i SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA SCHOOL HEALTH EDUCATION SERVICES AND REPRODUCTIVE HEALTH-SEEKING BEHAVIOUR OF JUNIOR HIGH SCHOOL ADOLESCENT FEMALES IN BAWKU WEST DISTRICT, UPPER EAST REGION BY DOROTHY AAWULENAA (10550820) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2016 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Dorothy Aawulenaa, declare that, this is the result of my independent investigation. I have made acknowledgement where my work is indebted to others. To the best of my knowledge, no previous submission of such research has been made here or elsewhere for the award of a degree. SIGNATURE:…………………………… DATE:………………………… AAWULENAA, DOROTHY (STUDENT) SIGNATURE:……………………………. DATE:………………………… PROF. KWASI TORPEY (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh ii DEDICATION I dedicate this work to my dear husband, Mr. Jacob Zurobire Soung and my children, Abidah Yentorgit Soung and Amiel Saalkayen Soung for their patience and endurance during my many days of absence from home as a result of this work. May the Almighty God guide, protect and bless them abundantly. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEGEMENTS I am most grateful to the Almighty God for his guidance, protection and direction throughout this course. My sincere gratitude goes to my supervisors, Prof. Kwasi Torpey and Dr. Margaret Atuahene for their patience, constructive criticisms and guidance which made this work a reality. I am also grateful to the staff of the School of Public Health, University of Ghana-Legon. To Mr. Abraham B. Mahama of UNICEF, thank you for your professional guidance and proof reading of this document. To my sister Rose P. Aawulenaa and the Aawulenaa Family, thank you for all the support, encouragement and prayers not forgetting my Aunty, Reverend Sr. Mary Rose Lanne of Catholic Education Unit, Tamale for your prayers and support. My sincere appreciation also goes to the Regional and District Directorates of Ghana Health Service and Ghana Education Service of the Upper East Region and Bawku West District respectively. I am indeed indebted to teachers and staff of Tanga and Tarikom Junior High Schools. To Ms. Christiana Azambasi, Sylvian Afina, Juliana Awinba, Mr. Eadbert Ansoba and Mr. Ebenezer Baba Asore, all staff of Bawku West DHA, I am grateful for your gracious support. The list is endless and I can only say that, may the God Almighty bless each and every one of you who contributed in diverse ways towards the success of this work. University of Ghana http://ugspace.ug.edu.gh iv TABLE OF CONTENTS DECLARATION ........................................................................................................... i DEDICATION .............................................................................................................. ii ACKNOWLEGEMENTS ............................................................................................ iii TABLE OF CONTENTS ............................................................................................. iv LIST OF TABLES ..................................................................................................... viii LIST OF FIGURES ..................................................................................................... ix ABSTRACT ...................................................................................................................x LIST OF ABREVIATIONS ........................................................................................ xi CHAPTER ONE ............................................................................................................1 INTRODUCTION .........................................................................................................1 1.0 Background ..........................................................................................................1 1.1 Problem statement ................................................................................................2 1.2 Rationale for the study .........................................................................................5 1.3 Conceptual framework for the study ....................................................................6 1.4 Research questions ...............................................................................................7 1.5 Objectives of the study .........................................................................................7 1.5.1 Main objective ............................................................................................... 7 1.5.2 Specific objectives ......................................................................................... 8 CHAPTER TWO ...........................................................................................................9 LITERATURE REVIEW ..............................................................................................9 2.0 Introduction ..........................................................................................................9 2.1 The Ghana School Health Education Programme..............................................10 2.1.1 Skills-based health education ...................................................................... 10 2.1.2 Disease prevention and control: .................................................................. 11 2.1.3 Food safety and nutrition education ............................................................ 12 2.1.4 Safe and healthy school health environment: .............................................. 13 2.1.5 Implementation constraints.......................................................................... 13 2.1.6 Mode of delivery: ........................................................................................ 13 2.2 Types of sexual and reproductive health information provided by school health education services ....................................................................................................14 University of Ghana http://ugspace.ug.edu.gh v 2.2.1 Scope of school-based sexual and reproductive health intervention in Ghana .............................................................................................................................. 14 2.2.2 Sources of adolescent sexual and reproductive health information ............ 15 2.3 Knowledge level of female adolescents on sexual and reproductive health ......16 2.4 Sexual and reproductive health-seeking behaviour of female adolescents ........17 2.5 Factors that hinder female adolescents from seeking sexual and reproductive health services ..........................................................................................................19 CHAPTER THREE .....................................................................................................21 METHODOLOGY ......................................................................................................21 3.0 Introduction ........................................................................................................21 3.1 Study design .......................................................................................................21 3.2 Study area ...........................................................................................................22 3.3 Themes explored ................................................................................................23 3.4 Sampling.............................................................................................................23 3.4.1 Study population .......................................................................................... 23 3.4.2 Sampling technique ..................................................................................... 23 3.4.3 Research participants ................................................................................... 24 3.5 Access to gatekeepers.........................................................................................25 3.6 Data collection tools and techniques ..................................................................25 3.7 Data quality management ...................................................................................26 3.8 Data processing and analysis..............................................................................26 3.9 Analytical processes of data ...............................................................................27 3. 9.1 Familiarization with data ............................................................................ 27 3.9.2 Initial codes generation ................................................................................ 27 3.9.3 Themes searching ........................................................................................ 27 3.9.4 Reviewing themes........................................................................................ 28 3.9.5 Defining and naming themes ....................................................................... 28 3.9.6 Ethical considerations .................................................................................. 28 3.10 Limitation of the study .....................................................................................29 3.11 Pretesting ..........................................................................................................30 University of Ghana http://ugspace.ug.edu.gh vi CHAPTER FOUR ........................................................................................................31 RESULTS ....................................................................................................................31 4.0 Introduction ........................................................................................................31 4.1 Background characteristics of respondents ........................................................31 4.2 Types of sexual and reproductive health information provided to in-school adolescents during school health services ................................................................32 4.2.1 Types of sexual and reproductive health information ................................. 32 4.2.2 Scope of school health education services .................................................. 33 4.2.3 Sources of adolescents’ sexual and reproductive health information .......... 34 4.3. Knowledge level of adolescents on sexual and reproductive health .................35 4.4 Health-seeking behaviour of adolescents ...........................................................38 4.5 Factors that hinder adolescents from seeking sexual and reproductive health services .....................................................................................................................39 4.5.1 Barriers to adolescent sexual and reproductive health seeking ................... 39 4.5.1.1 Misconception .......................................................................................... 40 4.5.1.2 High cost of reproductive services ........................................................... 40 4.5.1.3 Stigmatization ........................................................................................... 41 4.5.2 Enabling factors ........................................................................................... 42 CHAPTER FIVE .........................................................................................................46 DISCUSSIONS ............................................................................................................46 5.0 Introduction ........................................................................................................46 5.1 Types of Sexual and reproductive health information provided by school health education service ......................................................................................................46 5.1.1 Types of sexual and reproductive health information ................................. 46 5.1.2 Scope of school health education service .................................................... 46 5.1.3 Sources of adolescents’ sexual and reproductive health information .......... 47 5.2 Knowledge level of adolescents on sexual and reproductive health ..................48 5.3 Sexual and reproductive health-seeking behaviour of adolescents ....................49 5.4 Factors that hinder adolescents from seeking sexual and reproductive health services ................................................................................................................. 51 5.4.1 Barriers to adolescent sexual and reproductive health seeking ................... 51 5.4.1.1 Misconception .......................................................................................... 52 5.4.1.2 High cost of sexual and reproductive health services ............................... 52 University of Ghana http://ugspace.ug.edu.gh vii 5.4.1.3 Stigmatization ........................................................................................... 53 5.4.2 Enabling factors ........................................................................................... 54 CHAPTER SIX ............................................................................................................55 CONCLUSIONS AND RECOMMENDATIONS ......................................................55 6.0 Conclusion ..........................................................................................................55 6.1 Recommendations ..............................................................................................56 6.1.1 Recommendations for policy implementers ................................................ 56 6.1.2 Future research recommendations ............................................................... 57 REFERENCES ............................................................................................................58 APPENDICES .............................................................................................................64 Appendix 1: Participants’ information sheet for female junior high school pupils .64 Appendix 1.1: Participant information sheet—community health officers .............67 Appendix 2: Informed consent forms for focus group discussions ..........................70 Appendix 2: Informed consent forms for in-depth interviews .................................71 Appendix 3: Accent form for parents/guardians of adolescents less than 18years ..72 Appendix 4: Focus group discussion guide for Junior High school females ...........73 Appendix 4.1: In-depth interview guide for community health officers..................78 Appendix 5: Ethical approval letter .........................................................................83 Appendix 6: Introductory letters ..............................................................................84 University of Ghana http://ugspace.ug.edu.gh viii LIST OF TABLES Table 1: Characteristics of respondents ............................................................................ 31 University of Ghana http://ugspace.ug.edu.gh ix LIST OF FIGURES Figure 1: Conceptual framework for school health services and sexual and reproductive health-seeking behaviour of JHS female adolescents in Bawku West District ...................................................................................................... 