Contraception in Adolescents

#### **Chapter 1**

## Adolescents' Access to Contraception in Lesotho: A Gender and Social Inclusion Perspective

*Mathoka Khaile*

#### **Abstract**

Adolescents' access to contraception is a serious global and regional concern as a public health component. Therefore, this chapter analyses adolescents' access to contraception, using gender and social inclusion lens, where the access to contraception services and information is explored. Thus, legislative and administrative measures as well as practices focusing on access to contraception are analysed in this chapter, using desk review and content analysis from the gender and social inclusion perspective. The results reveal that Lesotho is a state party to treaties that obligate states to ensure access to contraception for adolescents from the gender and social inclusion perspective, and this has also been implicated in the Constitution of Lesotho. However, other laws do not provide for gender- and social-inclusive access to contraception for adolescents. Administratively, the National Family Planning Guidelines for Health Service Providers of 2017 and National Strategic Development Plan II are the only strategies that are gender-responsive and use social inclusion lens to facilitate access to contraception for adolescents. Other policies are gender-blind and silent about adolescents and access to contraception. Lastly, statistics show that many adolescents do not have access to contraception, and gender- and social-inclusion issues are not taken into consideration.

**Keywords:** adolescents, access, contraception, gender, social inclusion

#### **1. Introduction**

Contraception is one of the most significant determinants of fertility in developing countries [1]. The World Health Organisation emphasises that there is no method of contraception contraindicated on the basis of age alone [2]. Thus, this statement extends to adolescents who have the right to sexual and reproductive health services, including contraceptive care and counselling [3]. However, adolescents' access to contraception is a serious global and regional concern as a public health component [4]. Hence, Cook and Dickens argue that national healthcare services fail to respond to sexual and reproductive health needs of adolescents [5]. In addition, adolescents

of Lesotho have a challenge of accessing contraception at the health facilities [6], thereby increasing the vulnerability of adolescents to pregnancy and sexually transmitted infections [7]. Adolescence is a challenging stage for young people who rely on 'their families, peers, schools and health service providers for affirmation, advice, information and the skills to navigate the sometimes difficult transition to adulthood' [8]. For instance, statistics reveal that adolescents engage in sexual debut at a progressively younger age [9, 10], and this practice is linked to an increase in teenage pregnancy and sexually transmitted infections (see [7], p. 136). 50% of teenage pregnancies are unintended and result from low contraceptive usage [11].

Besides challenges faced by adolescents globally and regionally, the Government of Lesotho has made some strides to provide contraception to adolescents with the aim of promoting sexual and reproductive health and rights in the country. In this endeavour, the government is supported by development partners, international nongovernmental organisations and the civil society. Nevertheless, it is not clear if the access to contraception for adolescents has gender and social integration, even though it is expected that access to contraception is experienced differently by different groups of adolescents in the society in terms of gender, disability, geographic location and education. It has been noted that adolescents are a heterogeneous group. Therefore, it is significant to examine how adolescent girls and boys, as well as other socially excluded adolescents, have access to contraception in Lesotho. Thus, legislative and administrative measures as well as practices focusing on access to contraception shall be discussed in this chapter, using desk review and content analysis from the genderand social-inclusion perspective.

#### **2. International human rights law and adolescents' access to contraception**

Articles 2, 11 and 18 of the Vienna Convention on the Law of Treaties provide that once a state party accedes to an international or regional treaty, it is bound by the treaty and has to refrain from acts that would impede the achievement of the treaty's objectives and purpose [12]. Therefore, human rights treaties, of which Lesotho has ratified or acceded to, are binding, and they are analysed in relation to the adolescents' access to contraception through gender- and social-inclusion lens. The following human rights treaties are ratified by Lesotho and are analysed in this section: International Covenant on Economic, Social and Cultural Rights (ICESCR), Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), Convention on the Rights of the Child (CRC), Convention on the Rights of Persons with Disabilities (CRPD), African Charter on Human and Peoples' Rights (Banjul Charter) and Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa (Maputo Protocol).

#### **2.1 International covenant on economic, social and cultural rights**

Article 12 of this covenant enjoins state parties to have the provision for the reduction of the stillbirth rate and infant mortality and for the healthy development of the child. In addition, according the General Comment 14 of the Committee on Economic, Social and Cultural Rights, access to sexual and reproductive health services should not be hindered by practices based on conscience. That is, provision of sexual and reproductive health services should not be hampered by conscientious objection. Although this article is not specific about adolescents' access to

#### *Adolescents' Access to Contraception in Lesotho: A Gender and Social Inclusion Perspective DOI: http://dx.doi.org/10.5772/intechopen.112715*

contraception as one of the sexual and reproductive services, it is relevant to adolescents' access to contraception because if they do not have access to contraception for controlling their fertility or reproduction, some adolescents are prone to having unhealthy child development due to not having been developed enough to take care of babies. Furthermore, when the adolescents do not have access to contraception, they are susceptible to having stillbirths and infant mortalities, as contraception is effective for preventing pregnancy and reducing its adverse effects among both adolescents and babies [13].

It is noted from the provisions of the ICESCR, especially article 12, that it does not have a gender- or social-inclusion lens for adolescents' access to contraception. It is gender-blind and does not integrate social-exclusion considerations related to access to contraception for adolescents in Lesotho. Therefore, the state is not bound by the treaty to ensure that different categories of adolescents in different geographic locations of Lesotho have equal access to contraception, thereby necessitating strengthening sexual and reproductive health for Basotho adolescents, especially access to contraception in order to prevent unintended pregnancies that may result in maternal death due to unsafe abortion. 'Unsafe abortions continue to contribute to high maternal death numbers in the SADC region' [14]. According to the United Nations Population Fund, governments are obliged to take affirmative actions that ensure adolescents' access to contraception in both law and practice, applying a human rights-based approach [15]. The UNFPA assertion implicates that the international and domestic laws need to make provisions for access to contraception for the adolescents, although the ICESCR is silent on this issue.

Nevertheless, the General Comment 14 of the Committee on Economic, Social and Cultural Rights (CESCR) expounds that access to contraception should not be impeded by practices based on conscience; thus, the International Covenant on Economic, Social and Cultural Rights is against a social norm of regarding contraception as a taboo for adolescents, thereby deterring adolescents' access to contraception. Thus, there is a need to adopt social norms approaches that will be used to challenge conscientious objection in relation to providing adolescents with contraception because of age. In accordance with social norms approaches, the misalignment between people's behaviours, attitudes and existing social norms should be harnessed in order to effect change [16]. Strategies could include changing gender norms and attitudes among an influential group [17]. Accordingly, there should be strategies geared towards changing gender norms and attitudes of policymakers as an influential group in relation to access to contraception by adolescents. Parents also need to be targeted as they have influence on adolescents, thereby controlling their access to contraception. Inversely, active participation of parents in ensuring access of contraception to adolescents will result in making supportive parents to adolescents' access to contraception. Adolescents are reluctant to seek sexual and reproductive health services because of systematic and legal barriers; adolescents also do not want their parents to find out that they are sexually active [18].

