Community Attitudes Towards Condom Use and Unintended Pregnancies under Dual Modes of Sex Education in Ghana

doi:10.21203/rs.3.rs-3096605/v1

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Research Article

Community Attitudes Towards Condom Use and Unintended Pregnancies under Dual Modes of Sex Education in Ghana

https://doi.org/10.21203/rs.3.rs-3096605/v1

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Background: Condom education campaigns that aim to prevent early and unintended pregnancies (EUPs) can be undermined by local gender norms, religious edicts, and ineffective sex education policies. This study explored community attitudes towards condom education in the context of either comprehensive sexuality education or abstinence forms of sex education in three schools in Ghana.

Methods: The study adopted a qualitative case study approach informed by in-depth interviews with programme managers and students.

Findings: Findings show that condom education is implemented alongside abstinence education through partnerships between the school and the community. The community largely rejected condom education, while some parents encouraged their daughters into consensual relationships and contraception. The church also rejected condom education, contradicting parental encouragement for contraception use for young women in consensual relationships. The interplay between poverty and gendered power dynamics puts young women at a disadvantage in decision-making on sexual practice condom use. At the same time, cultural taboos and religious norms limit condom use and put 11-15-year-olds at risk of early and unintended pregnancy (EUPs).

Conclusion:It is essential to recognise the impact that local gender, cultural and religious norms have in shaping how sexual health education is delivered and how sexual health outcomes are produced.

Gender Studies

Health Policy

condom use

young people

promoting health-promoting schools

community attitudes

socio-cultural factors

Public health and development goals as set by the Joint United Nations Programme on HIV/AIDS, UNAIDS[1] and World Health Organization[2] have been strengthened to feature contraception, specifically condom use,¹ as a central feature of the prevention of early and unintended pregnancies (EUPs) among young people (10–19 years). In sub-Saharan Africa (SSA), 12 million young women aged 15–19 years give birth yearly (WHO, 2020). In Ghana, 14% of 15-19-year-olds have already begun giving birth [3]. The proportion may even be higher; EUPs also occur within child marriages, where teenage pregnancies are sometimes considered timely or planned due to unsound policy frameworks [4, pp. 1–646]. While international laws set the minimum age for marriage at 18 years, policies in countries such as Tanzania, Zimbabwe and the UK allow for marriage at 16 (with parental permission in the UK case), which makes problematic the undifferentiated criticism of teenage pregnancies because some are within marriage [5, pp. 51–74], [6, pp. 24–46], [7]. One in fourteen young women is married at 18 or younger in Ghana. In SSA, the figure stands at 40% [8, pp. 1–15], suggesting that statistics on EUP may be higher than reported in Ghana. The concern over EUPs is because ‘there is a correlation between lower age and the increased risk of adverse health and social consequences for the mother and her newborn’[9, p. 2] such that young mothers may be physiologically unprepared to give birth [10]. The stigma associated with EUPs may lead to an abandonment of financial responsibilities for the pregnant young mother by families they belong to, even if families may be socially and financially positioned to provide the necessary resources for the health and upkeep of both child and mother [11, p. 702].

Correct and consistent condom use is the surest way to prevent EUPs among young people, with a 98% effectiveness rate for avoiding EUPs [12], [13, p. 133]. However, between 1990 and 2015, women between the ages of 15 and 49 in SSA reported the lowest subscription to contraceptive methods (including condom use) of between 24 and 29%, compared to 61 to 62% for Asia and 67% for the Caribbean [14]. This represents a high unmet need for condoms among young people in SSA, accounting for the highest EUPs among young women globally [15, Vol. 2019].

The health, educational and economic implications of EUPs for young people are far-reaching. 99% of maternal and neonatal deaths among young people in SSA occur due to the physiological unpreparedness of teenage mothers for pregnancy [12], [16], [17]. In Ghana, demography and health surveys (GDHS) suggest that abortions account for 17% of deaths among young women aged 15–19 [3], [18]. Similarly, school dropout due to EUP leaves numeracy and literacy gaps among young women in Ghana and other countries, introducing or exacerbating cycles of poverty for young women and their families and leaving them unskilled to contribute to the success of struggling economies [19].

Since most of the world’s youth are engaged in school programmes [20], attempts have been made to promote condom use through school-based sex education programmes. For example, the UNAIDS target of 90% condom use at last sex among young people by 2025[1] is integrated into local sex education policies in Ghana under the target of 95% and 90% condom use by males and females by 2020 [21]. Condom education is included/expected within this and constitutes the central component of comprehensive sexuality education (CSE)².

