New Evidence on ADOLESCENT SEXUAL and REPRODUCTIVE HEALTH NEEDS

Protecting the Next Generation in Ghana NEW EVIDENCE ON ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH NEEDS Protecting the Next Generation in Ghana: New Evidence on Adolescent Sexual and Reproductive Health Needs Laura Hessburg Kofi Awusabo-Asare Akwasi Kumi-Kyereme Joana O. Nerquaye-Tetteh Francis Yankey Ann Biddlecom Melanie Croce-Galis Acknowledgments The authors thank the following colleagues for their com- de la Population (Burkina Faso); Kofi Awusabo-Asare and ments and help in developing this report: Akinrinola Akwasi Kumi-Kyereme, University of Cape Coast (Ghana); Bankole, Leila Darabi, Ann Moore, Jennifer Nadeau, Kate Alister Munthali and Sidon Konyani, Centre for Social Patterson and Susheela Singh, all currently or formerly of Research (Malawi); Stella Neema and Richard Kibombo, the Guttmacher Institute; Victoria Ebin, independent con- Makerere Institute of Social Research (Uganda); Eliya sultant; Augustine Tanle, University of Cape Coast; and Zulu, Nyovani Madise and Alex Ezeh, African Population Adjoa Nyanteng Yenyi, Planned Parenthood Association of and Health Research Center (Kenya); and Akinrinola Ghana. The report was edited by Peter Doskoch; Kathleen Bankole, Ann Biddlecom, Ann Moore and Susheela Singh Randall coordinated the layout and printing. of the Guttmacher Institute. Valuable guidance was pro- vided by Patricia Donovan, Melanie Croce-Galis and Leila The report greatly benefited from the careful reading and Darabi of the Guttmacher Institute. For implementation of feedback given by the following external peer reviewers: the national surveys of adolescents, the authors gratefully George Amofah, Ghana Health Service; Esther Apewokin, acknowledge the work of their colleagues at ORC Macro— National Population Council; A. F. Aryee, University of specifically, Pav Govindasamy, Albert Themme, Jeanne Ghana; Lord Dartey, Joint United Nations Programme Cushing, Alfredo Aliaga and Rebecca Stallings. Thanks on HIV/AIDS; Cornelius Debpuur, Navrongo Health are also due to Mary Amuyunzu-Nyamongo, formerly of Research Centre; Christine Oppong, University of Ghana; the African Population and Health Research Center, and and Eva Tagoe-Darko, Kwame Nkrumah University of Jennifer Nadeau, formerly of the Guttmacher Institute. Science and Technology. In Ghana, the University of Cape Coast was responsible This report is part of a larger project, conducted in Burkina for all research activities. The key institution in fielding Faso, Ghana, Malawi and Uganda, entitled “Protecting the the National Survey of Adolescents was the Institute of Next Generation: Understanding HIV Risk Among Youth.” Statistical, Social and Economic Research, University of The project was designed to contribute to the global fight Ghana; John Anarfi, Ernest Aryeetey and Kudjoe Dovlo pro- against the growing HIV/AIDS epidemic among adoles- vided important input and leadership during the fieldwork. cents by documenting and analyzing young people’s sexual The authors thank the large team of fieldwork staff, includ- and reproductive health needs; communicating the new ing the supervisors and interviewers who conducted several research findings to a broad audience to raise awareness; data collection efforts. The Planned Parenthood Association and stimulating the development of improved policies and of Ghana is carrying out communication and advocacy programs to serve youth. activities to ensure that the project’s findings contribute to Many individuals contributed to the successful imple- improved policies and programs for the country’s youth. mentation of the Protecting the Next Generation This project is supported by the Bill & Melinda Gates project. The research design, instruments and ana- Foundation, the Rockefeller Foundation and the National lytic approaches were developed by Georges Guiella and Institute of Child Health and Human Development (grant 5 Christine Ouedraogo, L’Institut Supérieur des Sciences et R24 HD043610). Protecting the Next Generation in Ghana Guttmacher Institute Table of Contents Executive Summary 4 Chapter 1: Introduction 6 Chapter 2: What Adolescents Tell Us About Their Sexual Behaviour 9 Chapter 3: Adolescents’ Knowledge Is Broad but Not Deep 14 Chapter 4: Adolescents Have Diverse Sexual and Reproductive Health Care Needs 18 Chapter 5: Adolescents Get Information from a Variety of Sources 21 Chapter 6: The Public Health Care Sector Can Do More 25 Chapter 7: Conclusions and Recommendations 28 Appendix Tables 32 References 43 Guttmacher Institute Protecting the Next Generation in Ghana Executive Summary exual activity among adolescents is a sensitive n Twelve percent of females aged 12–19 who had ever had topic, and addressing youth’s sexual and repro- sex and 5% of their male counterparts said that they ductive health in the public arena is challenging. had been forced (either physically or by threats) into However, the need for sexual and reproductive having sexual intercourse on at least one occasion. Shealth services for adolescents—and the potential benefit of