6 University of Ghana http://ugspace.ug.edu.gh x ABSTRACT This study explored the school health education programme and the reproductive health-seeking behaviour of adolescents in selected Junior High Schools in the Bawku West District. It touched on the scope of the school health education programme, knowledge of female students on sexual and reproductive health issues, their health- seeking behaviour and the factors that hinder adolescents from seeking formal health care. The study adopted a qualitative method, using criterion, convenient and purposive sampling approaches to recruit fifty-nine Junior High School females and four community health officers for six focus group discussions (FGDs) and four in-depth interviews (IDIs) respectively. Semi-structured interview guides, a note book and an audio tape recorder were used for the data collection. Thematic analysis of the data was done by coding and categorizing the data into themes for easy interpretation. The findings of the study were that, the School Health Education Programme provides varied health information ranging from personal hygiene to environmental hygiene, through to sexual and reproductive health issues. The result showed that, junior high school females were generally knowledgeable on sexual and reproductive health issues such as menstrual hygiene management, teenage pregnancy, family planning, unsafe abortion practices, signs and symptoms of sexually transmitted infections (STIs) and ways to prevent them. The study also identified stigma, misconception and high cost of services as some of the factors that hinder adolescents from seeking sexual and reproductive health services. The study recommends a strong support and strengthening of policy implementation in professional training on confidentiality, customer care and effective counseling to correct some misconceptions or myths that adolescents have about family planning methods. Gleaning from the study, there is the need for rigorous advocacy on responsible parenting to curb some of the reproductive challenges that adolescents face. The study also recommends future research on the subject matter with out of school adolescents, and with the broader adolescent group of 10-19 years in the same district or a different setting using a mix method. Keywords: Adolescent, school health, sexual and reproductive health, health-seeking behaviour. University of Ghana http://ugspace.ug.edu.gh xi LIST OF ABREVIATIONS ABC: Abstinence, Be faithful, Condom AIDS: Acquired Immuno-deficiency Syndrome ASRH: Adolescent Sexual and Reproductive Health BECE: Basic Education Certificate Examination BWDED: Bawku West District Education Directorate BWDHD: Bawku West District Health Directorate CHO: Community Health Officer DHA: District Health Administration DHMT: District Health Management Team FGDs: Focus Group Discussions GDHS: Ghana Demographic and Health Survey GES: Ghana Education Service GHS: Ghana Health Service GSS: Ghana Statistical Service HIV: Human Immune Virus HPO: Health Promotion Officer IDIs: In-depth Interviews PHC: Population and Housing Census RH: Reproductive Health RHA: Regional Health Administration RHS: Reproductive Health Service SHEP: School Health Education Programme SHS: School Health Services SRH: Sexual and Reproductive Health University of Ghana http://ugspace.ug.edu.gh xii SRHS: Sexual and Reproductive Health Services STDs: Sexually Transmitted Diseases STIs: Sexually Transmitted Infections UER: Upper East Region UHTC: Urban Health Training Center VYA: Very Young Adolescents WHO: World Health Organization University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0 Background Globally, it is estimated that adolescents form about 20% of the world’s population, and that 85% of this 20% live in Sub-Saharan Africa (Abajobir & Seme, 2014). In Ghana, the 2010 Population and Housing Census (PHC) report indicates that, about 38.3% of Ghana’s population is less than 15 years of age, and about 19% of the population of the Upper East region is made up of adolescents (Ghana Statistical Service, 2012). The adolescence stage is generally a challenging stage of life due to the forces and pressures, temptations and trials, and transition from childhood to adulthood. Rondini & Krugu (2009), noted that it is a stage where young people are torn between peers and parents, culture and religion, information and knowledge. The adolescents’ age can be an advantage for positive economic growth in a country. For instance, the Ghana Demographic and Health Survey (2014), report indicates that higher numbers of adolescents can serve as an economic potential for countries like Ghana if the right investments are made in them (Ghana Health Service & Ghana Statistical Service, 2014). In the resource library of Very Young Adolescents (VYA) Alliance, it cautioned however, that this stage, needs special parenting, schooling, planning and implementation of policies and programmes that will either make or unmake the adolescent, help build attitudes, values and behavior which will finally be transferred into the future (Very Young Adolescents, 2015). Available literature indicates that early and unprotected sexual practices by adolescents is a common trend which exposes them to many reproductive health challenges including unplanned teenage pregnancies, school drop outs, unsafe University of Ghana http://ugspace.ug.edu.gh 2 abortion, sexually transmitted infections (STIs) and HIV/AIDS (Tegegn, Yazachew, & Gelaw, 2008). The Ghana Health Service (GHS) and other non-governmental organizations are implementing adolescent friendly reproductive interventions such as antenatal and postnatal services, contraceptive services, voluntary counselling and testing for HIV/AIDS, comprehensive abortion services, School Heath Education Programme (SHEP), regenerative health and nutrition (Bawku West District Health Directorate, 2015). SHEP interventions has four main themes, namely; Skills-based Health Education, Disease Prevention and Control, Nutrition Control and Education and Safe and Healthy School Environment to primary and Junior High School pupils (Ghana Education Service, 2012). The unanswered question is whether these services are being accessed by all adolescents, especially those in junior high schools, and how is it influencing their sexual behaviour. 1.1 Problem statement Promoting adolescents sexual and reproductive health (ASRH) is a major global public health challenge. In their work, Aninanya et al. (2015), reiterated that many countries including Ghana, have pursued various strategies to address these ASRH challenges. According to Mensah & Owusu-Ansah (2014), about 70% of adolescents access SRH information from schools and the media. More so, an evaluation of a SRH intervention by (Geugten, Meijel, Uyl, & Vries, 2015), revealed that schools and private organizations contribute significantly to adolescents’ knowledge on SRH issues, especially HIV and AIDs. This according to the paper is done through the University of Ghana http://ugspace.ug.edu.gh 3 “ABC” strategy and media promotion. While there appears to be in abundance, information on ASRH in general, there is limited information on what is being provided at the basic level on SRH. Also, there is inadequate study on the knowledge level of junior high school female adolescents on SRH issues. Based on the above, the governments of Ghana over the years in their quest to support ASRH, formulated and adopted various policies including the Adolescent Reproductive Health Policy in 2000, the National HIV/AIDS and STIs Policy in 2001, and the School Health Policy in 2012 (Aninanya, Debpuur, Awine, & Williams, 2015). The Ghana Health Service (GHS) over the years embarked on the Adolescent Friendly Health Services’ (AFHSs) initiative to complement the on-going School Health Programme being implemented across the country (Ghana Health Service, 2007). The School Health and Education Programme (SHEP) was established in 1992 as a cost effective investment to improving health and education among in-school adolescents (Ghana Education Service, 2012). The main aim of the programme is to improve the health of adolescents, school personnel, family and other members of the school community. This became necessary following Ghana’s international obligation in its declaration of Education for All and ratification of the Convention on the Rights of the Child (Ghana Education Service, 2012). These aforementioned governmental and institutional interventions are all aimed at ensuring that female adolescent grow responsibly and become a productive person towards economic development in Ghana (National Population Council, 2000). As part of its mandate, the Bawku West District Health Directorate renders school health services to all Primary and Junior High Schools within its catchment areas University of Ghana http://ugspace.ug.edu.gh 4 (Bawku West District Health Directorate, 2015). However, available data from the Bawku West District Health Directorate indicate that teenage pregnancy increased from 15.7% in 2012 to 18.7% in 2014, with family planning uptake among adolescents declining from 8.3% in 2012 to 3.9% in 2014 (Bawku West District Health Directorate, 2015). According to BWDED (2015), voluntary counseling and testing for HIV has also been recording very low patronage among female adolescents over the same period. The District Directorate of Education has reports of a consistent increase in Basic Education Certificate Examination (BECE) candidates getting pregnant on annual basis prior to taking their examinations. In 2012, a total number of 9 girls between the ages of 12-18 years (that is from upper primary to Junior High Form 3) got pregnant, prior to the BECE. The figure rose to 20 in 2013 and to 23 and 29 in 2014 and 2015 respectively. Records show that, there have been extensive researches conducted in other districts on sexual and reproductive health services among the adolescents (Aninanya, et al., 2015). There has been no research on why teenage pregnancy among school going adolescents continuous to increase despite the school health education and other adolescent friendly services (Bawku West District Health Directorate, 2015), and the reasons that account for the low utilization of family planning services among the respondents in the study area. More so, not much has been done in the study area to assess the impact of these services on its beneficiaries regarding knowledge of female adolescents on SRH focusing on Junior High School adolescents (i.e. ages 12-18). To comprehensively address the above gap is the reason for this study. University of Ghana http://ugspace.ug.edu.gh 5 1.2 Rationale for the study The school health education intervention according to its programme document, aims to equip primary and junior high school pupils with basic SRH information in addition to what is already being taught from their curriculum (Ghana Education Service, 2012). This is to enable adolescents practice healthy sexual and reproductive lifestyles. According to a study in Sri Lankan, about 80% of adolescents are sexually active and over 90% of them are involved in risky sexual behaviours such as unprotected sex, multiple sexual partners, (Neelamani, Piercy, Salway, & Samarage, 2015). Teenage pregnancy is also still on the rise with its associated challenges of unsafe abortion and their related complications. According to Aninanya et al. (2015), many studies have been done to evaluate the impact of interventions with reference to adolescent’s SRH but much has not been done to assess the SHEP and how it influences adolescent’s sexual and reproductive health-seeking behavior. As academic document, the researcher employed a qualitative study approach to explore the issue of school health education services offered by GHS, and the reproductive health- seeking behaviour of selected junior high school adolescent girls in the Bawku West district. First, findings from the study will contribute to available literature on adolescent SRH issues in the Bawku West District. Second, the Ministry of Health (MOH) and GHS, and other relevant stakeholders that are into adolescent health issues in the district will find the findings as a useful policy implementation guide on school health, adolescent and reproductive health services. The study will also serve a purpose in the implementation of effective ‘Adolescent Friendly Services’ that will make the University of Ghana http://ugspace.ug.edu.gh 6 desired impact. Finally, the findings from the study will also create room for further research to be conducted on school health and adolescent reproductive health services. 1.3 Conceptual framework for the study Figure 1: Conceptual framework for school health services and sexual and reproductive health-seeking behaviour of JHS female adolescents in Bawku West District (Source: Adapted from Bandura, 1998). The above framework is based on the social cognitive theory, which explains human behavior in terms of a three-way, dynamic, reciprocal model. This model is based on three factors, namely; personal factors, environmental influences, and behavioral factors which continually interact (Bandura, 1998). For the purpose of this study, the researcher adopted two factors (behavioral factors and personal factors) of the social cognitive theory in order to achieve all the objectives of the study. This framework helped the researcher discover the human aspects that can influence school health SHS and SRHS seeking behaviour of JHS female adolescents BEHAVIOURAL FACTORS Health seeking behavior of female adolescents towards SRH PERSONAL FACTORS Knowledge of female adolescents on SRH Types of SRH information provided to female adolescents Factors hindering female from seeking adolescents SRHS University of Ghana http://ugspace.ug.edu.gh 7 services, and the SRH services seeking behavior of JHS female adolescents. The identification of danger and safe periods, family planning use, prevention of teenage pregnancy and safe abortion were considered to be segments of the four characteristics; (i) Types of SRH information provided to female adolescents, (ii) Personal factors (Knowledge of female adolescents on SRH), (iii) Behavioral factors (Health seeking behavior of female adolescents towards SRH), and (iv) Factors hindering female from seeking adolescents’ SRHS. The interconnection is such that the occurrence of one of any of the factors above is influenced by one or more of the other factors in the framework. 1.4 Research questions  What type of SRH information is being provided to in-school adolescent females by the school health education service programme?  What knowledge do in-school adolescent females have on SRH?  What are the current reproductive health-seeking behavior of in-school adolescent females?  What factors hinder in-school adolescents from seeking reproductive health services? 1.5 Objectives of the study 1.5.1 Main objective The study explored school health education services and the reproductive health- seeking behaviour of adolescents in selected Junior High Schools in the Bawku West District of the Upper East region. University of Ghana http://ugspace.ug.edu.gh 8 1.5.2 Specific objectives The study aimed at achieving the following specific objectives: 1. To identify the types of SRH information provided to in-school adolescents during school health services 2. To assess the knowledge level of female adolescents on SRH 3. To identify the current sexual and reproductive health-seeking behaviour of female adolescents 4. To identify the factors that hinder female adolescents from seeking SRH services University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter provides insights into other research works that have been done in relation to adolescent SRH. It touches on all key elements of the issue under study, and provides an in-depth knowledge of what has been done from the Ghanaian perspective on adolescent’s SRH, and the gaps yet to be filled. Adolescence is a stage generally characterized by fear and factors such as early or unwanted pregnancy, unsafe abortion, sexually transmitted diseases including HIV/AIDS, and sexual coercion (Chukwunonye et al., 2015). This therefore means that it is a period when one’s need for SRH information, education and services varies (Lindberg, Lewis-Spruill, & Crownover, 2006). Adolescents face numerous life challenges which impact negatively on their SRH as they grow into adulthood, mainly facilitated by their exposure to incomplete reproductive health information, the fear of being frowned on by society, and the lack of privacy and confidentiality at health facilities (Hagan & Buxton, 2012). Although many other factors are attributed to poor reproductive health seeking-behaviour of adolescents, inadequate school-based interventions has also been noted to contribute significantly to teenage pregnancy and unsafe abortion practices among adolescents (Kanku & Mash, 2010). Although SRH has become an issue of concern to policy makers all over the world, the needs of young people remain poorly understood (Rajapaksa-Hewageegana, Piercy, Salway, & Samarage, 2015). School health education has been found to delay early sex and increase condom use among adolescents (Bilal, Spigt, Dinant, & Blanco, 2015). It has also been found, the University of Ghana http://ugspace.ug.edu.gh 10 access to health education in schools increase adolescents chances of making healthy life choices, and are at lesser risk of contracting HIV (Hallfors et al., 2015). 