'They Call Me a Bad Girl': a Feminist Analysis of Agentic Behaviour in Pregnant Adolescents in Thailand Supiya Wirifai
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‘They call me a bad girl’: a feminist analysis of agentic behaviour in pregnant adolescents in Thailand By Supiya Wirifai Thesis Submitted to Flinders University for the degree of Doctor of Philosophy Doctor of Philosophy College of Nursing and Health Sciences 27th March 2019 Contents SUMMARY vi DECLARATION vii ACKNOWLEGEMENT viii LIST OF ABBREVIATIONS x CHAPTER 1 BACKGROUND 1 Introduction 1 Defining adolescence and adolescent pregnancy 2 The prevalence of adolescent pregnancy in Thailand 3 The challenges faced by pregnant adolescents 3 Health impacts related to pregnant adolescents and their babies 3 Being a pregnant adolescent in Thailand 8 Geographical profile of Thailand 9 Thai social culture, norms, and religion 10 Thai family structure 12 Contraceptive availability in Thailand 13 Reasons for conducting the research 14 Statement of research problems 15 The aims of the study 16 Research questions 16 Thesis outline 16 CHAPTER 2 LITERATURE REVIEW 18 Introduction 18 Methods 18 Results 19 Decision-making in pregnancy 20 Practicing health behaviours 22 Accessing health care 23 ii Maternal role development 24 Social stigma 25 Discussion 26 Summary 27 CHAPTER 3 METHODOLOGY AND METHODS 28 Introduction 28 Ontological and epistemological considerations 28 Methodological and Theoretical considerations 29 Research designs 33 Data collection methods 35 Semi-structured interviews 35 Participant observation 36 Field notes 37 Photo-elicited interviews 38 Research settings 40 Selection of participants 42 Ethical considerations 45 Entering the field 46 Trustworthiness 49 Transcription and translation 50 Data analysis 51 Thematic analysis 51 Theoretical analysis 53 Summary 55 CHAPTER 4 SOCIAL STIGMA, SUPPORT AND SUPPORT SYSTEMS 56 Theme 1. Social stigma: being a ‘bad girl’ 57 Being judged 57 No exceptions to stigma 58 iii Family violence exacerbates stigma 63 ‘It makes me ashamed’: living with stigma 68 Theme 2. Support and support systems 72 Financial hardship and support 72 Emotional support 78 Getting information 84 Summary 88 CHAPTER 5 CULTURAL HERITAGE AND SELF-CARE 90 Introduction 90 Theme 3. Cultural heritage 90 Religious beliefs 90 Traditional practices 95 Theme 4. Self-care 99 Care of the physical self 99 Getting help 104 Managing moods and emotions 107 Summary 108 CHAPTER 6 DISCUSSION 110 Introduction 110 Gender inequity 111 Intimate partner violence 111 Stigma as an act of gender inequity 114 Fear 119 Spirituality 124 Religion 124 Traditional practices 126 Summary 127 Chapter 7 Conclusion and recommendations 129 iv Introduction 129 Summary of key findings 129 Limitations of the study 133 Strengths of the study 134 Implications and recommendations 136 Implications for nursing practice 140 Implications for nursing education 143 Implications for further research 145 Summary 146 APPENDICIES 147 APPENDIX A Flow chart of literature search 148 APPENDIX B Summary of critical appraisal 149 APPENDIX C Interview guide for pregnant adolescents 150 APPENDIX D Interview guide for caregivers 151 APPENDIX E Ethics Approval to Conduct Research 152 APPENDIX F Ethics Approval to Conduct Research form Mahasarakham Hospital (English and Thai version) 158 APPENDIX G Introductory letter (English and Thai version) 164 APPENDIX H information sheets for pregnant adolescents and caregivers (English and Thai version) 168 APPENDIX I Consent forms for caregivers (English and Thai version) 182 APPENDIX J Consent forms for the permission of the parents or guardians (English and Thai version) 186 APPENDIX K Conference arises from this study 193 BIBLIOGRAPHY 194 v SUMMARY Background Adolescent pregnancy in Thailand has been associated with educational and financial disadvantages, and unfavourable health outcomes for mothers and infants. Pregnant adolescents have been shown to demonstrate little or no control in their decision-making regarding pregnancy, practicing healthy behaviours, preparation for parenting and future employment. This study sought to explore the role of agency in adolescents’ ability to exercise influence over events that affect their lives in a range of social and cultural contexts. Design Within a critical framework, this ethnographic study was conducted in an antenatal clinic and 15 villages in Mahasarakham Province, Thailand. Data was collected over a 6 month period from 15 pregnant adolescents and 15 caregivers. Methods of data collection included semi-structured interviews, photo elicited interview, and participant observation. Findings Four themes emerged from thematic analysis including social stigma, support and support systems, cultural heritage, and self-care. Feminist theoretical analysis of these themes identified that gender