Sample characteristics
Adolescent Mothers (n = 86)
Mean age was 17.6 years (range 15–18), and most were of Shona ethnicity (96.5%) (Table 1). Most were in married monogamous relationships (54.7%) and received high school education between Form 1–4 (82.6%); 41.2% were Pentecostal, 50% were dependent on their partner/family for income, and 88.4% had a previous pregnancy. Most had other children (74.4%), and the average number of other children was 1.1 (range 0–4), and 40.7% gave birth to their recent child in the hospital. Fewer were pregnant at the time of screening (17.4%), and most families knew of the pregnancy (86.7%). The mean months pregnant was 5.8, and 53.3% had attended an antenatal care visit with the first visit occurring on average at 4.6 months. Mean number of visits was 2.4 (range 1–4) and 50% attended a monthly visit. Most had a cell phone (73.3%) and used WhatsApp (58.7%).
Table 1
Socio-demographic Characteristics of Focus Group Study Participants (N = 135)
| Adolescent Mothers (n = 86) | Community Health Workers (n = 24) | Key Community Stakeholders (n = 25) |
Characteristic | n (%) | n (%) | n (%) |
Gender Female Male | 86 (100.0) 0 (0) | 23 (95.8) 1 (4.2) | 19 (76.0) 6 (24.0) |
Age Mean Age (Years) Age Range (Years) Missing | 17.6 15–18 0 | 60.3 37–77 1 (4.2) | 45.7 18–61 2 (8.0) |
Ethnicity Shona Other | 83 (96.5) 3 (3.5) | 24 (100.0) 0 | 23 (92.0) 2 (8.0) |
Marital Status Divorced or separated Married – Monogamous Married – Polygamous Never Married Widowed | 13 (15.1) 47 (54.7) 4 (4.7) 22 (25.6) 0 | 0 10 (41.7) 0 0 14 (58.3) | 5 (20.0) 7 (28.0) 4 (16.0) 3 (12.0) 6 (24.0) |
Highest Education Level Primary (Grade 1–7) High school (Form 1–4) Some College or University Bachelor's Other None Missing | 14 (16.3) 71 (82.6) 0 0 0 0 1 (1.2) | 1 (4.2) 4 (16.7) 3 (12.5) 1 (4.2) 15 (62.5) 0 0 | 3 (12.0) 20 (80.0) 0 0 1 (4.0) 1 (4.0) 0 |
Religious Affiliation Apostolic Christian Traditional Other Missing | 17 (19.8) 65 (75.6) 0 3 (3.5) 1(1.2) | 2 (8.3) 20 (83.3) 1 (4.2) 1 (4.2) 0 | 4 (16.0) 21 (84.1) 0 0 0 |
Main Source of Income Self-employed Formerly employed Dependent None Other Missing | 7 (8.1) 3 (3.5) 43 (50.0) 22 (25.6) 2 (2.3) 1 (1.2) | - - - - - - | - - - - - - |
Current Employment Yes No | - - | 24 (100.0) 0 | 6 (24.0) 19 (76.0) |
Prior Pregnancy Yes No Missing | 76 (88.4) 9 (10.5) 1 (1.2) | - - - | - - - |
Number of Prior Pregnancies 1 2 3 4 None Missing | 61 (70.9) 8 (9.3) 1 (1.2) 1 (1.2) 5 (5.8) 2 (2.3) | - - - - - - | - - - - - - |
Children Yes No Missing | 64 (74.4) 12 (14.0) 0 | - - - | - - - |
Number of Children Average Range | 1.1 0–4 | - - | - - |
Place of Last Birth Home Clinic Hospital | 1 (1.2) 28 (32.6) 35 (40.7) | - - - | - - - |
Currently Pregnant Yes No Missing | 15 (17.4) 68 (79.0) 3 (3.5) | - - - | - - - |
Family Know You’re Pregnant Yes No Missing | 13 (86.7) 1 (6.7) 1 (6.7) | - - - | - - - |
Months Currently Pregnant Average Range Missing | 5.8 3–9 2 (2.3) | - - - | - - - |
Attended ANC Yes No Missing | 8(53.3) 6(40.0) 1(6.7) | - - - | - - - |
Months Pregnant First ANC Average Range Missing | 4.6 3–7 3 (3.5) | - - - | - - - |
Number of ANC Visits Average Range | 2.4 1–4 | - - | - - |
Frequency of ANC Every month Other Missing | 4 (50.0) 2 (25.0) 2 (25.0) | - - - | - - - |
Cellphone Yes No Missing | 63 (73.3) 19 (22.1) 4 (4.7) | - - - | - - - |
WhatsApp Yes No | 37 (58.7) 26 (41.3) | - - | - - |
Community Health Workers (n = 24)
Mean age was 60.3 years (range 37–77) and 37.5% were Protestant. Most were widowed (58.3%), females (95.8%), of Shona ethnicity (100.0%) that resided in the study community (83.3%). Most had other education (62.5%), followed by high school Form 1–4 education (16.7%). They had an average of 27.9 years of experience as a community health worker (range 15–32) who worked with young women (96.0%).
