The study explored community perceptions and experiences of the stakeholder’s role in teenage pregnancy prevention, using the community-as-partner model. The study was contextual with an exploratory strategy. The research design is both qualitative and quantitative designs. The sample size for the study was determined by saturation of data and consisted of 75 participants who were teenagers, parents, teachers, professional nurses and community leaders living in the study area. The qualitative data gathering method was self-report using a semi-structured interview. Template analysis style was combined with content analysis using open coding according to Tesch’s approach for data analysis. The findings revealed that although teenage pregnancy initiative was in existence in the community, the majority of participants, especially the teenagers were not informed about it. All the participants (n = 75) viewed teenage pregnancy as a common occurrence in the community. Majority of the parent sample (10 of 15) in the study discouraged the use of contraceptives by teenagers for pregnancy prevention. The study provided evidence of the applicability of the “Community-as-Partner” Model in the prevention of teenage pregnancy. The findings of the study gave an insight to the level of community participation in teenage pregnancy prevention. The evidence generated from the study could serve as a departure point for the development of community-specific interventions in teenage pregnancy prevention.
Key words: Teenagers, teenage pregnancy, community stakeholders, community-as-partner model, contraceptives, termination of pregnancy.
Teenage pregnancy and parenthood has been a common recorded experience throughout history. The birth of an infant to a teenager represents a sudden role transition which has consequences not only for the teenager and her infant but the entire family system (Whitehead, 2007). Globally, early pregnancy and childbirth is closely linked to a host of critical social disadvantages, such as poverty and income disparity, overall child well-being, out-of-wedlock births and low educational status (Rosenthal et al., 2009:281; National Campaign, 2010).
The children of teenage mothers are more likely to have low birth weight, grow up in poverty and have higher risk of accidents, behavioural problems and becoming teenage mothers themselves (American College of Obstetricians and Gynecologists, 2007). Also, teenage mothers are more likely to suffer from anxiety and depression (Department of Education, 2009). Teenage childbearing has serious consequences for teenage mothers, their children and the entire society but despite the negative consequences of teenage pregnancy and childbirth worldwide the rate is still high. In the United States of America (USA), teenage pregnancy is reported to have occurred throughout the country’s history (Grant and Hallman, 2008; Centre for Disease Control, 2010; National Campaign, 2010; Solomon, 2011).
Although, South Africa has had enormous success since 1994 in achieving gender parity in basic education, teenage pregnancy remains a menace. This has under-mined the Department of Basic Education’s success towards ensuring female children contribute towards a good life, free of poverty, by remaining in school (Panday et al., 2009). Despite the notion that the campaigns against teenage pregnancy in South Africa are yielding positive outcomes, reports suggest the figures are still too high. The official statistics from the Department of Health shows a 13.2% reduction in teenage pregnancy rate between 2009 and 2010 (Hanson, 2009). In South Africa, teenage pregnancy is regarded as a hurdle because teenagers are responsible for 40% of all pregnancies in the country and close to 35% give birth before they are 19 years. Of all teenage pregnancies, 7% was reportedly amongst 15 to 16 years old and the remaining 93% amongst girls aged between 16 and 19 years (Macleod and Tracey, 2009).
Some researchers have indicated that teenagers are at risk of pregnancy and sexually transmitted infections due to the lack of adequate information on contraceptive use and sexual health prior to their being sexually active (Tette and Ladha, 2003; Department of Health, 2004; Jewkes and Christofides, 2008; Macleod and Tracey, 2009; Solomon, 2012). In the opinion of others, teenage pregnancy and parenthood are frequently the results of family dysfunction (Xu and Shtarkshall, 2004; Holgate et al., 2007; Solomon, 2012). Available evidence has revealed that teenage pregnancy is not a simple social problem that can be addressed with appropriate educa-tional and health promotion but through comprehensive evidence based approaches (Best Start and SIECCAN, 2009).
The motivation for the study was the high rate of teenage pregnancies in the study area and the lack of a structured community approach to reduce the incidence of teenage pregnancies. The high rate of teenage preg-nancies in the study area is a major concern to parents, teachers, health professionals and the community at large. The aim of this study was to generate evidence based data for community based interventions towards the prevention of unplanned teenage pregnancy.