2.1 The Ghana School Health Education Programme According to the GES (2012), school health education services have been identified as one of the major routes of strengthening health promotion and education activities among adolescents. The SHEP Unit under the Ghana Education Service (GES) is run jointly by the GHS and GES. Ministry of Education (MOE) plays the lead role with the Ministry of Health (MOH) providing the technical support in the implementation process. Target beneficiaries of SHEP are:  Pupils/students and teachers in public and private basic schools, including Pre- school, primary and junior high schools and special schools;  Students and teachers in public and private second cycle institutions;  Students in teacher training colleges;  School community workers. SHEP interventions consist of four main themes, namely; skills-based health education, disease prevention and control, nutrition control and education and safe and healthy school environment. 2.1.1 Skills-based health education This intervention delivers health education to the doorsteps of school children and students in order to equip them with basic life skills for healthy living. Interventions focus on behavioral change approaches and how to sustain the changes (Ministry of Education, 2010). These include both curricular and co-curricular activities and University of Ghana http://ugspace.ug.edu.gh 11 formation of relevant school health committees and clubs such as health and hygiene education through regular school lessons. Others are co-curricular activities such as quizzes, competitions, peer education, health talks, drama, role plays and mass media campaigns, formation and training of School Health Committees, Clubs and Peer Educators (Ministry of Education, 2010). There are also occasional road safety and fire safety education and campaigns in addition to outreach programmes in the communities. These activities and lessons are normally delivered by teachers, community health nurses from GHS and sometimes project staff of NGOs. Aninanya et al. (2015), emphasized that the skills-based health education as an intervention area of SHEP entails the collaboration between GHS and GES to improve knowledge and skill practice of in-school adolescents. The programme encompasses training of teachers on standard SRH curriculum and promotion of co- curricular and extracurricular activities. These trained staff employ in-class participatory teaching, and co-curricular SRH activities such as inter-school competitions and debates, video performances, dramas, and role plays, sports) in their delivery of adolescents SRH lessons (Aninanya, Debpuur, Awine, & Williams, 2015). It also done through SRH teaching and learning in schools. The key objective of the this theme is to provide accurate SRH in-school formation, building life-skills and changing sexual attitudes and behavior (Ministry of Education, 2010). 2.1.2 Disease prevention and control: This component of SHEP is carried out by trained staff of the GHS and sometimes staff of NGOs running intervention programmes in schools. It ensures early detection of diseases, defects and disability in school children for prompt referral and management. It promotes, prevents, cures, rehabilitates and regenerates children University of Ghana http://ugspace.ug.edu.gh 12 health in schools. This is done through regular school assessments and collaborative outreach programmes by screening of pupils and students and other educational workers (Ghana Education Service, 2012). These screening activities include general physical examination, vision testing, hearing, speech and language assessment, oral health and growth monitoring and promotion. It also ensures referral services, First–Aid facilities and treatment of minor ailments like headache, fever and diarrhea within the school premises. Other services rendered include de-worming, immunization against diseases, sensitization programmes on communicable diseases in children, including HIV and AIDS, STI, Tuberculosis, Cholera and other locally endemic diseases, prevention and control of non-communicable diseases, including violence, injury, mental health, substance (alcohol, tobacco, etc.) use and obesity. The effort of this theme is to ensure that preventive mechanisms are put in place to avoid as much as possible such preventable diseases from spreading. 2.1.3 Food safety and nutrition education This component of SHEP intervention focuses on food safety and quality, nutrition education and regular assessment of children’s nutritional status. It is also meant to promote healthy eating habits among school children and their teachers by identifying, training and monitoring of school food vendors to ensure food hygiene and nutrition. This component also ensures monitoring of the Ghana School Feeding Programme (GSFP). The key objective of this theme is to minimize the spread of diseases that arise through unhealthy food. University of Ghana http://ugspace.ug.edu.gh 13 2.1.4 Safe and healthy school health environment: This encompasses all the physical and social structures that promote effective teaching and learning, as well as the health and safety of members of the school community. It is aimed at creating an environment which encourages children to attend and stay in school. It includes the physical structures such as safe water for drinking and hand washing and provision of school latrines. This component of physical structures also makes room for disability friendly and gender sensitive environment. Basically, this theme tries to look at the safe physical environment, safe water and sanitation and healthy psychosocial environment. 2.1.5 Implementation constraints The policy document however revealed that, as a result of resource constraints and local conditions, some schools are unable to deliver all the above outlined services even though they are covered by SHEP and the schools syllabuses. Service delivery therefore varies from district to district and school to school and this is usually determined by the District SHEP Committee. 2.1.6 Mode of delivery: Most sexual and reproductive health topics in schools are delivered in the form of lessons by teachers, project staff of implementation organizations and health staff from the GHS (Geugten et al., 2015). There are lessons with questions and clarification as well as demonstration sessions. These lessons last for about 45-60 minutes once a week and it is meant to be offered to a class of about 25-50 pupils. University of Ghana http://ugspace.ug.edu.gh 14 2.2 Types of sexual and reproductive health information provided by school health education services 2.2.1 Scope of school-based sexual and reproductive health intervention in Ghana School health education has been found to delay early sex, and increase condom use among adolescents (Bilal et al., 2015). The 2014 Ghana Demographic and Health Survey report indicates that, nationally, 14% of adolescents between the ages of 15-19 years begun childbearing or have had a child by age 15 years, with the Upper East region recording 9.7% (Ghana Demographic and Health Survey, 2014). The report also revealed that, heightened sexual activity of adolescents facilitates the acquisition of sexually transmitted infections such as HIV, as they are less knowledgeable when it comes to HIV prevention methods. The report further indicated, knowledge on HIV prevention increases with increase in age, educational level and income status (Ghana Demographic and Health Survey, 2014). School-based reproductive health interventions provide varied SRH information to in- school adolescents in the form of lectures, slide presentations, classroom delivery by teachers, leaflets, and posters (Mason-Jones et al., 2012). These health interventions have been found to be one of the major routes of addressing adolescent SRH challenges, and have contributed significantly to improving knowledge on adolescent reproductive health issues (Capuanoa, Simeone, Serena Giuseppina Scaravillia, & Balbia, 2009). Literature available indicate that school-based comprehensive sex education has proven to delay early sexual intercourse and increases utilization of other reproductive services by adolescents (Awotidebe, Phillips, & Lens, 2014), in addition to impacting positively on the behaviour of adolescents with reference to safe sexual practices and decreased infections of STIs (Aransiola et al., 2013). University of Ghana http://ugspace.ug.edu.gh 15 According to Aninanya et al. (2015), adolescents who are exposed to SRH information double their chances of accessing treatment for STIs and other reproductive ailments such as menstrual disorders. This goes a long way to increasing contraceptive use among adolescents, reduced teenage pregnancy and its complications such us unsafe abortion, maternal and infant mortality. Access to comprehensive sexual and reproductive health information by adolescents in the early stages of their life, builds their self-efficacy in attaining safer sexuality. Adolescents’ SRH education needs to be factored in basic school’s curriculum. This will not only correct the myths and misconceptions surrounding SRH services for adolescents, but also improve health-seeking behaviour (Kotwal, Khan, & Kaul, 2014). 2.2.2 Sources of adolescent sexual and reproductive health information Adolescents have varied sources of accessing SRH information Biddlecom et al. (2006), report that, 6 in every 10 adolescents get their SRH information from the school (Bankole, Biddlecom, Guiella, Singh, & Zulu, 2007). Reports by the World Health Organization (WHO) also indicate that, most adolescents get their SRH information from peers, teachers, school counsellors, and health care providers, whereas others also access their information from the internet (World Health Organisation, 2007b). However, Hessburg, et al. (2007), revealed that adolescents aged 12-14 years prefer to receive SRH information from professionals such as health care providers, teachers, mass media, rather than their parents. The most common source of SRH information for adolescents is however the radio and television (Hessburg et al., 2007). Krugu et al. (2016), confirm that school-based sex education has proven to contribute positively to positive sexual behaviour of adolescent girls such as condom use and University of Ghana http://ugspace.ug.edu.gh 16 pregnancy prevention. They add that parents-adolescent communication also serves as a positive influencing factor (Krugu, Mevissen, Prinsen, & Ruiter, 2016). A study in Ethiopia by Bogale and Seme (2014), reported that early initiation of sexual activity by adolescents was a pre-requisite for unsafe sex. It added that quite a significant number of in-school adolescents are involved in early premarital sexual activities and this was being facilitated by their exposure to pornographic videos and other social media platforms. This early exposure according to the paper increases their risky sexual behaviour such as having multiple sexual relationships, sex under the influence of drugs and practicing of unprotected sex. The paper suggested that health care providers should pay significant attention to school-based SRH services in order to equip in school adolescents to practice safer sex (Bogale & Seme, 2014). 2.3 Knowledge level of female adolescents on sexual and reproductive health Studies show that, adolescents have limited knowledge on SRH issues (Abajobir & Seme, 2014; Adinew, Worku, & Mengesha, 2013; Aktar, Sarker, & Jenkins, 2014). However, other studies report that there is increase awareness of adolescent females on ‘danger periods’ during menstruation and contraceptive use Providing adolescents with knowledge and information on their physical and physiological changes that occur in their bodies help them make informed choices on SRH services (Rao, Lena, Nair, Kamath, & Kamath, 2008). Educated females, it is believed, delay marriage and childbearing. This eventually leads to improved health outcomes and socio-economic growth of both mother and child if the educated woman finally gives birth, thereby reducing the high incidence of maternal and infant mortality. Adolescents have unique health needs, expectations and behaviour which are not being met by many health care services. Literature has revealed that their knowledge University of Ghana http://ugspace.ug.edu.gh 17 on available youth friendly services are poor and hence most adolescent girls resort to friends for help with their problems. Studies have also identified inadequate access to reproductive health knowledge as pre-requisite for poor self-confidence among adolescents (Lindberg et al., 2006). Adolescent girls are gradually taking control of their lives through career goals and aspirations, and hence are very proactive and assertive when it comes to issues about their sexual and reproductive activities. Krugu et al. (2016), points to the fact that if adolescent girls are well informed of other hormonal contraceptives, in addition to the abstinence and condom use as the ways of preventing pregnancy, it will enable them make healthier sexual choices. According to a study by Mawunyo-Akakpo (2008), about a quarter of adolescents aged 10-14 years have ever heard of STIs, and 47% of adolescents knew STIs can be transmitted by having multiple sexual partners. The report further indicates that, about 76% of adolescents have heard of HIV/AIDS. 2.4 Sexual and reproductive health-seeking behaviour of female adolescents According to Yari et al. (2015), adolescents are challenges with different SRH problems which include unwanted pregnancy, unsafe abortion and STIs/STDs. Most of these problems are as a result of poor health seeking behaviour of adolescents which increases their vulnerability to teenage pregnancy and unsafe abortion practices and STIs and HIV (Brown & Guthrie, 2010). An estimated 750,000 adolescents get pregnant every year, 2 out of every 3 adolescents with STIs refuse seeking medical care, and about 50% of sexually active adolescent females have ever had unprotected sex (Aninanya et al., 2015; Hessburg et al., 2007). Cultural and religious beliefs, coupled with personal experiences, have University of Ghana http://ugspace.ug.edu.gh 18 made adolescents have negative perceptions about modern contraceptives (Okereke, 2010). According to Abajobir et al. (2014), about 50.6% of adolescents with reproductive health problems have never thought of seeking formal care, and that 34.4% did not see the need to seek care in the first place. The study also revealed that 24.3% lacked knowledge on formal care for their SRH problems, while 17.4% considered themselves to be healthy and too young to seek care even if they have a problem of the sort. However, it has also been revealed that provision of adolescent friendly services do not necessarily translate to improving health seeking behaviour of adolescents, hence the need for policy makers and programmers to factor in needs assessments before initiating AFHSs in order to know their current interest and preferences (Joshi et al., 2006). Additionally, making available correct and age- appropriate comprehensive sexual and SRH information will enable adolescent girls seek care when faced with a problem. Studies have shown that in order for adolescents to effectively utilize SRH services, information must be comprehensive, varied, non-discriminatory, be provided in a confidential environment and at a low cost (Bender & Fulbright, 2013). Professional training of health care providers on adolescent friendly service provision has been seen to improve service uptake by (Makenzius, Giland Gadin, Tyden, Ulla, & Larssen, 2009). Studies have shown that, though many teachers are in support of incorporating reproductive health into school curriculum, they do not completely support the promotion of contraceptives in schools and are not prepared to render individual counseling to pupils with SRH problems (Aransiola et al., 2013). More so, providing adolescent SRH services with the outmost privacy has been seen to encourage University of Ghana http://ugspace.ug.edu.gh 19 adolescents to utilize SRH services (Adogu, Udigwe, Udigwe, Nwabueze, & Onwasigwe, 2014) 2.5 Factors that hinder female adolescents from seeking sexual and reproductive health services Many adolescents in developing countries, upon their exposure to formal health and social services still prefer to confide in family and friends when faced with sexual and reproductive health problems. A study in Vanuatu reported that, about 12.6% of adolescent girls do not seek formal treatment for reproductive health problems as a result of fear and shame (Joshi et al., 2006). Most adolescents associate modern contraceptives with heavy menstrual flows, excessive weight gain and future infertility (Mitchell, Heumann, Araujo, Adesse, & Halpern, 2014). Other studies also identified the major factors contributing to adverse adolescent reproductive health and behaviour as inadequate parental control and employment, peer pressure and early age of menarche (Gebremichael & Chaka, 2015). Lack of confidentiality and the unfriendly nature of services have also been identified as some of the barriers that prevent accessibility of available services (Bender & Fulbright, 2013). Research has also shown that, inadequate access to appropriate SRH information contribute significantly to poor adolescent reproductive health seeking behaviour. This exposes adolescents to distorted SRH information, which eventually lead them to making uninformed decisions concerning their health (Woog et al., 2015). According to Adogu et al. (2014), many adolescents are aware that protected sexual intercourse decreases one chance of experiencing unplanned pregnancy. They are however challenged with society perceiving them as being promiscuous if they take University of Ghana http://ugspace.ug.edu.gh 20 up preventive measures such as condom use and other contraceptive methods. The same study also indicated that adolescents are also scared of the long term effects of these preventive methods on their fertility. University of Ghana http://ugspace.ug.edu.gh 21 CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter presents an overview of the study area, the methodology employed, study design and procedures for data collection among respondents in the study area. It also includes discussions on data analysis procedures that were adopted, and ethical issues that were considered before and during the study. 