Key Community Stakeholders (n = 25)
Mean age was 45.7 years (range 18–61), most were women (76.0%), of Shona ethnicity (92.0%), and resided in the study community (92.0%); 28.0% were Pentecostal, and 28.0% were monogamously married. Most had a high school Form 1–4 education (80.0%) and were not currently employed (76.0%); 44.0% worked with young women, and 60.0% had a female child of their own.
[Insert Table 1]
The Challenges Of Adolescent Motherhood
Most participants described adolescent motherhood in terms of the challenges of adolescent motherhood. Participants described challenges that centered on poverty and lack of employment opportunities with negative influences on health. An adolescent mother stated, “Most of the time we won’t have any money” (AM, Group 5). The lack of money was often a result of most adolescent mothers not finishing their education which then limited their employment prospects. A key community stakeholder explained:
Another issue is that these adolescents have not completed their education. So their brains, if they had gone maybe up to form 4, O Level (high school grade 11) they would have been mature and by going to school we meet teachers and learn different things. So being uneducated is also a problem again because they won’t really know what the future holds…If they could be taken back to school it would be nice. (KCS, Group 2)
Participants described financial worries leading to risky behaviors and poor health with a community health worker stating, “I think the main issue is on poverty, this will lead them to do everything and anything. They see what others would be having and start saying how can I get that. They end up getting into difficult positions which she was not supposed to due to poverty” (CHW, Group 1). These difficult positions included substance abuse and risky behaviors for financial compensation. A community health worker described:
Health with regards to adolescent mothers what we see is that they don’t do good to themselves, if they see that they have been given a child, let’s say they are a single mother, they no longer take care of themselves. They start smoking and drinking beer, they may actually go to beer halls thinking that they may get something, the beer hall is not good for health. They may find a lot of things that will trouble them, smoking will cause her to be sick and having so many boyfriends will cause her to be infected (with HIV). (CHW, Group1)
An adolescent mother added, “Our health can be affected through worrying on how we can take care of our children, money is a problem. Others don’t have anything to do that can give us money so our health can be affected through thinking about getting something to do” (AM, Group 10). Another adolescent mother added, “I think if adolescent mothers can work for themselves their health would be improved” (AM, Group 7) while a key community stakeholder described, “Something should be done for women for them to be able to earn a living and to empower them. We need to be taken to another level, out of the mud that we are currently in” (KCS, Group 2).