The community-as-partner model (Anderson and McFarlane, 2008) was chosen to guide the study as the focus of the model is health promotion of individuals and families within the context of the community. There are two central factors in this model (Figure 1.), a focus on the community as partner and the nursing process. The community as partner is represented by the community assessment wheel which represents the people that constitute the community, which include three parts: the community core, the community subsystems and the community perceptions. The first part of the community assessment wheel and the community core is divided into four aspects, which are the history, demographics, ethnicity, as well as the values and beliefs of the population. The community subsystem comprises eight subsystems that can influence the community. The eight subsystems are physical, environment, education, safety and transportation, politics and government, health and social services, communication, economics and recreation. The last aspect of the community assessment wheel and the community perceptions consists of the people’s feelings about their community and the potential problems that can be identified in the community.
The application of the theory in this study was the evidence needed to develop guidelines for community based intervention that can be implemented at the community level. This could help in preventing unplanned teenage pregnancy in order to ensure that the goal of the community-as-partner model is achieved. This will assist in maintaining a system of equilibrium and a healthy community, which include the preservation and promotion of community health
MATERIALS AND METHODS
The study was conducted in a township located in the Gauteng Province of South Africa. The strategy for the study was exploratory while the research design was qualitative. The target population were teenagers, parents, teachers, professional nurses and community leaders residing in the study area. The sampling method was convenient and purposive. The inclusion criteria for the study were teenagers between 13 and 19 years of age, parents of a male or female teenage child (if female, pregnant or not pregnant) between 13 and 19 years of age, high school teachers in the study area teaching pupils from Grade 7 to 12, professional nurses working with teenagers in primary health care clinics, religious and community leaders who reside in the study area and willingness to participate. The sample size was determined by saturation of data, which was achieved when 75 participants had been interviewed (15 participants from each sample group), each sample was saturated independently. A total of 60 interviews were analysed with new categories and 15 interviews analysed without new categories evolving. Referential adequacy was attained, partially fulfilling the requirement of trustworthiness (Lincoln and Guba, 1985).
Data gathering was through semi-structured interviews, using an interview schedule that was developed using the community assessment wheel of the community-as-partner model, which is the study theoretical framework for the study. Before the commence-ment of the study, approval were obtained from The Research Ethics Committee of the Tshwane University of Technology, the Gauteng Department of Health Tshwane Research Committee, Gauteng Department of Education, the Facility Manager of the Primary Health Care clinic and the School Principals, whose schools learners were interviewed. Prior to any interview, each participant’s rights was explained and informed consent and assent (due to the young age of some of the participants as they were less than 18 years, assent was obtained from the participants and consent from parents or legal guardians) were obtained, as well as the permission to use an audio recorder. To guarantee privacy, the interviews were conducted in a private room with only the participant and the researcher present. All the participants were in-terviewed within a period of five months (June to November, 2012).
For data analysis, a combination of three qualitative data analysis methods were used which include; the template analysis style, content analysis using open coding and the quasi-statistics (Polit and Beck, 2008; Creswell, 2009). The template analysis style was necessary for possible comparison of the five sample’s findings while the quasi-statistics was used as a validating method to ensure that the inferred themes and categories precisely reflect the perspectives of the participants involved in the study. To ensure trustworthiness, strategies, such as interpersonal relationship and trust building, triangulation of data gathering methods, peer examination, member checking, authority of the researcher, nominated sample, dense description, consensus with the independent coder and dependability audit were employed.
The findings of the study are presented according to the themes and sub-categories generated from the data (Table 1). Each of the themes is described with a summary of the categories.
Demography profile and knowledge of community based teenage pregnancy prevention programmes
In this study, a total of seventy five participants were interviewed (n = 75). As shown in Table 2, apart from the teenage participants, whose ages ranged from 13 to 19 years, the highest proportion of the teachers, professional nurses and parents were from the age group 31 to 40 years (32.0%), compared to community leaders with the highest proportion from 41 to 50 years (28.0%). The gender distribution favoured females, 73.4% (55 of 75). In terms of socio-cultural groups, the Tswana group had the highest members, 34.6% (26 of 75) followed by the Pedi, 17.3% (13 of 75). With respect to knowledge of community-based teenage pregnancy prevention programmes, the majority of participants (62 of 75) were not aware of any programmes, activities or interventions that are currently in taking place at the community level focusing on the prevention of unplanned teenage pregnancies. While only 13 of 75 (2 parents and teachers’ sample, 4 professional nurses as well as 5 of 15 of the community leaders but none of the teenage participants) were aware of intervention programmes in the community. Programmes mentioned were school health nurses, youth clinic and health seminars organised by the Department of Health.
