Confronting Religion: Perceptions and Health-Seeking Behaviors of Devout Adolescents when Faced with a Sexually Transmitted Infection in Ghana

GUJHS. 2008 Apr; Vol. 5, No. 1.

Matthew Crommett
Georgetown University
Dodowa Health Research Centre, Ghana

Introduction
The current population of adolescents in the world today is 1.2 billion, with 85% residing in developing countries (1). The number of adolescents in Sub-Saharan Africa is increasing, and the adolescent population in Ghana is no exception (2). With a population of slightly over 22 million, one in five people in the country is an adolescent (3). Along with the increasing population of adolescents in Ghana, available evidence suggests that there are many social and reproductive health problems that have demonstrated no signs of subsiding (4). Pre-marital sexual activity among adolescents is increasing in Africa, due in part to the changing social structure of adolescents as well as the behavioral choices that come along with this transformation. It is important to look at the behavioral choices with which adolescents are faced, but it is equally important to examine the consequences of these behaviors and the decisions made following an adverse outcome of an unsafe behavior. Sexual behavior commands and deserves the considerable amount of attention it gets in research and programming because of the negative health outcomes associated with early and unsafe sexual activity. The majority of HIV cases are contracted during adolescence, a fact that can be attributed to physical changes and social influences in one’s life during this formative time (6).
This study investigates the health-seeking behaviors of adolescents in three communities in Ghana when confronted with a sexually transmitted infection (STI). It looks into the reasons why adolescents choose certain sexual health services and support outlets over others and the general perceptions attached to an adolescent who has contracted a sexually transmitted infection. As religion has often been considered an important force in the formation of attitudes and practice toward sexual behavior (6), this study pays particular attention to the effect that religion has on the decisions made following the contraction of a sexually transmitted infection.

Concerned about the lack of information available to adolescents about sexual health, a Ghana Health Service (GHS) official stated the following regarding the necessity of providing information on STIs to adolescents:

“You know that even biologically, in most young people the reproductive tract is more fragile than that of adults, so for this reason, and psychologically too, most young people do not have their feet on the ground as far as their psyches are concerned and sometimes a STI can really bother a young person if he or she doesn’t know what to do, or if he/she knows what to do but doesn’t have resources… if we can get much information to them, I am sure they can make informed choices. Sometimes I think that we have not done much to get them informed about the bodily changes and to report these changes when they encounter these changes.”

This study hopes to investigate the gap between adolescent knowledge of STIs and their utilization of services and to use this examination to create strategies aimed at improving the sexual health status of adolescents.

Methods
Study Site
This study took place in the Agomeda, Zongo, and Ologotsowe communities in Ghana. These communities lie within the Ayikuma and Dodowa Area Councils of the Dodowa sub-district of the Dangme West District of the Greater Accra Region. All communities are considered rural. The people of Zongo are primarily Muslim in religious affiliation while Agomeda and Ologotsowe are known for their diversity of Christian denominations.

Survey Instruments
Data for this study was gathered through in-depth interviews, focus group discussions (FGDs) and the administering of a survey.  The principal investigator used a 26-point interview guide to conduct the in-depth interviews. The interviews were conducted in English, recorded and later transcribed. A trained and experienced public health nurse conducted the focus group discussions (FGDs), while a research assistant copiously took notes. The FGDs were conducted in Dangbe, the local language, while the notes were written in English to render them manageable for the English-speaking primary researcher. The quantitative fieldwork was carried out by seven Dangbe-speaking fieldworkers between the ages of 19 and 23 years. Training of field workers was carried out prior to data collection to equip fieldworkers for the rigors of fieldwork, and to ensure quality through proper translation of the sensitive questions of the research tool. The data collection tool was a 43-question, closed-ended questionnaire. All data, qualitative and quantitative, was gathered during the last week of October and the first three weeks of November 2007.

Sampling
Five key informants were interviewed for this study, their professions ranged from a pastor, a community health nurse at a local clinic, a district disease control officer, and two Ghana Health Service National Program Managers. The key informants were chosen due to expertise in various topics affecting the health-seeking behaviors of adolescents. Four FGDs were held, two in Zongo and two in Agomeda. The focus groups in Agomeda included adolescents from Ologotsowe. Community contacts purposefully selected participants from various households using provided criteria on age and sex. The focus groups were separated into male and female discussions, and included forty-three adolescent participants in total. The minimum number of participants in the FGDs was nine and the maximum was fourteen. One hundred and four persons were interviewed using the questionnaire. The sample size was determined using EpiInfo statistical software; 7,198 adolescents reside in the Dodowa sub-district, thus a minimum of ninety five respondents were determined as the sample using an acceptable frequency of 50% with a worst acceptable frequency of 40% and a confidence level of 95%.  The number of respondents interviewed was distributed among the three communities based on relative population size. Using the Demographic Surveillance System (DSS) data available in Dodowa, all adolescents in the three communities were randomized in order to select specific households from within the communities.  Field workers targeted individuals from the randomized list until the goal number of respondents within each community was reached. Equal numbers of adolescents were interviewed from the Dodowa Area Council (Zongo) and the Ayikuma Area Council (Agomeda and Ologotsowe).