#### **2.2 Convention on the elimination of all forms of discrimination against women**

Article 12 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) provides that states parties should ensure equal access of men and women to health-care services related to family planning. Moreover, article 16 obligates states to ensure that women have a right to decide on the number of children to have and how to space them, and the CEDAW Committee General Recommendation

24 on article 12 states that women should not be impeded by states to pursue their health goals. A commitment to the two articles implicates that Lesotho is expected to avail equal access to sexual and reproductive health services, which include access to contraception, thereby including respecting other fundamental human rights. Cook asserts that the right to liberty and security of a person is violated when his/her fertility is denied by the state [19]. Therefore, Lesotho provides for access to contraception for adolescent girls concomitantly with CEDAW, even though it has been noted that the convention regards adolescent girls as a homogeneous group. Access to information about contraception and contraceptive services is determined by different factors such as literacy, age geographic location, disability and social norms.

Furthermore, the CEDAW Committee raised a concern about Basotho women's limited access to quality sexual and reproductive services in rural and remote areas [20]. As a result, the committee urges the state to ensure that women in rural areas and remote areas do not have barriers to access to family planning information and services and to promote education on sexual and reproductive health targeting adolescent girls and boys. Sochacki argues that the CEDAW Committee should do more to pressurise states parties to increase access to contraception as many international treaty-monitoring bodies have not fully exercised their powers to ensure that member states comply with ensuring access to contraception. It is against this backdrop that it has been discovered that although Lesotho has ratified CEDAW, thereby necessitating access to contraception by adolescent girls, there is no compliance to international law. Adolescent girls do not have access to contraception. Therefore, the CEDAW Committee needs to devise monitoring tools that will ensure that Lesotho ensures access to contraception for adolescents, using a gender- and social-inclusion lens in order to prevent maternal mortality and morbidity linked to adolescence. Culwell et al. state that states must provide enough health care to prevent maternal mortality and morbidity, as well as reduce unwanted pregnancies and unsafe abortions [21], as Maziwisa argues that the right to contraception is intricately linked to the right to life [see 18].

#### **2.3 Convention on the rights of the child**

Article 24 of the Convention on the Rights of the Child (CRC) obligates states parties to take effective and relevant measures to abolish traditional practices that are prejudicial to the health of children. Traditional practices which are detrimental to the health of children include teenage pregnancy or the practice of young mothers (young mothers are female adolescents who have babies), and the aforesaid practices affect both adolescent girls and boys, adolescents living in the urban or rural areas, literate or illiterate, and adolescents without or with disabilities. Cook asserts that article 9(1) of the International Covenant on Civil and Political Rights (ICCPR) read with article 19 of the CRC shows that lack of access to contraception-related information, education and services violates adolescent girls' rights to liberty and security of the person (see [19]). Therefore, impeding access to information and education about contraception by the adolescents is a violation of fundamental human rights.

Failure to ensure access to sexual and reproductive health and rights (SRHR) education results in increased risk of early pregnancies that may result in complications such as foetus loss, infant mortality and vesicovaginal fistulas for adolescent girls (see [19]). That is why Durojaye argues that there is a strong existing correlation between adolescent girls' literacy and sexual and reproductive health and rights [22]. 'Literacy facilitates access to SRHR information and can help reduce early pregnancies, STIs,

#### *Adolescents' Access to Contraception in Lesotho: A Gender and Social Inclusion Perspective DOI: http://dx.doi.org/10.5772/intechopen.112715*

HIV, and early marriage, especially in the rural areas where adolescent-friendly services are not easily accessible' (see [18]). Therefore, states must facilitate education on the correct use and effects of contraceptives to enable adolescent girls to protect themselves when they begin exploring their sexuality (see [18]). Nevertheless, more focus on the raised arguments is based on adolescent girls as a homogenous group, not unpacking all groups of adolescents.

The Committee on the Rights of the Child General Comment No.20 states that all adolescents need access to confidential, adolescent-responsive and nondiscriminatory sexual and reproductive health services that include contraception, because access to high-quality child-friendly sexual and reproductive health services could transform the situation [23]. In addition, General Comment No.4 emphasises that states should reduce maternal morbidity and mortality in adolescent girls. This implies that the practice of deterring adolescents from having access to contraception as a social-exclusion practice is a prejudice against adolescents which may negatively affect their health. In addition, article 3(1) of the CRC enjoins states parties to take all actions concerning children, prioritising the best interests of the child. Similarly, in cases where the child's views and/or interests are distinct from those of parents, the best-interests test can be used to legitimately respect the child's right to receive sexual and reproductive health services, including counselling and treatment, and override parental consent. Thus, failure to facilitate access to contraception by adolescents does not prioritise the principle of the best interest of the child because when adolescents prioritise not to bear children, yet there are no contraceptive services that help them prevent pregnancy; they are more prone to unintended pregnancy that may result in adverse health effects. Kangaude et al. posit that adolescent pregnancy and childbearing have adverse health and social effects on adolescent girls [24]. Therefore, Lesotho as a state party to CRC has committed itself to facilitate access to contraception for the adolescents in order to protect and improve their health, although the convention does not precisely refer to gender- and social-inclusion considerations.

#### **2.4 Convention on the rights of persons with disabilities**

The Convention on the Rights of Persons with Disabilities (CRPD) enjoins states parties to recognise that persons with disabilities (PWDs) have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability. Thus, article 25 provides that states parties should ensure access to gender-sensitive health services which include sexual and reproductive health services to persons with disabilities. However, the Committee on the Rights of Persons with Disabilities Draft General Comment No. 3 of 2016 notes that women with disabilities are denied access to information related to contraception and family planning because they are assumed to be asexual, yet they have the right to choose the number and spacing of their children like all women. Moreover, children with disabilities lack access of a full range of appropriate and freely chosen contraceptives; as a result, adolescent girls with disabilities experience unwanted pregnancies and sexually transmitted infections [25].

It has been noted that Lesotho has ratified CRPD; therefore, it is obligated to provide adolescents with disabilities with access to gender-sensitive contraception. Thus, the expectation is that this provision of the CRPD is reflected in the healthrelated legislation, policies, guidelines and practices of the Kingdom of Lesotho. Nevertheless, there are also some gaps identified in the convention: PWDs have

been stated as a homogeneous group in the convention. As a result, literacy issues and geographic locations of other people with disabilities have been ignored by the convention.

#### **2.5 Protocol to the African charter on human and peoples' rights on the rights of women in Africa**

Under the African human rights system, Lesotho has ratified the African Charter on Human and Peoples' Rights (Banjul Charter) and African Charter on Human and Peoples' Rights and Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa (Maputo Protocol). The Banjul Charter is silent on contraception or sexual and reproductive health; nevertheless, article 14 of the Maputo Protocol focuses on sexual and reproductive rights of women in Africa. Article 14 binds states parties to ensure that the right to sexual and reproductive health of women is respected and promoted, including the right to choose any method of contraception, control fertility, have family planning education and decide whether to have children, the number of children and the spacing of children. Accordingly, Maziwisa argues that article 14 of the Maputo Protocol protects the rights of adolescent girls to family planning education, controlling their fertility by deciding whether to have children, the number and spacing of children and choosing any method of contraception [see 18]. Maziwisa further states that Maputo Protocol obligates states to ensure that they protect adolescent girls against sexually transmitted infections such as HIV and AIDS and stay informed about their own or partners' health status, especially if they are infected with sexually transmitted infections.

