Adolescents in Ghana: Sexual and Reproductive Health
Nearly one in three Ghanaians are between the ages of 10 and 24. Many of these young people are at risk or already struggling with the consequences of an unplanned pregnancy or a sexually transmitted infection (STI), including HIV/AIDS. To minimize these risks and secure a healthy future for adolescents, policymakers, journalists, service providers and advocates need solid evidence regarding the sexual and reproductive health needs of Ghanaian youth. This Research in Brief documents what is known about Ghanaian adolescents' sexual and reproductive health behaviors and needs, with particular emphasis on HIV/AIDS, and points the way toward improving policies and programs.
• Four in 10 Ghanaian women and two in 10 men aged 15-19 have ever had sex.
• By age 20, 83% of women and 56% of men have had sex; the median age at first intercourse is 17.4 for women and 19.5 for men.
• Among those who have had sex, four in 10 women and six in 10 men aged 12-24 have had more than one sexual partner.
• The proportion of 15-19-year-olds who have had sex declined substantially between 1993 and 1998: from 59% to 38% among women and from 33% to 19% among men.
• Sexual coercion is a common occurrence: One in four sexually experienced* young women say that they have ever been forced against their will to have sexual intercourse (8% of sexually experienced young men report the same). Twelve percent of women and 2% of men were forced into their first sexual experience.
• Among 15-19-year-olds, 76% of women and 88% of men are aware of at least one modern family planning method. The condom is the most frequently cited method.
• Although about two-thirds of 15-19-year-olds (female and male) approve of family planning, most sexually active teenagers do not use contraceptives. Among sexually active adolescents in this age-group, 80% of females and 63% of males currently do not use any modern method (chart a).
• Only 10-12% of 15-19-year-olds who are not currently using contraceptives intend to use a method in the next 12 months.
• Young people do not feel confident insisting on condom use: Twenty-seven percent of men and 30% of women say that they could not insist on using a condom if their partner did not want to use one.
• The average time between first sexual activity and marriage is about two years for young women and more than five years for young men.
• More than half of young women in Ghana marry in their teens. However, they are waiting longer to get married: Half of women aged 20-24 in 1998 had married by age 19.3; in 1988, half had married by 18.7.
• Men marry later than women: In 1998, half of men had married by age 24.8.
• Twelve percent of women and 1% of men aged 15-19 have ever had a child.
• One in 10 births in Ghana occur among adolescent mothers.
• Adolescent women in rural areas are more than twice as likely as those in urban areas to have a child.
• Abortion occurs among adolescents: Sixteen percent of women and 11% of men aged 12-24 who ever had sex reported being involved in terminating a pregnancy.
• Not all abortions take place in a clinical setting: Thirty percent of women and 39% of men aged 12-24 say that the last abortion they were involved in took place at home.
• Young women most often cite a desire to continue their education, the lack of financial means to support a child or their male partner's denial of paternity as the main reason for having an abortion.
• About one in four adolescents (27% of males and 22% of females) say that they know one or more people who have ever had an STI.
• After HIV/AIDS, adolescents are most likely to have heard of gonorrhea, followed by syphilis. Other STIs, including herpes, genital warts and chlamydia, are also important health concerns in Ghana, but are less well-known by adolescents.
• Among adolescents who have ever had an STI, three-quarters of young men and more than half of young women sought treatment, most often from a drug store, hospital or clinic.
In response to the outbreak of the HIV/AIDS epidemic in 1986, the Ghanaian government embarked on a set of educational programs designed to increase awareness. By 1998, general awareness of the disease was nearly universal among 15-19-year-olds, with 97% of both males and females reporting that they had heard of HIV/AIDS. However, about one in five young men and women still cannot name any specific way by which HIV is transmitted, and only about one in four believe themselves to be at risk of infection (chart b).
Who Is at Risk and Why?
Because the majority of adolescents are sexually experienced by the time they turn 20, most young Ghanaians are at risk of infection. In 2002, more than 3% of 15-24-year-olds were estimated to be HIV positive. Women—particularly young women—are at a greater risk of HIV/AIDS and are infected at a younger age than are men. Between 1986 and 2001, women accounted for 61% of the cumulative AIDS cases in Ghana.
Unmarried adolescents. The gap between first intercourse and first marriage leaves a window of time when adolescents are potentially at high risk of HIV/AIDS and other STIs, as well as unplanned pregnancy. This is partly because this period may involve sexual experimentation, relationship instability and a lack of access to health services. In Ghana, this window of exposure is approximately two years for women and more than five years for men, and is a crucial period for adolescents to protect themselves from the consequences of risky sexual behavior that could shorten or change their lives.