Data Analysis
All data was entered using EpiData, and analyzed using SPSS statistical software. All relationships deemed significant in the study were calculated using a 95% confidence interval. Means and cross tabulations utilizing Chi-Square tests were the most frequently used calculations.

Quality Assurance Precautions Taken
Sexual behavior, and all the social factors surrounding this topic, is inarguably a sensitive issue. Previous studies of health-risk behaviors in the district had proven the welcoming attitude of community members to studies of sensitive natures. Although knowledge of this previous experience lessened the worry of objections from assumed traditionally minded religious leaders, parents and community members, appropriate steps were still taken to mollify any potential dissent.  Community entry strategies were carefully upheld, insuring that a community leader had previous knowledge of every FGD or disembarkation of data collection. To enhance honesty and candidness, respondents were advised to not give their surnames. Questionnaire-led interviews began with demographic information and eased the respondent into information concerning knowledge of STIs and sexual health services, as well as perceptions of adolescents with STIs and their health-seeking behaviors, before finally leading into detailed questions about religiosity and religious influences in sexual health decision making.

Results
Basic Demographic Characteristics
Table 1 shows the essential demographic characteristics of survey respondents; similarly distributed data holds true for the demographics of the FGD participants. In each area council, two more girls were interviewed than boys, but the same number of adolescents were involved from both area councils. The average age was 14 years, with all respondents being between the ages of 10 and 19 years. All respondents were single. The majority of respondents were in Primary or Junior Secondary School. There was similar distribution of males and females over the categories of education level, occupation, and ethnic group. The number of those who have been to school or are in school currently (98%) is of tremendous importance, as health programs including information about STIs take place in schools.

Table 1: Demographic Characteristics

 

 

Ayikuma Area Council [Agomeda & Ologotsowe Communities] 

N = 52
n                     %

Dodowa Area Council
[Zongo Community] 

N = 52
n                    %

Total 

 

 

N = 104
n               %

 

Gender of respondent

 

Age of respondent (years)

Respondent’s
Highest level of education attained

Respondent’s
Occupation

Respondent’s
Religious Affiliation

Ethnic Group

 

 

Male

Female

 

10-14

15-19

 

None

Primary

Junior Secondary School (JSS)

Completed JSS/ In SSS

 

Student

Unemployed

Other

 

Christian

Muslim

 

Ga-Dangme

Ewe

Akan

Northern

Hausa

 

25                   48

27                   52

 

27                   52

25                   48

 

2                     4

25                   48

22                   42

3                     6
47                  89

2                    4

4                    7

 

45                  86

7                   14

 

39                  75

2                     4

3                     6

0                     0

8                    15

 

25                 48

27                 52

 

29                 56

23                 44

 

0                   0

21                 40

25                48

6                 12

46                 88

3                   6

3                   6

22                 42

30                 58

 

7                  14

13                 25

4                   8

1                   1

27                 52

 

50             48

54             52

 

56             54

  1. 46

 

2               2

  1. 44

 

  1. 45

9               9
93            89

5              5

  1. 6

67            64

37            36

 

46            44

15            14

7              7

1              1

35            34

In terms of religious affiliation, 64% of respondents are Christians and 36% profess to Islam. However, there are significant differences among religious affiliations, communities and ethnic groups. The vast majority of Muslim participants live in Zongo and are of Hausa ethnicity, while Christians live primarily in one of the Ayikuma communities and are of Ga-Dangme (67%), Ewe (21%) or Akan (10%) ethnicity. No respondents reported involvement in a traditional religion or with no religion at all. Both the religions of Islam and Christianity denounce pre-marital sex.

Perceptions of Adolescents who Contract Sexually Transmitted Infections
When asked of their opinions of someone who was their age and has contracted a sexually transmitted infection (STI), the respondents held a range of judgments. The majority of the respondents felt that the person in question was promiscuous (64%); nearly half believed that the infected was a bad person (48%), while 34% believed the person to be a prostitute. Of the respondents, 10% offered that the subject was foolish, 8% felt that the person was uneducated and the same percentage stated the adolescent with the STI was ‘not religious’. The FGDs yielded similar comments; participants volunteered information on how an adolescent who contracts a STI would usually be “the town helper,” a local phrase describing promiscuity. In the FGDs, there was often argument about the religiosity of the adolescent in question, with all groups deciding that both religious and non-religious persons could contract a STI. The same conclusion was drawn about educated versus uneducated adolescents. One description, that of the adolescent being an embarrassment to his/her family, only received one percent of the responses, yet it was often discussed in the FGDs.