Despite in-school condom promotion campaigns, differing socio-cultural and religious norms negatively influence attitudes to condom use [22], [23]. In SSA, opposing forces include teachers’ personal beliefs on condom use, which can hinder condom use education or target reaching [24], [25, pp. 61–69]. In Ghana, cultural norms at variance with the condom education agenda lead to parents’ non-acceptance of condom use and misinformed and hostile community attitudes towards condoms, leading to a rejection of condom education [26]. Lack of equity and negative, sexist gender norms have also been identified as putting young women at a disadvantage in requesting condom use in consensual relationships, thus contributing to high rates of EUPs in Elmina and Cape Coast, Ghana [27, p. 93], [28, p. e0236552], [29, p. 382]. Still, despite the 90%/95% condom-use target in Ghana, a predominantly abstinence-based, morally-focused³ sex education curriculum persists [30], denying young people the opportunity to access condoms, which is seen as suggesting promiscuity [31]. This means that condom targets (and therefore condom promotion) operate alongside a predominantly abstinence-based and morally focused curriculum. This is what we mean by the ‘duality’ of sex education interventions in this paper.

Local factors regarding condom use also disrupt the relationship between policies on condom use and the implementation of condom education. Specifically, due to socio-cultural and religious norms that clash with condom use, unsound policy frameworks may not be nuanced enough to adequately inform condom promotion, as we concluded previously from studying ten schools in another part of the country [32, p. 15487]. This was also the conclusion of our more extensive study, which is introduced below.

This article reports on a study of how condom education is implemented within three schools' sexuality education programmes with contrasting sex education curricula. The key feature of the context was whether their sex education programme reflected abstinence or a comprehensive sex education approach. However, we also attended to community attitudes towards condom education being rolled out from schools and the local sociocultural, religious and gender equity factors influencing community attitudes towards condom education. It also draws on a previous study of the delivery of sex education in 10 Junior High Schools in Ghana [32, p. 15487]. In this, we found that the dynamics shaped young people’s intentions for condom use at play between local sociocultural factors and school and community sex education policies.

Further, we also concluded that anti-condom local socio-cultural norms reshaped the policy stipulations guiding condom use, thereby introducing ambiguity in implementation, and limiting the effectiveness of condom promotion programmes among young people [32, p. 15487], [33]. In abstinence-only and comprehensive sex education policy contexts, teachers – influenced by personal beliefs and values – assented to/delivered abstinence education and rejected condom use. Even more problematically, their view was that condom use should be allowed in the light of perceived at-risk sexual behaviours of certain ‘confident’ young people. This produced moral exceptionalism that stigmatised some young people. Mixed policies and conflicting social forces even disseminated incorrect sex education messages on condom use among young people, for instance, the belief that condoms could break during sexual intercourse. The existence of dual modes of sex education in the Ghanaian basic school system [34, pp. 486–500], that is, attempts to deliver condom and abstinence education, needs closer examination. This analysis seeks to understand how these opposing modes of sex education influence community attitudes towards condom use in this same regional context.

This Study

In-depth interviews were used to investigate the delivery of sex education in three Ghanaian Junior High Schools in the K.E.E.A district in Elmina. These examined the strengths, weaknesses, opportunities, and threats to sex education and identified the implications of these findings for improving sex education in these schools. Contextualised in the form, structure, and content of school sex education, we developed a model which described local socio-cultural, religious and gender-based factors influencing intentions for condom use while at the same time explaining community attitudes to condom use as a continuum of condom education through schools. The Health Promoting Schools (HPS) framework was adopted for its criteria for describing and evaluating local socio-cultural factors underpinning school-community interactions in health promotion programmes. The HPS[35], [36, pp. 677–685] has been influential internationally in creating health promotion interventions and examining the local and culturally specific factors shaping the health behaviour (and intentions) of young people [37, pp. 262–264], [38, pp. 138–153]. This framework is therefore suited to investigating local factors that underpin community attitudes toward young people’s condom use and condom promotion programmes in schools and the community.

