Introduction

Stigma “deeply discredits and transforms people from whole individuals to tainted, discounted ones” [1,2]. It is a complex, contextual, dynamic social process that “marks” an individual for an attribute that violates social expectations and is devalued culturally [1,2]. Stigma scholars have described it as driver of health inequalities and a fundamental social determinant of health [3–5]. The majority of research considering the health-related causes and consequences of stigma have focused on stigma specifically occurring with mental illness, minority sexual orientation, obesity, HIV/AIDS, disability, and minority race/ethnicity [1–11].

Stigma occurring in the context of adolescent sexual behavior, pregnancy, early childbearing, abortion, and sexually transmitted infections (STIs) may lead to adverse health and social consequences, including shame, social marginalization, violence and mental health morbidity [12–21]. Our recent work has formally conceptualized and measured social stigma spanning a broader continuum of SRH events to explore whether adolescent SRH stigma at the environmental or community level negatively influences family planning decision-making and behaviors [22–24]. Based upon formative qualitative research [22,23], we developed an Adolescent SRH Stigma Scale to assess environmental stigma within the community accompanying different dimensions of SRH and family planning [24]. The 20-item instrument, which comprises Internalized Stigma, Enacted Stigma, and Stigmatizing Lay Attitudes sub-scales, was then tested in a survey study of 1,080 women ages 15–24 recruited from schools, health facilities, and universities in two cities in Ghana.

While this work was useful in providing initial estimates of SRH stigma and documenting relationships between girls’ higher SRH stigma scores and nonuse of modern contraception [22–24], findings alone are not sufficient to inform targeted, multi-level interventions to reduce or manage SRH stigma. Indeed, the causes of adolescent SRH stigma have been given little attention in research to date, but a better understanding of the factors contributing to environmental SRH stigma is needed to identify young women and communities most at risk for stigma and its adverse consequences. Such research is also needed to guide more holistic public health practices, programs and policies that ultimately de-stigmatize SRH for adolescents in Africa and elsewhere.

We investigated a diverse set of demographic, social and health factors associated with environmental SRH stigma perceived by adolescent girls from two urban communities in western Sub-Saharan Africa.

Materials and methods

Results

Characteristics of the sample are presented in Table 1. The mean age of participants was 20 years. Equal proportions were from Kumasi and Accra. Half (52%) self-identified as Akan ethnicity. The predominant religious affiliation was Christian/other (88%), with 77% reporting religion as extremely/very important and 80% attending religious services weekly or more frequently. Less than half had completed secondary school (42%) and three-quarters (74%) were not employed. Nearly half were in a romantic or sexual relationship (47%), though few were married or engaged (15%). For health and social wellbeing, 37% rated their health as ≤ good; 8% had a history of chronic health condition. Current depression, anxiety and stress symptoms were reported, on average, one to two times per month (means 2.40, 2.19, and 2.09, respectively, on 1–5 scale). Mean scores on the everyday discrimination and stressful life events scales were 4.46 (range 0–25) and 3.07 (range 0–9), respectively. For sexual and reproductive histories, intercourse experience (lifetime 69%; last 12 months 63%) was common, with 43% reporting ≥ 2 lifetime partners. Half (52%) reported ever use of contraception; 41% had used contraception at last sex. Receipt of formal family planning services was less common (35%). Half had ever been pregnant (49%); a quarter had given birth (26%) and 10% reported an abortion history. Nearly one-third reported a history of sexual assault (30%).

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Table 1. Characteristics of the sample.

https://doi.org/10.1371/journal.pone.0195163.t001

Sexual and reproductive health stigma

Responses to the SRH Stigma Scale, sub-scales, and individual items are presented in Table 2. The mean score on the SRH Stigma scale was 13.11 (SD 3.78, range 1–20), with mean sub-scale scores highest for enacted stigma (4.55, SD 1.82, range 0–7) and similar for internalized (4.28, SD 1.42, range 0–6) and stigmatizing lay attitudes (4.28, SD 1.47, range 0–7). Agreement with the various stigma items was common, with 15 of the 20 items having >60% agreement. Stigma of abortion (64–92%), sex (56–86%), and childbearing/pregnancy (49–78%) had the highest rates of agreement while family planning stigma had the lowest agreement (31%-65%) (Table 2).