inequity, fear, and spirituality were key factors in shaping the agency of pregnant adolescents in Thailand. Conclusion Gender inequity predominantly impeded agentic behaviour. Some adolescents however resisted the prevailing social forces of inequity, thereby acting agentically. Fear was a pervasive force that impeded agentic behaviour. Spirituality presented as a paradox where it both enabled and impeded agency. Agency and the sociocultural factors that shape adolescent behaviour must be essential considerations for the care and wellbeing of pregnant adolescents in Thailand. vi DECLARATION I certify that this thesis does not incorporate without acknowledgment any material previously submitted for a degree or diploma in any university; and that to the best of my knowledge and belief it does not contain any material previously published or written by another person except where due reference is made in the text. Signed.................................................... Date.........27/03/2019............................. vii ACKNOWLEGEMENT This thesis would not have been successful without the assistance of my supervisor team, Associate Professor Julian Grant and Dr Lana Zannettino. They provided constant support and worked tirelessly to assist me in reaching my PhD milestones and the standards of Flinders University. They provided dedicated effort and knowledge to guide me in developing the quality of my thesis. They also offered critical suggestions on my work that helped me to enhance my abilities to analyse information and integrate various sources of knowledge to develop my thesis. At every meeting, they provided a supportive environment and offered opportunities to share knowledge and experiences. I understand it is difficult to supervise a student who had English as a second language. Their patience, understanding, and encouragement improved my confidence to communicate and to enhance my academic writing. I would like to thank them deeply for all the support. It was a privilege to have them as supervisors. Second, I would like to deeply thank the Royal Thai government for providing financial support in the form of a scholarship to enable me to study for a doctoral degree. I also would like to acknowledge the support from the Office of Educational Affairs, the Royal Thai Embassy in Canberra and their staff. They were quite caring and supported me throughout the time of my study in Australia. I would like to gratefully thank the Praboromarajchanok Institute of Health Workforce Development and Srimahasarakham Nursing College who provided this great opportunity for higher degree study. I gained knowledge in doing research in the area of nursing and experienced a very different culture. I would like to deeply thank the 15 pregnant adolescents and 15 caregivers who participated in this study and shared their experiences, perspectives, and beliefs with me. Without the assistance of nurses, doctors, and the administrative staff of the prenatal clinic, Mahasarakham Hospital, Mahasarakham Province, my project would not have been successful. I would like to acknowledge Mrs. Arunee Srisuying, who was involved with the safety protocol by accompanying me on my visits to the participant’s residences. I really appreciate her friendship. Without their valuable support it would not be possible to conduct this study. My sincere thanks also go to Dr Robert Muller who engaged in the professional editing of this thesis. His work edited my grammar,but did not change the content of the thesis. I learned how to write academic work from him. Last but not the least, the unconditional love of my family members: Sommai Wirifai, Patharawadee Wirifai, Thetiya Wirifai, Issac and Newton who supported me spiritually as sources of strength in writing this thesis and in my life in general. This thesis is dedicated to my father and my mother who are worked hard all their lives and provided support to help to make a better life for my family members. viii Finally, thank you for my PhD friends who shared their knowledge and experience and supported me emotionally throughout my PhD journey. Without the support of the staff in School of Nursing and Midwifery, it would not be have been possible to complete this study. The great experiences I had at Flinders University forever engraved on my memory. Supiya Wirifai 27th March 2019 ix LIST OF ABBREVIATIONS WHO World Health Organisation GDP Gross Domestic Product UNICEF The United Nations Children's Fund UNFPA United Nations Population Fund x CHAPTER 1 BACKGROUND Introduction Adolescent pregnancy is a significant public health problem affecting 21 million girls in developing nations (Darroch, Woog, Bankole, & Ashford, 2016). In Thailand, adolescent pregnancy has been steadily increasing since the start of the 21st century (UNICEF, 2015). The rate of adolescent pregnancy in Thailand is highest