In addition, Maziwisa asserts that article 14(2) enjoins states to take appropriate measures geared towards providing enough, affordable and accessible sexual and reproductive health and rights education in rural areas. The cost of contraception services and methods may be too costly for adolescents, thereby prohibiting them from accessing contraceptives [26]. Therefore, Lesotho has committed itself to provide adolescent girls with affordable and accessible sexual and reproductive health and rights and education in the rural areas. On the other hand, Maputo Protocol does not have provisions for adolescent boys and specific provisions for adolescents with disabilities. Thus, the protocol does not entail contraception issues for adolescents through the gender- and social-inclusion lens, thereby leaving gaps for binding Lesotho to ensure equitable access to contraception for adolescent girls and boys, even though it could be argued that the protocol is gender-specific – it is focusing on women only in Africa.

#### **3. Domestic laws for adolescents' access to contraception in Lesotho**

This section entails constitutional provisions and other statutory provisions that link access to contraception for adolescents, and they shall be linked in conformity with international norms.

#### **3.1 Constitution of Lesotho**

Sexual and reproductive health rights of adolescents, including a right to contraception, are enshrined in the Constitution of 1993, which provides that every citizen has fundamental human rights and freedoms. Section 27(1)(a) provides that Lesotho

#### *Adolescents' Access to Contraception in Lesotho: A Gender and Social Inclusion Perspective DOI: http://dx.doi.org/10.5772/intechopen.112715*

shall adopt policies aimed at ensuring the highest attainable standard of physical and mental health for its citizens, including policies designed to reduce stillbirth rate and infant mortality rate and improve health development of the child. Thus, adolescents are citizens of Lesotho, and they have a right to health, including contraception. However, the right to health is non-justiciable because it is a socio-economic right in the Constitution of Lesotho. The right to health is closely related to and dependent on the realisation of the right to life [27]. 'Therefore, violation of the right to health is concurrently a violation of the right to inherent life' [28]. Moreover, the case of *International Pen and others (On behalf of Ken Saro-Wiwa) v Nigeria* links the right to health to the right to life [29]. The right to life is provided in Section 5 of the Constitution. Shah and Ahman assert that unwanted pregnancy is a serious risk to the life, survival and development of adolescents in Africa [30], thereby necessitating protection of life by ensuring that children avoid unwanted pregnancy and have access to contraception (see [24]).

Section 18 of the Constitution prohibits discrimination, and Section 18(2) provides that no person shall be treated in a discriminatory manner by any person acting by virtue of any written law or in the performance of the functions of any public office or any public authority. Kangaude et al. assert that non-discrimination means that health-care providers should not discriminate against minor girls in terms of access to contraceptives; moreover, states should be aware of intersectional discrimination in terms of age, gender and disability (see [24]). It seems that the Constitution does not discriminate between adolescents against access to contraception from the gender- and social-inclusion perspective, though it is not explicitly stated.

Furthermore, Section 14(1) provides for the freedom of expression for every person, including freedom to receive ideas and information without interference. According to UN Committee on the Rights of the Child (CRC) General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24), 17 April 2013, CRC/C/GC/15, children should express their views on accessing and using contraception, as well as their experience of the quality of care [31]. Therefore, health-care providers should provide appropriate information to adolescents in a manner that respects their level of maturity and engage the adolescents in decision-making according to their evolving capacities [32]. Section 14(1) of the Constitution of Lesotho protects different groups of adolescents against violation of the freedom to receive information about contraception and express their opinions about contraceptive services they receive. Therefore, the Constitution implicates access to contraception for adolescents using the gender- and social-inclusion lens because it makes a provision for freedom to receive information for every Mosotho.

#### **3.2 Children's protection and welfare act 2011**

Section 6 of the Children's Protection and Welfare Act of 2011 (CPWA) makes a provision of protecting adolescents against any form of discrimination on the basis of sex, disability or socio-economic status. Therefore, CPWA provides for equal access to contraception for adolescents where such services are available. In addition, Section 11(1) and (6) of the act upholds children's rights to access to sexual and reproductive health information appropriate to their age. Thus, the act provides for access to contraception information for adolescents. On the other hand, the enforcement of this law is a challenge [33]. Nevertheless, the act does not have provisions in terms of gender equality and social inclusion so as to ensure equal access to contraception

information. As a result, disadvantaged and marginalised adolescents are excluded from being protected by the aforementioned section of the CPWA. It has also been noted that the act is silent on access to contraception.

#### **4. Administrative measures for providing contraception**

This section provides details about administrative measures taken by the state to ensure that there is access to contraception. The measures will be analysed by looking into adolescents' access to contraception from gender- and social-inclusion perspective.

#### **4.1 Lesotho health policy 2011**

The objective of the Lesotho Health Policy of 2011 is to make pregnancy and childbirth safe for mothers and newborns and reproductive health services acceptable to individuals, families and communities. The policy measures include:


This policy facilitates adolescents' access to contraception where it makes reference to ensuring access to family-planning services to youth and promoting and enhancing adolescent sexual and reproductive health. However, the policy is genderblind because it does not clarify gender considerations linked to adolescents in terms of access to contraception. Furthermore, social-inclusion issues such as considering access to contraception in the rural areas and for adolescents with disabilities have not been part of the policy.

#### **4.2 Village health Programme policy 2020**

The Village Health Programme Policy's mission is to have equitable access to quality health services. Assumably, quality health services include sexual and reproductive health services that include equitable access to contraception for adolescents. Furthermore, one of the guiding principles of the policy is gender sensitivity and responsiveness, as well as special consideration of women because of their special reproductive role. The objectives of the policy include to extend health-care coverage to all citizens of Lesotho, including people with disabilities and people living in remote, rural and hard to reach parts of the country.

The policy generalises facilitation of equitable access to health-care services at the community level with a specific objective on inclusive health-care services. However, the policy is silent on adolescents as a group; they are assumed to be part of the society eligible for access to health-care services at the community level. Moreover, the policy is silent on access to sexual and reproductive health services, and therefore, it does not have policy objectives or strategic actions on access to contraception for adolescents. Thus, the Village Health Programme Policy of 2020

is not gender-responsive or socially inclusive for advancing access to contraception for adolescents at the community level.

#### **4.3 National Family Planning Guidelines for health service providers 2017**

The guidelines state that it is crucial to ensure that adolescents have access to youth-friendly contraceptive information, services and counselling in Lesotho. Furthermore, the guidelines provide that all individuals have a right to access to sexual and reproductive services, regardless of their gender or sexual orientation, marital status, age, religious or political beliefs, ethnicity or disability or any other characteristics which could make individuals prone to discrimination. In addition, one of the general guiding principles of these guidelines is that 'family planning services should be made available to all who need them, including adolescents, men and people with disabilities and special needs'. Lastly, there is a specific section about adolescents, including adolescents with disabilities, in the National Family Planning Guidelines for Health Service Providers.

The National Family Planning Guidelines for Health Service Providers guide health-care service providers to provide equitable and inclusive contraceptive services to adolescents, using a gender- and social-inclusion lens because the guidelines do not regard adolescents as a homogenous group. Therefore, these guidelines are responsive to the needs of adolescents in terms of access to contraception in Lesotho.

#### **4.4 National Strategic Development Plan II**

One of the strategic objectives of the National Strategic Development Plan II (NSDP II) 2018–2023 is to increase access, coverage and effectiveness of quality health-care service delivery for all by providing universal access to sexual and reproductive health-care services to all people, with a focus on adolescents, youth and other vulnerable groups. Thus, NSDP II plans to promote equitable and inclusive access to contraception to adolescents because it singles out adolescents and other vulnerable groups.

