Based on the perceptions of community stakeholders, how can adolescent pregnancies be prevented? A qualitative study

Introduction

Approximately, two million adolescent females aged under 15 years become pregnant in developing regions every year, according to World Health Organization (WHO) figures from 2018. Almost four million adolescent females in this age group undergo unsafe abortions with complications (See WHO fact sheet on Adolescent pregnancy). According to data from the WHO, the adolescent birth rates in the various countries worldwide ranges from 1–200 per thousand girls. Adolescent pregnancy remains a major cause of death among mothers and children while contributing to the cycle of ill-health and poverty (WHO, 2018). In the three years from 2012 – 2014, Thailand had adolescent pregnancy rates of 53.4, 51.2 and 47.9 per thousand among adolescent women aged 15–19 years, respectively (Tantisewas et al., 2014).

Regarding guidelines for solving the aforementioned problem, the WHO and the United Nations Population Fund (UNFPA) published guidelines in 2011. They recommended that political leaders, planners and community leaders build understanding and support for reducing pregnancies among women under 20 years of age (United Nations Population Fund (UNFPA) & Roger I, 2016; WHO, 2014). Thailand recognized the seriousness of its adolescent pregnancy problems. Its government set policies to address this problem, in addition to promoting social measures that attempt to curb adolescent pregnancies. These include more comprehensive sex education, allowing students who have become pregnant to finish their studies, control of the dissemination of pornography, and greater parental involvement in their children’s lives. Consequently, each ministry is required to have working guidelines to reduce the incidence of teenage pregnancies. (Tantisewas et al., 2014).

Based on performance evaluation, no clear and integrative problem management approach has been found effective. Policies are inconsistent and efforts are both wasteful and complicated (Chamrunsawat, 2014; UNICEF, 2016). Adolescents have little participation in these programs. Each ministry functions slightly differently and there is little communication between them (Health Assembly, 2016; Poonkhum et al., 2010). Comprehensive sex education and adolescent-friendly activities are not being conducted in every educational facility. Activities in the areas of physical and social relations are not being presented to adolescents at risk. Furthermore, there is a general lack of involvement among the relevant government agencies (Chamrunsawat, 2014) in improving adolescent health. Addressing these issues must begin from the early adolescent period (ages 10–14) (Chandra-Mouli et al., 2015). Many factors are related about adolescent pregnancy preventions. For example, at a personal level, knowledge, skills and empowerment must be developed. Furthermore, safe places must be created where young people may go and be free of sexual pressures imposed by their peers. Family and friends need closer relationships and a high degree of communication. Communities and local organizations need to provide convenient services and opportunities for adolescents in places such as schools (Svanemyr et al., 2015; WHO, 2014). Additionally, youth-friendly guidelines need to be developed based on community needs (Cassell et al., 2005).

There are teenagers who do not see school as important. Among some adolescent females, there is a positive attitude about becoming pregnant, even outside of marriage. If a girl becomes pregnant, it is unlikely that she will continue with her studies. Focus must be placed on changing negative social values and norms along with developing adolescent sexual and reproductive health. This can be done by raising awareness, acceptance and support for youth-friendly sexual and reproductive health education services. Gender inequality, in terms of beliefs, attitudes and norms, needs to be addressed (Chandra-Mouli et al., 2015) in addition to creating connections that link services in various settings, such as schools, to promote utilization of these services (Denno et al., 2015). At the broadest societal level, efforts to concurrently build awareness of adolescent sexual and reproductive health must be made through mass media approaches.

Therefore, efforts to improve adolescent health must be made by recognizing and using a variety of driving mechanisms (Kuruvilla et al., 2016). From the aforementioned principles, participation is an excellent method for planning projects and policies because it helps ensure the strategies developed are appropriate for the targeted age group in culturally and geographically diverse communities. Support for stakeholder participation in the target groups creates more effective results and combines democratic principles in the decision-making process as well as maintaining strong partnerships (Tevendale et al., 2017). For example, a study of community participation in a campaign for prevention of teenage pregnancies found that parents in communities changed their attitudes about sex, had more positive thoughts, communicated with and understood adolescents to a greater degree than before the project (Phoochaemchot & Chomnirat, 2012). Additionally, a study that implemented community-based empowerment interventions found that the project could be improved with earlier active participation by unmarried pregnant adolescents and increased support by parents (Leerlooijer et al., 2013).

Although we have a good understanding of adolescent needs and problems, there are still many gaps in our knowledge and understanding (UNICEF, 2016). Based on evaluations and interventions related to prevention of adolescent pregnancies, evidence-based practices remain important for outlining a national policy framework (Lavin & Cox, 2012). Thus, the purpose of this research was to study stakeholders’ perceptions about prevention of adolescent pregnancies and planning for teenage pregnancy prevention with community participation.