3.1 Study design The researcher adopted a cross-sectional study design using a qualitative research approach. This approach is suitable for the study because it is flexible, and enabled respondents to provide detailed information on school health services, information on SRH issues, as well as their health-seeking behaviors which otherwise would have been challenging to capture if a quantitative research approach was employed (Ritchie, Lewis, Nicholls, & Ormston, 2005). Again, using a qualitative research approach was also seen as advantageous in that, it enabled the researcher to focus on a smaller number of respondents who provided useful and detailed information, rather than focusing on a larger number of respondents who would have provided less information (Denzin & Lincoln, 2011). Additionally, qualitative study design was adopted to enable the researcher understand the reasons in-school adolescents, and community health nurses, assign to poor adolescent sexual and reproductive health- seeking behaviours. Studying this problem required the researcher to interact and gather data in a natural setting where the respondents experienced the problem under study (Creswell, 2013). University of Ghana http://ugspace.ug.edu.gh 22 The phenomenological research design is adopted by the researcher to enrich the research findings, since it enabled the researcher to obtain rich and useful information through interactions with respondents in their natural settings (Denzin & Lincoln, 2011) The phenomenological research design was appropriate because it ensured in- depth exploration of issues in relation to the objectives of this study (Mathews & Ross, 2010). 3.2 Study area The Bawku West district is one of the thirteen administrative districts of the Upper East Region of Ghana. It lies roughly between latitudes 100 30’N and 110 10’N, and between longitudes 00 20’E and 00 35’E. The district shares boundaries with Burkina Faso in the North, Bawku Municipality to the East, Talensi and Nabdam Districts to the West and East Mamprusi District to the South (Bawku West District Health Directorare, 2015). According to the 2010 Population and Housing Census, the district has a projected population of 99,813, comprising of 48,967 (49.1%) males and 50,846 (50.9%) females. Expected pregnancy and children (0-11) constituting 3,993 (4%), and Women-in Fertility Age representing 23,955 (24%) of the population. The main referral hospital in the district is the Bawku West District Hospital, located in the Zebilla, the district capital. There are a total of thirty three health facilities manned by various categories of health staff who deliver different range of services from clinical care to public health interventions (Bawku West District Health Directorate, 2015). Two junior high schools namely, Tarikom Junior High School in the Tilli-Widnaba Sub-district, and Tanga Junior High School in the Tanga-Timonde sub-district of the University of Ghana http://ugspace.ug.edu.gh 23 Bawku West district were purposively selected as a result of the high number of teenage pregnancies recorded in these schools over the past three years. 3.3 Themes explored The following major themes and sub-themes were explored by the study:  Types of SRH information provided to adolescents females during SHEP  Knowledge level of female adolescents on SRH  Sexual and reproductive health-seeking behavior of female adolescents  Factors that hinder adolescents from seeking SRH services 3.4 Sampling 3.4.1 Study population Population is generally defined as a group of people with similar characteristics (Polit & Beck, 2010). In the context of this study, population refers to forms 1, 2, and 3 junior high school females aged 12-18 years in public schools. The study population also included community health officers (CHOs) who offered school health services to the selected junior high schools. The researcher considered them suitable for the study because they either benefited from or provided school health services, and as such were able to provide detailed information which enriched the discussions. 3.4.2 Sampling technique Three sampling techniques namely, criterion, purposive and convenient sampling techniques were employed to recruit respondents who were willing to participate voluntarily in the study. Purposive sampling was seen to be an appropriate sampling technique adopted in selecting the CHOs because it allowed respondents to be University of Ghana http://ugspace.ug.edu.gh 24 selected based on their rich knowledge in delivering adolescent health services, and diverse views and perspectives on adolescent SRH issues, as well as SHEP services (Creswell & Clarke, 2007; Bryman, 2012). The researcher also found criterion sampling technique suitable for recruiting the junior high school female adolescents because it allowed for conscious selection of respondents from the target population who met the inclusion criteria for the study (Polit & Beck, 2010). Convenient sampling was employed in selecting the female pupils in each class. This was as a resulted of all classes coincidentally having a maximum of 12 female pupils or less, hence making all female pupils in these class potential participants. The inclusion criteria was the applied to recruit the respondents in each class. Inclusion criteria The inclusion criteria was that a participant must be a female pupil of a public junior high school, and enrolled in the selected school for the past three or more months, must be aged 12-18 years. Also, their parents who must assent to her participation in the study if she is less than 18 years. 3.4.3 Research participants Only female pupils who met the selection criteria participated in the study. Two facilities who serve the selected schools were also selected. Two CHOs were selected from each facility and engaged in in-depth interviews (IDIs) conducted by the researcher. . One in-depth interview was held with each of the Community Health Officers. Only respondents who showed voluntary interest in consenting to take part University of Ghana http://ugspace.ug.edu.gh 25 in the study, and agreed to be audio-recorded were approached and recruited by the researcher A total of 63 respondents participated in the study comprising of 59 junior high school females and 4 CHOs. One FGD was held with 8 to 12 pupils from each class making a total of 6 FGDs. The minimum number of respondents who participated in a FGD was 8 and the maximum was 12. Two CHOs were selected from each facility. Each of the CHOs participated in a face- to-face In-depth interviews conducted by the researcher. 3.5 Access to gatekeepers The researcher collaborated with the head teachers of the schools, and the District Director of Health Services who acted as gatekeepers in the selected junior high schools and health facilities respectively in the district. These gatekeepers fostered cooperation and mutual trust between the researcher and study respondents. Headmasters of the two schools served as gatekeepers in the research as they supported the researcher to get access to respondents for the study. 3.6 Data collection tools and techniques A semi-structured in-depth interview guide, and a FGD guide developed in English were used for the data collection. The semi-structured interview guide contained open-ended questions and discussion points which allowed respondents to speak freely to questions that came up during face-to-face interactions with the researcher. The semi-structured IDI (see Appendix 4) was used to conduct face-to-face IDIs with CHOs on a one-on-one face-to-face basis, while the FGD guide (see Appendix 4) used during discussions with female pupils. University of Ghana http://ugspace.ug.edu.gh 26 One and a half hour training was organized by the researcher for the research assistant recruited to assist with the data collection. The training provided detailed instructions and opportunity for practice sessions using the data collections tools. All the interviews were tape-recorded after the consent of each respondents was sought. Detailed field notes were also taken to help in the triangulation of data gathered from interviews and group discussions. The arrangements for data collection were done by the researcher and respondents in relation to time, venue and date for FDGs and IDIs. 3.7 Data quality management Data collection was carried out at safe, secure and conducive venues which allowed respondents to interact freely. Additionally, less noisy environments were selected to conduct FGDs and IDIs in order to obtain clear audio-tape recordings of interviews and discussions. All tape recordings were kept confidential and in pass worded folders on the researcher’s computer, in line with the processes and procedures of the University of Ghana. 3.8 Data processing and analysis Data gathered from the FGDs and IDIs were transcribed verbatim by playing tape recordings and typing out the interviews in ‘Microsoft Office Word’ document template. The transcribed data were then subjected to thematic analysis using the five steps proposed by Braun and Clarke (2006). Thematic analysis was suitable for the data generated from the study because it provided clear and easy to understand guidelines pertaining to the analysis of qualitative data. It helped the researcher University of Ghana http://ugspace.ug.edu.gh 27 describe data, formulate and find close relationships between the data generated (Mathews & Ross, 2010; (Braun & Clarke, 2006). 3.9 Analytical processes of data The five-steps to thematic analysis was used to analyze data. These steps are described below. 3. 9.1 Familiarization with data The researcher read through respondents’ transcribed data over and over again as well as her field notes in order to relate the transcribed data to the aim and objectives of the study. This repeated reading was also meant to ensure that she is familiar with the data. Audio tapes were also replayed severally to ensure that what has been recorded is what has been typed out in Microsoft word. 3.9.2 Initial codes generation The researcher used phrases and keywords to identify key features of the data that were related to the research questions and objectives to generate codes from the transcribed data. In generating the initial codes, the researcher used different font colours to highlight keywords and features in the transcribed data that were important in the code formulation. 3.9.3 Themes searching The researcher then grouped similar codes using the data extracts which highlighted interesting local expressions into sub-themes to form potential themes. University of Ghana http://ugspace.ug.edu.gh 28 3.9.4 Reviewing themes In this step, the researcher reviewed the themes developed to ensure that they did not fall under other themes by overlapping, or there was enough data to support them in relation to the research objectives. 3.9.5 Defining and naming themes In defining and renaming the themes, the researcher determined the nature of each theme and what it was about, which data in the transcripts best explained the generated themes and reviewed them as such. These were then used by the researcher to describe the research findings in the form of a story. 3.9.6 Ethical considerations Ethical clearance for the study was obtained from the Ghana Health Service Ethical Clearance Committee (see Appendix 5) through the School of Public Health, University of Ghana. Letters of introduction (see Appendix 6) were obtained from the University of Ghana, Regional Directorates of Health and Education Service and Bawku West District Directorate of Education. These introductory letters enabled the researcher to provide information on the study to the related departments which enabled her got access to respondents. Aside the letters of introduction, the researcher had face-to-face interactions with head teachers in the selected schools, and discussed the tools and processes that were to be followed to collect data. Prior to the commencement of IDIs and FGDs, information about the study was communicated through verbal means to each participant. Additionally, respondents University of Ghana http://ugspace.ug.edu.gh 29 received verbal explanations on the details of the informed consent form (see appendix 2), and a hard paper copy to enable each participant decide whether to voluntarily take part in the study. Also information on their right to withdraw at any time they wish to. Furthermore, verbal explanations and hard paper copies of assent forms (see appendix 3) were given to the parents of pupils who agreed to participate in the FGDs, to give their permission for their wards to take part in the study. Preceding every discussion or interview session, the researcher did a verbal explanation on the essence of the study to respondents and provided respondents a printed copy of participants’ information sheet (see Appendix 1) and informed consent form. The researcher explained to respondent(s) the details in the forms, solicited their voluntary participation and pledged to ensure confidentiality and anonymity of any information they will provide. 3.10 Limitation of the study This study encountered a number of limitations, one of which involved financial cost. Hence the study could not cover many of schools to present a more holistic view of the story. The researcher initially proposed to tell the story of early female adolescents aged 12- 15 years on SRH issues because according to the Ghana educational system at age 15 years, one should complete or about to complete Junior High School. This was however not possible since most of the pupils were above the proposed age range. The researcher therefore widened the age range to 18 years in order to increase the number of respondents. University of Ghana http://ugspace.ug.edu.gh 30 3.11 Pretesting Pretesting in research is generally done to assess the feasibility of the study, test the data capturing tools and techniques, and make adjustments as and when necessary for the actual study (Polit & Beck 2010). Based on these, the researcher conduced a pre- tested study in a nearby sub-district in Yelwoko junior high school using respondents who met the inclusion criteria. This pre-testing was made of one in-depth interview and one focus group discussion. The pre- however enabled the researcher identify challenges with data collection tools and processes, and the necessary changes effected before the actual study (Polit & Beck 2010). University of Ghana http://ugspace.ug.edu.gh 31 CHAPTER FOUR RESULTS 4.0 Introduction This chapter presents the research findings from the field work that was carried out by the researcher. The chapter presents the results (obtained from the thematic analysis of interviews and discussions data). The results reflected the four main research objectives; types of SRH information provided to in-school adolescents during school health services, knowledge level of female adolescents on SRH, sexual and reproductive health-seeking behaviour of female adolescents and factors that hinder female adolescents from seeking SRH services. 