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Table 2. Sexual and reproductive stigma scale, sub-scale, and item descriptives.

https://doi.org/10.1371/journal.pone.0195163.t002

Factors associated with SRH stigma

In the unadjusted analysis (Table 3), factors associated with SRH stigma scores included: age, city, religious affiliation, educational attainment, relationship status, self-rated health, and histories of sexual intercourse, receipt of family planning services, modern contraceptive use, pregnancy, and number of sexual partners (p-values<0.05). Compared to their counterparts, SRH stigma scores were higher among girls who were younger, residing in Accra, Muslim religious affiliation, still in or had dropped out of secondary school, unemployed, in excellent/very good self-rated health, and who reported prior pregnancy(ies) and higher numbers of sexual partners (Table 3). On the other hand, SRH stigma scores were lower among girls who were in a relationship and those who had sexual intercourse experience, received family planning services, and used contraception (Table 3).

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Table 3. Factors associated with sexual and reproductive health stigma in unadjusted analyses.

https://doi.org/10.1371/journal.pone.0195163.t003

In multivariable linear regression analyses (Table 4), factors positively associated with higher SRH stigma scores included history of pregnancy (β = 1.53, 95% CI = 0.51,2.56) and reporting excellent/very good (vs. ≤ good) self-rated health (β = 0.89, CI = 0.20,1.58). Older age (β = -0.17, CI = -0.24,-0.09), higher educational attainment (secondary school or greater vs. still in school/school drop-out, β = -1.22, CI = -1.82,-0.63), and sexual intercourse experience (β = -1.32, CI = -2.10,-0.55) were associated with lower SRH stigma scores.

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Table 4. Multivariable linear regression models of factors predicting sexual and reproductive health stigma.

https://doi.org/10.1371/journal.pone.0195163.t004

Discussion

Using a new validated Adolescent SRH Stigma Scale we developed and tested among adolescents in two urban, western Sub-Saharan African communities, we found high levels of environmental SRH stigma, especially reported by the youngest girls. Our nuanced measurement approach highlighted varying degrees of negative social and community norms, attitudes and beliefs occurring across different dimensions of SRH. While high levels of abortion stigma were not surprising, similar levels of abortion stigma reported for sexual intercourse and pregnancy–two distinct reproductive events that have been less studied in stigma research—were perhaps less expected. Building upon prior stigma work in the U.S. and Africa largely focused on HIV and abortion stigma, our findings add estimates of environmental SRH stigmas across a broader spectrum of reproductive life experiences. They also provide insight into SRH stigma specifically perceived by adolescents—a vulnerable but understudied group in African family planning and stigma research, despite the severe impact of stigma and its health and social consequences for this group [30–32].

We explored a diverse set of demographic, health, and social context factors associated with adolescent SRH stigma. Prior pregnancy was perhaps the clearest, strongest predictor among our young Ghanaian sample. This finding is consistent with those of studies (ours and others’) in which previously pregnant or parenting adolescents, both in U.S. and African cohorts, have reported discrimination, marginalization, and violence [15–17,33,34]. However, this relatively modest body of work has not explicitly conceptualized or formally measured SRH stigma. Also, congruent with our larger project in which we postulated that SRH stigma serves as a barrier to family planning, higher levels of stigma here were reported among girls who had never used contraceptive methods or services, though this trend was not significant in multivariable analyses. On the other hand, prior sexual intercourse experience was associated with lower levels of stigma. It is not clear from our data whether girls had disclosed prior sexual experiences, such that sex itself may not have been a stigmatizing event but rather the perceived social manifestations and consequences of it were. Alternatively, it may be that sex without the consequence of pregnancy could foster stigma resilience, or even a sense of pride or accomplishment. This requires further study. Of note, our survey items were designed to measure SRH stigma within women’s social environments and not (necessarily) experienced stigma; although in this analysis we explicitly assessed girls’ histories of a range of SRH events. Our ongoing work in Africa and the U.S. is further investigating stigma directly attributable to sex, pregnancy, contraceptive use, abortion and family planning service use.