The Organisation of Education

In Ghana, the basic school system consists of Kindergarten, two (2) years; Primary school, six (6) years; and Junior High, three (3) years (for 11–15 years). This study is focused on sexuality education for young people at the Junior High School level. In response to young people’s sexual health problems, including EUPs, the Ghana Education Service incorporated an abstinence-based sex education curriculum under the School Health Education Programme (SHEP) in selected regions and districts [39], [40]. The Central Region was the focus of our study because of the implementation of the SHEP programme in basic schools and the high prevalence of EUPs among young women in basic schools [41]. Previous research in the Komenda Edina Eguafo Abrem (KEEA) Municipality in the Central Region has highlighted the impacts of poverty in shaping relationships and expectations, such that, for instance, some young people are expected by their parents to fend for themselves from the age of 11 years rather than rely on them [19].

The KEEA region is also interesting because of its status as a UNICEF-Government of Ghana enhanced-School Health Education programme (e-SHEP) district. Under e-SHEP, community-school relations constitute a significant feature called the Community directed pillar which seeks to engage with parents and community leaders on the sexual health of young people [42]. The Municipality is, therefore, suitable for investigating community attitudes towards condom use under the Community directed pillar of e-SHEP in basic schools.

In addition, having worked in the KEEA Municipality as a teacher, Author A can confirm existing research findings, such as those by Author A[33], [43], [44, pp. 1–14], [45, p. 15487] and by others[34, pp. 486–500], [46, pp. 629–645] on the implementation of dual modes of sex education: abstinence education (the official stance of the Ghana Education Service (GES) alongside comprehensive forms of sex education such as condom promotion by nurses from the Ministry of Health [47], [48]. The involvement of nurses in condom promotion programmes fulfils the Ministry of Health’s role in giving technical support to the GES under school health programmes [39].

Furthermore, KEEA accounts for most school related EUPs in the Central Region. In addition, it is argued that ‘irresponsible parenting’ and poverty push young women into early but consensual relationships in this Municipality [27, p. 93], [29, p. 382], [41]. This makes it a suitable place to investigate the incidence of teenage pregnancies in the context of dual modes of sex education and local factors such as poverty. The aim was to examine local socio-cultural, religious and gender-based factors influencing intentions for condom use.

Schools

In the KEEA Municipal Education Directorate, three contrasting Junior High Schools (with children ages 11–15 years) were identified according to two criteria: the level of the sex education content in school curricula and the number of sex education programmes implemented under school-community programmes. Author A assessed the level of incorporation of sex education into the curriculum from the lesson notes of teachers for the last two terms that the Headteacher provided. The implementation of school-community health promotion programmes was assessed from a record of school health activities in a school health education assessment tool called the HIV Alert Tool. The schools were ranked to reflect the amount of school health education curricular and extracurricular activities they ran through assessments made with the Municipal SHEP Coordinator and school health education coordinators. The three schools selected for inclusion in the study were the highest, lowest, and middle terms of ranking⁴.

Participants

School health education for young people aged 11–15 years at the JHS level is overseen by the Municipal School Health Education Coordinator, who was invited to participate in this study. In each basic school, the school-based coordinators oversee health education provision. Each of these was invited to participate in the research to give their views as key stakeholders in local health education.

Six students (a girl and a boy per school) were recruited. The students were peer educators trained to facilitate school health clubs under the e-SHEP programmes in basic schools.

The Municipal and school-based coordinators were asked about their perspectives on how condom education is implemented in school-based sex education programmes and their views on community attitudes towards condom education stemming from their engagements with parents and community members. Students were asked about the content of condom education in school programmes, their views on community attitudes towards condom use, and factors perceived to influence these attitudes. There were, therefore, 13 key informants—all of these participants identified as Christian.

Five of the six students were between 15 and 19 years old (See Table 1 below), making them suitable to give perspectives on the content of condom education in the sexuality education curriculum and what they thought influenced community attitudes towards contraception. As we discuss later, five of them lived with their parents, indicating their potential to share information on condom education with parents.

Table 1

Socio-Demographic Characteristics of Interviewees in Komenda Edina Eguafo Abrem Municipality, Ghana (N = 13)
Students (N = 6)		School-Based and Municipal Health Education Coordinators (N = 7)
	n (%)		n (%)
Age 11–14 15–19	1(17) 5(83)	Age 25–30 31–35 36–40 41–45 46–50 51–60	2(29) 1(14) 1(14) 0(0) 1(14) 2(29)
Sex Female Male	3(50) 3(50)	Sex Female Male	4(57) 3(43)
Religion Christianity Others	6(100) 0(0)	Religion Christian Other	6(100) 0(0)
Current Grade Level JHS 1 JHS 2 JHS 3	0(0) 4(67) 2(33)	Education Level Diploma Bachelor Masters	0(0) 5(71) 2(29)
Living With Parents Relatives Others	5(83) 1(17) 0(0)
*JHS (Junior High School)

[1] In this article, contraception is referred to interchangeably with condom use because condom use is the most accessed mode of contraception among young people in Ghana and elsewhere [22], [55, pp. 46–54], [65]. Condoms offer safer sex between men, too but are not promoted publicly for this in this area for some of the same reasons explored here.