meeting that need—is great. Improving the sexual and Many sexually active adolescents do not use reproductive health of adolescents is important not only from a public health perspective, but also from an economic contraceptives one. Early marriage and childbearing, as well as the effects n Among adolescents aged 15–19 who had had sex in the of HIV/AIDS among young people, can greatly undermine past three months, only 64% of all males, 51% of females a country’s socioeconomic development. Increased invest- not in a union and 38% of females in a union reported ment can both improve adolescent sexual and reproductive that they were using a modern contraceptive method. health and contribute to wider development goals by giving The male condom was the most commonly used contra- adolescents a chance to become healthy adults. ceptive method. This report presents findings from a new body of research n Among adolescents aged 15–19 who had ever had sex, on adolescent sexual and reproductive health in Ghana. those with more formal education reported higher levels of The findings are primarily derived from data collected in contraceptive use than their peers with less schooling. a 2004 nationally representative survey of young people n Among females aged 15–19 who were not in a union, aged 12–19, and in focus group discussions and in-depth almost one-third desired to wait for nine or more years interviews conducted in 2003 and 2004, respectively. before having a child. Females are more likely than males to have sex as n Forty-two percent of adolescents aged 15–19 who had ever had sex had already been pregnant. Among 15– teenagers, have early sex and have unwanted sex 19-year-old females who had already had a baby, only n Among 20–24-year-old females, 8% had had sex before 24% had wanted to have a child at the time of their 15 years of age, 43% before age 18 and 71% before age last conception. 20. Among males, 4% had had sex before they were 15 years old, 26% before age 18 and 55% before age 20. Fear of pregnancy, not of STIs, motivates many n Forty-seven percent of females aged 20–24, but only youth to avoid sex or use contraceptives 13% of males, had married by age 20. More than 90% of n Adolescents aged 12–19 who had never had sex were adolescents aged 12–19 (and more than 80% of sexually more likely to cite fear of pregnancy, rather than fear of experienced respondents) said that youth should remain HIV or other sexually transmitted infections (STIs), as virgins until they marry, yet among those who had ever the main reason they had abstained from sex. had sex, only 15% of females and 5% of males had had their sexual debut with a spouse or live-in partner. n Similarly, adolescents were more likely to use condoms spe- Protecting the Next Generation in Ghana Guttmacher Institute cifically to protect against pregnancy rather than to protect based programmes can be an effective means of providing against HIV and other STIs. Seventy-one percent of females sexual and reproductive health information and services aged 15–19 who had had sex in the prior year and 45% of to adolescents. However, adolescents who do not attend their male counterparts said they used condoms only to school or who leave school before receiving family life edu- protect against pregnancy, whereas just 5% of females and cation need access to information and services. 38% of males used condoms only to protect against STIs. Adolescents prefer to obtain reproductive health Adolescents lack adequate knowledge about care at clinics—but are often too shy to do so sexual and reproductive health issues n Among adolescents aged 15–19 who knew of any source n Although awareness of contraceptive methods is high, for obtaining contraceptives, 63% of females and 56% most adolescents lack critical knowledge about how to of males said their preferred source was a public clinic avoid pregnancy. For instance, among those aged 15– or hospital; among those who knew of any source for 19, only 28% of females and 21% of males were aware obtaining treatment for STIs, 87% of females and 91% of of a woman’s fertile period, were able to reject several males said they would prefer public clinics or hospitals. popular misconceptions about pregnancy and knew of n Among sexually experienced 15–19-year-olds who knew a at least one modern contraceptive method. The propor- source for contraceptives or STI treatment, 53% reported tions were even lower among 12–14-year-olds. that feelings of shyness or embarrassment were a barrier n Nearly all adolescents were aware of HIV/AIDS. However, to obtaining contraceptives, and 51% said that such feel- only about one-third of adolescents aged 15–19 and ings were a barrier to obtaining treatment for STIs. fewer than one-fourth of adolescents aged 12–14 could correctly identify ways of preventing the sexual trans- Action is needed on many fronts to meet the sexual mission of HIV and could reject major misconceptions about HIV (e.g., that a healthy-looking person cannot be and reproductive health needs of adolescents infected).

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