#### **4.5 Lesotho gender and development policy 2018: 2023**

The objective of this policy is to ensure access to health services to different groups of people of all ages and encourage male involvement in sexual and reproductive health issues. Furthermore, its strategic actions are to promote quality health for all regardless of gender or sexual orientation and provide a wide range of family planning methods and contraceptive options. The Lesotho Gender and Development Policy is not adolescent-responsive because it does not address adolescents' sexual and reproductive health issues from the gender perspective – it is silent about adolescents as a group. Apart from that, the policy is also silent about access to contraception for adolescents.

#### **4.6 National Adolescent Health Policy 2006**

The National Adolescent Health Policy of 2006 points out that male adolescents who herd animals are more likely to have their rights violated than other adolescents. Moreover, through this policy, the Government of Lesotho commits itself to ensure

that quality sexual and reproductive health services are available to all adolescents, and objective 4 of the policy is to reduce the levels of unwanted pregnancies among adolescents by raising the contraceptive use in sexually active adolescents by 20%.

The policy identifies male adolescents having barriers to access to sexual and reproductive services, thereby not having access to contraception. Therefore, this part is gender-sensitive. On the other hand, the target of 20% is not sex-disaggregated or disaggregated by social groups.

#### **4.7 Empirical findings**

Lesotho Demographic and Health Survey of 2014 shows that 79.9% of sexually active females aged 15–19 years were not using any contraception. It also shows pregnancy and pregnancy-related deaths that cause mortality for married and unmarried girls between the ages of 15 and 19 in Lesotho. According to 2016 Population and Housing Census Report of Lesotho, teenage pregnancy is as follows in Lesotho (**Table 1**).

In addition to the findings of the Population and Housing Census Report, the Lesotho Multiple Indicator Cluster Survey 2018 shows that adolescent birth rate1 is 59 in the urban areas and 114 in the rural areas; in ecological zones, it is 77 in the lowlands, 163 in the foothills, 114 in the mountains and 91 in the Senqu River Valley. Furthermore, the survey shows that the percentage of male adolescents aged 15–19 years who have fathered a live birth is 0.4% for both urban and rural areas.

The three reports show that there is high teenage pregnancy in Lesotho, and this implies that adolescents are still debarred from having access to contraception. Moreover, there are some identified gender gaps and social-exclusion issues in terms of access to contraception for adolescents. The surveys did not capture information on adolescents and contraception using a gender lens or focus on social inclusion issues. This shows that administrative measures to facilitate access to contraception for adolescents are not gender-responsive and integrating social inclusivity. Accordingly, the CEDAW Committee recommended Lesotho to target adolescent girls and boys with special attention to early pregnancy and the control of STIs by providing them with sexual and reproductive health education.


#### **Table 1.**

*Teenage pregnancy in Lesotho.*

<sup>1</sup> Adolescent birth rate is the number of births to women aged 15–19 years

*Adolescents' Access to Contraception in Lesotho: A Gender and Social Inclusion Perspective DOI: http://dx.doi.org/10.5772/intechopen.112715*

#### **5. Conclusion**

It has been found that Lesotho is a state party to different treaties which bind it to promote access to contraception for adolescents from the gender- and social-inclusion perspective, though some treaties are not gender-specific. Thus, Lesotho facilitates access to contraception for adolescents from the gender- and social-inclusion perspective in respect of international law, and this has barriers to implementation because provisions of treaties are only justiciable in Lesotho if they have been domesticated.

The Constitution of Lesotho implicates equitable access to contraception for adolescents from the gender- and social-inclusion perspective because the Constitution provides for gender sensitive and inclusive access to information on sexual and reproductive health. Nevertheless, the Children's Protection and Welfare Act does not have provisions on gender equality and social inclusion so as to ensure equal access to contraception information for adolescents. As a result, disadvantaged and marginalised adolescents are excluded from being protected by the law with respect to right to access to contraception. The act is also silent on access to contraception.

Administratively, National Family Planning Guidelines for Health Service Providers of 2017 and National Strategic Development Plan II are the only strategies which are gender-responsive and use social-inclusion lens to facilitate access to contraception for adolescents. Other policies are gender-blind and silent on adolescents and access to contraception. Lastly, empirical findings show that many adolescents do not have access to contraception, and gender- and social-inclusion issues are not taken into consideration where adolescents may have access to contraception. Therefore, concerted efforts of different stakeholders are required for advancing adolescents' access to contraception from a gender- and social-inclusion perspective in order to enhance universal access to contraception by adolescents in Lesotho.

#### **Author details**

Mathoka Khaile1,2

1 University of Pretoria, South Africa

2 Lesotho Nutrition and Health System Strengthening Project, Ministry of Health, Lesotho, South Africa

\*Address all correspondence to: mkhaile2014@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[25] Assefa N et al. Reported barriers to healthcare access and service disruptions caused by COVID-19 in Burkina Faso, Ethiopia and Nigeria: A telephone survey. The American Journal of Tropical Medicine and Hygiene. 2021;**105**(2):323-330

[26] Todd N, Black A. Contraception for adolescents. Journal of Clinical Research in Paediatrics. 2020;**12**:28-29

[27] CESCR General Comment 14 UN Doc E/C.12/2000/4 para 21

[28] Khaile M. Access to Emergency Contraception for Rape Survivors in Lesotho [Thesis]. Pretoria: University of Pretoria; 2019

[29] International Pen and others (On behalf of Ken Saro-Wiwa) v Nigeria

[30] Shah IH, Ahman E. Unsafe abortion differentials in 2008 by age and developing country region: High burden among young women. Reproductive Health Matters. 2012;**20**:170

[31] UN Committee on the Rights of the Child (CRC) General comment No. 15 on the right of the child to the enjoyment of the highest attainable standard of health (art. 24). 2013. CRC/C/GC/15

[32] Coughlin KW. Medical decisionmaking in paediatrics: Infancy to adolescence. Paediatrics & Child Health. 2018;**23**(2):138

[33] Shale I. Sexual and reproductive rights of women with disabilities: Implementing international human rights standards in Lesotho. In: African Disability Rights Book. Vol. 3. Pretoria, South Africa: University of Pretoria; 2015. p. 45

#### **Chapter 2**

## Adolescents, Social Media and Access to Reproductive Health Information and Services in Ghana: Prospects and Challenges

*Rahma Salifu and Abdulai Abubakari*

#### **Abstract**

Social media is one of the variables affecting sexual behavior among teenagers in today's society. This study was conducted in Tamale, Ghana, to examine adolescents' application of social media to access and use reproductive health services. The study involved 342 adolescents randomly selected from multicultural and diverse backgrounds of students drawn from four Senior High Schools in the Tamale metropolis of the Northern Region. Data was collected using semi-structured questionnaires and interview guides. The quantitative data were analyzed using STATA 16.0, chi-square test of association, and binary logistic regression at a 5% significance level. The study found that 45.4% of adolescents accessed reproductive health (RH) information through social media. The study showed that there was a significant association between using a mobile phone to access RH information and romantic relationship (p < 0.001), awareness of reproductive health (p < 0.040), respondents' place of residence (p < 0.040) and occupation of guardian (p < 0.040), mobile phone ownership (p < 0.004), social media use (p < 0.001), means of accessing RH using a mobile phone (p < 0.02) and whether their problem was solved (p < 0.001). The study concludes that, despite the high utilization of social media and awareness of reproductive health services, less than half (45.4%) of the adolescents use social media by adolescents to access adolescent reproductive health services in the Tamale metropolis.