Methods

This study on the perceptions of participants included public health officers, nurses from heath promoting sub-district hospitals, district hospitals, public health officers, public health volunteers, key persons in the communities, teachers, representative students and parents. There were 103 persons purposively selected. The participants were involved in adolescent pregnancy problems or part of adolescent pregnancy reduction operations from hospitals, schools and communities. The researcher had issued self-introduction letter from Khon Kaen University in order to meet with Director of Public Health Officer, Director of hospitals and Director of the secondary schools of each province and to explain purposes of the research. They also included; for hospitals, invitations for personnel relating to teenage pregnancy reduction operations in hospitals and the community, for schools, invitations to teachers, students and parents or guardians involved in teenage pregnancy reduction operations to participate in the conference and group discussion. People from these communities all volunteered to participate in the study

The communities under study were Kalasin, Khon Kaen, Mahasarakham and Roi-et provinces. The adolescent birthrate of these areas during 2011–2013 was 35–54 per 1,000 women aged 15–19 years old. (Bureau of Reproductive Health, 2014) All 4 provinces are located within central area of Thailand´s northeastern region. Volunteered participants taking parts in the research in Kalasin were from district region and sub-district region for Khon Kaen, Mahasarakham, and Roi Et. Data used in the research were collected from September-November 2014.

The research instruments consisted of conferences, documents, field notes and stakeholder responses captured using audio recorders. Documents used were summary results of the survey on sexual behaviors in students Grade 7 and 8, which was collected 3 months prior to the group discussion, and reports on operation results of youth friendly health service clinic from district hospital in Kalasin province.

This initial study was conducted in June-July 2014 in district of Kalasin and sub-district of Khon Kaen, Mahasarakham, and Roi Et Province, central northeastern Thailand. Participants were students in grade 7 and 8. 624 students were included in the study. The study was explained to the students and parental consent forms were given. After both students and their parents give written informed consent the student were given a self-administered questionnaire to fill out. Exclusion criterion was failure to give consent. The study was approved by the Ethics Committee of Khon Kaen: code 571119. The questionnaire asked about demographics characteristics and sexual risk behavior (Questionnaire is available as Supplementary File 1). Students who had sexual intercourse were asked about their first sex age, contraception, STI, pregnancy and abortion. Questionnaire data were entered into Microsoft Excel 2008 in duplicate. The data were frequencies and percentage.

Data were collected from group discussions (conducted by a public health officer) using participatory activities on four occasions in the four communities mentioned above. The number of participants in each group was 25–28 persons. Each session was conducted for 6–7 hours in which the participants shared their opinions about prevention of adolescent pregnancies. The participatory activities consisted of introduction, adolescent pregnancy problem analysis, plan of problem solving and presentation of plans.

Data was collected as part of empowerment evaluation of the program to reduce teenage pregnancy in central northeastern Thailand. Instruments used in data collection were adapted from Empowerment Evaluation Principles in Practice. The researcher utilized and adapted the concept of Empowerment Evaluation from David M. Fetterman (Fetterman DM, 2001, Fetterman DM, Abraham Wandersman A, 2005) to determine activities and activity planning conferences for teenage pregnancy reduction project. Activities and contents were adapted to suit issues within the study areas, with activity details as follows:

1. Mission review process included identifying/determining things that needed to be done together and the common mission.

2. Activity review and prioritizing process was to analyze weaknesses and strengths of the project (Taking Stock)

3. Planning for the future.

For Kalasin, the conference location was the district hospital´s conference hall. For Khon Kaen, Mahasarakham, and Roi Et, the conferences were held at the sub-district secondary school conference rooms. The conference took 6–7 hours, with a team of 1 lecturer and 4 facilitators consisting of 1 university professors with expertise in evaluation, a public health officer with over 10 years of experiences as a facilitator who conducted the group discussion, 1 professional nurse, and 2 doctoral students (1 doctoral student was a researcher SP). Activities during the conference consisted of 4 stages as follows:

Part 1: Introduction; The activity began with introduction of each researcher, research purposes, lecturer team members, participants, and survey results regarding sexual behaviors in secondary schools within each province´s area for the participants to acknowledge the current situation.

Part 2: Adolescent pregnancy problem analysis was conducted by each participant voicing their opinions regarding pregnancy issues within the region, causes, circumstances (as established by survey results) or emotions towards the issue. The second activity was stopped when no more new opinions were being provided. The duration was approximately 1 hour.

Part 3: Plan of problem solving was an activity where the participants determined necessary things that needed to be done together and prioritized activities. The participants were divided into 3 subgroups: One group consisted of persons relating to public health and hospital operation. One group consisted of persons relating to school operation. One group consisted of persons relating to community operation. Activity duration was approximately 4 hours.

Part 4: Presentation of plans was the presentation of the result gained from subgroup meeting and then gathered similar activities into one single project, and determined the person in-charge, which later on will be made into the adolescent pregnancy reduction plan for each area.

Group discussion were recorded and transcribed verbatim. Data was read and re-read. Theme form data were initially identify by the first author, and subsequently verified by both authors for coding consistency, emergence of main themes, and extraction of statements to support the themes.