[2] “Comprehensive sex education is an age-appropriate, culturally relevant approach to teaching about sexuality and relationships by providing scientifically accurate, realistic, non-judgmental information” [66, p. 12].

[3] Haberland & Rogow [67, p. 17] define abstinence sex education as the exclusive promotion of abstinence (from premarital sex), and the exclusion of information about condoms and contraception.

[4] A tabular representation of the three contrasting schools is reported elsewhere in [68, pp. 153–166].

Semi-structured interviews were used for the collection of data. Interviews were conducted in schools One, Two, and Three located across the KEEA Municipal Directorate and in the Municipal Education Office in 2016 by Author A. Interview guides were followed to support the ethical elicitation of participants’ views of sensitive issues such as love, sex, and relationships [49, pp. 2954–2965]. They helped to generate rich data on the content specific to sex education/condom education in the curriculum of the three schools, the contexts within which the community were engaged in sex education/condom education programmes, local factors perceived to influence community attitudes towards sex/condom education; and their suggestions for improvement of the delivery of education around sexualities.

Data were analysed using a template analysis format [50, pp. 11–22]. As an example of thematic analysis, King’s template analysis uses a tabular format to correlate qualitative interview data after transcription. It can allow for the accurate aggregation of interview data from multiple perspectives while identifying important quotations from participants to support identified themes. Using interview questions in rows, the following participant responses were tabulated in columns according to the research questions of the study: that is, as local socio-cultural, religious and gender-based factors influencing condom use and community attitudes towards condom use: the content of sex education, modes of dissemination of condom education from the school to the community, community/parental attitudes towards condom and sexuality education rolled out from the school, and factors perceived to influence community attitudes. Next, the interviewee’s perspectives on parental/community attitudes towards contraception, sexuality education and the sexual health of young people were analysed as a basis for establishing parental/community attitudes towards condom use and the factors that influenced these intentions.

The study implemented the ethical guidelines of the British Educational and Research Association [51]. Ethical approval was obtained from the Research Ethics Committee of University College London, UK, and the Education Office of the KEEA Municipality. It was copied to the headteachers of participating schools. After reading the Participant Information Sheet, some teachers and students sought clarification over confidentiality issues and once re-assured about anonymity, were happy to sign the Consent Form. Interviews for students were conducted in quiet classrooms with no interruptions by teachers - some students had expressed concerns about the confidentiality of their answers to teachers. To ensure participants felt free to express themselves, Author A allowed plenty of time for deliberations and as little intervention as possible. However, students were continuously reminded of the option to refrain from answering sensitive interview questions on love, sex, relationships, and condom use if they felt uncomfortable. All participants agreed to be audio recorded.

The more comprehensive report[33] presented interview data on the opportunities and weaknesses in delivering comprehensive sex education against UNESCO’s International Technical Guidance on Sexuality Education [52], and this article looks in more detail at how critical stakeholders in education in this context explained the findings shared with them.

The findings represent themes identified from 34 pages of interview data generated using the template analysis framework [50, pp. 11–22]. The research questions which guided the template analysis for the present paper were the forms of condom education implementation in the school’s sex education curriculum, the modes of dissemination of condom education to the local communities, and the local socio-cultural and religious factors perceived to influence community attitudes towards condom use by young people.

The template analysis allowed the organisation of interviewees’ views on these topics: condom education in school sexuality education, community condom education, community attitudes towards condom use, and our analysis of factors perceived to influence community attitudes towards condom use.