Married adolescents. Over half of Ghanaian women marry while still in their teens. Those who marry early may have older husbands who are likely to have had more sexual partners; as a result, some young women may become infected with HIV or another STI.
Adolescents who experience sexual coercion. A significant proportion of the sexual experiences of young women are coerced. Because they are not prepared for sex and may not have been able to protect themselves, these women are at risk of infection and unintended pregnancy. Another dimension of sexual coercion is the perception among males—and even many females—that women cannot or will not say "no" to sex. Such attitudes can translate into an acceptance of sexual violence that puts young women at risk.
Adolescents engaging in multiple sexual partnerships. High levels of multiple partnerships, particularly among young men, put many Ghanaian adolescents at risk of infection.
Where Do Young People Get Information About HIV/AIDS?
The mass media and the workplace are the main sources of HIV/AIDS information for adolescents. Among those aged 15-19 who have heard of HIV/AIDS, the reported sources of information for females and males, respectively, are:
- radio (66% and 68%);
- workplace (52% and 50%);
- television (49% and 46%);
- print (13% and 18%);
- friends and relatives (7% and 5%); and
- health workers (2% and 3%).
Focus group discussions with young people show that adolescents do not believe that older people, especially parents, can answer questions about sexual and reproductive health. They also fear that a young person would be branded as "bad" just for asking a parent about these issues.
How Do Adolescents Protect Themselves?
Six in 10 teenagers say that knowledge of HIV/AIDS has influenced their behavior, according to one study of 10-19-years-olds in three areas of Ghana. National studies have shown that adolescents were less likely in 1998 than in 1993 to report that they had begun having sex, although this may not be entirely a response to the epidemic. National studies have also shown, however, that fewer than half of adolescents who have heard of HIV/AIDS have actually changed their behavior by abstaining from sex, limiting their number of partners or using condoms as a result of HIV/AIDS knowledge (chart c).
The vast majority of adolescents who have had sex know where to obtain a condom, and sizable proportions—29% of females and 55% of males—have ever used one. However, just 12% of all (married and unmarried) sexually active women and 27% of all sexually active men currently use a condom. Among those who had used a condom the last time they had sex, only about half of young women and one-quarter of young men did so to prevent the transmission of HIV/AIDS—indicating that preventing unintended pregnancies may be a greater concern among sexually active adolescents.
Persuading sexually active youth to use condoms is fraught with challenges. Many young people do not feel sufficiently secure in their relationships to insist on condom use. In addition, a study of three Ghanaian towns showed that 65% of 12-24-year-olds thought it was inappropriate for males to carry condoms, and 78% thought it was inappropriate for females to do so. In another study of 12-24-year-old students in the Central region, more than 40% of respondents agreed with the statement that a young woman who carried a condom in her purse was "bad."
Knowing one's HIV status and that of one's partner can encourage protective behaviors. Most Ghanaian adolescents (82%) are aware that there is a blood test that can establish HIV status. Information about voluntary HIV counseling and testing (VCT) began to be widely disseminated at the beginning of 2002; even before then, more than half of the 222 organizations active in HIV/AIDS-related programs promoted VCT, although the extent of activities is not well documented. Beginning in December 2003, VCT activities intensified as part of a program to bring antiretroviral drugs to people living with HIV/AIDS in Ghana.
What Policies and Programs Are Available to Young People?
Although HIV/AIDS is addressed in the 1999 National Youth Policy and the 2000 Adolescent Reproductive Health Policy, the National HIV/AIDS and STI Policy issued in 2001 provides a comprehensive strategy for addressing the needs of young people in Ghana. The policy established the Ghana AIDS Commission and placed a special emphasis on youth; it seeks to mobilize parents, policymakers, media and religious organizations to influence public opinion and policies in regard to youth and STIs, particularly HIV/AIDS. The goals include improving the quality and coverage of in-school and out-of-school education programs, ensuring access to youth-friendly facilities and services, promoting the support and care of young people living with HIV/AIDS and strengthening the integration of HIV/AIDS education into the school curricula beginning at the primary school level. Although the Ghanaian government has reacted positively to the difficulties facing youth in various areas, the challenge is to ensure the translation of all policy objectives into effective programs and activities.
Current sexual and reproductive health services for young people are in the broad areas of media campaigns, peer education and outreach, youth development, counseling, education and service provision. Programs exist through the school system and in other, informal settings. Health information and services for young people, however, tend to be unevenly concentrated in urban areas, leaving remote, rural areas largely underserved. Further, current programs tend to focus more heavily on information provision than on services.