When asked where someone who had contracted a STI would go to seek medical care, nearly every respondent (95%) perceived someone would go to the health facility; 25% perceived that someone would go to the traditional healer; 11% believed that a prayer camp would be the destination for treatment; 10% thought someone would go to the pharmacy; 5% thought the chemical shop would be the adolescent’s target location; 3% believed the adolescent would go to the Planned Parenthood Association of Ghana (PPAG); 2% felt that God would cure the person; and 1% thought that a drug peddler would provide medical care.

The respondents who perceived the health facility as the place where the adolescent would go, believed that they would go there because it offered the best care. FGD participants added evidence to this notion by providing examples of potential treatment mechanisms offered at the health facility. Respondents perceived that the traditional healer would be inexpensive, provide a sense of comfort, serve as a hide out (a private place that would conceal the infection from community members), and that the healer would be friendly. The FGD participants echoed these sentiments, professing that when one had no money for the clinic, they would go to “[the traditional healer] because that’s where they can get cured”. The reasons to attend prayer camp are because it is free and a hide out. The pharmacy is also targeted because of cheapness, but those who perceived adolescents as going there cited quality of care and friendliness of staff in a significant number as well. The chemical shop was chosen for its cheapness and closeness in proximity. Those would go to PPAG because it is perceived as religiously acceptable. The lone percent that believed the drug peddler would be a place of destination mentioned its inexpensive nature as the reasoning behind this choice for medical care.

Table 2: Perceived Health Providers for Adolescents and Their Beneficial Aspects

Name of Health Provider Percent Chosen Beneficial Aspects
Health Facility 95% Best care
Traditional Healer 25% Inexpensive, comfortable, hide out, friendly
Prayer Camp 11% Free, hide out
Pharmacy 10% Inexpensive, best care, friendly
Chemical Shop 5% Inexpensive, close in distance
Planned Parenthood Association of Ghana 3% Religiously acceptable
Drug Peddler 1% Inexpensive

Nearly all respondents believed that infected adolescents would go somewhere for support, with only one percent noting “nowhere” as a response. Father (65%), mother (63%), friends (38%), the health facility (33%), religious leader (12%), and a boyfriend or girlfriend (7%) were other perceived support outlets.

Reasons behind Health-Seeking Behaviors
On the quantitative research tool, adolescents were asked to respond with the extent to which they agreed (choosing either strongly agree, agree, do not know, disagree, or strongly disagree) to a number of statements regarding sexual health services. When prompted with a statement about the cost of the health facility, 73% agreed or strongly agreed that it was, in fact, too expensive. A majority (62%) of respondents agreed that transport to the nearest health facility was easy to obtain. FGD participants also agreed with these statements, often mentioning that the health facility had the best care, but that the cost would drive adolescents to seek care elsewhere.

When asked to state the extent to which they agreed that they would be comfortable approaching a nurse at the health facility with a STI, 80% agreed or strongly agreed that they would be comfortable. Also, 61% disagreed that the nurse would shout at them, 54% agreed that they would have enough privacy, and 38% disagreed that they would be too ashamed to seek sexual health services at the health facility. However, for the large minorities that felt that the nurse would shout at them (39%) or that they would have insufficient privacy (46%), there was a significant relationship with also feeling too ashamed to seek services (52%).

Respondents also answered questions about their general knowledge of STIs. 96% of respondents had heard of STIs, gaining this knowledge from a teacher (83%), a friend (41%), a parent (30%), the mass media (18%), a religious leader (14%), or a nurse (4%). All respondents who had heard of STIs had heard of HIV/AIDS, 45% had heard of gonorrhea, 21% knew of syphilis, 13% had heard of candidiasis, and 2% had heard of chancroid. None of the adolescents surveyed had heard of chlamydia, trichomoniasis, or genital herpes. Respondent awareness of gonorrhea, syphilis, and chancroid increased significantly with increased education level. Age also played a significant role in the knowledge of gonorrhea, older adolescents knew of the disease more often than younger adolescents.

Adolescents who heard of STIs from a teacher were more likely to also hear of gonorrhea in addition to AIDS knowledge. If the adolescent heard about STIs from a nurse, they were more likely to have heard of chancroid and candidiasis, in addition to gonorrhea and HIV, than other adolescent respondents.