Community core: Values and beliefs
In terms of meaning and acceptance of dating, the consensus meaning of dating was a way of having fun but not including sexual intimacy (59 of 75). Regarding the acceptance of dating in the community, the majority of the participants (59 of 75) responded that dating is acceptable, but 26 of the 59 added the stipulation of only after 18 years. Only a small group (16 of 75) indicated dating was not accepted in the community. Although, dating was not seen as behaviour that is accepted culturally (54 of 75). One response was:
“No my culture does not allow dating, it is a taboo in my culture” (a teacher)”
With respect to the occurrence of teenage pregnancy, all the participants (n = 75) viewed it as a common occurrence in the community while in the case of acceptance of teenage pregnancy, more than two-thirds (64 of 75) of the participants indicated it was not accep-ted. The majority (13 of 15) of teenagers and teachers, almost all (14 of 15) parents and community leaders and almost two thirds (9 of 15) of professional nurses indicated that pregnancy amongst teenagers is not accepted. When asked about the extent of family support for pregnant teenagers, the majority of the participants (64 of 75) indicated most families do give support. They specified the continued support by family members is essential in maintaining the pregnancy, as well as the care for the baby after birth.
“Yes teenage pregnancy is becoming a norm you see in different section or streets. There are about 5 girls in my street now, even younger than my age, some 2 to 3 years younger, like 15 years, who are already pregnant. Some even have two children already” (a teenager).
The risk factors for teenage pregnancy in the community, as indicated by the participants, were categorised as personal and psychosocial, family, societal and media pressures and economic risk factors. To compare the responses of the samples, the following grading scale was used:
A total number of 8 responses and above (n = 15) indicated a yes √, indicating that the majority of the sample had the same perception;
As shown in Table 3, the perceived causes of teenage pregnancy, as indicated by the participants were grouped into four categories, which include, personal and psychosocial factors, societal and media pressures, family and economic reasons. Only teenagers mentioned the maintenance of the relationship as a cause of teenage pregnancy.
On the recognition of role played in teenage pregnancy prevention, all the participants (n = 75) recognised that they have a role to play in the prevention of teenage pregnancy in their community either by participating in sexuality campaigns or to encourage teenagers to abstain or use contraceptives. With respect to teenage pregnancy prevention strategies, the participant’s respon-ses were grouped into sex education, preventive health care, youth participation and community engagement strategies and family life strategies (Table 4). In the case of the target age group in teenage pregnancy prevention initiatives, the majority (41 of 75) of the participants indi-cated that it will be more helpful to commence sexuality education before the age of 10 years, however, (34 of 75) of the participants are of the opinion that it should commence after the age of 10 years.
Community subsystems: Health and social services
In terms of knowledge of contraceptive, all the partici-pants (n = 75) had previous knowledge of contraceptives although some, especially the male participants (20 of 75), had inadequate knowledge. With regards to the acceptance of contraceptive use by teenagers, almost two thirds (43 of 75) of the participants accepted the fact that teenagers should use contraceptives, especially the professional nurses (11 of 15). However, just more than one third (32 of 75) of the participants discouraged teenagers from using contraceptives (10 of parents sample, 5 of the teenagers and teachers, as well as 7 of 15 of the community leaders).
On the effectiveness of contraceptives, the participants’ perception of the effectiveness of contraceptives was explored to determine if they had confidence in its usage and more than two thirds (57 of 75) belief if used properly they were efficient. When the issue of parental consent for teenage contraception use was explored, the majority (48 of 75) of the participants indicated it was important to involve parents, as teenagers are still minors, however, one third (27 of 75) cautioned that involving parents could discourage teenagers from using contraceptives. These were some of the reasons offered:
“No, I will never encourage contraceptive use, because if you encourage it you are encouraging immorality, which is against the word of God and His commandments. Never, my child should abstain, which is what God says” (a community leader).
No, because it is not a solution to pregnancy prevention but abstinence is the real thing” (a parent).
“No, it is not necessary to…..because if you ask their parents to come, then they will not use it” (a professional nurse).
