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ADOLESCENTS' SOURCES of HEALTH INFORMATION and SIBLING COMMUNICATION in GHANA: a MIXED METHODS ANALYSIS a Dissertation Presen

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ADOLESCENTS' SOURCES of HEALTH INFORMATION and SIBLING COMMUNICATION in GHANA: a MIXED METHODS ANALYSIS a Dissertation Presen ADOLESCENTS’ SOURCES OF HEALTH INFORMATION AND SIBLING COMMUNICATION IN GHANA: A MIXED METHODS ANALYSIS A Dissertation Presented to the Faculty of the Graduate School of Cornell University In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy by Deladem N. Kusi-Appouh August 2012 © 2012 Deladem N. Kusi-Appouh ADOLESCENTS’ SOURCES OF HEALTH INFORMATION AND SIBLING COMMUNICATION IN GHANA: A MIXED METHODS ANALYSIS Deladem N. Kusi-Appouh, Ph. D. Cornell University 2012 Adolescence is an important developmental stage usually characterized by physical changes, psychosocial changes, and a tendency towards new experiences, such as sexual activity. It is generally understood that adolescents learn about sexual and reproductive health from multiple sources, including parents, friends, and the media. Less studied – particularly in non-Western and/or African contexts – is the role of siblings in shaping adolescents’ knowledge, attitudes, and behaviors. This study is a secondary analysis of data collected from focus group discussions (FGDs), in-depth interviews (IDIs), and a nationally representative survey among 12-19 year-olds in Ghana as part of a four-country project assessing the sexual and reproductive health of adolescents in sub-Saharan Africa. Through a mixed methods approach, the present study examines similarities and differences in the health information that adolescents receive from various sources. Using social learning theory and differentiation theory as frameworks, the study hones in on the contributions of siblings. Analyses of all three data sources produce complementary results. FGDs and IDIs show clear similarities in the timing and nature of sexual and reproductive health information that adolescents receive from other sources and from siblings, especially regarding sexual abstinence and preventing early pregnancy. The FGDs and IDIs also provide evidence of social and observational learning, showing that siblings serve as agents of socialization, advisors, confidants, and role models. Findings from the survey and IDIs highlight the preponderance of communication and interactions between same-gender sibling dyads. Additionally, multivariate analyses show that older adolescents (15-19 years) are twice as likely to communicate with a sibling about sex-related matters as younger ones and that the likelihood is even higher among male adolescents who have at least one older sibling. Adolescents from rural areas, however, were significantly less likely to communicate with a sibling. Besides establishing the need to consider siblings as an important target group in adolescent and family-centered policy and programmatic interventions in Ghana, results from this study emphasize the duality of adolescents as siblings who exchange sexual and reproductive health information and who can potentially impact the transition to adulthood. BIOGRAPHICAL SKETCH Deladem Kusi-Appouh received her undergraduate degree in Sociology and Anthropology from Agnes Scott College in 2001. Soon after, she went on to work with John Snow, Inc. in their Denver office as a Project Associate on the Infertility Prevention Project. Deladem earned her Master’s in Development Sociology from Cornell University in 2007, with a concentration in Population and Development. She was selected as a Fred. H. Bixby Fellow at the Population Council and will start a 2-year fellowship working out of the Lusaka, Zambia office, starting in August 2012. She looks forward to a successful career as a social demographer and to producing research that will make an impact on population issues, particularly those pertaining to adolescents and the African region. v This dissertation is dedicated to: Nancy J. Hafkin, Ph.D. Catherine Gabianu Mike Kosi George Ansah, Ph.D. … and to overcoming adversity. vi ACKNOWLEDGMENTS The significance of my name Deladem – which translates into ‘The Lord has delivered me’ in the Ewe language spoken in Ghana and Togo – never became more apparent as it did during this dissertation journey. Starting with a broken ankle after slipping on ice on February 14, 2008 requiring two surgeries and the insertion of seven screws to being diagnosed with cerebral sinus venous thrombosis on October 18, 2011, this journey has been bumpy to say the least. But the Almighty God did deliver me from all these obstacles and I give Him all the praise. Throughout this journey of pain and discovery, I have been motivated by Ecclesiastes 9:11 which reads “I have seen something else under the sun: The race is not to the swift or the battle to the strong, nor does food come to the wise or wealth to the brilliant or favor to the learned; but time and chance happen to them all (NIV, 1984). May my completing this dissertation be a testimony to others who are in still in the race. This dissertation could not have been completed without the help of my professors, family, and friends, all of whom I would like mention here as a small