Condom education in school-based sexuality education

Despite the government policy in favour of abstinence education[39] which is implemented generally through curricula and extracurricular activities, condom use is integrated into teaching and learning activities through processes such as integration and infusion⁵, which allows for teachers and religious groups to engage students in sexuality education within and outside the classroom: “The Enhanced School Health Education Program promotes the teaching of sex education in the classroom in two forms: Integration by which the topic is directly related to the content of the curriculum....for infusion, topics is mentioned but not as the main part of the curriculum” (Municipal SHEP Coordinator). The Municipal SHEP Coordinator explained that nurses from the Ministry of Health employed infusion to teach condom promotion, which is not part of the mainstream Government approved curriculum.

Most of the six teachers reported that the curriculum focuses primarily on reproductive health and sexuality, aiming to educate students on the dangers of premarital sex. For instance, here, a headteacher and a school-based coordinator each note the heterosexual reproductive health emphasis of sex education and that the avoidance of consequences such as teenage pregnancy is emphasised: “Sex education is being aware of sex in boy-girl relationships and how to protect themselves from consequences such as teenage pregnancy” (Headteacher, School 3), and “At this point in the students’ lives [age 11 to 14], they should be taught to abstain from premarital sex, and that is why subjects like Science and Religious and Moral Education teach topics such like reproductive health and morality” (School Based Coordinator, School 3).

The church was also involved in the implementation of sexuality education to support the abstinence message: ‘The Methodist Church (also) has in place sex education activities which has a special interest in the promotion of sexual abstinence” (Headteacher, School Three).

On the other hand, it also became evident from some responses that nurses from the Ministry of Health discussed contraception and condom use even to the point of condom demonstration. This aligned with the overarching policies guiding school health from the Ministries of Education[40] and Health [47]. Under these policies, nurses offer technical support in school health programmes like condom education. The Municipal SHEP coordinator distinguishes sex education provided by the Ghana Education Service and nurses from the Ministry of Health: “Ghana Health Service also has school services, it does, so when they go to the school, they teach the inclusive measures such as condom use through demonstration, we (teachers) also teach the abstinence form of it” (Municipal SHEP Coordinator).

A male student in School Two confirmed the involvement of nurses in sex education with a focus on content bordering on HIV/AIDS and teenage pregnancy - with condom use as a way of preventing both: “Nurses come around during school hours to talk to us about teenage pregnancy and AIDS. They also teach about how to avoid getting pregnant through the use of condoms” (Student Two, School Two).

A female student defined sex education as covering either abstinence or condom education. She described the focus of sex education as helping those in sexual relationships remain in school and avoid teenage pregnancy. For her: “Sex education helps those who have boyfriends not to get pregnant, and it also helps us not to drop from school” (Student One, School One). This specifies neither abstinence nor condom use education but seems to imply the existence of sexual relationships among young people and the need to prevent teenage pregnancy and, subsequently, school dropout through a method which is not clearly stated.

Condom education to the community/Community condom education

Programme managers (school-based coordinators and the Municipal School Health Education Coordinator) made conscious attempts to implement the community-led pillar of enhanced school health education, which calls for the involvement of community members in sexuality education [42]. These collaborations between the school and the local community enabled sex education activities to extend into communities, thereby facilitating the dissemination of condom education content in the community. This is exemplified in collaborations between the school and traditional authorities and NGOs, like here: “It is a strategy (Community directed pillar) that we use because we believe that the children come from the community and since sex education is not taught as a subject, we need the parents to support us in the community. So, during Parent Teacher Association and School Management Committee Meetings or whichever forums which bring the parents together, we equip them with necessary skills to impart sex education to the children”. The Municipal School Health Education Coordinator gives another example: “We also have the Queen Mothers’ Association which has been very, very helpful... so we involve them in our activities in the community”…. “The Queen Mothers’ [Association] take an active part in the education of young girls to stay away from premarital sex to safeguard their education for a better future” and notes that “We have lots of NGOs working on sexuality education in the community. So, the children can access some of their services”.

The Parent Teacher Association and School Management Committee also allowed time during meetings for school-based coordinators to discuss issues relating to students’ sexual and reproductive health. The school-based coordinator for School One stated, "During P.T.A. meetings, I am given some time, about 10 to 15 minutes, to talk about important issues about sexual and reproductive health” (School Based Coordinator, School One). School-based coordinators said they had raised issues such as the lack of parental involvement in keeping young people at home late at night and that sexual relationships threatened to truncate young women’s education.

One female student described parents discussing sex education with their children and students sharing information on sex education at home with parents. This allows her to make a comparison between parents and teachers as sex educators: “Because the teachers have gone through the practicals, they even teach it (sex education) far better than our parents (teach us at home)” (Student One, School One). Although she does not specify the type of sex education (abstinence or condom), the point here may be that the students themselves disseminated sex education information to parents, sharing information among the community.