In terms of the safety of the school environment, the majority (43 of 75) of the participants indicated that the schools environment is safe and conducive to learning, but more than one third (32 of 75) did not believe this to be so. Of concern, was that the majority (9 of 15) of the teenage sample, more than one third (6 of 15) of parents sample, one teacher, half (7 of 15) of the professional nurses and two thirds (9 of 15) of the community leaders mentioned some teachers had sex with school girls resulting in many becoming pregnant. One response was:
“I can say no because some of the male teachers get attracted to our girls and they are using them, they just sleep with them, they are failing as teachers, many of the girls are impregnated by teachers, you see they are not safe even in the school”(a parent).
On the significance and existence of parent-child communication, all the participants (n = 75) described parent-child communication as a way that parents can communicate, interact or build rapport with their children, or openness between parents and their children. The majority of the participants (61 of 75) indicated the existence of parent-child communication in their homes especially the professional nurses and the community leaders. However, more than half (8 of 15) of teenage samples declined the existence of parents-child communication in their homes.
With respect to parents’ involvement in teenage sexuality education and participation in their child’s education, all the participants (n = 75) indicated that parents can be involved in teenage sexuality education by educating and giving them adequate information. This is achievable by inviting parents in the community to the clinics for necessary sex education and by attending parents-teachers meetings at schools where they can receive advice on how to get involved in teaching their children sex education. Similarly, parents can also receive sex education in churches or during community meetings. Two thirds (50 of 75) of the combined sample indicated that most parents are not actively involved in their child’s education. Two thirds (10 of 15) of the teenagers, parents and professional nurses, almost two thirds (9 of 15) of the teachers and the majority (11 of 15) of the community leaders all indicated that most parents are not actively involved in their child’s education. The participants’ views on how teenagers can resist pressure from their peers were categorized into personal responsi-bility and determination and family and community support (Table 5).
Community perceptions: Perception
The knowledge of sexual experimentation among the teenagers showed that sexual experimentation among teenagers is not culturally acceptable in the community (n = 75). Only few (11 of 75) of the participants were of the opinion that sexual experimentation among teenagers is accepted by some parents in the community. The majority (12 of 15) of teenagers and parents, almost all (14 of 15) of the teachers, the majority (13 of 15) of professional nurses and community leaders believed teenage sexual experimentation is not accepted in the community. The perceived consequences of teenage pregnancy and child bearing as indicated by the partici-pants were categorized into health, economic and social consequences (Table 6). A notable difference was the teenagers’ perception that the community will reject them if they became pregnant but none of the other samples perceived rejection at all.
As teenagers attempt to discover mutually satisfying relationships, basically through friendship and marriage, the successful ability to negotiate this stage can result in intimacy that can be experienced at a deep level. Isolation and distance from others can take place if this stage was unsuccessful (Arlene and Harder, 2012). According to Whitehead (2007:148), teenage child-bearing in some parts of South Africa is celebrated as it is seen as an evidence of fertility. As found in the study, majority of the participants (64 of 75) signified that most families do support their pregnant teenagers. Jewkes and Christofides (2008), highlight the role of low socio-economic status on teenage pregnancy prevention as it influences teenagers’ social environment as well as their access to quality information and education. Other rea-sons are the lack of confidential, sensitive and affordable contraceptives services, as well as the denial of precise and honest education on sex (Mbokane and Ehlers, 2007:8). Furthermore, poor family relationships and family factors have also been linked to increased risk of teenage pregnancy. In this study, poverty and social grants, alcohol, substance abuse, rape and incest, lack of love, divorce and parental guidance, failure to use contraceptives, peer pressure and lack of discipline amongst teenagers were indicated by all the participants as varying reasons for teenage pregnancy in the community.
A universal access to sexual information and skills is necessary for all young people, as they will have to deal with their sexuality at some point in time so as to be able to make informed sexuality choices (Panday et al., 2009).
In this study, all participants mentioned the importance of sex education campaigns at schools, abstinence from sex by teenagers, avoidance of alcohol and drug usage and the provision of recreational facilities for teenagers are some of the effective ways or the preventive strategies of teenage pregnancy.