Of the 96% of respondents who had heard of an STI, 86% had seen or heard of someone with a STI. Also, 80% of these respondents knew that he/she could access sexual health services at the health facility. When asked to reply with the extent to which they agreed with the statement, “I would know if I had contracted a STI”, 30% strongly agreed, 8% agreed, 25% disagreed and 37% strongly disagreed.

The Effect of Religion
The questionnaire included a notable amount of questions regarding religion, but examination into the effect of religion can also begin to be described by significant relationships between answers to some of the questions already discussed. For example, those who would perceive that other adolescents would go to their religious leader for support after contracting a STI also believed that these adolescents would go to prayer camp for medical care.

Those who heard about STIs from their parents or religious leaders were usually Christians. Of the small percentage (2%) who heard about STIs from PPAG, all were Muslim adolescents. The discussion groups in Zongo (the predominantly Muslim community) also discussed how PPAG would talk to adolescents about STIs outside of religious gatherings at the mosque.

All 7% who perceived that other adolescents would go to their respective boyfriend or girlfriend for support were of the Christian faith. Significantly more Muslim adolescents held the perception that other adolescents would use their religious leader as a support outlet after STI contraction.

Table 3: Significant Religious Differences

Respondent heard about STIs from a parent
Yes No Total
Christian 25% 40% 65%
Muslim 5% 30% 35%
Total 30% 70% 100%
Respondent heard about STIs from a religious leader
Yes No Total
Christian 13% 52% 65%
Muslim 1% 34% 35%
Total 14% 86% 100%
Respondents heard about STIs from the PPAG
Yes No Total
Christian 0% 65% 65%
Muslim 2% 33% 35%
Total 2% 98% 100%
Adolescent would go to boyfriend or girlfriend for support
Yes No Total
Christian 7% 58% 65%
Muslim 0% 35% 35%
Total 7% 93% 100%

Three questions were asked to gauge the religiosity of respondents. The first question asked about religious background; just under two thirds of respondents were Christian (64%) and just over one third were Muslim (36%). Depending on their aforementioned religion, the respondents were asked either how often they attended worship services or how often they went to the mosque or prayed. Of Christians, 50% attend worship services once a week, 45% attend two or more times in a week, 4% attend one or more times a week, and 1% attend less than once a week. Of Muslims, 89% pray or go to mosque five times a day, 9% go more than once in a day but less than five times a day, and 2% never go to the mosque.

When asked to declare the extent to which they agreed with the statement, “I am a devoutly religious person”, 71% strongly agreed, 25% agreed, and 4% disagreed, no one strongly disagreed. There was no significant difference in the frequency that the Muslim respondents pray or go to mosque and how devout they proclaimed themselves. However, for Christians, those who attend worship services more frequently considered themselves more devout than those who attend services less often.

To a large extent (81%), respondents disagreed or strongly disagreed that their religion influences their decisions about seeking STI services. However, there is a significant difference between the responses of Muslims and Christians to this statement. Of the 19% who agreed or strongly agreed, a significant number were Muslims. 86% of respondents disagreed that thoughts about God or Allah influenced their decisions about seeking sexual health services.

Table 4: Religious Influence on Decisions about Seeking STI services

Religion influences decisions about seeking STI services
Strongly Agree Agree Disagree Strongly Disagree Total
Christian 3% 4% 22% 36% 65%
Muslim 7% 5% 7% 16% 35%
Total 10% 9% 29% 52% 100%

Respondents from both religions disagreed that their religion directs them to shun people who have contracted STIs. 83% disagreed or strongly disagreed and 17% agreed or strongly agreed. Different thoughts were expressed during the FGDs, with at least two participants in every discussion mentioning how their religions tell them to “separate” themselves from those who are infected.

Respondents from both religious backgrounds strongly agreed that they would be more inclined to visit sexual health services supported by a faith-based group. 64% strongly agreed, 26% agreed, while only 8% disagreed and 2% strongly disagreed with the statement.

In FGDs, feelings were mixed in regard to seeking services for a STI from a nurse with which one fellowships. In one discussion, all respondents gave a resounding “yes” when asked if they would go to a health worker with whom they fellowshipped.  In the other discussions, participants were worried that the nurse would point fingers at the adolescents, that the nurse would tell others including colleague nurses and church elders, and that, as an adolescent, one would be too shy to see a nurse they worshipped with because it would mean that they had not listened to the lessons taught in church. Some participants would prefer to seek care from a nurse that they fellowshipped with due to potential sympathy this nurse would have for them. Other participants said they would prefer to seek medical attention from a stranger. Overall, the results from the questionnaire proved similar to those of the FGDs; 61% agreed or strongly agreed that they would prefer to seek care from a nurse with which they fellowshipped, one percent did not know, while 9% disagreed and 29% strongly disagreed.