**Keywords:** adolescents, social media, reproductive health service, knowledge, sexually transmitted infections

#### **1. Introduction**

The new digital media field has changed how young people obtain information and interact with one another [1]. Computer-mediated systems which allow individuals and communities to connect, interact, link and share content are known as "social media" Field [2]. Social media initiatives can instantly reach bigger followers via recognizable venues, using social networks' credibility and impact [3]. Social media platforms are constantly changing [4], as a result, young people

are increasingly communicating online instead of in person, and smartphones can obstruct face-to-face conversations adolescent females are avid users of social media as compared to boys, are more vulnerable to cyberbullying, and are more likely to suffer from mental health issues [5].

Approximately half the global population possesses a mobile phone, and 42% access the Internet Okeleke [6]. Peer pressure and unpleasant behaviors, such as cyberbullying, internet fraud, pornography, computer or cell phone gaming, video gaming are some of the few examples that social media can have adverse effects on adolescents' self-perception as well as interpersonal connections [5]. In the United States in 2014, 81% of 12–17 years used social media. Internet connectivity and social media use by young people in low- and middle-income nations are growing, although not to the exact extent as in high-income one's [3].

Social media platform is one of the variables affecting sexual behavior among teenagers in today's society. Using these platforms has positive and harmful effects on adolescents, particularly regarding sexual content. They learn through watching individual interactions displayed on these platforms and then assimilating them, notably when their personalities are recognized or seem spared from the consequences of their actions [7].

According to Jumia's Annual Mobile Report 2018, Ghana is one of the top mobile markets in Africa, with 34.57 million users and a subscriber base of 119%. (www. ghanaweb.com). According to a study by international digital organizations. We Are Social, and Hootsuite, Ghana has 5.6 million active social media users, 19.53 million phone users, and 9.28 million active wireless internet clients, making up 32% of the country's population. (www.businessworldghana.com).

Most teenagers prefer to be alone at this age rather than share time with their parents and family. Due to this, most parents find it challenging to hold conversations with their children. As a result, they get much of their sexual information from colleagues, friends, and social media. Adolescent interaction is most productive when it occurs within a client-therapist relationship that is transparent and nonjudgmental, fosters trust and mental comfort, and provides a sense of involvement and liberty [8].

Adolescents even have social media mentors as artists, actors, broadcasters, and entertainers. Those influencers frequently share details about their private lives, fashion choices, and views on sexual topics on social networks. Adolescents can be greatly affected by culture and the surrounding environment. As a result, adolescents pick up information from their surroundings. Their sexual behaviors are influenced by their mimicking or emulating sexual actions on social media. Adolescents acquire sexual practices including the frequency of sex depicted as appropriate on social media, several sex partners, casual sex partners, and contraception.

Social media users may be susceptible to concerns such as inaccurate self-diagnosis, decreased personal interaction, dependency, probable privacy violations, insecurities, and anxiety [9, 10]. Despite these obstacles, numerous studies have shown positive impacts linked with social media utilization, such as availability of information, support availability through online support groups, drive, and personal worth [11, 12].

Several studies have been conducted in Ghana on adolescent reproductive health information, service, and associated factors. An investigation was undertaken to evaluate the perception level and point out the main factors of measuring the standard of care [13]. A study on adolescent reproductive health to assess the influencing factors, education and the usage of reproductive health facilities indicates that 85% had the knowledge sexually transmitted infections as the prevailing issue, with 78% and 50% of adolescents had gone through reproductive health education [14].

*Adolescents, Social Media and Access to Reproductive Health Information and Services in Ghana… DOI: http://dx.doi.org/10.5772/intechopen.111768*

Adolescents experience mental, physical, physiological and mental challenges that affect their developmental and productive potential. Girls forced into undesirable relationships or marriages become victims of unsafe abortions, unintended pregnancies, high-risk childbirth, STDs, and even HIV. A study conducted in Yong Dakpemyili shows that 37% of pregnant adolescents have abortions, 11% go through cesarean section during delivery, 8.9% are stillborn and 7% have early neonatal mortality Field [15]. Adolescents frequently lack knowledge about sexually transmitted infections (STIs), pregnancy, HIV/AIDS screening and treatment, and other reproductive health issues, all serious health concerns in Ghana. As a result, the country's progress toward achieving Sustainable Development Goal 3 is hampered.

By the District Health Information Management System of Ghana Health Service, from 2016 to 2020, there are 555,575 adolescent pregnancies in Ghana; 13 teenage pregnancies were recorded each hour, and 110,000 were recorded in 2020. Despite the prospect of social media in disseminating juvenile sexual and reproductive information, this has not been explored in Ghana. For instance, there needs to be more research on how adolescents utilize social media to seek resources for reproductive health. In the Tamale metropolis, more study is required on this subject. Against this backdrop, this study aims to assess the contribution of social media usage in adolescent reproductive health services and information in the Tamale metropolis.

#### **2. Theoretical framework**

The Unified Theory of Acceptance and Use of Technology (UTAUT) serves as the theoretical foundation for this study. The need to employ technological innovation is influenced by performance expectations, effort expectations, and social influence [16]. The theory is renowned for examining the moderating impact of user demographics on the link between social media variables and user behavioral intention. This theory is an integration of eight other crucial theories, such as the Technology Acceptance Model (TAM) by [17], the Model of Personal Computer Utilization (MPCU) by Varela et al. [18], the Innovation Diffusion Theory (IDT) by Rogers [19], the Theory of Reasoned Action (TRA) by Fishbein and Ajzen [20], the Motivational Model (MM) by Davis et al. [21], the Theory of Planned Behavior (TPB) by Ajzen [22], Social Cognitive Theory (SCT) by Compeau and Higgins [23], and finally a Combined TAM-TPB (C-TAM-TPB) by Taylor and Todd [24]. It is crucial to note that UTAUT is shown to be a better acceptable predictor of the chance of technology innovation success after a thorough analysis of other reliable models [25]. UTAUT aids in a better understanding of the factors that influence adolescents' adoption of technology, who are notoriously aggressive and engaged in pursuing sexual and reproductive options. UTAUT is the preferred theoretical framework for this study because it has four aims. The Unified Theory of Acceptance and Use of Technology (UTAUT) is formulated after empirically examining the existing users' acceptance models and confronting the eight models described above. It is then validated. It is crucial to remember that sociocultural influences play a role in the social media usage of adolescents in Ghana. According to the theory, individual intentions to employ technological innovation are influenced by social influence, effort, expectations, and performance. Social media offer adolescents the space mentioned above. Peer influence, coupled with their youthful exuberance and desire to try new things, found expression in social media, which meets their expectations. The theory is well recognized for examining the moderating effect of user demographics on the association

between social media factors and user behavioral intention. UTAUT was chosen for this study because it is a more accurate predictor of the likelihood that technological advances will succeed [25]. UTAUT provides the required philosophical underpinning to understand the factors that influence technology acceptance and adolescents' use of social media to access sexual reproductive information so that the necessary policies can be developed.