Academic skills and educational aspirations are recognized inhibitors of teenage pregnancy. Teenagers who are deprived, as well as those with low educational achievement are at greater risk of teenage pregnancy (Department of Health, 2004). Anderson and McFarlane (2008), explained that stressors are tension-producing stimuli that have the ability of causing disequilibrium in the system which can originate from inside or outside the community. The degree of reaction, according to Anderson and McFarlane (2008) is the disruption, because of stressors affecting the community’s line of defence, and can be reflected in the community teenage pregnancy statistics, for example. The last aspect of the community assessment wheel and the community perceptions consists of the people’s feelings about their community and the potential problems that can be identified. In the study, teenage pregnancy was viewed as a common occurrence by all the participants who also highlighted several consequences of teenage pregnancy in their community.
According to Anderson and McFarlane (2008), health is defined as a resource for everyday life and not the objective of living. The focus of the model is health promotion of individuals and families within the context of the community and nursing is seen as prevention. All aspects of nursing are considered to be preventive so as to improve the health and well-being of the community. Community development enables community members come together to interact as a collective unit, express a sense of community and move to community action, which in this case is the intervention programme on the prevention of unplanned teenage pregnancy. An inter-vention programme must bring about health promotion with community collaboration. It was indicated that when it comes to the issue of teenage pregnancy prevention, a single intervention strategy by only a sector of the society will not solve the problem but a comprehensive approach which connects and foster linkages with one another (Panday et al., 2009; Solomon, 2011).
The study provided evidence of the applicability of the community-as-partner model to community participation in teenage pregnancy prevention. The model focuses on the community as a whole and partnering with the community stakeholders is an important aspect of wor-king in the community. The main function of the nurse is to assist the community to reach, maintain and promote health issues with the aim of acting as a health advocate or facilitator so that the community can have the neces-sary power that will help to control its reaction to the high prevalence of unplanned teenage pregnancy within the community. As a result the community normal line of defence is expected to be strengthened, an increased resistance to stressors by the community. In line with the principles of primary health care, it is the community’s (stakeholders) competence to attend to its own problems that strengthen its lines of defence that leads to comprehensive teenage pregnancy interventions.
Based on the findings of the study, the following are recommended:
1. Cultural myths/beliefs that encourage teenage pregnancy should be corrected by the registered nurses. This could be done through the provision of health educa-tion to parents and the community at large, where the disadvantages of teenage pregnancy are properly emphasised.
2. Professional nurses should organise regular sexuality education campaigns and workshops in the clinics, schools, community centres and religious settings. Early sex education at home by parents and other adults should be encouraged.
3. Parents and guidance should be encouraged by the teachers and other community stakeholders to participate adequately in their children’s education as well as in all other aspects of life. Parents should attend parent-teachers meeting and do regular follow-up on their children performances and behaviours in the school.
4. Lastly, health professionals need to work together with the government and all non-governmental organizations that are providing youth-friendly services and campaigns to inform teenagers and the community at large about teenage sexual and reproductive health.
5. The community at large should be made to understand the importance of open communication between parents and their children. This could be done through the use of campaigns, workshops and rallies in the clinics, community centres, social, cultural and religious groups.
6. Provision of comprehensive reproductive healthcare, contraceptives and preventative services that are confidential and anonymous in the clinics, schools, community and youth centres by registered nurses. Registered nurses should emphasise to teenagers the significance of regular, long-term and proper use of contraceptives.
7. Contraceptive use amongst sexually active teenagers should be encouraged by all stakeholders in the community, especially the practice of dual protection, which involves safe and protected sex. The Departments of Health and Education should provide extended clinical services in schools in order to provide accessible confidential services to teenagers.
8. Safe and conducive school environments that are able to monitor learners’ movements, prevent sexual harassment specifically by the teachers and provision of adequate security should be guaranteed by the school authority. Appropriate punishment of teachers found guilty of abusing their students must be ensured.
9. Teenage sexual experimentation should not be condoned without proper sex education starting early from homes, clinics and at school by the parents, professional nurses, teachers and other community stakeholders.
10. And conclusively, community awareness campaigns about the possible consequences of teenage pregnancy and childbirths should be undertaken.
The limitation of the study is the purposive and convenient sample of teenagers and the community stakeholders (parents, teachers, teenagers, professional nurses, religious and community leaders) living in the study area, hence the results are not generalizable to a larger context.
The authors are grateful to the Tshwane University of Technology for providing the funds for this investigation. The authors are also grateful to all who granted them permission for this study to be conducted and every stakeholder who agreed to be interviewed.
CONFLICT OF INTERESTS
The author(s) have not declared any conflict of interests
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