4.1 Background characteristics of respondents Table 1: Characteristics of respondents Name of school/facility Form No. of respondents Age/(yrs) respondents No. CHOs Tanga JHS 1 12 13-16 2 2 9 14-15 3 7 14-16 Tarikom JHS 1 12 15-17 2 2 11 15-17 3 8 18 The minimum age of the respondents for the FGDs was 13 years while the maximum was 18 years with the least number of participants in each form for the FGD being seven and the maximum number being twelve. University of Ghana http://ugspace.ug.edu.gh 32 4.2 Types of sexual and reproductive health information provided to in-school adolescents during school health services Respondents mentioned three types of SRH information provided to in-school adolescents during school health services, hence the researcher sub –categorized this objective as types of SRH information, scope of SHEP services and sources of adolescents’ SRH information. 4.2.1 Types of sexual and reproductive health information Respondents mentioned menstrual hygiene, family planning, teenage pregnancy and abortion as some of the SRH information provided by the school health programme. “They advised us to use condom during sex and that we should come for the family planning” (FGD, a 17 year form 3 girl.) “That we should avoid living in filthy areas, we should live a hygienic life” (FGD, an 18 year form 3 girl.) “They taught us how to protect ourselves from pregnancies e.g. family planning methods such as needle injection” (FGD, a 15 year form 3 girl.) “They advise us to concentrate on our school rather than indulging in sex” (FGD, a 14 year form 3 girl.) “They advised us to abstain from sex, however if know that we cannot abstain, we should come for family planning because if we become pregnant we cannot continue with our education” (FGD, a 16 year form 2 girl.) “They told us to wear pads during our menses that we should bath at least three times a day during our menses.” (FGD, a 15 year form 2 girl.) University of Ghana http://ugspace.ug.edu.gh 33 4.2.2 Scope of school health education services Respondents also indicated that, the scope of reproductive health information provided by the school health education programme was wide and that they have other sources of getting these information. The findings revealed that the SHEP as an intervention provides varied SRH information to school pupils including aspects of personal hygiene. ” We give health education, we educate them on important health topics and after that we do screening so that if we get any abnormality, we will refer the person.” (IDI, Female CHO) “The nurses taught us how to control ourselves from sex, that we should make family planning, we should use condom, that we should avoid sex.” (FGD, an 18 year form 3 girl.) “They told us that if we want to continue with our education well, we should protect ourselves from pregnancy by taking family planning, however they cautioned us not to involve in sex any how after taking the family planning” (FGD, a 16 year form 2 girl.) “They advised us not to have sex with many boys. They teach us how to protect ourselves from pregnancies e.g. family planning methods such as needle injection.” (FGD, a 16 year form 1 girl.) “we give the health education, we educate them on how to take care of themselves during menstruation, and then how to take care of themselves not to become pregnant… we also educate them to practice family planning so that or to abstain so that they will not get any STIs….” (IDI, Female CHO) University of Ghana http://ugspace.ug.edu.gh 34 As to what determines the topic for discussions during a visit, respondents stated that it is either deduced from interpretation of the monthly data on adolescent health services rendered for the month, or based on the request of the teachers if there is a pertinent issue bothering the pupils. It also came out that, the conditions brought by adolescents to the health facility also influenced the topic for discussions. Teachers were also said to make requests for specific topics, based on their observations. “Sometimes we go and inform the headmaster of an emerging health issue that we will want to alert the students on.” (IDI, Female CHO). “Their complaints, what the adolescent will tell you when she visits the clinic will determine what you will discuss during school health.” (IDI, Female CHO). Prior notice, according to the findings, is normally given to teachers to pre-inform pupils before the team visits a school. Sessions are done in the form of lectures and are normally ended with open fora. Respondents indicated that a session normally last for a minimum of 30 minutes and a maximum of one hour. According to the respondents, subsequent visit dates are announced to both pupils and teachers before a session ends. More so, pupils with special needs are normally requested to come to the facility for individual attention and counseling. 4.2.3 Sources of adolescents’ sexual and reproductive health information Touching on where adolescents get information concerning their SRH, most respondents mentioned that major sources of information were from health workers, parents, teachers, television, radios and friends. However, CHOs indicated that they get their adolescent SRH information from reading books, trainings from workshops, and news from television. University of Ghana http://ugspace.ug.edu.gh 35 “I sometimes read books and then when we go for workshops or training.” (IDI, Female CHO). “Our friends too give us information” (FGD, a 17 year form 3 girl.) “We get our health information from the nurses and our teachers.” (FGD, a 17 year form 2 girl) “We also get information from the television and radio.” (FGD, a 13 year form 1 girl.) “We get our family planning and menses information from the nurses and our school health teachers.” (FGD, a 16 year form 1 girl) “Besides the fact that I was trained in school on those issues, I equally go online…, I have my books with me, I glance through, and sometimes too we have our immediate authorities which is the DHA, our health information officers are there, and the authorities are also there, so they explain it further to me”. (IDI, Male CHO). 4.3. Knowledge level of adolescents on sexual and reproductive health Most respondents explained that SRH has to do with STIs/STDs, pregnancy, family planning, menstruation and abortion. “It is about how to prevent ourselves from getting teenage pregnancies and sexually transmitted diseases.” (FGD, 17 year form 3 girl). “It is about how to prevent ourselves from sexually transmitted diseases.” (FGD, 13 year form 1 girl). University of Ghana http://ugspace.ug.edu.gh 36 “It is health aspects that concerns about adolescents which include abortion, menstruation, pregnancy, and those things.” (IDI, Female CHO). This was confirmed when most respondents mentioned the different types of STIs/STDs, their signs and symptoms, and how to prevent themselves from getting these diseases. “STIs are a lot, like HIV and gonorrhea, Hepatitis B and then this candidiasis”. (IDI, Female CHO.) “Examples of STIs are gonorrhea, Syphilis, candidiasis, HIV/AIDS, ‘whites.”(FGD, 16 year form 1 girl) Respondents mentioned loss of weight and appetite, headache, smell from the private part, sensative itching of the vagina and general weakness as some of the signs and symptoms of STIs. “For HIV, the person will grow lean, lose appetite and will not be strong.” (FGD, 13 year form 1 girl). “Itching in the ‘private part and also bad odour from the private part” (FGD, 14 year form 1 girl) “You will see white water coming from the vagina.” (FGD, 18 year form 3 girl). “Itching of the body or the vagina and the white fluid coming from the vagina, then sometimes pains.” (IDI, A female CHO) “Gonorrhea, that one too you will experience pains when you are urinating, and then you will be urinating frequently.” (IDI, A female CHO. University of Ghana http://ugspace.ug.edu.gh 37 Respondents stated that the use of condom, avoidance of multiply relationships and abstaining from sex were some of the ways one can prevent him or herself from getting STIs on . “Using condoms and also prevent yourself from having oral sex” (FGD, 17 year form 2 girl). “If you want to marry, just marry, don’t have many boys. If you want to have one boy, ei! a boy, take one boy” (FGD, 16 year form 3 girl) “they should abstain from sex or they should use the family planning like may be condom, or they should be educated on how to take care when they are having sex that is the education on family planning,.” (IDI, A female CHO). Some respondents were however not able to describe the signs and symptoms of Syphilis and Hepatitis B, even though they listed them as some of the STDs/STIs. “Madam I don’t understand the word syphilis” (FGD, 17 year form 3 girl). They were however very articulate when it came to signs and symptoms of HIV/AIDS and candidiasis (popularly known as ‘whites’). Touching on menstruation, respondents explained menstruation to be the monthly flow of blood through the vagina. On what period one can get pregnant, respondents mentioned that during menstruation and ovulation. “Ovulation, is the period during which a woman can become pregnant” (FGD, 18 year form 2 girl). Exploring respondents’ understanding of family planning, they mentioned methods such as injectable, condom, pills and the loop as the most popular contraceptives available. Respondents could also describe the signs and symptoms of pregnancy and University of Ghana http://ugspace.ug.edu.gh 38 the associated risks of unsafe abortion. They mentioned weight gain, heavy breast, pimples on the face, sudden weight lost, paleness and sudden withdrawal from public activities as some of the signs and symptoms of pregnancy and unsafe abortion. “The eyes will become white, breast will become big, stomach become big, and you will have pimples around your face.” (FGD, 15 year form 1 girl) “Sometimes when someone is pregnant the person becomes fat but when the person aborts she begins to lose weight.” (FGD, 17 year form 3 girl). 4.4 Health-seeking behaviour of adolescents When asked what they do when faced with a SRH problem like menstrual pain or pregnancy, most respondents indicated that they discussed with their parents, friends, elder sisters, nurses and school health teachers if she is a female. Others, on the contrary, said they would resort to an abortion with reference to the pregnancy. “When they come and we test, like we listen to their complaints and test if positive we advise the person or refer the person to the hospital for further investigation.” (IDI, A female CHO) Although some indicated that they go to the hospital to seek for abortion services, others were also of the view that most of them resort to various crude means of getting rid of unwanted pregnancies through drinking of grounded broken bottles, herbs, consumption of Guinness alcoholic drink mixed with sugar, and buying drugs from the pharmacy. It was realized that although respondents knew the adverse effects of unsafe abortion practices such as death and infertility, they were quick to justify their actions with aspirations and educational and career goals, and dropping out of school being reasons why they would resort to abortions. University of Ghana http://ugspace.ug.edu.gh 39 “Emmm.., we have to give them health education for them to know more about pregnancies, and when they become pregnant the consequences they will get, so we tell them that they will dropout from school, then they won’t get any job to do, they won’t get care, their parent cannot take good care of them.” (IDI, A female CHO). 4.5 Factors that hinder adolescents from seeking sexual and reproductive health services The findings revealed that, factors that hinder adolescents from seeking formal care for their sexual and reproductive health problems can be broadly categorized into three major headings namely high cost of SRH services, misconception about some ASRH services like family planning and stigmatization. The researcher therefore sub-categorized this objective as barriers to adolescent SRH and facilitating factors. 4.5.1 Barriers to adolescent sexual and reproductive health seeking Respondents mentioned issues of misconception about the side effects of family planning, ignorance, high cost of family planning and abortion services, unprofessional attitude of health staff and stigma attached to adolescents who use family planning as some of the barriers that prevent them from seeking formal care even when they are confronted with a SRH problem. These factors are discussed in detail below. University of Ghana http://ugspace.ug.edu.gh 40 4.5.1.1 Misconception According to respondents, most of them refuse to access family planning services as a result of the side effects it poses. Respondents indicated that family planning can lead to future infertility, unhealthy weight gain or weight loss. “The drugs can affect you because if you take the drugs you will feel like you are sick. If you do the family planning after sometime you will not be able to become pregnant again).” (FGD, 16 form 2 girl). “Some people will grow lean whiles others grow fat when they take the family planning drugs.” (FGD, 14 year form 2 girl). “Some people always say that if you go for that drug, you may not give birth again.” (FGD, 15yr form 2 girl) “Because the robber always cover the surface of the penis and they will enjoy but they will not enjoy to their satisfaction.” (FGD, 14 year form 2 girl) When asked the source of these information about family planning, they indicated that they were experiences shared by their friends, sisters and mothers and hence that is what deters them from accessing family planning services. 4.5.1.2 High cost of reproductive services Respondents indicated that adolescents resort to other routes of seeking care as a result of high cost of family planning devices and other reproductive services such abortion services. According to them, it was expensive to do abortion at the hospital and cheaper to get abortion drugs in the drug stores or pharmacies as well as other concoctions used to carry out unsafe abortion at homes. University of Ghana http://ugspace.ug.edu.gh 41 “Those who cause abortion at home complain that they do not have money to go to the hospital to do it and it is not covered by insurance, they should make the service free.” (FGD, 14 year form 1 girl). “Ei! the injection is GH₵5.00 and you cannot tell you mother or father to give you GH₵5.00 for injection, she will insult and even beat you.” (FGD, 15 year form 3 girl). “We do not have money to do family planning that is why we don’t do it.” (FGD, 14 year form 1 girl). 4.5.1.3 Stigmatization The fear of being perceived by the community and even health staff of being a “bad girl” when you are seen accessing or using family planning services is what also deter respondents from seeking such services. They also added that, the utterances of some health workers also push them away from seeking formal services. “Because we feel shy to go and tell them that we want family planning and if we go there and our friends are there they will say we are coming to make family planning.” (FGD, 18 year form 2 girl) “Ei! Madam! If the grown-ups know that you have taking family planning or you even buy condom, they will say you are just sleeping around and they will be talking about you.” (FGD, 18 year form 2 girl) “If they know that you have caused abortion, they will be talking about you everywhere, so we hide to do it” (FGD, 17 year form 1 girl) “If the person goes to the clinic to do it and hears the information outside the community sometimes, it causes sickness.” (IDI, A female CHO). University of Ghana http://ugspace.ug.edu.gh 42 “Sometimes it is ignorance and some too they feel shy to come and ask, they don’t want you to know their problem.” (IDI, A female CHO). “It’s the behaviour of the health worker. Like the way you will approach the person, the way you will talk to the person and the education you will give to them. If she knows that you can help her, she will continue to come.” (IDI, A female CHO) On staff attitude, respondents in the focus group discussions stressed that staff interrogate them too much which makes them uncomfortable to visit the health facility. Other concerns raised were issues of confidentiality since some facilities were too small and all clients who visit the facility were lumped together to render services. “Some nurses too will ask you a lot of question. They will be asking questions like, are married and you want to have sex?” (FGD, 15 year form 1 girl). “The problem is that, they do it openly, no privacy and they ask a lot of questions.” (FGD, 18 year form 2 girl). 