Community attitudes towards condom education

The study drew on teacher reports of parental attitudes towards sex education/condom education and parental cooperation on matters of young people’s sexual health to glean information about community attitudes to condom education disseminated from the school. Despite collaborations on sex education programmes between schools and the community, teachers suggested that parents exhibited an interesting variation in attitudes from accepting to rejecting sexuality education in general and mixed views of contraception or condom use. Firstly, most teachers and headteachers reported that the community generally disagreed with sex education being taught to students, with the potential for the community and parents to introduce contrasting messages to what is taught at school. For instance, one coordinator said: “The community is not prepared to accept what the teachers teach, especially regarding condom education. The community does not accept what the students tell them and, in the end, influences the students too...The community is okay with what society teaches, mainly about staying away from sex before marriage” (School Based Coordinator, School Three). From this, it appears that there is also the danger of corruption of what is learnt in school by opposing elements in the community.

Accounts from one headteacher and the Municipal School Health Education Coordinator suggest that while some parents disagreed with condom education as an approach to sex education, other parents encouraged their daughters into consensual relationships with older men to satisfy monetary needs. The Municipal-SHEP Coordinator said: “Some parents suggest through indirect comments to their daughters to enter intimate relationships with men (to get money) to satisfy monetary needs and wants”, and some parents encourage their daughters into sexual relationships perhaps in the hope of the financial cost of schooling their daughter becoming shared or becoming unnecessary if the relationship leads to marriage since it is assumed that schooling would end if married. The Headteacher from School One saw this too: “Parents encourage their daughters into sexual relationships and sometimes contraception to avoid financial commitments to education”. Although several teachers reported it, the reasons parents might encourage consensual relationships and, specifically, contraceptive use by their daughters are not made clear. It could be to avoid pregnancy because they perceive EUP to be shameful or fear it will be seen as shameful; for fear of contracting STIs or HIV, or because they do not want their daughters to lose opportunities for employment and earning. Parental views and perspectives are undoubtedly varied and sometimes rather complex.

In addition to putting girls at risk of EUPs, and STIs, including HIV, teacher perspectives showed that some parents were also perceived to exhibit a very non-cooperative attitude towards young people's negative sexual behaviours, which would have required collaboration between teachers and parents to redress. One said: ‘We identify certain behaviours of young girls and boys and invite parents over to discuss, but parents have adopted a very non-cooperative attitude, including the refusal to honour invitations to discuss identified sex-related problems associated with their children” (School Based Coordinator, School One). For example, there are instances where parents have refused to engage with the school regarding the sexual relationships among young people that teachers were aware of.

Factors perceived to influence community attitudes towards condom use

Teachers and students also had a range of opinions on socio-cultural factors such as poverty and gender, as well as culture and religion, which were perceived to influence the sexual behaviour of young people. A headteacher shared their view on how poverty interacts to limit the effectiveness of sexuality education: “Poverty renders (sex education) efforts useless if girls go back into sexual relationships for money (Headteacher, School Three).

Furthermore, the same Headteacher also identified other gender dynamics of poverty, pointing to the mythical nature of social roles like the male breadwinner ideal, suggesting the need to demystify certain masculinities that relationships between young women and older men thrive on: “Much education should be made on the myth that men solve financial problems since in the long run the women suffer and work economically more than men” (Headteacher, School Three).

At the same time, a female student in School One seemed to agree with the headteacher of School Three on the overall negative influence of poverty on effective sexuality education. To make sexuality education effective, there was the need to provide for the needs of girls to prevent consensual relationships with older men. She said: “I think providing (financial) markets for girls will prevent them from entering into sexual relationships (Female Student One, School One).

Some respondents further suggested that sex education included a discussion of cultural and religious influences because religious considerations impacted them hugely. The Headteacher for School Two told of an in-depth approach to sex education by the church, at variance with the preference for abstinence:

“If church leaders are made to understand it is not only because (about) it (sex) being a sin, but it will also have a deeper perspective and meaning” (Headteacher, School Two). Author A’s culturally situated interpretation of this was that it is a suggestion that a more comprehensive discussion of sexuality and relationships is offered from within a religious approach, which could be a challenge to the most conservative faith messages about abstinence before marriage or could be to expand by making relevant discussions about sexual activity and safety choices within marriage.

