Stigma and adolescent sexual and reproductive health in Ghana
Awarded 2014
Large Research Grants
Kelli Hall, PhD, MS
University of Michigan

This project examined social stigma in shaping Ghanaian adolescent sexual and reproductive health experiences and specifically as a barrier to modern contraception use. The project applied a mixed-methods (qualitative and quantitative) approach across two research study phases carried out in Kumasi and Accra, Ghana. The first study phase consisted of qualitative work to provide a more in-depth understanding of young women’s experiences with reproductive health-related stigma (i.e. stigma associated with adolescent sexual activity, contraceptive use, pregnancy, childbearing and abortion). We conducted in-depth, individual qualitative interviews with a purposive sample of 63 adolescent and young adult women ages 15-24 years recruited from 5 Ghanaian Health Services (GHS) facilities (antenatal/postnatal, adolescent health, and family planning clinics) and 4 secondary schools in the greater Kumasi and Accra areas. We completed thematic analysis in 2015 and prepared and submitted two manuscripts based upon those findings. Those papers are currently under peer review. Our second research study phase entailed development, validation, and administration of a new formal adolescent sexual and reproductive health stigma scale. The scale was administered in a survey study of 1,080 adolescent and young adult women recruited from 5 GHS health facilities, 4 secondary schools, and 2 universities in Kumasi and Accra in the spring and summer 2015. Quantitative survey data were cleaned, coded, and prepared for analysis in fall 2015 and spring 2016. We have now completed two primary analyses of these data. First, we conducted a formal factor analysis and psychometric evaluation of the stigma scale, which included a validation analysis examining the impact of stigma on modern contraceptive use. Second, we have analyzed a broad range of sociodemographic, health and reproductive characteristics as predictors of adolescent sexual and reproductive health stigma. Our project has provided new insights into the multiple intersecting factors operating at interpersonal, community and macro-social levels of young Ghanaian women’s environments which influenced their sexual and reproductive health decision-making and behaviors, with important consequences for their family planning outcomes. More specifically, adolescent sexual and reproductive health experiences were described as cutting across five stigma domains: community norms, enacted stigma, internalized stigma, non-disclosure, and stigma resilience. Our resulting conceptual models of stigma and the social ecology of adolescent sexual and reproductive health can guide multi-level health service, public health, and policy efforts to address young women’s unmet family planning need. Moreover, the new Adolescent Sexual and Reproductive Health Stigma Scale offers a valid, reliable instrument for quantitatively assessing sexual and reproductive health stigma and its impact on family planning outcomes. The scale can be used to inform and evaluate interventions to reduce/manage stigma and foster resilience among young women worldwide.