#### **3. Methods**

#### **3.1 Study setting**

Tamale is the official capital town of the Northern Region. It also unofficially doubles as the capital of northern Ghana because it hosts all manner of people across the north and south of Ghana. It is a cosmopolitan settlement and the third-largest city in Ghana. In the past three decades, sporadic and spasmodic eruptions of ethnic, religious, chieftaincy and land conflicts, forced hundreds of people from the hinterlands to migrate to Tamale. The metropolis also has some of the best educational institutions in Ghana; three universities, two colleges of education, two nursing training colleges, about 20 Senior high Schools and more than 200 basic schools. Tamale also has some of the best health facilities, including the Tamale Teaching Hospital, Tamale West Hospital, Central Hospital, SDA Hospital, and many other private hospitals.

Tamale was chosen for the study because it has some of the best socio-economic infrastructure and offers opportunities to many people across the globe. Due to its cosmopolitan nature, it also has cultural diversity and offers a resemblance of miniature Ghanian and global cultures. More importantly, the study dwelled on Senior High Schools (SHS) because most of the adolescents using the social media are concentrated in these schools. Secondly, due to the computerized SHS placement system adopted in Ghana over a decade ago, the SSS comprises students from all over Ghana and from different geographical, religious, cultural and ethnic backgrounds.

#### **3.2 Study population and sampling**

Teenagers (10–19) enrolled in senior high schools in Tamale Metropolis were the target population. The formula for a point estimate sample developed by Snedecor and Cochran [26] was used to determine the sample size. In a survey by Marie et al. in 2020, they indicated that about 66.7% of teenagers used social media to look up health-related information. This study also adopted 66.7% proportion of social media usage as the basis.

$$\mathbf{N} = \mathbf{Z}\mathbf{2} \begin{pmatrix} \mathbf{P} \end{pmatrix} \begin{pmatrix} \mathbf{1} - \mathbf{P} \end{pmatrix} / \mathbf{m}^2$$

Z Standard value for %confidence level ( 95 ) = 1.96

P Proportion of social media usage for AS ( RHS % ) = 66.7 0.667 ( )

m margin of error % ( ) = 5 0.05 ( )

N –/ = 1.962 0.667 1 0.667 0.052 { }{ }

*Adolescents, Social Media and Access to Reproductive Health Information and Services in Ghana… DOI: http://dx.doi.org/10.5772/intechopen.111768*

N / = 3.8416 0.667 0.333 0.0025 { }{ }

N = 341.3

In all, the total sample size was 342 adolescents.

#### **3.3 Sampling technique and procedure**

The Tamale Metropolis has eight public senior high schools, including vocational ones. Using a multistage selection strategy, the adolescents for this study were selected for the sample. The first stage involved the simple random selection ('the lotto technique') of the Senior High Schools in the Tamale metropolis. This was to ensure that all the SHS have equal chances of being selected. Thus, four SHS were selected; Ghana Senior High School, St. Charles Seminary, Vitting Senior High and Tamale Girls' Senior High School. The second stage involved sampling adolescents from these schools. A proportionate-to-size sampling approach was used to determine the number of adolescents to be selected from each school. A simple random sampling approach was then used to select students eligible to participate in the study. The eligibility criteria were being an adolescent and having access to a computer or cell phone. Thus, 342 adolescents were selected. In addition, six focus group discussions (FGD) were held in various parts of Tamale; Bamvum, Changli, Zogbeli, Gumani, Dungu and Kpalsi. Two groups were a mixture of boys and girls, another two groups were only boys, and the last two were only girls. The mixed focus groups comprised of eight adolescents, four girls and four boys. The purpose of the FGDs was to get detailed information from the adolescents to complement the survey data (**Table 1**).

#### **3.4 Data collection tools and procedures**

Self-administered questionnaires were used for data collection in this study. The questionnaire was the leading tool to gather the data, and it was made of three sections, including sociodemographic characteristics of respondents, knowledge and utilization and the factors influencing adolescent sexual and reproductive health services.

#### **3.5 Data management and statistical analysis**

Data collected were entered into Microsoft Excel 2017, cleaned and imported into STATA version 16.0 for analysis. The researchers ensured that participants were


#### **Table 1.**

*Proportion of students sampled from selected senior high schools.*

taken through the questionnaire to understand each question well. Respondents were also given 2 weeks to return the completed forms. This provided them ample time to respond to all the questions. Categorical variables such as sex, marital status, religion, utilization of services, type of media and the platform used were analyzed and summarized using frequencies and proportions at a 95% Confidence Interval (CI). Quantitative continuous variables such as age were summarized into mean and standard deviation. A chi-square test of association was employed to evaluate the relationship between the result variable and the different variables. The chi-square analysis's level of significance was set at 5%. At a significance threshold of 5%, a crude and adjusted binary logistic regression was employed to assess the strength of the correlation between the outcome variable and the numerous variables.

#### **4. Results**

#### **4.1 Sociodemographic characteristics of the study participants**

Of the 342 students studied, 98.3% were between 15 and 19. About two-thirds of the students were females. More than half (57.0%) reside in urban areas. The majority, 95.3%, were single in terms of marital status. The occupation of their parents or guardians, most of them were traders. Most of the students were from the second year (**Table 2**).

#### **4.2 Study participants reproductive health characteristics**

More than one-third of the respondents (40.6%) were in a romantic relationship, and 86.8% mentioned they were not sexually active at the time of the study. Their awareness of reproductive health services, almost all (93.9%) were aware of the services, with the majority of the respondents (85.7%) getting their source from schools (**Table 3**).

#### **4.3 Social media utilization among study participants**

On their access to social media, when asked about the ownership of mobile phones, more than two-thirds (76.9%) answered affirmatively, 51.5% accessed social media, and 71.2% mentioned Facebook as the most frequently used social media. On how often they visited social media, the majority 74.3% said sometimes. The majority of the respondents (69.6%) preferred accessing reproductive health services via social media, and most of them stated that the problem for which they accessed social media reproductive services was solved after accessing it (**Table 4**).

#### **4.4 Accessing reproductive health information through social media**

Out of the 342 students studied, 45.4% 95%CI (40.0–51.0) indicated they have ever accessed reproductive health information through social media (**Figure 1**).

#### **4.5 Sociodemographic characteristics of the participants, Tamale Metropolis, 2022**

The Chi-square analysis showed that respondents' place of residence (p < 0.040) and occupation of guardian (p < 0.040) were significantly associated with accessing reproductive health information via social media (**Table 5**).


*Adolescents, Social Media and Access to Reproductive Health Information and Services in Ghana… DOI: http://dx.doi.org/10.5772/intechopen.111768*

#### **Table 2.**

*Sociodemographic characteristics of the study participants.*



#### **Table 3.**

*Study participants reproductive health characteristics.*


**Table 4.**

*Social media utilization among study participants, tamale metropolis.*

*Adolescents, Social Media and Access to Reproductive Health Information and Services in Ghana… DOI: http://dx.doi.org/10.5772/intechopen.111768*

#### **Figure 1.**

*Accessing reproductive health information through social media, Tamale Metropolis. Chi-square test of Association between accessing RH using social media and.*



#### **Table 5.**

*Bivariate analysis of the association between accessing RH using social media and sociodemographic characteristics of the participants.*

#### **4.6 Participants reproductive health characteristics, tamale metropolis**

The Chi-square analysis showed that being in a romantic relationship (p < 0.001), and having an awareness of reproductive health (p < 0.040) were significantly associated with accessing reproductive health services via social media (**Table 6**).