Additionally, given the cross-sectional nature of our data, we were unable to establish temporality or examine time-varying levels of SRH stigma that may change over time as a result of new exposures. It is likely that stigma and SRH perceptions and experiences are bi-directionally associated–that one’s perceptions of SRH shaped by the SRH experiences of one’s own, one’s friends, family, or community members, which in turn may or may not be accompanied by stigma [22–24]. Conversely, one’s SRH experiences may be shaped by negative attitudes and beliefs about SRH, which further perpetuate stigma. Additional longitudinal studies are needed to disentangle the complex, dynamic interrelationships between adolescents SRH perceptions, experiences and stigma.

Regarding social and health predictors, lack of education, unemployment, and religious affiliation (Muslim) were associated with adolescent SRH stigma, findings which align with results of other studies documenting high levels of reproductive and other types of stigmas among vulnerable or conservative groups [1–11,15–17,33,34]. Social discrimination, depression, anxiety, and physical health conditions were not associated with stigma, although psychological stress and adverse life events were marginally associated. Perhaps other stigmatized identities, in this case mental or physical illness or other factors contributing to discrimination, foster stigma resilience. It is also possible that while discrimination and mental health morbidity have historically been conceptualized as common correlates of stigma [1–11], perhaps they do not contribute to SRH stigma specifically, or even to stigma in this geographic/cultural context. In our longitudinal analysis of a cohort of adolescent girls in the United States [34], we found that history of pregnancy was the strongest predictor of everyday discrimination and of stress but not depression; stigma was not measured. For the current study, it is also possible that other confounding factors not comprehensively measured, such as violence exposure, relationship dynamics, or health, account for associations of interest (or lack thereof). Moreover, to our knowledge, items from the Everyday Discrimination Scale and the Patient Health Questionnaire have not been widely validated among African or adolescent samples, and we adapted abbreviated versions of these scales which offer limited measurement of relatively complex health and social constructs. Overall, the interrelationships between social wellbeing, physical and mental health, and SRH stigma require further investigation using more holistic bio-psycho-social frameworks and methodological approaches.

In addition to the above-described limitations, our results were likely impacted by social desirability bias given the sensitive nature of our study and our young sample. Additionally, we focused on two major cities in Ghana and on participants recruited from schools and health facilities, such that our findings are not generalizable to all girls in Sub-Saharan Africa or other sociocultural or geographic contexts in which SRH stigma may be perceived or experienced differently. Although, the SRH stigma found here is perhaps notable given the relatively developed reproductive healthcare infrastructure in Ghana compared to other countries. We did not explore the perceptions or experiences of SRH stigma and its predictors among adolescent boys or of transgendered youth, which are highly relevant sub-populations for which SRH stigma has been understudied and deserve future research inquiry. Finally, our stigma scale did not capture the full spectrum of SRH stigmas, for example HIV, STIs or sexual minority stigmas, or an exhaustive list of potential predictors of stigma.

Nonetheless, our study suggests that these adolescent girls endorse stigmatizing attitudes around issues of SRH and/or have observed or felt SRH stigma in their environments. Some life experiences or lack thereof appear to render some girls more vulnerable to stigmatizing beliefs (e.g. no prior health challenges, having had a pregnancy, never having had sex), and others more resilient to stigma (e.g. being sexually active but successfully avoiding pregnancy). While our findings provide insight into a diverse set of factors associated with SRH stigma in Ghana, they also highlight clear remaining gaps in adolescent health research and important directions for future study. Research is needed to inform more holistic, evidence-based practices, programs and policies that can foster stigma resilience at the individual level and counter adolescent SRH stigma at the environmental level in order to improve SRH outcomes for young women and communities across the globe.

Acknowledgments

This work was supported by the Society of Family Planning Research Fund Award #SFPRF8-1, the National Institute of Child Health and Human Development (NICHD) #1K01HD080722-01A1 (KSH), NICHD #K12HD001438 (for KSH while she was at the University of Michigan, PI Johnson), and awards from the University of Michigan’s African Social Research Initiative and Office of the Vice President of Research. Funding sources had no involvement in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.