4.5.2 Enabling factors Respondents mentioned some of the factors that influence them to share and seek formal care with their SRH in problems as trust, experience and professionalism. “You go to the hospital for some treatment because they are trained in such areas.” (FGD, 15 year form 2 girl) “They come to us, some of them come to us or some of them their boyfriends will come and discuss the problem with us.” (IDI, A female CHO) University of Ghana http://ugspace.ug.edu.gh 43 “They know that we know much about it, then we can give them solution, we can help them, because we are health providers, and because we go there to educate them and we tell them that if they have any problem they should come to us that is why they come.” (IDI, A female CHO). Responses from respondents however revealed that, adolescents’ SRH issues can be addressed at both the school and health facility level. Respondents also suggested some lead facilitators of the improvement process as both teachers and health staff as well as their parents. Details of these responses are outlined below. Respondents mentioned that improving on issues of confidentiality and provision of comprehensive SRH information, and education on available services would make a difference in the service uptake. “Nurses need to be talked to not to tell other people what we discuss with them in private.” (FGD, 16 year form 1 girl). “Some of us if we go to clinic to do the family planning and someone hears or sees he or she would be going about disgracing you, that’s why we do not want to go.” (IDI, A female CHO). “If we form adolescent school so that we get some days and fix like the way they come for pregnancy school, we will get them to access the services.” (IDI, A female CHO) “We need to also educate their parents for some don’t mind their children, they don’t even care about what they are doing. If their parents can also help.” (IDI, A female CHO) “They should reduce the money for abortion because it is too expensive. They should make it free for students/pupils” (FGD, 18 year form 3 girl) University of Ghana http://ugspace.ug.edu.gh 44 “They should let some of our community members render the service so as to make things easier for us” (FGD, 13 year form 1 girl) Respondents also indicated that availability of a resident staff can facilitate their access to the services since they will go at their own convenient time without anybody seeing them. “The nurses do not stay at the facility, as such we are not able to use the services because when we go there during the day, the elderly women condemn you.” (FGD, 15 year form 1 girl) “The government should extend electricity to the clinic so that the nurses can stay and render family planning service for us the pupils at night.” (FGD, 16 year form 1 girl) At the school level, respondents advocated for the strengthening of School Health Clubs and individual counseling by the school health teachers. “We will educate ourselves through our school health clubs” (FGD, 15 year form 3 girl) “Start with the authorities of the school; the head master is there, ranging down to the teachers before it gets to the students. So before we even make the students understand how important adolescent health is, we might want to let the masters understand why it is important to the students.” (IDI, Male CHO) “Our teachers and nurses should be advising us all the time.” (FGD, 17 year form 3 girl) University of Ghana http://ugspace.ug.edu.gh 45 “The teachers to talk to our parents to provide our needs so that we stop following boys.” (FGD, 18 year form 2 girl) Respondents mentioned that teachers and the health professionals should lead the process in improving adolescents’ access to SRH services. “They have to teach us how to prevent the STIs, pregnancy and how to do family planning.” (FGD, 18 year form 3 girl) A few however added that, parents should be more responsible by providing the basic needs of their adolescent females in order to prevent them from facing some of these problems. “We need to also educate their parents since some don’t mind their children, they don’t even care about what they are doing. If their parents can also help.” (IDI) “Yes, so at the facility level, I have always said it, let’s change our attitude as health staff. If we are able to change our attitude, not judge people, give them what we are supposed to give them, I think it will go a long way to help. But when they come in, we dampen their spirit, judge them and discourage them or demotivate them from coming to purchase or even to ask questions. Then it will not help us.” (IDI, Male CHO) University of Ghana http://ugspace.ug.edu.gh 46 CHAPTER FIVE DISCUSSIONS 5.0 Introduction This chapter presents a detailed discussion of the research findings in the previous chapter. It draws implication and inferences from other works that have been done on the subject matter. 5.1 Types of Sexual and reproductive health information provided by school health education service 5.1.1 Types of sexual and reproductive health information The results indicate that the school health education programme provides pupils with information on family planning, menstrual hygiene practices, teenage pregnancy prevention, family planning methods available, counseling and education. These findings confirm the findings of a similar study by Mason-Jones et al. (2012), which reported that school-based interventions have been found to provide variety of SRH information to adolescents. 5.1.2 Scope of school health education service What scope the school health education programme? The findings of this study revealed that the programme provides varied information to pupils, ranging from personal hygiene to environmental hygiene. More so, the results indicated that topical issues for discussion during school health education sessions are either influenced by emerging health threats, a request by teachers or an observation made by health staff during their monthly data analysis. Other influencing factors are commonly identified University of Ghana http://ugspace.ug.edu.gh 47 conditions reported by adolescents to health facilities and also issues of concern raised by parents of adolescents. This backs the call by Joshi, et al. (2006), for policy makers and programmers to factor in needs assessments before initiating adolescent-friendly services in order to know adolescents current interest and preferences. The school health programme also screen and refer pupils to the appropriate levels for treatment of management. 5.1.3 Sources of adolescents’ sexual and reproductive health information Hessburg, et al. (2007), revealed that adolescents aged 12-14 years prefer to receive SRH information from health care providers, teachers, and mass media, rather than their parents. This was confirmed by respondents of the study who indicated that apart from what their teachers and the nurses provide, television, radios, friends, movies were other sources of getting information on SRH. This findings is similar to that of Hessburg et al. (2007), where they reported that, the most common source of SRH information for adolescents is the radio and television. A report by WHO also backs the findings of this study by indicating that, most adolescents get their SRH information from peers, teachers, school counsellors and health care provider’s (World Health Organization, 2008). CHOs who deliver the school health education programme indicated that, they get their information on adolescent SRH from reading of books, trainings from workshops and news from television as well as emerging issues from the internet. University of Ghana http://ugspace.ug.edu.gh 48 5.2 Knowledge level of adolescents on sexual and reproductive health The findings indicate that most respondents generally have some knowledge on what SRH is all about. Respondents from the FGDs described SRH as something that has to do with pregnancy and STIs/STDs prevention, while others added that it also includes issues about abortion, menstruation and women hygiene. This was thus a clear indication that respondents knew what SRH is. This finding confirms that of Hessburg, et al. (2007), which indicate there was an increase in awareness of adolescent females on ‘danger periods’ during menstruation and contraceptive use. With regards to the different types of STIs/STDs, respondents mentioned gonorrhea, syphilis and candidiasis as some of the STIs/STDs, a confirmation of Mawunyo- Akakpo (2008), who stated that about a quarter of adolescents have ever heard of STIs, and that 47% of adolescents knew STIs can be transmitted by having multiple sexual partners and that about 76% of adolescents have heard of HIV/AIDS. On the signs and symptoms of each of the listed STIs, respondents outlined each one as; HIV/AIDS- loss of weight and appetite, persistent cough, diarrhea and skin rashes. Signs and symptoms of candidiasis according to the respondents included the following; itching of the private part, painful sensation, white discharge from the vagina and bad odour. That of gonorrhea was described as frequent urinating and pain when urinating. It was realized from the discussions that although participants were able to mention syphilis and hepatitis B as being sexually transmitted diseases, they could not state their signs and symptoms. This may be due to the inadequate descriptions of these diseases in the educational curriculum as well as during school health education University of Ghana http://ugspace.ug.edu.gh 49 sessions at the junior high school level. Also reproductive health education has been minimal at the lower levels of the educational ladder in Ghana. Touching on how to prevent these diseases, respondents were unanimous in advocating for abstinence, condom use, avoidance of multiple sexual partners or relationships. On the issue of menstruation, respondents explained menstruation to be the monthly flow of blood through the vagina and ovulation to be the release of the egg. A few of the respondents knew that one can get pregnant during ovulation and menstruation. This is a clear gap that needs to be filled in the sense that even though they have the information, it was not complete to protect them as stated by Rao, et al. (2008), that providing adolescents with knowledge and information on their physical and physiological changes that occur in their bodies help them to make informed choices on SRH services. Exploring respondents understanding on family planning, they mentioned methods such as injectable, condom, pills and the loop as the most popular contraceptives available. They were however quick to add that it is not easy for them to access family planning services due to stigma, cost of services and misconception surrounding adolescents use of contraceptives. 5.3 Sexual and reproductive health-seeking behaviour of adolescents Poor health seeking behaviour of adolescents does not only make them vulnerable to teenage pregnancy and unsafe abortion practices but also increase their risk of STDs of which HIV is not an exception (Brown & Guthrie, 2010). Responses from respondents indicated that, female adolescents knew the measures to take to prevent University of Ghana http://ugspace.ug.edu.gh 50 them from encountering some of the SRH challenges that they face. For instance, respondents know that, having unprotected sex increases one’s risk of teenage pregnancy, having multiple sexual partners also increases one’s risk of being infected with STIs. These findings were however contrary to what Abajobir, et al. (2014), revealed that about 24.3% adolescents lacked knowledge on formal care for their SRH. This contradiction could be attributed to the large sample size of 415 employed in their study, compared to the 63 study respondents in this study. More so, it was also indicated in the findings, that respondents did not see the need to take up any measure of protecting themselves from these SRH challenges which was consistent with Abajobir, et al. (2014), that 34.4% of adolescents do not see the need to seek care with their problems. They argued that this was as a result of stigma as stated by Kennedy, et al. (2013) that about 12.6% of adolescent girls do not seek formal treatment for reproductive health problems as a result of fear and shame. Additionally, respondents indicated unnecessary interrogation by health staff and high cost of family planning devices as some of the reasons why they do not seek formal care and this confirms what Okereke (2010), revealed that personal experiences, have made adolescents to have negative perceptions about modern contraceptives (Okereke, 2010). It became clear from the discussions that female adolescents were more comfortable discussing their reproductive health problems with their parents (mothers), friends, elder sisters, nurses and school health teachers if she is a female and this attest to (World Health Organisation, 2007a), observation that adolescent access their SRH information from peers and school counselors. University of Ghana http://ugspace.ug.edu.gh 51 Although some indicated that they go to the hospital to seek solutions for their health problems such as abortion services, others were also of the view that most of them resort to various crude means of getting rid of unwanted pregnancies. Some of which were mentioned as drinking of grounded broken bottles, herbs, consumption of Guinness mixed with sugar and buying of drugs from pharmacy. These findings are similar to what Adogu et al. (2014), revealed in his study that adolescents resort to taking concoctions to prevent unwanted pregnancies. It was also realized that, even though respondents knew the adverse effects of unsafe abortion practices which they mentioned to include death and infertility they were however quick to justify their actions with aspirations and educational goals career and dropping out of school. 5.4 Factors that hinder adolescents from seeking sexual and reproductive health services 5.4.1 Barriers to adolescent sexual and reproductive health seeking The findings revealed that adolescents know where to seek help when they have SRH problems. They are however deterred by the high cost of some of the services, myths and misconceptions about family planning and the stigma society attached to adolescents who seek for SRH services such as family planning and abortion. University of Ghana http://ugspace.ug.edu.gh 52 5.4.1.1 Misconception Misconception on the side effects of contraceptives especially with reference to future infertility came out as a major barrier to adolescent’s taking up family planning methods during the discussions. The respondents said these were experiences shared by people and hence they find it difficult to also try it. This is in agreement with Okereke (2010), study which found that cultural and religious beliefs, coupled with personal experiences, have made adolescents to have negative perceptions about modern contraceptives. Another study by Chauhan et al. (2015), also revealed similar findings that the use of contraceptives leads to womb destruction. Similar studies also revealed that most adolescents associate contraceptives to excessive weight gain and weight loss, heavy menstrual flow and future bareness (Adogu et al., 2014). These revelations therefore calls for improving on providing comprehensive sexual and reproduction health information to in-school adolescents especially with reference to the various contraceptive devices. This will disabuse the perceptions they have surrounding family planning services. 5.4.1.2 High cost of sexual and reproductive health services Respondents mentioned issues of cost of family planning products and abortion services as a barrier that prevent them from seeking formal care when they are confronted with a problem. This attest to the findings by Biddlecom et al. (2006), and Gebremichael & Chaka (2015), which identified factors contributing to adverse adolescent reproductive health and behaviour to peer pressure, early age at menarche, and lack of parental guidance with reference to SRH issues. University of Ghana http://ugspace.ug.edu.gh 53 This is an indication that, if SRH services such as family planning and abortion services are rendered free, it will improve adolescents’ uptake. 