Las categorías

Social and cultural factors “are often intertwined to impact health behaviours among a population” (Roberts et al., 2005 p.1489). However, they vary within countries and cities (Couch et al., 2006). The socio-cultural contextual factors discussed in this section pertain to norms and beliefs, gender, and stigma linked to adolescent sexuality, sexual activity and help-seeking.

Norms/belief about adolescent sexuality, sexual activity and help-seeking

Norms and beliefs pertaining to adolescent sexuality and sexual activity affect how adolescents view SRH issues, and by extension, how they deal with their SRH concerns. In much of Africa and the Caribbean, adolescents’ sexual activity is taboo and not condoned (Kumi-Kyereme et al., 2007; Kempadoo and Dunn, 2001). Some authors (e.g. Meekers et al.,

2001; Kumi-Kyereme et al., 2007) have argued that in these contexts, adolescents may forgo or delay help-seeking to prevent accusations that they are sexually active, and other consequences for sexual involvement, such as stigma (see discussion on stigma in this section).

For example, Meekers et al. (2001) reported that adolescents in urban Botswana did not want to be seen obtaining condoms because they did not want their parents to know they were sexually active. According to the authors, this was despite adolescent sexual activity being the norm in Botswana. This suggests potential tensions between subgroup norms and norms in the wider population that can affect help-seeking, and may be worthwhile to explore in the Grenada context. MacPhail and Campbell (2001) pointed out that adolescent boys in the two South African townships in their qualitative study viewed condoms as a waste of time and did not use condoms at all. This was attributed to the fact that parents did not condone adolescents’ use of condoms, and discouraged its use by encouraging abstinence through gossiping and punishment.

However, some types of help-seeking appeared to be more acceptable and supported by different social networks than others. For example, in some contexts, adults may be supportive of adolescents seeking SRH information. Ouedraogro et al. (2007), cited in Biddlecom and collegues (2007) reported that adults in Burkina Faso were more supportive of adolescents accessing SRH information than RH services. And, in the Gambia the older people advise and refer young people in the traditional ways, such as drinking local herbs or going to traditional healers for treatment of STIs and other SRH concerns (Miles et al., 2001). This may be indicative of a generation gap regarding preference for treating SRH issues, and may help to explain why adolescents in the study also use Western medical care alongside traditional treatments. Also, Kiapa-Iwa and Hart (2004) reported that nurses in Uganda were of the view that adolescent girls were encouraged by boyfriends and some schools to use the pill and injectable contraceptives rather than condoms. However, these beliefs still leave adolescents vulnerable to STIs/HIV, while providing some protection from pregnancy. Although Kiapa-Iwa and Hart (2004) did not provide sufficient background details about the site of the study for transferability for the Grenada context, they point out that these beliefs are common in reports of AIDS control in East Africa.

Additionally, some parents and health providers (e.g. nurses) believe that explicitly providing adolescents with sexual and reproductive health information will encourage sexual activity, which is deemed adult behaviour. This was reported among nurses in Zimbabwe (Langhaug et

al., 2003), nurse-midwives in Kenya and Zambia (Warenius et al., 2006), and adolescents in Jamaica (Crawford et al., 2009). For example, Langhaug et al. (2003) posit that nurses’ beliefs, stemming from cultural beliefs about adolescent sexuality result in nurses being unwelcoming and judgemental, which consequently discourages adolescents from seeking help. However, referring to school-based sexuality education, research has shown that providing adolescents with sexuality information does not encourage or increase sexual activity (Kirby et al., 1994;

Kirby, 2007).

The above studies suggest that adolescents may be keen to seek types of help that are deemed more socially acceptable, in light of other barriers to access discussed in this chapter.

Additionally, a few studies (Mmari and Magnani, 2003; Stephenson et al., 2007) have shown that social acceptance (e.g. from community members, parents) of adolescents’ utilization of SRH services increases adolescents’ utilization of SRH services.

