanuel Arhin, a student of the School of Public Health, University of Ghana, Legon; in order to explore the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region. Purpose of the Study This research is to explore the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region. 74 University of Ghana http://ugspace.ug.edu.gh Findings from this study will provide a better understanding of the psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta Region and help develop informed policy on the appropriate psychosocial interventions. Procedures This is an exploratory facility-based qualitative study using narrative and phenomenological approach. The qualitative method involves In-Depth Interviews (IDIs) of selected pregnant adolescents aged 10-19 years leaving within the Ho Municipality. The participants will be included based on their acceptability, willingness to participate and provide information for this study. The interview will be divided into two sections. The first aspect of the interview will last for 15–30 minutes. Participants will be asked questions related to demographics and risks of adolescent pregnancy. This interview will promote the next interview by creating easiness and develop trust. Part two of the interview will take about 30–60 minutes. Participants will describe their psychosocial challenges as pregnant adolescents based on the main themes psychological challenges with the subthemes: depression, anxiety, violence, sadness, suicidal tendencies, anger, loneliness and social challenges with subthemes: lack of community / family support, isolation, lack of partner support, lack of proper self-care and stigmatization and discrimination. In order to minimize respondent bias and the risk of reactivity, open-ended questions will be arranged to follow the cues from participants. This will enable a full description of the challenges of adolescent pregnancy. All interviews will be recorded using an audio recorder. Notes will also be taken. Both the recording and the notes are to help ensure accuracy of data and to facilitate analysis. The IDIs will be carried out at the Volta Regional and Municipal Hospitals. 75 University of Ghana http://ugspace.ug.edu.gh The interview is expected to last for an average of 30 to 60 minutes. Possible Risk and Discomforts There is no possible risk associated with this study but we anticipate some discomfort during the interview process given the sensitivity of some of the questions. You may feel uncomfortable answering those questions or you may not know the answer to a particular question. You are free to skip any questions you are not comfortable answering. Possible Benefits There is no monetary benefit to the participants of this study. However, the information you will provide will contribute to the overall knowledge about the psychosocial challenges of pregnant adolescents and how to help overcome this challenges will be generated from this study. This information will help us identify the factors associated with the psychosocial challenges of pregnant adolescents within the Ho Municipality of the Volta region and Ghana at large. Voluntary Participation and Right to Refuse Your participation in this study is absolutely voluntary. During the interview, you can choose not to answer any answer any question that you do not want to answer. Additionally, you are at liberty to withdraw from the study or stop the interview at any time. However, we will encourage you to participate and complete the questions since your options are very important in helping us to understand the psychosocial challenges of pregnant adolescents. Confidentiality 76 University of Ghana http://ugspace.ug.edu.gh We would like to assure you that whatever information you provide will be handled with strict confidentiality, it will be used solely for research purpose and will never be used against you. Data analysis will be done at an aggregate level to ensure anonymity. Your name or personally identifying information will not be published in any report. Some members of the research team (principal researcher and research supervisors) may sometimes review the research records, but no unauthorised individual(s) will be able to access the information. Compensation There is no compensation for participants in this study. Contact for Additional Information If you have any questions about the study later, you may contact: (Emmanuel Arhin, Tel: 0209185742, Email:earhin3@gmail.com) Your Right as a Participant If you have any questions about your rights as a research participant, you can contact the Ghana Health Service Ethical Review Committee at the following address: Hannah Frimpong GHS-ERC Administrator GHS-Ethical Review Committee Research and Development Division Ghana Health Service P. O. Box MB 190 77 University of Ghana http://ugspace.ug.edu.gh Accra-Ghana Office: 233(0)243235225 / 0507041223 Email: Hannah.Frimpong@ghsmail.org VOLUNTARY CONSENT I hereby declare that the above document describing the purpose, procedure as well as risks and benefits of the research titled “Psychosocial challenges of pregnant adolescents in the Ho Municipality of the Volta region” has been thoroughly explained to me in English/Ewe language. I have been allowed to ask any question about the research which have been answered to my satisfaction. I hereby voluntary agree to participate as a subject in this study. __________________ _____/______/______ (Participant‟s Signature (Date) Or Thumbprint) 78 University of Ghana http://ugspace.ug.edu.gh APPENDIX 2 INTERVIEW GUIDE: Psychosocial challenges of pregnant adolescents in Ho Municipality of the Volta Region (modified from Amoah, 2013) 1. Demographic Background Participants‟ initials Age of participant What are you doing now? How many siblings do you have? Whom are you staying with? How old is you pregnancy? How many children do you have? Which religion do you belong? What is your educational level? SECTION B What circumstances led to this pregnancy? What was your reaction when you were told that you were pregnant? How would you describe your current situation? What has been the most challenging part of your pregnancy? Who has been most helpful? In what ways has he/she been most helpful? Who has been the least helpful? In what ways has he /she been least helpful? What are the attitudes of your family of origin, partner, neighbours, peers, school and health care providers towards you? 79 University of Ghana http://ugspace.ug.edu.gh What is the change in relationship between you and partner since this pregnancy? How has the physical changes of your body affected you? What are the specific changes that have affected you? Who looks after you now? How are your needs met? How would you describe support of your boyfriend and family? How would you describe your health status generally now that you are pregnant? 80