Programs and services are currently being offered to young people by a range of governmental and nongovernmental organizations; some are long-standing programs, whereas others are short-term and ending soon.
• Media campaigns (radio and television series and advertisements) such as those developed by the Ghana Social Marketing Foundation focus on encouraging condom use among sexually active young people.
• The "Young and Wise" campaign of Planned Parenthood Association of Ghana provides sexual and reproductive health information, counseling and services at special youth-friendly service centers.
• The African Youth Alliance provides HIV/AIDS-related information and services specifically to young people in 20 districts (ending in 2005).
• The School Health Programme (SHEP) covers practical aspects of personal hygiene and environmental studies in primary schools.
• As part of the Stop AIDS Love Life national program, the Ghana Education Service Girls Education Unit has formed "Sara Clubs" to help young women develop self-efficacy and decision-making skills to protect themselves from HIV infection.
• Numerous other programs run by organizations such as the Young Women's/Men's Christian Association, the Catholic Youth Association and Moslem Youth promote abstinence and monogamy and focus on reaching youth in religious settings, street youth and special groups such as female porters.
Certain subgroups of disadvantaged youth are particularly at risk of HIV, other STIs and unintended pregnancy.
Street youth. The majority of street youth (both women and men) have ever had sex, and only 29% of those who are sexually active have regular sexual partners. Some have sex to obtain money for basic needs, such as food or shelter, putting them at particular risk of STIs and unplanned pregnancy.
Women in the Trokosi system. In parts of the Volta and Greater Accra regions, a virginal young woman can be given to a shrine to atone for a family member's crime. This system denies young women their personal liberties, including schooling and the right to marry. Their status as property of the shrine's priest puts them at risk of infection, unintended pregnancy and abuse.
AIDS orphans. Ten percent of all Ghanaian children are orphans, and an estimated 27% of those were orphaned as a result of AIDS. Little information exists about the plight of AIDS orphans other than their numbers, which are expected to rise over the next decade. These children may engage in unsafe sex—exposing them to the risk of HIV— in an attempt to meet their basic needs.
Where Do We Go From Here?
Although this report shows that a great deal is known about adolescents' sexual and reproductive health knowledge and behavior, much remains unclear. Ghanaian adolescents remain vulnerable to HIV/AIDS—in large part because they do not believe they are at risk or their understanding of the risks does not prompt them to take action to protect themselves. We need to know why. We also need to know more about where adolescents go for health-related information and care and how to make it easier for them to obtain the services they need. The strategies for meeting these challenges are of concern to government and traditional leaders, program managers, parents and young people themselves. The end goal is a secure and healthy future for Ghana's youth.
The Way Forward—Filling the Gaps
Assess the progress towards national policy goals. Systematic measurement of the risk and protective behaviors of Ghanaian adolescents over time is necessary to assess how well the country is meeting the sexual and reproductive health needs of this next generation.
Understand health-seeking behaviors. More information is needed to explain the gap between awareness of sexual and reproductive health services and actual utilization of these services.
Find out why. Much of the existing evidence shows the levels and patterns of risky sexual and health behaviors and outcomes among adolescents, but very little evidence exists to explain why young people behave as they do. This information is critical for designing and implementing effective programs.
Explore the interventions. There is a lack of information about the implementation, monitoring and, most importantly, the evaluation of interventions aimed at improving the sexual and reproductive health of Ghanaian youth. Without this information, it is difficult to know which interventions are most effective and worth supporting.
This publication is drawn from Awusabo-Asare K, Abane AM and Kumi-Kyereme A, "Adolescent Sexual and Reproductive Health in Ghana: A Synthesis of Research Evidence," Occasional Report, New York: The Alan Guttmacher Institute, 2004, No. 13. It was written by Melanie Croce-Galis. Except where noted, all statistics in this document are based on nationally representative surveys: The Ghana Demographic and Health Surveys and the 1998 Ghana National Youth Reproductive Health Survey. A complete listing of references can be found in the Occasional Report.
Both publications were supported by The Bill &Melinda Gates Foundation as part of the project Protecting the Next Generation: Understanding HIV Risk Among Youth. The project, being carried out in Burkina Faso, Ghana, Malawi and Uganda, seeks to contribute to the global fight against the growing HIV/AIDS epidemic among adolescents by raising awareness of young people's sexual and reproductive health needs with regard to HIV/AIDS, other STIs and unwanted pregnancy; communicating the new knowledge to a broader audience, including policymakers, health care providers and the media in each country, regionally and internationally; and stimulating the development of improved youth-serving policies and programs.