Gender norms

Adhering to strict gender norms can affect how adolescents cope with SRH concerns, and put them at risk for STIs/HIV (Rivers and Aggleton, 1999). Referring to mental help, Raviv et al. (2000) argue that help-seeking is a more socially acceptable and positive behaviour for females than males. Hence, the range of studies (e.g. Boldero and Fallon, 1995; Schonert-Reichl and Muller, 1996; Biddlecom et al., 2007) show more females than males seek help for SRH health and other concerns. Van der Reit and Knoetze (2004), in their study among in-school adolescents in two South African Provinces, are among the minority of authors who report that gender did not play a significant role in adolescents patterns of help-seeking or sources of help utilized. The only significant difference Van der Reit and Knoetze (2004) found was that female participants accessed formal/professional sources while male participants did not. The authors attributed this to socializing factors, such as males being required to be strong and cope with problems without the help of professionals. An alternative explanation may be due to self-reporting bias, which may support the authors claim. However, claims about significance are unsubstantiated due to the qualitative nature of the study. Gender norms are also linked to stigma. Roberts et al.’ (2005) study among adolescents in Mongolia indicated that boys can be stigmatized if they try to seek information about sexual activity, because they are “supposed to naturally know” (p.1494). This may therefore hinder help-seeking, and help explain some of the discomfort boys reported regarding discussing sexuality topics with health providers.

Nonetheless, male and female adolescents were reportedly uncomfortable discussing a range of sexuality and sexual health topics with health providers. According to Ackard and Neumark-Sztainer (2001), among in-school adolescents in the United States, although more girls than boys reported discomfort discussing issues related to puberty and sexuality, both boys and girls were uncomfortable as illustrated in Table 2-1. And, a study among adolescents in Thailand reported that the boys in their study often reported more positive experience of help-seeking than girls (Tangmunkongvorakul et al., 2005). While findings from studies in Thailand and Mongolia may not be transferrable to the Grenada context, they are useful to highlight some of the tensions and complexities resulting from and perpetrating gender norms that may affect help-seeking.

P-value =.001 represent significant gender differences

Stigma related to the need for help

In Erving Goffman’s theory of social stigma, stigma is defined as an attribute, behaviour, or reputation which is socially discrediting and undesirable, resulting in the devaluation of a person (Goffman, 1963). Several factors can result in adolescents, especially girls, being stigmatized as a consequence of having SRH concerns and seeking information

and/or services for SRH concerns. Actual or perceived stigma can hinder help-seeking for SRH concerns. Cross-cultural studies have shown that fear of being seen utilizing RH services by someone known to the adolescent (Langhaug et al., 2003), embarrassment (Berhane et al., 2005), and concerns about their reputation (MacPhail and Campbell, 2001) were major barriers to help-seeking. Stigma can be viewed as a cross-cutting factor resulting from beliefs and norms, including gender. For example, earlier girls were discussed as being uncomfortable procuring condoms because of norms against girls’ sexual activity (Meekers et al., 2001).

However, the authors further stated that girls feared being stigmatized as prostitutes for engaging in sexuality activity, and as a result, girls in addition to boys preferred sources where they felt less embarrassed, such as retail outlets to procure condoms (males 77%; females 61%) compared to health facilities where they are provided freely. Atuyambe et al. (2009) also noted that pregnant adolescents in Uganda preferred to seek help from traditional birth attendants as a strategy to avoid encountering their in-school non-pregnant peers because they felt ashamed and stigmatized.

Fear of stigma also resulted in adolescents’ hiding their SRH concerns, which result in delayed or forgoing help-seeking (Miles et al., 2001; Kumi-Kyreme et al., 2007). For example, in Ghana there is stigma attached to premarital sex (Kumi-Kyreme et al., 2007) and stigma attached to STIs (Miles et al., 2001), which may result in adolescents and young people hiding the infections and finding it difficult to seek health care or to inform adults. Miles et al. (2001) also point out that stigma may result in a lack of full disclosure about the actual problem to health workers, which may affect treatment options. MacPhail et al. (2001) suggest that fear of stigma appeared to be more influential than fear of the progression of the disease as it relates to seeking treatment.