Participants also described challenges with adolescent motherhood due to marriages with a participant stating, “If you have your own money that would be better, a lot are not getting into marriages by choice, it is driven by that idea that maybe my life will be changed but you end up seeing that your life is actually getting worse” (AM, Group 4). The participant was referring to the cultural practice of brides price or “lobola” paid by the groom to the bride’s family. Another adolescent mother added:
It’s so difficult to be a mother while you are still young because what you face in the marriage, its different from someone who is married at 25 years, that person will be mature and knowledgeable. You might come across a situation let’s say the husband does not go to work, it becomes difficult for you as you have to provide for yourself. So it is so difficult being a mother while you are still young…life is just difficult if you are the mother of the house. (AM, Group 8)
Participants also described being chased away from home by relatives, being left by the person who impregnated them, and abuse as negatively affecting adolescent mother’s mental health. An adolescent mother stated, “To be impregnated and someone leaves you is such a painful thing so you won’t have mental stability” (AM, Group 7). Another adolescent mother described, “Being abused by a husband can cause you to have bad mental health, you will always think about what your tomorrow will be like if I spend of my days being abused and beaten, it causes you to be always thinking” (AM, Group 1). A community health worker added:
The other thing that causes them not to run to relatives is because they are too harsh with them. She would have gone to tell them about her situation and she is beaten up. She is chased away from the house and is told to go back to the boyfriend who may not be stable. The adolescent mother becomes stress that is when you see her becoming suicidal or hurting herself because she will be overwhelmed with the problem, the relatives would have chased her away. That is why she looks for refuge outside to us as community health workers because she knows that we will give her advice on way forward. (CHW, Group 1)
Gaps In Adolescent Mother Services And Programming
Most participants identified gaps in services and programming for adolescent mothers in their community. An adolescent mother stated, “There is need even for building of play centers where people can meet and socialize relieving their stress as women” (AM, Group 1) and another added:
If they could get some projects that they can do as this reduces their stress because if you are at work you are occupied with what you have to do than spending the whole day seated, that’s when you start having stress…So if you have something to occupy you that would be better. (AM, Group 1)
Peer support groups for adolescent mothers were welcomed to meet needs of adolescent mothers and engage them in activities with peers for knowledge sharing and skills building. An adolescent mother stated, “I think us as young people should get the opportunity to get into groups educating each other, people giving each other advice. I think that will help us as adolescent mothers on how we can live” (AM, Group 8). A key community stakeholder explained:
I think support groups is something they would really like because they know that they will get something out of it. You don’t get something while you are just seated at home, you can only get this when you are in groups. Forming support groups is a good way we can mobilize these children. (KCS, Group 1)
Peer Support Group Structure
Facilitators
Participants described that peer support groups should be delivered by trusted and informed people such as nurses and adults with health knowledge. An adolescent mother stated,
“These can be delivered by someone whom we trust that they can get back to us with an answer, we would have put all our trust in that person” (AM, Group 6). Another adolescent mother added, “The nurse from the clinic should be able to help us” (AM, Group 6), while another explained, “I think we would need adults who know about health” (AM, Group 3). Key community stakeholders reiterated the need for older adults to facilitate the groups with a stakeholder stating, “Older women and even men can be part of the group...if there are adults in there, there will be some order” (KCS, Group 1).
Location
Most participants preferred that the peer support groups be conducted at the local clinic, “They should be delivered here at the clinic” (AM, Group 5). Participants described clinics, along with community hall, schools, and churches, as central and trusted settings.
Frequency
The preferred frequency of peer support group sessions varied from meeting every day to once a month. An adolescent mother stated, “I think it should be done on a monthly basis” (AM, Group 3), while another explained, “If we are brought together as young people and we meet at least twice per week we can be able to learn, get to know each other and share information” (AM, Group 5). Another adolescent mother described, “I think every week, let’s say we meet once a week, by the end of the month we would know that we have four days that we meet educating and encouraging each other, doing our things as a unit” (AM, Group 8).
Duration
Participants described that peer support groups should meet about two hours at a time, over varying periods of time. Responding to how long peer support groups should be offered, an adolescent mother replied, “Two hours” (AM, Group 3). Participants wanted the peer support groups to be offered continuously with an adolescent mother describing, “As long as forever, the whole life because more and more adolescent mothers are being added every day” (AM, Group 1). Another adolescent mother added, “We would want them to be around for a long time so that they can assist even other adolescent mothers who will come after us” (AM, Group 10). Shorter term group meetings were also described with adolescent mothers suggesting that groups, “…can go to up to a year” (AM, Group 2) and “6 months” (AM, Group 4).