5.4.1.3 Stigmatization It was evident from the discussions that confidentiality and comprehensiveness of information were issues of concern to adolescents regarding matters concerning their SRH. They added that, lack of privacy at health facilities, unprofessional attitude of health staff who “leak” their secrets and also society’s perception of them being promiscuous were some of the reasons why they do not seek formal care. These findings confirms Bender & Fulbright (2013), which identified lack of confidentiality and the unfriendly nature of service providers as barriers to adolescents access to SRH services. Additionally, adolescents also expressed the fear of being mocked by friends and also being seen as school dropouts, hence the reasons for involving unsafe abortion practices. This also attest to the findings by Chauhan et al. (2015), that 12.6% of adolescent girls do not seek formal treatment for reproductive health problems as a result of fear and shame. It is therefore suggested that health professionals should intensify community sensitization to raise awareness in communities on the benefits of adolescents seeking SRH services. Community-based health facilities should also market their adolescent friendly services within their catchment areas. University of Ghana http://ugspace.ug.edu.gh 54 5.4.2 Enabling factors Respondents mentioned factors that influence their health-seeking preferences as trust in the professional competence of the person delivering the service and also the person’s ability to keep what they share with him or her confidential. Partners of female adolescents also serve as facilitators when it comes to seeking reproductive health services. On where and why they seek help from particular places and people when they have SRH problems, participants mentioned experience and professionalism as some of the factors that motivate them to share their problems. According to respondents they confide in some particular people when faced with SRH problems because those people are knowledgeable and also because they trust them. They stressed that interventions should ensure that their ‘secrets’ are not shared with their parents or the community in order to improve their health seeking behaviour. This may be due to the stigma attached to adolescents seeking reproductive health services. Respondents also indicated that availability of a resident staff will facilitate their access to the services since it will enable them access services at their convenient time. At the school level, respondents advocated for the strengthening of School Health Clubs and individual counseling by the school health teachers. Participants during the discussions were unanimous that teachers and health professionals should lead the process in improving adolescents’ access to SRH services. A few however added that parents should be more responsible by providing the basic needs of their adolescent females in order to prevent them from facing some of these problems. University of Ghana http://ugspace.ug.edu.gh 55 CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS 6.0 Conclusion This chapter summarizes major findings of the study, issues of concern that emerged from the study and proposes recommendations for improving the school health education programme and future research. The study set out to identify the type of SRH information that the SHEP is providing to junior high school females, their knowledge and understanding of these information and its influence their health-seeking behaviour. The study also wanted to find out the factors that hinder adolescents from seeking formal care for their SRH problems. Findings of the study revealed that, the SHEP provides adolescents with basic information on teenage pregnancy prevention, family planning services available, causes, signs and symptoms of STIs/STDs and how to prevent themselves from infections. Respondents had general knowledge on basic sexual and reproductive issues such as teenage pregnancy and STIs prevention and their respective signs and symptoms. It also identified stigma, misconception and high cost of services as some of the factors that hinder adolescents’ access to reproductive health services. It however came out from the findings that SHEP package did not make room for individual counseling since service sessions were generally short, that is 30 minutes to one hour and its one class per session visit. This therefore does not create opportunity for consultation and counseling. Pupils are therefore referred to health facilities for counseling as and when the need be. University of Ghana http://ugspace.ug.edu.gh 56 The results also indicated that most respondents have the desire to abandon some of the risky behaviours they are involved in but are uncertain of confidentiality, stigma and future implications especially when it comes to family planning services. On ways to improve SRH of adolescents, respondents called for professional training on confidentiality and also intensive public education on the SRH issues. There is also the need for separate facilities for adolescent services to ensure the privacy that they desire. In conclusion, these views expressed by just a limited number of respondents reflects their opinions and experiences with regards to adolescent SRH. It is therefore recommended future research should be carried out with broader adolescent group of 10-19years in the same district or a different setting to assess their knowledge on SRH issues and how the knowledge influence their health seeking-behaviour. 6.1 Recommendations Based on the findings of the study and the conclusions, the following recommendations are made; 6.1.1 Recommendations for policy implementers  Ministry of Health and Ghana Health Service should fast track the implementation of the AFHSs initiative in all facilities at all levels to ensure that adolescents get the privacy that they so desired. This will motivate them to access the services available to them thereby, averting the negative consequences associated with their SRH problems University of Ghana http://ugspace.ug.edu.gh 57  Ghana Health Service should carry out regular training of its staff on adolescent health issues and counseling. It should also supervise staff effectively to ensure they render confidential adolescent health services.  It is also recommended that vigorous public education on the benefits of parent- ward communication on SRH issues since respondents indicated that they confine in their parents when they are faced with a SRH problem. There is also the need for regular training for school health teachers so that they can be abreast with emerging issues on adolescent health.  Service providers should also carry out advocacy at all levels, that is community, media and national level to change public perception about adolescents who seek SRH services 6.1.2 Future research recommendations  This study had a limited scope as it was conducted in only two schools and therefore makes it difficult to generalize the findings. Hence the need for future studies in many schools to widen the scope and use of both qualitative and quantitative approaches. 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Protecting the Next Generation: New Evidence on Adolescent Sexual and Reproductive Health Needs. Joshi, B. N., Chauhan, S. L., Donde, U. M., Tryambake, V. H., Gaikwad, N. S., & Bhadoria, V. (2006). Reproductive health problems and help seeking behavior among adolescents in urban India. The Indian Journal of Pediatrics, 73(6), 509– 513. http://doi.org/10.1007/BF02759896 Kanku, J., & Mash, B. (2010). Attitudes, perceptions and understanding amongst teenagers regarding teenage pregnancy, sexuality and contraception in Taung. South African Family Practice, 52(6), 563–572. http://doi.org/10.1080/20786204.2010.10874048 Kotwal, N., Khan, N., & Kaul, S. (2014). Knowledge of reproductive health among adolescent school girls of Jammu district. Health Science International Journal of Research in Health, (2), 563–569. Krugu, J. K., Mevissen, F. E. F., Prinsen, A., & Ruiter, R. A. C. (2016). Who ’ s that girl ? A qualitative analysis of adolescent girls ’ views on factors associated with teenage pregnancies in Bolgatanga , Ghana. Reproductive Health, 13(39), 1–12. http://doi.org/10.1186/s12978-016-0161-9 Lindberg, C., Lewis-Spruill, C., & Crownover, R. (2006). Barriers to Sexual and Reproductive Health Care: Urban Male Adolescents Speak Out. Issues in Comprehensive Pediatric Nursing, 29(2), 73–88. http://doi.org/10.1080/01460860600677577 Makenzius, M., Giland Gadin, K., Tyden, T., Ulla, R., & Larssen, M. (2009). Male students’ behaviour, knowledge, attitudes, and needs in sexual and reproductive health matters. The European Journal of Contraception & Reproductive Health Care, 14(4). http://doi.org/10.1080/1325180903015871 Mason-Jones, A. J., Crisp, C., Momberg, M., Koech, J., De Koker, P., & Mathews, C. (2012). A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health. Systematic Reviews, 1(1), 49. http://doi.org/10.1186/2046-4053-1-49 Mathews, B., & Ross, L. (2010). Research Methods: Practical guide for Social sciences. London: Pearson Education Ltd. Mensah, Oforiwaa Harrient, Owusu-Ansah, S. (2014). Assessment Of Communication Messages Used In Adolescent Reproductive Health Education, 4(8), 81–93. Ministry of Education. (2010). TEACHING SYLLABUS FOR SOCIAL STUDIES (SENIOR HIGH SCHOOL 1 - 3). Mitchell, E. M. H., Heumann, S., Araujo, A., Adesse, L., & Halpern, C. T. (2014). Brazilian adolescents’ knowledge and beliefs about abortion methods: a school- University of Ghana http://ugspace.ug.edu.gh 62 based internet inquiry. BMC Women’s Health, 14(1), 27. http://doi.org/10.1186/1472-6874-14-27 National Population Council. (2000). ADOLESCENT REPRODUCTIVE HEALTH POLICY. Neelamani, R.-H., Piercy, H., Salway, S., & Samarage, S. (2015). Sexual and reproductive knowledge , attitudes and behaviours in a school going population of Sri Lankan adolescents. Okereke, C. I. (2010). Unmet reproductive health needs and health-seeking behaviour of adolescents in Owerri, Nigeria. African Journal of Reproductive Health, 14(1), 43–54. http://doi.org/10.2307/25766338 Polit, D., & Beck, C. (2010). Essentials of Nursing Practice: Appraising Evidence for Nursing Practice (7th Editio). Philadelphia: Lippincott William and Wilkins. Rajapaksa-Hewageegana, N., Piercy, H., Salway, S., & Samarage, S. (2015). Sexual and reproductive knowledge, attitudes and behaviours in a school going population of Sri Lankan adolescents. Sexual & Reproductive Healthcare, 6(1), 3–8. http://doi.org/10.1016/j.srhc.2014.08.001 Rao, R. S. P., Lena, a, Nair, N. S., Kamath, V., & Kamath, a. (2008). Effectiveness of reproductive health education among rural adolescent girls: a school based intervention study in Udupi Taluk, Karnataka. Indian Journal of Medical Sciences, 62(11), 439–443. http://doi.org/10.4103/0019-5359.48455 Ritchie, J., Lewis, J., Nicholls, C. M., & Ormston, R. (2005). Qualitative Research Practice. London: Sage Publications. Tegegn, A., Yazachew, M., & Gelaw, Y. (2008). Reproductive Health Knowledge and Attitude among Adolescents : A community based study in Jimma Town , Southwest Ethiopia. Ethiop. J. Health Dev., 22(3), 243–251. Very Young Aadolescents. (2015). Very Young Adolescent ( VYA ) Sexual and Reproductive Health Resource Library. Woog, V., Singh, S., Browne, A., Philbin, J., Woog, V., Singh, S., … Philbin, J. (2015). Adolescent Women ’ s Need for and Use of Sexual and Reproductive Health Services in Developing Countries. World Health Organisation. (2007a). Adolesecnt Friendly Health Services-Agenda for change. World Health Organisation. (2007b). Unsafe Abortion: Global And Regional Estimates Of Incidence Of Unsafe Abortion Associated Mortality In 2003 (5th Editio). Geneva: WHO. University of Ghana http://ugspace.ug.edu.gh 63 World Health Organization. (2008). Preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries: what the evidence says. University of Ghana http://ugspace.ug.edu.gh 64 APPENDICES Appendix 1: Participants’ information sheet for female junior high school pupils Research topic: School health services and reproductive health-seeking behavior of Junior High School female adolescents in Bawku West District I am Dorothy Aawulenaa, a student pursuing a Master of Public Health degree at the University of Ghana, Legon. This document aims to provide you with information about a research I intend to carry out. Your decision to participate will be voluntary. If your questions have been answered to your satisfaction, and you decide to participate in this research, you will be asked to sign a consent form. If you consent, you will be interviewed about your school health services and reproductive health services available to you. Purpose of the study The study seeks to explore school health services and the reproductive health-seeking behaviour of female adolescents in selected Junior High Schools in the Bawku West District of the Upper East region. The objectives of the research are: 1. To identify the types of sexual and reproductive health information provided to in-school adolescents during school health services 2. To assess knowledge level of female adolescents on sexual and reproductive health services 3. To identify the current sexual and reproductive health-seeking behaviour of female adolescents University of Ghana http://ugspace.ug.edu.gh 65 4. To identify the factors that hinder female adolescents from seeking sexual and reproductive health services The findings of the research will be of great value in exploring school health services and female adolescent health seeking behaviour among Junior High School pupils in the Bawku West district. The results will further contribute to the completion of my master’s degree. Research Procedures The study will involve Junior High School girls aged 12-15 years of age who are willing to participate with informed consent. A tape recorder will be available during the interview session, but will only be used if the participants agree. Between 6-12 participants from Forms 1, 2 and 3 will be selected to participate in focus group discussions. Time required The participants will be requested to spare 45 minutes – 1 hour for the focus group discussions with the researcher. Risks and discomfort The study will involve minimal risks to the participants. Interviews and all information will be kept confidential. Benefits There will be no direct benefits to individuals who will participate in the study. However, there will be an overall benefit of the research because the findings will University of Ghana http://ugspace.ug.edu.gh 66 give us more information on how school health services and adolescent reproductive health seeking behaviour could be enhanced. Confidentiality The researcher will ensure that confidentiality is kept. The data record form used to transcribe information from the respondents will have codes instead of names of the respondents. All data will be stored in a locker, and will be locked and it will be accessible only to the researcher and my supervisor. Participation and withdrawal Your participation is entirely voluntary. Your refusal to participate will not affect you or your school. Even if you consent to be part of the study, you have the right to withdraw at any time up to the analysis of the data. You could therefore withdraw up to two weeks after the interview. Questions about the study If you have questions or concerns even after completion of the study, please contact: Researcher: Aawulenaa Dorothy (daawulenaa@st.ug.edu.gh) Supervisor: Supervisor: Dr. Margaret Atuahene, PHD (magat2006@yahoo.com). University of Ghana http://ugspace.ug.edu.gh 67 Appendix 1.1: Participant information sheet—community health officers Research topic: School health services and reproductive health-seeking behavior of Junior High School female adolescents in Bawku West District I am Dorothy Aawulenaa, a student pursuing a Master of Public Health degree at the University of Ghana, Legon. This document aims to provide you with information about a research I intend to carry out. Your decision to participate will be voluntary. If your questions have been answered to your satisfaction, and you decide to participate in this research, you will be asked to sign a consent form. If you consent, you will be interviewed about the school health services and reproductive health services you provide to Junior High Schools in your catchment area. Purpose of the study The study seeks to explore school health services and the reproductive health-seeking behaviour of female adolescents in selected Junior High Schools in the Bawku West District of the Upper East region. The objectives of the research are: 1. To identify the types of sexual and reproductive health information provided to in-school adolescents during school health services 2. To assess knowledge level of female adolescents on sexual and reproductive health services 3. To identify the current sexual and reproductive health-seeking behaviour of female adolescents 4. To identify the factors that hinder female adolescents from seeking sexual and reproductive health services University of Ghana http://ugspace.ug.edu.gh 68 The findings of the research will be of great value in exploring school health services and female adolescent health seeking behaviour among Junior High School pupils in the Bawku West district. The results will further contribute to the completion of my master’s degree. Research Procedures The study will involve Community Health Nurses who provide school health