Modulación

Physical signs refer to adolescents’ experiences of visible signs that may be observed by others. Physical signs as a determinant of participants’ identification of a SRH concern were observed only among female adolescent participants. Based on participants’ narratives, physical signs included:

 Constant eating and cravings, nausea and vomiting (i.e. morning sickness)

 First menstrual bleeding (i.e. menarche)

 Irregular menstruation (related and unrelated to pregnancy)

For example, 16-year old pregnant adolescent, Mary, discusses constantly eating and her menstrual period skipping as a sign that she could potentially be pregnant:

One Saturday I just get up [awoke] that day and I just start to eat, eat, eat, eat. Everything pass I eating and when me period supposed to come it didn’t come

(PAM, RI14)

Despite these initial signs Mary identified about her potential pregnancy, Mary remained uncertain and decided to observe whether the signs persisted and did not identify a need to seek help at that time. This suggests that uncertainty about the nature of the sign can delay progression through the stages of help-seeking. Although other adolescents attending PAM also discussed experiencing similar signs, 16-year old Carmen was the only other female adolescent participant who discussed believing her signs were related to a potential

pregnancy. However, unlike Mary, Carmen did not identify her signs as a cause for concern, as she explains in the following excerpt:

Carmen: Yeah, but the whole time since ah had sex [unprotected] ah just find something was SO wrong. Ah dey in class now ah find ah dosing off, ah tired ah trying to walking up the hill, ah drifting backwards. When ah going up ah going backwards.

Interviewer 1: Uhuh

Carmen: Ah was like no. Then, but then the thing is, ah saw me period but it wasn't as it supposed to be for five days. Three days and the blood came so lightly well ah say well it still come. So ah wasn't bothering about it.

Interviewer 1: Okay

Carmen: And afterwards now mommy find no. She say, "no." We agree something wrong, face getting fairer, “well you picking up size” and I'm not a fat person.

(PAM, RI15)

Above, Carmen discusses that her signs were identified as a concern by her mother, after she ignored them as a SRH concern, although she had engaged in unprotected sex. Additionally, Carmen’s narrative suggests that family members play an important role in adolescents’ identification of their need for help. This is consistent with other adolescents who experienced pregnancy which was initially identified by a female family member, particularly mothers. One such example was found in the interview with 17-year old adolescent mother, Linda:

You know sometimes ah used to be vomiting and stuff. Buh I never used to, like ah din *wasn’t+ checking on like pregnancy and stuff. Buh is like my mom maybe realize ah used to vomit, like ah vomiting a lot (Uhuh) and ah morning she tell me [she’ll+ go bring me by the doctor.

(PAM, UI13)

In the above excerpt, Linda perceives that her mom believed that she might be pregnant because she was vomiting after meals. However, unlike Carmen and Mary above, Linda did not consider the possibility of pregnancy, which suggest a lack of vulnerability on Linda’s part (section 5.2.1). Linda’s excerpt above also highlights the earlier point about the simultaneous way in which concerns and need for help are identified (section 5.3.2).

For a few adolescent mothers, other signs related to pregnancy were downplayed if the menstrual period occurred after sexual activity, suggesting the absence of the menstrual period may be one of the most important signs of conception for adolescents. Related to this is the following example of 17-year old Linda who identifies the absence of her menstrual period prior to sexual activity as a concern.

Ah went and stay by my father for two months and like my period skip months but ah never used to have sex.

(PAM, UI13)

The above excerpt suggests that Linda links her “period skip*ing+ months” with sex and pregnancy, indicating a lack of knowledge about normative maturational/pubertal issues. It is possible that Linda may have experienced irregular menstrual period due to any number of stressors, including her temporary living arrangements, as she discussed usually living with her mother and described their relationship as “not too bad”. Other female adolescents discussed identifying their SRH concerns because they lacked the knowledge about the physical signs they experienced. For example, two rural female adolescents discussed identifying the sign of blood during menarche as a cause for concern. The following is 17-year old Donna’s experience as she discussed it:

First thing was my period. I didn’t know nothing what going on, it just that when, I just feel this thing coming out on me, when I went into the bathroom, I was like,"A! What this blood is about"?

(Adolescent Female, RCI2)

However, while Donna reported not knowing what was happening to her, 17-year old Jenna from the same community discussed that she identified her sign of blood as a concern although her mother had previously spoken to her about it, albeit in a harsh way. This suggests that communication style may be a factor in adolescents’ identification of SRH concerns (section 6.2).