gesture to show my sincere appreciation. Lindy Williams, my dissertation advisor whose reserves of patience I may have abused. Thank you for your intellectual and personal guidance in producing a body of work that I can be proud of. Alaka Basu and Josephine Allen – both dissertation committee members – for your support and guidance that went above and beyond the halls of Uris, Warren, and Martha Van Rensselaer. Parfait Eloundou-Enyegue, my fourth committee member, for your guidance and for imparting knowledge even in the most casual of circumstances (e.g. while practicing your golf swing!). Sharon Sassler, for taking me under your wing and for your honesty in how to achieve academic productivity and balance family life (advice you cannot find in books!). Jennifer Tiffany, for your support, guidance, and vii mentoring since our first encounter in 2004. Thank you for believing in me and cheering me all along the way. Sena Gabianu, my mother, whose love and support became overwhelming at times, but helped me to stay on track. Nancy Hafkin, for enduring the day-to-day rollercoaster of this journey, for an outpouring of love even when I didn’t know I needed it, and for giving me strength to keep pushing when I had none left in my body. These past two years have been so meaningful and rewarding. A very special thank you also goes to Charles Wolfson for your support throughout and to George Ansah for accepting the responsibility of being my guardian angel. I would also like to thank the following sets of persons: (A) Nana Mockoah Ackatia- Armah, Pearl Kyei, Bubu Banini, Satvika Chalasani, Nana Ama Adom-Boakye, Mercy Lung’aho, and Sade Owolabi, who were a hybrid between dissertation coaches and cheerleaders. Thank you for allowing me to infiltrate your private time with incessant questions, requests, and demands. You made me believe in myself and the merits of my dissertation topic and I am truly grateful for that. Also, special thanks to Anita Chikkatur for inviting me to spend the coldest days in Carelton, Minnesota, which gave me the peace to focus on my data analysis; (B) my #1 cheerleaders’ squad: Ama Fordjour, Naa Oyoo Quartey, Kelly Limes-Taylor, Mekedes Demissew, Ribka Berhanu, Buddy Buruku, Astro E. Darkoh, Stephen Abebreseh, Nana Ama Asare, Jumoke Warritay, Kwesi ‘Kraazy’ Ansah, and Diana Hernandez. I could not have made it without your constant support and faith. You saw the end before I ever did; (C) my dissertation buddies: Inku Subedi, Naoko Mizuno, Hyunok Lee, Florio Arguillas (thank you for saving me from near disasters with CISER!), and Fenaba Addo. Thank you for keeping me sane throughout the process. And to Lydiah Gatere: what can I say? Our unapologetic takeover of libraries and perseverance paid off and can now have our weekends to ourselves (I think?); (D) my immediate and extended family: Catherine Gabianu, Nnena Sharp, Maja Kabasa, Edem Kabasa, Suzie Gabianu, viii Kosi Kpotivi, Mercy Kpotivi, Anita Opoku, Diana Opoku, Patrick Amoaku, Ohemaa Nyanin, Marilyn Aniwa, Cleopatra Warritay, Illeme Amegatcher, Theophilus Amegatcher, Nirina Diop, Debbie Terkper, Seth Terpker, Sika Tettey, Kwame Boadi, Yaa Felicia Boadi, Yaw Amoah, Ben Gyepi-Garbrah, Erwin Kwawu, Kofi Afful, Fauziah Ibrahim, Joseph, Elizabeth, and Dan Pleck, and the Kosi Family; (E) my undergraduate professors who planted the seed of intellectual pursuit in me: Yvonne Newsome, Brenda Hoke, and Isa Williams; (F) those whose actions have blessed me and for whose friendship I am eternally grateful: Hilda Mensah-Adibuer, Ehui Adovor, Amanda Flaim, Daniel Alhquist, Sara Keene, Ian Bailey, Elizabeth A. Yankah, Joanne Awuor Oport, Mawuli Lekettey, Wisdom Akpalu, Edem Kumaga, Rahel Merissa, Kenny Ajayi, Taiwo Ajayi, Kari Midthun, Delali Ankamah, Steve Welch, Devparna Roy, Jennifer Cowan, Bibigi Haile, Kweku Ainuson, Fatou Jah, Vongai M. Kandiwa, Yared Haile, Christian Lentz (for wisdom about approaching the dissertation as discrete tasks), Gayatri Menon (for wisdom about the last three weeks of the dissertation being when it finally clicks), John S. Manyo-Plange, Rachel Reichenbach, Sandra Mulumba-Sala, Dovelle Sala-Diakanda, Louis Serge Akadia, Adwoa Agyeman, Abena Agyeman, Oumou Bengeloune, Rakibou Ouro-Djobo, Nana- Ama Kyerematen, Ola Alade, Sylvie Babadjide, Michelle Patrick Hall, Aimee Ahmed, and other members of the Sungoddess Sisterhood, Nansata Yakubu, Welela Haileselassie, Befekadu Ayenew, Regis Zoula, Dolapo Enahoro, Niilante Amissah, Edward Abrokwah, Naalamle Amissah, Kunbi Adeyemo, Alberta Tete-Lartey, and Nalini Rao; (G) members of Cornell University’s community who helped me survive my graduate years: Tracy Aagaard, Laurie Johnson, Terri Denman, Tom Hirschl, Brenda Wickes, Brendan O’Brien, professors and graduate students of the Department of Development Sociology, Professor Muna Ndulo and Jackie Sayegh of the Institute for African Development; (H) doctors, nurses, and nurses’ aides at the Framingham ix Metro West emergency room as well as the UMass Medical Center Neurology Unit and Anti-Coagulation clinic in Worcester, MA, who helped me successfully recover from my terrifying diagnosis; (I) Jill Keesbury, Paul Hewett, Saumya Ramarao, Hannah Taboada, and Karen Austrian for the opportunity to be a Fred H.
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