Results

This study obtained results in the following three areas: (1) adolescent pregnancy prevention programs in hospitals and schools, (2) attitudes and perceptions of the adolescent pregnancy problem, and, (3) adolescent pregnancy prevention guidelines in the community.

Discussion

This study is an expression of the stakeholder opinions regarding how pregnancy prevention should be carried out simultaneously among adolescents, families and networks.

According to our findings, adolescents do not communicate with their parents. Knowledge, understanding, attitudes and value adjustment of stakeholders on sex and undesirable pregnancies should be created along with pregnancy prevention skill development. Teenagers should receive sex education in schools in addition to cultivation of morality and ethics consistent with principles of adolescent development. Furthermore, they should be supported to gain knowledge, skills and empowerment (Svanemyr et al., 2015; WHO, 2014).

Families – The main problem is lack of communication on sexual topics within the family. According to studies in Thailand, parents are not likely to speak openly about sexual intercourse with their adolescents. (Nitirat, 2007; Sridawruang et al., 2010a) Studies also showed that parents experience difficulty in talking about sex and contraception with their children, or view sexual health as a topic that should not be discussed because of cultural traditions and beliefs (Sridawruang et al., 2010b) while other parents believed that their teens were still too young to learn and engage in sexual activity (Meechamnan et al., 2014). This study shows that adolescents also did not dare to communicate with parents. This idea is congruent to the study of Aroenthaweesub M. which found that the most difficult topics for adolescents in communicating with their parents were their personal issues such as opposite sex relationships and sexuality. (Aroenthaweesub & Hale, 2011) They feared the misunderstanding of the parents knowing that they were having sex and of being judged or rejected by their parents. (Meechamnan et al., 2014) Stakeholders had the opinion that emphasis should be placed on activities to strengthen families, enabling them to develop communications regarding sex, community values and morality. Families can participate in traditional activities in the community to build closer relationships (WHO, 2014).

Community Work Problems – The findings indicated there is insufficient cooperation between government agencies, such as hospitals and schools with parents, guardians and community members. According to Chamroonsawadi K., the weaknesses of work to solve teen pregnancy problems are unclear policies, lack of clarification to create mutual understanding between government agencies, lack of integration of thought, inefficient use of budget from duplication of activities among the same target groups, lack of a meeting between the central administrators and local operators to create mutual understanding and sense of belonging in the same work (Chamrunsawat, 2014) UNFPA found that in Thailand the implementation of the problem of pregnancy in adolescents is a complex issue. Some agencies may not be familiar with the problem, and each agency had a different perspective on the nature of "problems" and "solutions" and maybe lack of sense "ownership". Work to solve teen pregnancy problems has found the problem of discontinuity in driving policy. Each agency does not see it as only their work and therefore not their direct duty to solve teen pregnancy problems often meaning they fail to continue to work on the issue. The plan to solve problems did not involve teenager or family participation (United Nations Population Fund (UNFPA) & Roger I, 2016; UNICEF, 2016). This is prudent as communities have an important role in improving adolescent health (Svanemyr et al., 2015; WHO, 2014). Additionally, friendly and guideline based communities should be formed (Cassell et al., 2005). Stakeholders thought that networks should be developed and strengthened, and that participation in the community should be through adolescent-friendly activities. Some examples include special centers for solving adolescent problems and projects to encourage adolescent pregnancy prevention with the participating community agencies engaging in self-assessment of their effectiveness. Some of the findings indicated that pregnancy prevention activities are comprised of promoting quality and access to youth-friendly reproductive health services, providing education on pregnancy prevention to stakeholders, and working with adolescents who engage in risky sexual behaviors. The community should analyze their problems and mobilize to develop solutions to their problems (Mueller et al., 2017). Additionally, other findings support the concept that community partners should support and organize community resources in the form of comprehensive, effective and sustainable programs (Cassell et al., 2005).

However, the problem of access to pornography is difficult to control. Therefore, the government must work to find measures for controlling and preventing these media from being disseminated to adolescents. Youth can be educated so that they become aware of the dangers of pornography.

Conclusions

According to stakeholders’ perceptions regarding adolescent pregnancies, the problems originate from adolescents, families, friends and the media. There are many organizations that work for prevention of adolescent pregnancies in rural communities. The results of this study suggest the need for participatory action by all agencies responsible for addressing the problem. There is a strong need for families to develop the ability to communicate with each other about sexuality and reproductive health such as develop the parenting skills on how and when to talk about sex with their adolescents, open parental communication on sexuality issue at home (communication skill of the parents) Activities need to be developed for adolescents who are more inclined to engage in risky sexual behaviors.

Data availability

Raw datasets have not been made available at the request of the ethics committee in order to maintain participant confidentiality. Using Thai language as the national language of Thailand during the process of data gathering, all data including quotes are available in Thai translation and access to the complete raw data can be obtained upon request and with the permission of Ethics Committee of Khon Kaen University (www.ekku.ac.th). Anyone wishing to access the data should first contact the corresponding author who will facilitate contact with the ethical review board (Contact email:sampinit@hotmail.com)