Respondents from both religious backgrounds agreed or strongly agreed that they would be more inclined to visit sexual health services if their religious leader recommended it. 48% strongly agreed, 14% agreed, 10% disagreed, and 28% strongly disagreed that they would be more inclined to visit services with the leader of the religion’s recommendation.

The questionnaire proposed four statements about certain health topics discussed during religious gatherings, to which respondents could strongly agree, agree, disagree, or strongly disagree, based on the extent to which these topics were talked about. The four topics ranged from broad topics such as health services and adolescent health services to STIs and HIV/AIDS. Health services are discussed at both Christian and Muslim religious gatherings, with 87% of respondents agreeing or strongly agreeing and 13% disagreeing or strongly disagreeing. Adolescent health services are discussed at a similar rate, with 86% agreeing (71% strongly agreeing) and 14% disagreeing or strongly disagreeing. STIs are talked about less often, with 64% of respondents agreeing that they are discussed and 36% disagreeing. HIV/AIDS is talked about in the least amount of respondents’ religious gatherings, with 55% agreeing and 45% disagreeing that the disease is discussed. However, there is a significant difference between the amount of Christian and Muslim respondents’ religious gatherings that speak about HIV. Christian religious gatherings speak about it notably more often than Muslim religious gatherings. The vast majority (93%) of respondents wish that information about their health were dispensed during religious gatherings.

The final statement on the questionnaire was, “Abstinence is the only way to prevent sexually transmitted infections”, to which 72% strongly agreed, 12% agreed, 7% disagreed and 9% strongly disagreed. Following this statement were three questions used to understand the amount of respondents who were sexually active and also what their boyfriend or girlfriend status was. 14% had a boyfriend or girlfriend, 21% have had a boyfriend or girlfriend at some point in their lives, and 14% have had sex.  There was no significant relationship between boyfriend/girlfriend status, sexual activity and any of the above results from the survey.

Study Limitations
This study was limited by the time available, and the small sample size represents only preliminary findings about the state of adolescent sexual health in Ghana. Although out-of-school youth were not excluded from the study, the difficulty in locating them within the time constraints almost left them completely out of the results.

There were differences found between the religions surveyed; yet due to lack of time, no leaders of the Muslim faith were interviewed in the qualitative arm of the study. This study lacks data on followers of traditionalist beliefs, as none of the 104 respondents to the questionnaire, nor the 43 participants in the FGDs subscribe to traditionalist faiths.
This study did not look into the specifics of cost variations among sexual health services offered. The term “inexpensive” was used to describe several services, but this is a relative term.

There was also some confusion to whether, in regard to Muslims, “religious gatherings” included gatherings outside of the mosque. This was not addressed during the FGDs and was corrected to include gatherings both inside and outside of the mosque for the quantitative survey.

Not to be forgotten is the inherent discomfort that some respondents may have had answering questions about taboo topics. Although much attention was devoted to easing the adolescents into the more sensitive questions, sheer humility on the part of the respondents could have limited what they were willing to truthfully answer.

Discussion and Recommendations
It is clear from the findings that adolescents harbor a negative perception towards other adolescents who have contracted a STI. When words such as ‘promiscuous’ and phrases such as ‘bad person’ roll of the tongues of adolescents during FGDs with other adolescents with whom they are not necessarily familiar or comfortable, it is not hard to imagine the negativity surrounding the contraction of a STI.

During an in-depth interview with a parent of adolescents, who also happens to be a GHS National Program Manager, she explained the popular notion that the generation gap between parents and their children prevents adequate knowledge exchange.

“Generally adolescents are suspicious of adults, and their own parents, because they know that parents want them to tow a certain line… I think that they think we are not as civilized as they are. They look at us with suspicion. They siphon information, they will not tell you everything, and it depends on how a parent is with a child, even if you are very close to a child they do not want to disappoint you. So it is not easy for them to seek services especially if they think someone will go and tell your mother.”

When in reality, the data collected rejected this misconception; the most preferable source of support for STIs is parents: 67% said they would go to their fathers for support and 65% said they would use their mothers as a support outlet.

The negative perceptions also have great bearing on many of the reasons why adolescents seek sexual health services in the manner that they do. In particular, the focus groups revealed that having a STI is shameful to one’s family, especially in that when the public finds out, “No one would want to marry from such a family”. This embarrassment was not reflected in the quantitative, closed-ended research tool. The open-ended responses during the FGDs and in-depth interviews led to greater understanding of this association between STIs and the perception of embarrassment.