In addition, the Municipal School Health Education Coordinator suggested that stakeholders should take a second look at cultural values underpinning the agenda that sex education is wrong: “We have to look at our cultural values and norms that guide our thought (because) in some cultures you can’t just talk about sex, so the curriculum developers should look at that”.

The references to poverty, its gendered dimensions, and cultural and religious norms speak to the importance of these considerations in the design of sexuality education in general and condom education in particular.

[5] Integration and infusion (later described in the analyses) constitute two local terms for describing how sex education is infused into the e-SHEP curriculum. Therefore, it may not be popular to mainstream scholarly discourses on sex education curricula.

This study aimed to examine community attitudes towards condom education implemented in local schools whose approaches to sex education were either abstinence or a comprehensive approach (CSE). It also investigated local factors underpinning community attitudes towards condom use and how these attitudes address the contraceptive health needs of young people, especially young women.

As a component of CSE, condom promotion/education faces barriers to implementation that are underpinned by multiple local socio-cultural factors. They appear to be concerned with gender, age, faith, and money. The interrelated nature of these cultural factors influencing attitudes towards condom use in the community is unsurprising, given that the same diversity reflects the disjointed sex education policies that allow for abstinence and CSE in the participating schools and, by extension, communities. Different community attitudes towards condom use reflect the disjointed nature of sex education policies through the HPS framework, which posits that health promotion programmes through schools have ripple effects on the community [35]. We might see contrasting approaches conversely reflecting a community's multiple discourses or values.

Against this background, it can be argued that the disjointed approach to sex education delivery in the three health-promoting schools and the community may account for community rejection and simultaneous acceptance of condom use. This finding agrees with our earlier study[45, p. 15487] that assessed abstinence and CSE modes of sex education in 10 health-promoting Junior High schools in Ghana that highlighted mixed teacher attitudes (rejection and acceptance) towards condom use. Different teachers had different views for and against condom use. The complicated mixture of opinions sometimes introduces incorrect messages about condom use to young people [45, p. 15487].

The HPS framework, which argues that the effects of health promotion interventions in schools extend to the community, can be applied to show that mixed community attitudes towards condom use may reflect dual modes of sex education in the schools. Teachers and students in this study did not report diverse attitudes towards condom use, perhaps because CSE-supporting participants opted in. However, the conclusions from our previous study[45, p. 15487] that mixed teacher and student attitudes towards condom use could be a result of misaligned policies could be extended to show that diverse community attitudes towards condom use may be the result of misaligned policies on sex education allowing for simultaneous abstinence education and condom promotion programmes. However, a cause-and-effect relationship between local cultures and policies is not easy to establish and likely not unidirectional.

The further analysis highlights other factors influencing the community’s response to condom education. Firstly, poverty forced some parents to encourage their daughters into consensual relationships with older men, under which condition condom use was generally rejected. This finding also ties in with a study by Krugu et al.[53, pp. 293–307] on factors accounting for EUP in Bolgatanga, Ghana, which showed that economic factors account for sexual relationships. The finding from the present study, however, assumes a complete shift from existing scholarship in that parents did not only expect their children to fend for themselves but some were perceived to encourage their daughters into consensual relationships and contraception. Existing gender and cultural norms put young girls in this study at risk of EUPs under this arrangement; While condom use in consensual relationships has been found to empower young girls to be confident and negotiate gender inequalities [54, pp. 1253–1262], the case may be different in Ghana, where research shows that gender norms put young women in a disadvantaged position in the power dynamics of making decisions on condom use [55, pp. 46–54]. Indeed, similar research on sexual negotiation practices among young women in the nation’s capital, Accra, showed that differing styles of masculinities influenced women’s approach to sexual negotiation, of which decisions on condom use form a significant component [56, pp. 146–160]. Indeed, studies in various national settings reflect this issue of gendered power dynamics even where relationships are described as ‘equal’ or egalitarian ([57, pp. 171–191], [58] for the UK, etc.). Relating this to young women in the three schools receiving sparse information on gender-power dynamics in consensual relationships, they may be ill-equipped to make informed decisions on condom use in consensual relationships encouraged by parents. Besides, the variation in attitudes of gatekeepers (such as parents) towards condom education can introduce confusing messages to young people on condom use and corrupt the sparse details they have gained from educational sessions. The interplay of poverty and gender norms, therefore, puts young women at risk of EUPs due to power dynamics in decisions on condom use, thus agreeing with studies that negative gender and cultural norms may be a contribution to the high rates of EUPs in the KEEA Municipality [27, p. 93], [29, p. 382].