Topics
Participants described topics that included income generation, life skills, sexual health, mental health, gossip, hygiene, abuse, and breastfeeding. An adolescent mother described, “We would like to be helped with money so that we can be able to carry out these projects for a living” (AM, Group 10), while another adolescent mother added, “Maybe on drug abstinence because many adolescent mothers are now abusing drugs” (AM, Group 7). Adolescent mothers described gossip as a key barrier to communication between peers and community members. Gossip was also characterized as a contributor to the stigma of being an adolescent mother along with experiences of social isolation and depressive symptoms. An adolescent mother described:
If you hear something, let’s say your brother’s daughter has come to tell you her problem, you should not say as soon as she tells you, you are taking that to the next person. Then you hear that from so and so to say we heard this about you, that way we won’t be in good books with each other. So what we are asking is if you could go out there and educate them that they should not say if we come with our problems to them they go out spreading the word, selling it everywhere. (AM, Group 9)
Describing additional topics, a community health worker stated, “I think if projects could
be done for them so that they may have time to come together doing something together and
their minds can be stabilized as they work for themselves, I think that could work. Because some of them do not know how to work for themselves” (CHW, Group 1). A key community stakeholder added, “I think on sexual and reproductive health, which is one topic that is very important for these young people” (KCS, Group 1).
Name
Most participants named the peer support groups “Young Women of Today” (Madzimai eChidiki Anhasi) to emphasize their identity as young women first, then mothers who face current issues.
Whatsapp Messenger Use
Likes of WhatsApp
Use of WhatsApp Messenger to support intervention efforts was welcomed by most participants. Participants liked WhatsApp due to its ease of communication and affordability; how it allows information to travel fast; and the ability to share ideas, get help, and participate in group discussions, provide amusement, and learn. An adolescent mother explained, “If someone has encountered a problem at home we could use the WhatsApp groups to share ideas, people can help you here and there without waiting to meet in person, people can assist you fast” (AM, Group 1). Another adolescent mother added, “WhatsApp is good because if you don’t have enough money to phone you can talk through WhatsApp because if you juice up a dollar you can go for a week talking” (AM, Group 2).
Dislikes of WhatsApp
Most participants described that they disliked WhatsApp due to chain messages,
inappropriate messages, network challenges, identification of phone number, overuse, hacking of account, and its role in spreading misinformation. An adolescent mother stated, “Someone might actually be saying bad things in those groups which does not go in line with the purpose of the group” (AM, Group 3), while another added, “Bad influence, gossip, sharing bad videos” (AM, Group 4). A community health worker explained, “I don’t like chain messages and some messages you just delete before reading” (CHW, Group 1).
Frequency of WhatsApp Use
WhatsApp Messenger was used frequently among those who had the messaging app with adolescent mothers stating they used WhatsApp “The whole day” (AM, Group 1) and “I think I can use it for almost 14 hours of my day” (AM, Group 2).
Reasons for WhatsApp Use
Most participants described that they used WhatsApp for communicating with family and friends, church groups, and for learning and current affairs/news. An adolescent mother stated, “Most of the time I will be talking to people in our church group” (AM, Group 8) and another added, “I have WhatsApp groups from church where we are updated on what is happening, family groups and other relatives. It is easy to communicate with than phoning” (AM, Group 1). An adolescent mother stated, “I have a number of groups that I am part of, for novels and cooking. So if I see that I have received quite a number of messages on the novels, I switch off data and start going through the novels. I can also copy a recipe that I want from the group” (AM, Group 6). Another adolescent mother explained:
We can use it telling each other good information. Like what we were saying if there is one of us who has got a challenge, she can share it on the group. As adolescent mothers we should encourage each other, not laugh at her. That is what we would like to use WhatsApp for, to encourage each other as young people. (AM, Group 5)