The findings suggest that there are a multitude of reasons behind the health-seeking behaviors of adolescents when faced with a STI. From the results, you can infer what was apparent from the FGDs: that adolescents would go to the health facility if they were looking for quality care, but that cost impedes this route and forces them down a road of non-formality and, in general, lower quality care. Shame affects health-seeking behaviors, as a significant number of adolescents cite “hide-out” as a beneficial aspect to the place from where they would perceive others as seeking care. Not to be underestimated is actual knowledge that one is presenting with a STI.

Knowledge that adolescents can access services at the health facility is not a colossal problem, as 80% know about these available services. It is more the lack of knowledge of the diseases contracted through unprotected sex and the symptoms involved with these diseases that presents a problem. Only 38% of respondents who had heard of STIs would agree that they would know if they had contracted one of these infections. The sources of knowledge that provide the little information that adolescents do know range from teachers, friends, parents, the mass media, and religious leaders. However, Muslim respondents hear about STIs significantly less often than their Christian counterparts from parents and religious leaders.

Wherever adolescents obtain information on STIs, the scope of information is severely limited. Of STIs, HIV/AIDS is far and away the most recognizable, with 96% of respondents familiar with the disease. The rest of the spectrum of STIs is where this knowledge gets hazy, less than half (45%) know of gonorrhea, less than a quarter (21%) have heard of syphilis, and only an eighth have heard of candidiasis, while negligible quantities have heard of chlamydia, chancroid, trichomoniasis, and genital herpes. These numbers are similar to the reports from most recent data in Ghana, but that does imply a sufficient level of knowledge by any means (7).

Teachers supply knowledge most often, to about 81% of respondents, but teachings from these pedagogues is suspected to be insufficient as shown by the general lack of knowledge held by adolescents. Gonorrhea was the only disease that students who had heard about STIs from their teachers knew more often than adolescents who did not hear from their teachers. Comments by a community health nurse and also from both GHS National Program Managers interviewed confirm the general lack of information teachers are able to disperse:

“Teachers –there is a life skills subject in schools- that has [STIs] as a component, but most teachers are not able to teach this in a correct way. Most schools don’t have capable teachers to teach these skills. So we need health workers to come and teach it. STIs should be part of our health education as one of the priorities.” – GHS National Program Manager

The community health nurse re-iterated the necessity of having correct lessons of sexual health in schools, and explained that when possible, she and a team of nurses will go to schools and educate. However, busy schedules and lack of coordination sometimes prevent the health workers from visiting every school, and they most definitely cannot visit consistently enough to ensure information retention. An improved school health program, utilizing coordination between the Ministry of Education and the Ministry of Health could make for huge gains in STI knowledge.

Other reasons, besides knowledge, that have an effect on the health-seeking behaviors of adolescents are less concrete. Although privacy inside the health facility was not a huge issue, with less than half reporting it a problem, the public nature of the facility may serve as a barrier. One-fifth of respondents perceived adolescents as seeking services because these services doubled as a “hide out”. During an interview, a nurse from the health facility reproduced these thoughts, and explained how, from her personal experience, adolescents would arrive to the facility via a back entrance or show up at her door for treatment. “Hide out” was also suggested to be an appealing quality of services provided by the traditional healer and at prayer camp. The health facility has begun to rectify their public nature, by beginning the construction of a building specifically designed for adolescents that will serve to enhance privacy and will be built adjacent to the current health clinic. The successful integration and utilization of this adolescent facility will be crucial in the promotion of safe health-seeking behaviors.

Although the friendliness of staff was not something that drew adolescents to seek care at the health facility in a statistically significant number, there are findings that suggest that services at the health facility are adolescent-friendly. One of the GHS National Program Managers interviewed mentioned that in the past decade, making services adolescent-friendly has been one of the overarching goals of the National Adolescent Health Program. She reflected on the reasons why health workers were unfriendly in the past and the reasons that adolescents would not go to the health facility to seek care:

“The health workers began to explain their reasoning for being unfriendly, they said, ‘You know, when you are in the medical school or the nursing school, adolescent health is mentioned in passing, nobody really teaches it as a whole subject for you to follow through with. So it is like when young people come, you feel uncomfortable because you feel inadequate’….[Adolescents] have complained about our negative attitudes. Confidentiality is lacking in most of our facilities and sometimes you are in a consultation, and others are listening or looking on.”