Teachers reported cultural and religious norms as shaping community disapproval of condom education. The church view is rooted in abstinence, and in one of the study schools where the church has a managerial role, I (Author A) disagree with the school’s approach to condom education. In addition, the community, in general, were reported to reject content on condom education disseminated from the school. Community rejection of condom education was characterised by the uncooperative attitudes of parents on matters of young people’s sex and relationships. These findings speak to the ‘silent’ and disapproving attitude on taboo topics such as love, sex and relationships exhibited by gatekeepers such as parents and the church in Accra and Kumasi, Ghana [59, pp. S15–S26]. Cultural and religious norms may limit discussions on taboo topics such as condom use, though there may be a need among sexually active young women in consensual relationships. The present study joins in the call by other scholars in Ghana (e.g.,[53, pp. 293–307] ) for a more open approach to discussing culturally sensitive issues such as condom use. Cultural and religious norms also work together to inform community attitudes towards contraception.

Further, the findings from this study challenge the idea from existing research in SSA that abstinence and CSE can be mixed in educational settings[60, pp. 81–94] yet agree with Frances & DePalma on the need to realign sex education policies to work with local factors, such as those we have sought to identify here. However, the multiplicity within local values means that there are choices about whether to refer to children or young people, for instance, which set up different discourses of either protection from or right to information about sex and different bases for the delivery of sex education [61], [62]. This is seen in the comments of some of the teacher participants who believed that students at this point in their lives should be taught to abstain from sex, relegating students they engage with to the status of children and not adults or even potential sexual subjects [63, pp. 389–404].

This study, therefore, concludes that in the broader contexts of dual modes of sex education through school community links under HPS, the community exhibits mixed attitudes towards condom use influenced by local socio-cultural factors. These include power and gendered norms, which put young girls at a disadvantage in making decisions on condom use, as well as cultural and religious norms, which limit discussions on taboo topics such as condom use. In both ways, girls and young women are at higher risk of EUPs. By implication, intentions for condom use by the community may be underpinned by prevailing local socio-cultural, religious and gender factors that reduce condom use and increase the risk of EUPs.

While implementing condom education under disjointed sex education policies through health-promoting schools in the community, it is essential to remain sensitive to local factors which shape the various meanings of condom use and dictate the spaces in which condoms are to be used. This approach is consistent with best practice evaluations of condom education programmes in Thailand and Uganda[64] which posit that the design and implementation of condom education programmes should be done about other strategies and considering local socio-cultural and religious factors. School-based condom education should address misaligned sex education policies and discuss the local socio-cultural factors which mis/inform parental attitudes towards contraception and produce mixed community attitudes towards condom use. Further research should explore the factors that lead to parental encouragement of their daughters into early consensual relationships and contraception and the presumption that educational needs end upon marriage.

Ethical Approval

Ethical approval was obtained from the Research Ethics Committee of the University College London Institute of Education (UCL IOE) for conducting interviews with program managers and students. The key considerations in the approval were consent to participate in the interviews, assurance of anonymity, and consent to publish any findings that derive from interviews.

Competing Interests

The authors declare no conflicts of interest to declare, financial or otherwise.

Authors’ Contributions

Authors A and B prepared the original manuscript, A prepared the table, and A & B reviewed drafts and final versions.

Funding

Funding was received from the Commonwealth Scholarship Commission, UK, for the MA program under which Author A was enrolled, and data was collected. No funding was received for dissemination purposes.

Availability of data and materials

The data supporting this study’s findings are unavailable in any repository but at a request made to Author A to allow for other dissemination purposes.

Acknowledgements

This work was supported by funding from the Commonwealth Scholarship Commission, UK, under the Master of Arts in Education, Health Promotion and International Development program at UCL Institute of Education, on which author A was enrolled.

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Community Attitudes Towards Condom Use and Unintended Pregnancies under Dual Modes of Sex Education in Ghana

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Abstract

Introduction

This Study

The Organisation of Education

Schools

Participants

Methods, Analysis and Ethical Issues

Findings

Condom education in school-based sexuality education

Condom education to the community/Community condom education

Community attitudes towards condom education

Factors perceived to influence community attitudes towards condom use

Discussion

Declarations

References

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