#### **4.7 Social media utilization among study participants, tamale metropolis**

The Chi-square analysis showed that respondents' mobile phone ownership (p < 0.004), social media use (p < 0.001), means of accessing RH using a mobile


*characteristics.*

#### **Table 6.**

*Bivariate analysis of association between accessing RH using social media and participants' reproductive health characteristics.*

*Adolescents, Social Media and Access to Reproductive Health Information and Services in Ghana… DOI: http://dx.doi.org/10.5772/intechopen.111768*

phone (p < 0.02) and whether their problem was solved (p < 0.001) were significantly associated with accessing reproductive health services via social media among the study participants (**Table 7**).

#### **4.8 Factors associated with using social media to access reproductive health services**

Male students were more likely than female students to use social media to get reproductive health services, with a difference of 62%. (aOR = 1.62, 95% CI 1.01–2.59). Students who resided in urban areas had 55% higher odds of accessing reproductive health services via social media than their rural dwelling colleagues (aOR = 1.55, 95% CI 1.00–2.41). On their relationship status, students who were in a romantic relationship had 2.3 times increased odds of accessing reproductive health services via social media compared to their colleagues who were not in any romantic relationship (aOR = 2.25, 95% CI 1.39–3.64,). Among students who use social media,


#### **Table 7.**

*Association between accessing RH via social media and social media utilization among study participants.*


**Table 8.**

*Multivariate analysis of factors associated with using social media to access reproductive health services.*

there were 6.37 times increased odds of accessing reproductive health services via social media compared to their colleagues who do not use social media (aOR = 6.37, 95% CI 3.68–11.05) (**Table 8**).

#### **4.9 Prospects and challenges**

The prospects of using social media to access reproductive health information is grate. The fact more adolescents are using it means it can survive generations. Secondly, there is wider coverage of internet serves in Ghana. The last point is that there is no restrictions to the use of social media in Ghana.

However, the use of social media to access sexual reproductive health information by adolescents comes with some challenges. The study revealed that it has cost implications as it requires smartphones and data for the internet. The study showed that 89% of adolescents considered this twin cost the main obstacle. Smartphones are costly, and only a few adolescents from well-to-do families can afford them. During the FGDs, it came up strongly that most adolescents' desire to own smartphones compels them to engage in thievery. They claimed that most girls who cannot afford them are also involved in prostitution to be able to acquire and maintain them.

Another challenge frequently mentioned by the respondents is the authenticity of the information they obtained through various social media. They get the information mainly from Tiktok, Instagram, Twitter, Whatsapp, Facebook, as well as Google and Yahoo search engines. Sometimes it is difficult to authenticate the veracity of the information they consume. Over three-quarters of the respondents (87%) claimed that some of the information they get from these sources is unreliable and has cost many complications for most adolescents. During the FGDs, respondents cited examples of girls who got pregnant and complicated their situation by relying on social media information to get rid of their pregnancies.

The third major challenge they cited was time consuming, especially by the students. Adolescents spend a lot of time on the social media at the expense of their studies. They claimed that most adolescents spend 2–3 hours per day on their phones. This affects not only their studies, but also their socialization processes. They indicated that most adolescents are engaged in cybercrimes, fraudulent internet deals, games, and pornography.

#### **5. Discussion**

The advent of mHealth is due to the development of mobile communication. mHealth services have the chance to make health promotion, protection and prevention interventions easy to access and may also reduce time and distance [27]. With the fast development of mobile communication, there has been a rush in a study into the health advantages of mobile phone use. Experts from various academic fields have been researching popular social media platforms like WhatsApp, Twitter, and Facebook in light of today's culture, including the issues they raise for politics, interpersonal relationships, the general welfare of society, and mental health. With the development of digital and mobile technology, people are now more able than ever to engage in extensive engagement; as a result, a new media era has emerged, having interaction at the core of new media activities.

This study accessed Tamale Metropolis's teenage reproductive health services and information via social media. According to the report, less than half of the teens in

the survey had ever used social media to acquire knowledge or services related to reproductive health. This shows that even though teens in the Tamale metropolitan use social media frequently, less than 50% use it to find resources for their reproductive health.

This aligns with research from the Internet and American Life Project at the Pew Research Center, which found that an estimated 30% of youth use social media to learn about health-related topics. This, however, conflicts with the results of a study done in Nigeria with 1800 girls randomly chosen from 18 public senior secondary schools in Lagos State, where social media was the least reliable source of information or services on reproductive health [28]. Additionally, although 94.6% of adolescents use social media, only 3.5% said they used it to look for health-related information, according to a survey by Plaisime et al. [29]. Furthermore, most participants in a cross-sectional study in Nigeria stated that social media was the most often used channel for receiving SRH information and services [30]. Additionally, a study conducted in 2015 by González-Ortega, Vicario-Molina, Martnez, and Orgaz shows that 68.4% of teenagers utilize social media for sexual education.

The use of social media will affect how often teenagers use it to receive services related to adolescent reproductive health. Compared to teenagers who do not use social media, those who do are more likely to discover and use reproductive services. This study found that social media is used by half of the teenagers. Paraphs, because the study was conducted in school, where the school authorities restrict students from using, cell phones, that was why only half of them claimed they used cell phones. A much higher proportion was reported in a study conducted in Philadelphia, USA, where 94.6% of teens said they used social media [29]. The inconsistency in findings could be attributed to the disparity in the settings of the studies.

Regarding social media, they frequently visited, most mentioning Facebook. However, this is inconsistent with a study by Plaisime, which reported Instagram as the social media frequency by study participants [29].

Policymakers and organizations participating in adolescent reproductive health services will make better decisions if they know and comprehend adolescents' choices when deciding how to receive reproductive health information and services. This study found that most teenagers would instead use social media to acquire reproductive health information and services than go to reproductive health facilities. When asked why they would not want to attend a health centre for their reproductive health concerns, students in a focus group discussion cited the attitude of the staff members and how others saw the institution. This conclusion is supported by research by Gray et al. [31], which found that the internet and GPs/family doctors were teenagers' primary sources of knowledge on reproductive health (49.1% and 38.9%, respectively). However, this is inconsistent with the findings of a study conducted by Lim et al. [32], where fewer participants reported being comfortable getting information from social media. The disparity in findings could be attributed to the difference in the characteristics of the study participants. Lim et al., [32] studied young people aged 16–29 years, unlike this study, which interviewed adolescents aged 10–19.

A study by Goodyear et al. [33] stated in general, when looking for healthcare information, young people are turning to new technologies, notably social media. According to their research, social media provides extraordinary and unusual opportunities for the young to be educated and know about health. Additionally, it has a great range of effects on behavioral changes regarding health and lifestyle. Furthermore, persons 18–29 years old were shown to be much more likely to use

*Adolescents, Social Media and Access to Reproductive Health Information and Services in Ghana… DOI: http://dx.doi.org/10.5772/intechopen.111768*

social media sites to seek remedies for health issues. The survey also discovered that joining health groups on social media is simpler than joining traditional health or fitness groups [33]. Texting on cell phones is more frequent among Ghanaian young aged 18–34 than those aged 35 and beyond [34]. Media has long been recognized as a valuable instrument for enhancing health. The World Health Organization (WHO) proposed transferring health-related information via engaging and audio-visual tools in 1986. Following this, digital technology, also called mobile health (mHealth), has emerged as a means for fostering and attaining health. Using a mobile phone to improve healthy behaviors is known as the mHealth [35].