In the sub-district in which this study was conducted, it seems that the campaign to educate health workers on the needs and sensitivity of adolescents has paid off to a certain degree. A surprising amount (33%) of adolescents would go to the health facility for support. The large majority (80%) would be comfortable approaching a nurse with a sexually transmitted infection and 61% disagreed that the nurse in question would shout at them. However, the percentage that believed the nurse would shout also believed they would not have enough privacy and significantly agreed that they would be too ashamed to seek services from the health facility. More directed research is needed to fully analyze the effectiveness of the adolescent-friendly services campaign, and these figures only serve as initial findings into an evaluation.
It is irresponsible to ignore the effect that religion has on adolescents in regard to sexual health practice and the health-seeking behaviors that follow sexual intercourse. Although undoubtedly devoutly religious, Christian adolescents in this study say that religion does not influence their decisions about seeking sexual health services. Muslim respondents constituted the minority of adolescents surveyed who believe that religion does influence their decisions about seeking sexual health services. The disconnect between the thoughts that a religious leader has and the actual practice of adolescents is exemplified in this quote from an interviewed pastor:

“Yes, religion affects great decisions on [seeking sexual health services].  If only we (the leaders) can teach it, it has great affects on those decisions.”

86% of adolescents say that their health is discussed in religious gatherings. Yet, these percentages drop when topics such as STIs and HIV/AIDS are specified. As mentioned previously, 64% of respondents’ religious gatherings have talked about STIs and 54% have talked about HIV.  This could be due to a variety of reasons, the least most likely not being the comfort level of religious leaders in speaking about these issues and also the perceived relative importance of discussing these issues in services. Yet, the fact that a majority of religious gatherings do touch on these issues shows that leaders and congregations are concerned about the health of adolescents.
This also provides an illustration of how religious gatherings could be more effectively used in the distribution of sexual health statistics, advice, and counsel. From statements regarding the frequency that Christians speak about STIs in religious gatherings, it is fair to say Christian adolescents hear about STIs more often from their religious leaders than Muslim adolescents. Christian adolescents also hear about STIs from their parents much more often than their Muslim peers.

One pastor expressed that he does speak about STIs, but not about the disease facet of the infection, only that contraction should be avoided:

“We don’t directly teach them about the effect of AIDS, the disease aspect, but we teach them about the sin aspects against God. In involving yourself in pre-marital sex, you are not married and God never allowed you to enter into that pre-marital sex, so if you do it – it is against God’s word. Yes we do talk about it with adolescents during services.”

He later agreed that putting these expectations on adolescents would increase the stigma of diseases such as AIDS, because:

“Yes, [stigma] would be something that is attached to an adolescent who had a sexually transmitted disease …God’s word tells us that you must have no company with such a one because of the sin being committed.”

Although Muslim adolescents did not report hearing about STIs and HIV in religious gatherings at a high rate, they did mention in the FGDs that PPAG would meet with them outside of the mosque to discuss sexual health issues. The Muslims who said that they heard of STIs from PPAG also were more likely to hear of syphilis in addition to knowing about gonorrhea and HIV. Thus, PPAG provides a good alternative for Muslims who may be denied this knowledge during everyday calls to prayer. Yet, despite not hearing about STIs from their religious leaders, it is interesting that Muslim adolescents perceive others as using religious leaders as support outlets. Significantly more Muslim adolescents held this perception over Christian adolescents. Further research into the dynamics of Islam in relation to support systems is needed in order to explore this finding fruitfully.

Also, regardless of religious background, adolescents wish that information about their health were distributed at religious gatherings. 93% of respondents agreed with this desire and it made no difference how much previous health information had been dispensed. This proves the curiosity of adolescents and their interest in their personal health.
With this realization of interest, religious leaders and health workers must distribute realistic and useful information on STIs. 84% of adolescents in this study believe that abstinence is the only way to prevent STIs. Only 16% know that they have other options. This would not be so alarming if the 16% happened to include the 14% who have had sex. However, there is no relationship. Thus, it can be inferred that adolescents are having unsafe sex and are ignorant that they have options to protect themselves once they have made the decision to have sex. In-depth interviews, FGDs, and common knowledge purports that abstinence is taught in worship services. This practice is fine, but additional information must be interspersed with abstinence to give a well-rounded education on STI prevention and treatment. If nurses trained religious leaders, in the same way that health workers have been trained to improve their adolescent health skills, leaders would feel more comfortable discussing adolescent sexual health issues.  If these nurses were taken from within their congregation or mosque, it could alleviate the discomfort with the issues even further.