services and are willing to participate with informed consent. A tape recorder will be available during the interview session, but will only be used if the respondent agrees. These will be one-on-one with the researcher. Time required The participants will be requested to spare 30 – 45 minutes for the in-depth interviews with the researcher. Risks and discomfort The study will involve minimal risks to the participants. Interviews and all information will be kept confidential. Benefits There will be no direct benefits to individuals who will participate in the study. However, there will be an overall benefit of the research because the findings will give us more information on how school health services and adolescent reproductive health seeking behaviour could be enhanced. University of Ghana http://ugspace.ug.edu.gh 69 Confidentiality The researcher will ensure that confidentiality is kept. The data record form used to transcribe information from the respondents will have codes instead of names of the respondents. All data will be stored in a locker, and will be locked and it will be accessible only to the researcher and my supervisor. Participation and withdrawal Your participation is entirely voluntary. Your refusal to participate will not affect you or the health facility where you work. Even if you consent to be part of the study, you have the right to withdraw at any time up to the analysis of the data. You could therefore withdraw up to two weeks after the interview. Questions about the study If you have questions or concerns even after completion of the study, please contact: Researcher: Aawulenaa Dorothy (daawulenaa@st.ug.edu.gh). Supervisor: Dr. Margaret Atuahene, PHD (magat2006@yahoo.com). University of Ghana http://ugspace.ug.edu.gh 70 Appendix 2: Informed consent forms for focus group discussions Research topic: School health services and reproductive health-seeking behavior of Junior High School female adolescents in Bawku West District [Instruction: Please tick () if eligible and consenting] I have read the participant information sheet and this consent form, and I understand what is being requested of me. I understand that I may withdraw from this study without giving a reason, and I can request my data not to be included if I wish, up until the date given for analysis of the data. My questions concerning this study have been answered to my satisfaction. I freely consent and accept that the researcher can access my information. I have been provided a copy of this form. My parents have assented to my participation in this study I give consent to be part of the research. I give consent to be audio-taped during the interview. I accept to take part in the focus group discussions. ________________________________ ___________ Name and signature of participant Date _______________________________________ ______________ Name and signature of researcher Date University of Ghana http://ugspace.ug.edu.gh 71 Appendix 2: Informed consent forms for in-depth interviews Research topic: School health services and reproductive health-seeking behavior of Junior High School female adolescents in Bawku West District [Instruction: Please tick () if eligible and consenting] I have read the participant information sheet and this consent form, and I understand what is being requested of me. I understand that I may withdraw from this study without giving a reason, and I can request my data not to be included if I wish, up until the date given for analysis of the data. My questions concerning this study have been answered to my satisfaction. I freely consent and accept that the researcher can access my information. I have been provided a copy of this form. My parents have assented to my participation in this study I give consent to be part of the research. I give consent to be audio-taped during the interview. I accept to take part in the in-depth interview. ___________________________________________ ___________ Name and signature of participant Date _________________________________________________ ______________ Name and signature of researcher Date University of Ghana http://ugspace.ug.edu.gh 72 Appendix 3: Accent form for parents/guardians of adolescents less than 18years Research topic: School health services and reproductive health-seeking behavior of Junior High School female adolescents in Bawku West District [Instruction: Please tick () if eligible and accenting] I have read the participant information sheet and this assent form, and I understand what is being requested of me. I understand that I can withdraw my ward from this study without giving a reason, and I can request my ward’s data not to be included if I wish, up until the date given for analysis of the data. My questions concerning this study have been answered to my satisfaction. I freely assent and accept that the researcher can access my wards’ information. I have been provided a copy of this form. I give my assent for my ward to be part of the research. I assent to my ward to be audio-taped during the interview. I accept that my ward takes part in the focus group discussions. ________________________________ __________ Name and signature of parent Date __________________________________ _____________ Name and signature of researcher Date University of Ghana http://ugspace.ug.edu.gh 73 Appendix 4: Focus group discussion guide for Junior High school females Research Topic: School health services and reproductive health-seeking behavior of Junior High School female adolescents in Bawku West district, Upper East region NOTES:  Ensure that participants are comfortable  Introduce myself and the study  Check that each participant has: o Read and understood the Participant Information Sheet o Signed the consent forms (and also consented to being audio-recorded)  Ask for participants’ permission to start discussions, and then switch on audio- recording device to start interview Lead question  Tell me about how your studies are going?  ? How is studies going on? Section A: Knowledge of female adolescents on sexual and reproductive health 1. Can you tell me what you know about sexual and reproductive health? Probe:  Sexual health- menstruation, ovulation, STDs  Reproductive health-Family planning, teenage pregnancy, abortion 2. What sexually transmitted infections/diseases can affect in-school adolescent females in your school or community? University of Ghana http://ugspace.ug.edu.gh 74 Probe:  Do you have any more to add?  Can you tell me some of the signs/symptoms of these sexually transmitted infections/diseases? [Interviewer to take note and discuss in detail each health problem/infection mentioned]  Can you tell me about how each of these sexually transmitted infections/diseases can be prevented? [Interviewer to take note and discuss in detail each health problem/infection mentioned]  Can you tell me about what can be done when an in-school adolescent female contracts these sexually transmitted infections/diseases? 3. What sexual and reproductive health problems can affect in-school adolescent females in your school or community? Probe:  Do you any more to add?  Can you tell me some of the signs/symptoms of these sexual and reproductive health problems? [Interviewer to take note and discuss in detail each health problem/infection mentioned]  Can you tell me about how each of these sexual and reproductive health problems could be prevented? [Interviewer to take note and discuss in detail each health problem/infection mentioned]  Can you tell me about what can be done when an in-school adolescent has sexual and reproductive health problems? 4. Where do you normally get information on sexual and reproductive health from? University of Ghana http://ugspace.ug.edu.gh 75 Probe:  Which other sources do you get sexual and reproductive health information from Section B: Types of reproductive health information provided to in-school adolescence during School Health Services 1. I understand some nurses normally come to your school. Can you tell me what they do when they come to you? Probe:  How do you get to know they will be coming?  How often do they come?  How long do they stay in the school to provide their health services?  What do they tell you concerning their next visit when they come and are about leaving? 2. The Nurses who come to your school for school health services, what sexual and reproductive health issues do they normally discuss with you? Probe:  Any other sexual and reproductive health services they talk to you about? Section C: Sexual and reproductive health-seeking behavior of female adolescents 1. If you have a problem concerning your menstrual cycle or ‘period’ or anything about sexual or reproductive health, what would you do? Probe: University of Ghana http://ugspace.ug.edu.gh 76  What do adolescent girls do when they are pregnant but do not want to be mothers? 2. Who do you normally talk to when you have sexual and reproductive health problems? Probe:  Why do you prefer talking to this/these person(s)? 3. Where would you go to get contraceptives if you needed them? Probe:  How easy is it to get contraceptives? Section D: Factors that hinder adolescents from seeking sexual and reproductive health services 1. As an in-school adolescent female, why do you think most adolescents do not seek adolescent health services available to them? Probe:  Why do you think in-school adolescent females do not access sexual and reproductive health services available to them in the health facility located in this community?  What are some of the things that make it easier for in-school adolescent females to access reproductive and health services they need in the health facility located in this community?  What are some of the things that may stop an adolescent who is already seeking reproductive and health services to stop? University of Ghana http://ugspace.ug.edu.gh 77 2. How do you think adolescent sexual and reproductive health problems must be addressed? 3. What can be done to improve adolescent sexual and reproductive health services? Probe:  What could be done to improve adolescent sexual and reproductive health services during school health sessions/visits?  What could be done to improve adolescent sexual and reproductive health services in health facilities?  Who should lead in these improvements in the schools?  Who should lead in these improvements in health facilities? Concluding questions and statements  Is there anything else you would like to add or share about this topic that you feel is important for me to know beside what we have talked about? Thank you for your time and participation in this study! University of Ghana http://ugspace.ug.edu.gh 78 Appendix 4.1: In-depth interview guide for community health officers Research Topic: School health services and reproductive health-seeking behavior of Junior High School female adolescents in Bawku West district, Upper East region Notes:  Ensure that participant is comfortable  Introduce myself and the study  Check that participant has o Read and understood the Participant Information Sheet o Signed the consent forms (and also consented to being audio-recorded)  Ask for participant’s permission to start interview, and then switch on audio- recording device to start interview 1. Lead question  How is work going on here at this facility?  Tell me about the work you do in delivering adolescent health services? Section A: Knowledge of female adolescents on sexual and reproductive health 5. Can you tell me what you know about sexual and reproductive health? Probe:  Sexual health- Menstruation, ovulation, STDs  Reproductive health-Family planning, Teenage pregnancy, abortion 6. What sexually transmitted infections/diseases can affect in-school adolescent females in your catchment area? Probe:  Do you have any more to add? University of Ghana http://ugspace.ug.edu.gh 79  Can you tell me some of the signs/symptoms of these sexually transmitted infections/diseases? [Interviewer to take note and discuss in detail each health problem/infection mentioned]  Can you tell me about how each of these sexually transmitted infections/diseases can be prevented? [Interviewer to take note and discuss in detail each health problem/infection mentioned]  Can you tell me about what can be done when an in-school adolescent female contracts these sexually transmitted infections/diseases? 7. What sexual and reproductive health problems can affect in-school adolescent females in your school or community? Probe:  Do you have any more to add?  Can you tell me some of the signs/symptoms of these sexual and reproductive health problems? [Interviewer to take note and discuss in detail each health problem/infection mentioned]  Can you tell me about how each of these sexual and reproductive health problems could be prevented? [Interviewer to take note and discuss in detail each health problem/infection mentioned]  Can you tell me about what can be done when an in-school adolescent has reproductive health problems? 8. Where do you normally get information on sexual and reproductive health from? University of Ghana http://ugspace.ug.edu.gh 80 Probe:  Which other sources do you get sexual and reproductive health information from Section B: Types of reproductive health information provided to in-school adolescence during School Health Services 1. Can you tell me what services you render when you go for school health services? Probe:  Concerning adolescent sexual and reproductive health services, what do you do, when you go for school health services?  What determines(s) what you discuss during each visit?  How long (on the average) do you stay in the schools you visit?  How do the students know you would be coming for school health services?  How often do you render these services?  What do you tell the students when you are leaving the school you visit for school health services? 2. Can you tell me more about adolescent sexual and reproductive health services you render in your facility? Probe:  What kind of sexual and reproductive health information do in-school adolescents have?  What determines(s) what you discuss?  Where do you provide these services for adolescents in this facility? University of Ghana http://ugspace.ug.edu.gh 81 Section C: Sexual and reproductive health-seeking behavior of female adolescents 1. Where do in-school female adolescent females seek support when they have any sexual and reproductive health problems in your catchment area? Probe:  Are there any other places they go to seek support?  Why do you think they seek support from these places? 2. What sexual and reproductive health services are available to in-school adolescent females in your facility? Probe:  Which of these sexual and reproductive health services do in-school adolescents seek mostly in your facility?  Which other services concerning sexual and reproductive can you tell me of that are not available in your facility? Section D: Factors that hinder adolescents from seeking sexual and reproductive health services 1. As a health worker, can you tell me why most adolescents do not seek adolescent health services available to them? Probe:  Why do you think in-school adolescent females do not access sexual and reproductive health services available to them in your facility? University of Ghana http://ugspace.ug.edu.gh 82  What are some of the things that make it easier for in-school adolescent females to access sexual and reproductive health services they need in your facility?  What are some of the things that may stop an adolescent who is already seeking sexual and reproductive health services to stop? 2. How do you think adolescent sexual and reproductive health problems must be addressed? 3. What can be done to improve adolescent sexual and reproductive health services? Probe:  What could be done to improve adolescent sexual and reproductive health services during school health sessions/visits?  What could be done to improve adolescent sexual and reproductive health services in your health facility?  Who should lead in these improvements in the schools?  Who should lead in these improvements in your health facilities? Concluding questions and statements  Is there anything else you would like to add or share about this topic that you feel is important for me to know beside what we have talked about? Thank you for your time and participation in this study! University of Ghana http://ugspace.ug.edu.gh 83 Appendix 5: Ethical approval letter University of Ghana http://ugspace.ug.edu.gh 84 Appendix 6: Introductory letters University of Ghana http://ugspace.ug.edu.gh 85 University of Ghana http://ugspace.ug.edu.gh 86 University of Ghana http://ugspace.ug.edu.gh 87 University of Ghana http://ugspace.ug.edu.gh