Consequently, mHealth is viewed as having potential since it addresses the challenges of services being out of reach, if not completely inaccessible, for the most vulnerable people and sexual and reproductive health topics being controversial in most societies [36]. According to recent studies, youth support mobile health programs that can raise general health awareness [36]. mHealth is gathering steam as a critical avenue for connecting young people who face numerous obstacles and difficulties in gaining access to adolescent youth-friendly institutions and has been an effective tool for offering young people information on adolescent reproductive health and services [37]. Health may solve this nomad problem by giving young people ongoing access to knowledge and information. In a research conducted in Ghana in 2015, 31% of participants aged 14–18 and 71% of participants aged 19–25 owned a mobile phone, while 77% of those aged 14–18 and 91% of those aged 19–25 had used a cell phone in the previous 4 weeks [38].

Although the potential for government m-health initiatives to improve healthcare in locations with limited resources has received widespread praise, this opportunity has not yet been fulfilled in the execution of large-scale policy [39]. According to a survey, men are more likely than women to use mobile phones, and young people from higher socioeconomic levels are also more likely to purchase and use mobile phones [40]. According to a study by Rokicki [36], mHealth platforms for teenagers have the potential to engage and increase health awareness among teenage girls from all socioeconomic backgrounds, particularly those who are more likely to experience poor sexual and reproductive health outcomes.

According to the study, a statistically significant link exists between having sex and using teen reproductive health services. Males in this study had higher odds of accessing adolescent reproductive health services via social media than their female counterparts. This may be explained by the fact that guys make up most of the study's social media users. The results of a survey by Marie, which showed a statistically significant sex difference in the frequency of Facebook, Twitter, and Instagram usage for reproductive health information and services, are consistent with these findings [29].

Students' residency during school breaks was another factor that significantly influenced the use of social media to access adolescent reproductive health information and services. Students who resided in urban areas during school breaks were found to have higher odds of accessing health information via social media compared to their counterparts who dwelled in rural regions during school breaks. This could be explained by the availability of electricity and internet connectivity in urban settings compared to rural locations.

Another element that was discovered to be connected to teens using social media to seek information on adolescent reproductive health was their relationship status. Comparatively to those who were not in a romantic relationship, adolescents were more likely to receive information about reproductive health.

The type of reproductive health information and services adolescents are interested in depends significantly on how sexually active they are. Adolescents who engage in sexual activities are more inclined to learn about reproductive health than adolescents who are naïve to sexual activity. More than two-thirds of them were found to be inactive sexually, according to the study. It can be inferred that most teenagers had not engaged in sexual activity. This contrasts with the results of a survey conducted by Asare et al. [41], which indicated that 50.4% of young people were sexually active and that 77.3% of them initiated sex after the age of 15.

Individuals' awareness and knowledge about a service influences their engagement or utilization. Adolescents will only use social media to access reproductive health information and services if they are aware of these services and which social media to visit for this information. This study revealed that over 90% of participants were mindful of adolescent reproductive health services. This suggests that most adolescents in the survey know the benefits of adolescent reproductive health. This aligns with the findings of cross-sectional research on reproductive health knowledge and practices among female adolescents in a Mumbai urban slum, where 212 (88%) women were aware that ARHS services were offered [42]. The consistency in findings can be attributed to the urban nature of the settings of these studies. The results of a survey conducted in Oyo state, Nigeria, where just 13.1% of participants were aware of the adolescent reproductive health services; however, contradict this finding [43].

Adolescents' awareness and use of these services will be influenced by the sources of information and services available to them on adolescent reproductive health. Regarding their source of information, the study revealed that the majority cited school as their source of reproductive health information. This could be explained by the fact that all the adolescents studied were second and third-year students who received lectures on adolescent reproductive health in social studies. Knowing that most adolescents obtain information on their reproductive health from schools, it will be essential to introduce courses that teach students the correct information without shying them away. In a similar study, the majority of the respondents, 72.4 per cent, learned about adolescent reproductive health services school staff. Also, most believed that adolescent sexual and reproductive services and information were critical for young people [44]. This consistency in findings could be attributed to the fact that both studies were conducted among adolescents in secondary schools.

The judgmental nature of health care providers at our health facilities is a critical factor that shies adolescents from accessing reproductive health services. Adolescents will, however, rely on social media, where there will be no individual to judge the kind of information they search for or the questions they ask. Also, the students stressed the need for more practical examples in our facilities as one of the reasons why they will prefer getting reproductive health information via social media instead of the health facility. On social media, video evidence of questions is provided to illustrate further for students to understand. Considering the age of these students, they would prefer visuals as a means of communication compared to just words or statements.

This aligns with another study examining how teens utilize social media to get reproductive health care. This study identified a barrier to young people using the services provided by adolescent health clinics as the absence of confidentiality at the delivery stations [45]. Facilities have to arrange to give privacy to patients or clients during their sessions, whether via physical boundaries between counseling and professional areas or other appropriate arrangements. Another study in Uganda discovered that most service facilities lacked enclosures to give young girls and boys privacy. Only one higher-order hospital was known to have a site where youth programming

*Adolescents, Social Media and Access to Reproductive Health Information and Services in Ghana… DOI: http://dx.doi.org/10.5772/intechopen.111768*

might be offered. With this, no healthcare facility had a separate reception area for young people to provide service without interruption from other staff [46].

In addition, many teenagers think it would be humiliating to have their marital status questioned if they were to engage in family planning because most of them will not be married then. Additionally, one person said family planning was not for adolescents but for grownups [44]. In this same survey, A service giver stated his hesitation about delivering contraception to a 13-year-old girl.

Just like every study, this study has certain restrictions. The findings are based on self-reported, individual data that respondents' social desirability may skew due to participants filling out surveys in a school setting.

#### **6. Conclusion**

Social media has come to stay. It has started having a tremendous influence on the youth and adolescents who have found it safer and more convenient to consult rather than relying on their parents and families for sexual reproductive information, which in most societies is taboo to discuss. Adolescent heavily rely on social media because there is a lack of access to this information in a safe, friendly and culturally sensitive manner. Those who attempt to obtain this information are either rebuked or tagged as bad. As a result of the stigma associated with getting sexual reproductive health information from peers, family members, and teachers, they find social media the most convenient place to obtain this information. Sex, social media usage, urban or rural residence and adolescent romantic relationships were factors significantly associated with their access to juvenile reproductive health information via social media. Despite the high utilization of social media for reproductive health services, there is no clear-cut policy in Ghana on social media and how to regulate it to ensure that the information put out there is not harmful to the adolescents.

#### **Author details**

Rahma Salifu1 and Abdulai Abubakari2 \*

1 Ghana Health Service, Tamale, Ghana

2 Institute of Interdisciplinary Research (IIR), University for Development Studies, Tamale, Ghana

\*Address all correspondence to: abdulai.abubakari@uds.edu.gh

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### Section 2