The discourse that surrounded the preference of visiting a nurse for a STI with whom you fellowship released more evidence that religion greatly affects the psyche of adolescents when deciding to, or not to, seek sexual health services. Adolescents said they would be more inclined to visit services if their religious leader recommended it.  An endorsement of the health facility’s services by the religious leader may increase the already 61% who would prefer to seek care from a nurse they fellowship with.
Programming involving health workers or nurses within religious gatherings (or outside of, similar to PPAG’s work) would be the ideal way to consistently spread information about STIs.  Those who heard about STIs from nurses knew more types of the infections than any other category of respondent. It is important to either use these knowledgeable citizens to enhance the knowledge of teachers, religious leaders, and parents, or to use them directly to dispense information. A GHS National Program Manager shares this view, and speaks on how she was brought in to speak on sensitive issues after a worship service:

“The religious people will call us when they are having major campaigns and I was called by this Methodist church about maternal death. And I didn’t go with abortion, but I mentioned all the things that were happening, but people bring up abortion and that it is a problem. See, you don’t want to address the problem, but if people are comfortable with talking about it, because it is not comfortable, then you can address it. So, yes, some of the best practices are religious groups.”

If more health workers undertake programs similar to this one, at a more frequent rate, on topics such as STIs and HIV, knowledge would begin to spread and deaths spawned from the fertile reproductive tracts of adolescents would decrease.

Conclusion
From the results, the outlook may seem bleak for an adolescent who contracts a STI.  The negative perceptions attached to the diseases, the unreliable non-formal care routes often chosen by adolescents, and the general lack of knowledge of symptoms of the various STIs seem to add to the mounting social problems affecting this age group. Yet, the interest in learning more about these infections that is possessed by adolescents, an interest discerned from observation in FGDs and also gleaned from interviews of health workers, makes the situation appear brighter. One community health nurse from a health facility in the sub-district studied stated this about the curiosity of adolescents during health programming in schools:

“…And the adolescents, they want to know more. They ask more and more questions at school health. The education must be better. Not once in a while…no…the education must be continuous.”

This nurse is stressing the importance of more regular and routine education for adolescents, something that deserves a look from multiple angles and can be derived from the aforementioned analysis.

Although it has been shown that religiosity has an inverse relationship with adolescent sexual behavior in developed countries, the same cannot be said to hold true in Ghana (8). Religiosity has no bearing on the number of respondents in this small study who have had sexual intercourse, as nearly all who have had sex declared their devoutness to Christianity or Islam and provided evidence to this declaration through frequency of church attendance. Adolescents disagree that religion affects their decision-making in regard to seeking health services and also disagree that thoughts about God or Allah influence their decisions about sexual health services.

This is not to say that religion does not play a large part in their lives. With roughly 98% going to church more than once a week and the same percentage going to mosque many times in a day, religious gatherings still consume a large portion of their time. Adolescents say that they would be more inclined to visit faith-based sexual health services along with any services that their religious leader recommends. This recommendation could alleviate the negative perception of the disease and unlatch more avenues for information distribution. This leaves the door open for discussion about how effective services and education can be better implemented. Could religious gatherings become hubs of effective STI information distribution? It is hard to gauge the willingness of leaders in adopting lessons that do not only teach abstinence. Although controversial, religious gatherings could be a powerful way to educate about STIs, consequently reducing STI transmission and slowing the ongoing epidemic of AIDS.

References
1. UNFPA. (2005). “The Unmapped Journey: Adolescents, Poverty and Gender”. The State of World Population. Retrieved on October 14, 2007 from file:///Users/mattcrommett/Desktop/dangme%20west%20research%20project%20/7.%20UNFPA%20
State%20of%20World%20Population%202005.webarchive

2. UNFPA. (2005). Overview: Ghana. Retrieved on October 16, 2007 from http://www.unfpa.org/profile/ghana.cfm

3. Koster, Kemp & Offei. (April, 2001). “Utilization of Reproductive Health Services by Adolescent Boys in the Eastern Region of Ghana”. African Journal of Reproductive Health. Vol. 5, No. 1, pp. 40-49.

4. Okonofua, Friday. (2000). “Adolescent Health: Future Challenges”. African Journal of Reproductive Health. Vol. 4, No. 1, pp. 7-12.

5. Adaba, Godfried. (2005). “Young People and Sexually Transmitted Infections in Ghana”. Karolinska Institutet.

6. Addai, Isaac. (March, 2000). “Religious Affiliation and Sexual Initiation among Ghanaian Women”. Review of Religious Research. Vol. 41, No. 3, pp 328-343.

7. Awusabo-Asare, K. et al. (2006). “Adolescent Sexual and Reproductive Health in Ghana: Results from the 2004 National Survey of Adolescents”. Guttmacher Institute.

8. Woodruff, Timothy J. (1985). “Premarital Sexual Behavior and Religious Adolescents”. Journal for the Scientific Study of Religion. Vol. 24. No. 4, pp. 343-366.