How culture shapes the sexual and reproductive health practices among adolescent girls in Eastern Equatoria, South Sudan
Abstract
Background: From 2011 to 2014, a programme aimed to improve sexual and reproductive health practices among adolescent girls was implemented by the non-governmental organization BRAC in partnership with the Government of South Sudan and with funding from the World Bank. The distinctive culture and norms in South Sudan offered unique challenges to the implementation of such a programme, which this study sought to explore.
Objectives: This study investigated the sexual and reproductive health (SRH) behaviour of women and men in Eastern Equatoria State to identify the social norms and beliefs that affect communities’ perception and behaviour regarding SRH issues.
Methods: Data were gathered from seven key informant interviews and nine focus groups of adult women and men and adolescent girls and boys in Torit and Magwi Counties in Eastern Equatoria.
Results: The study found a strong cultural preference for girls to demonstrate their fertility by beginning to have children at an early age (13–16 years) and to have many children (8–12). It also found that education on HIV/AIDS had been effective.
Conclusions: To be effective in South Sudan, adolescent sexual and reproductive health programmes must take the current social norms and practices into account and learn from the successes of HIV/AIDS education programmes.
Keywords: sexual and reproductive health, South Sudan, BRAC, adolescent girls, cultural beliefs and practices
Introduction
South Sudan has one of the world’s youngest populations with 72 percent of the population below 30 years of age and 7 percent of adolescent age (15 to 19 years) [1]. After decades of political unrest and civil war, South Sudan’s population, especially girls and women, have been left impoverished, undereducated and underemployed with limited access to health services [2]. Data from the 2010 South Sudan Household Health Survey found that 26 percent of adolescent girls (aged 15–19 years) are mothers [1]. However, interventions targeting adolescent girls can both support and empower this group to make safe and healthy choices [3,4].
One such intervention was the Adolescent Girls’ Initiative (AGI), created through a partnership between BRAC and the South Sudanese Ministry of Health with funding from the World Bank. The initiative provided opportunities for girls to gain life skills to help them make informed choices about sex, reproduction and marriage. It also offered vocational skills to enable them to start small-scale, income generating activities.
BRAC South Sudan’s Adolescent Girls Initiative and its Evaluation
BRAC South Sudan’s AGI was launched in 2011 to socially and economically empower adolescent girls in Central Equatoria, Eastern Equatoria, Jonglei, and Lakes States. Under this intervention (2011–2014), 100 adolescent girls’ clubs were formed, reaching a total of 3,000 girls. The clubs served as protected local spaces where girls could meet, socialize, receive information on sexual and reproductive health, and privately discuss issues of concern. Each club had 30 regular registered members between 15 and 24 years old.
The clubs encouraged recreational activities, such as reading, singing, dancing, plays, and games, and held training sessions on health issues, including menstruation, family planning, pregnancy, sexually transmitted diseases, and HIV. Club members also received vocational training in areas such as hairdressing, tailoring, agriculture, poultry care, and starting a small business.
BRAC had implemented similar interventions in Uganda, Tanzania, Liberia, and Sierra Leone in Africa. A study in Uganda in 2012 found that the intervention contributed to several positive changes: early marriage or cohabitation fell by 58 percent and adolescent pregnancy fell by 26 percent relative to control groups; reported incidents of girls being forced to have sex fell by 41 percent; and there was a 26 percent increase in condom use among girls relative to control groups [5]. When BRAC undertook an evaluation of AGI in South Sudan, however, positive changes in behaviour and practices related to adolescent sexual and reproductive health were not found to be significant. In order to investigate obstacles to the effectiveness of the AGI programme in South Sudan, BRAC undertook a qualitative study in two counties of Eastern Equatoria in 2014, looking into attitudes and practices relating to adolescent sexual reproductive health and other related topics. This paper reports the findings from this qualitative study.
Context
The study was undertaken in Torit and Magwi Counties in Eastern Equatoria State in March, 2014 (see map Figure 1). These locations were chosen because of BRAC’s presence in these counties and the fact that they were less affected by the violence in 2013 than other counties.
Figure 1. Torit County and Magwi County in Eastern Equatoria State, South Sudan (credit Rebecca Langstaff).
Torit County has a population of 110,662 living in 128 villages [6, 7]. It has one state hospital, 4 primary health care centres (PHCCs), and 14 primary health care units (PHCUs) [7]. Magwi County has a population of 169,826 [7]. It has 12 PHCCs and 23 functional PHCUs [7].
Method
A qualitative study was designed on topics related to sexual and reproductive health behaviours, practices, beliefs, and social norms among community members. In-depth interviews with key informants from the Ministry of Health and NGOs directly involved with the health system in the study areas, and focus groups with women, men, and adolescent girls and boys were used. Researchers used semi-structured interviews with key informants; data was collected through a dialogical format, allowing for follow-up and probing questions.
A total of nine focus groups were conducted (five in Torit County and four in Magwi County) with a minimum of two focus groups each for women 20 years of age and over (n=25), men 20 years of age and over (n=15), adolescent girls aged 12 to 19 (n=17), and adolescent boys aged 12 to 19 (n=14) (Table 1). Interviews and focus groups were conducted in the local languages of Juba Arabic and Acholi; they were recorded and then translated into English and transcribed.
Table 1. Participants and samples for in-depth interviews and focus group discussions
|
Data Collection Method |
Number of Participants |
Description |
Issues Discussed |
|
In-depth Interviews |
7 persons |
|
|
|
Focus Group Discussions |
71 persons in 9 groups |
|
|
The research team consisted of six members, coordinated by Joyce Inna, a South Sudanese Senior Program Officer with BRAC’s Health Program who is fluent in Juba Arabic and Acholi. Data from interviews and focus groups were analysed and coded by senior programme staff at BRAC South Sudan to determine factors influencing the uptake of adolescent sexual and reproductive health practices.
Results
Health Service Facilities: Long Distance and Inadequate Services
Almost all of the participants mentioned the long distance to health facilities as a major barrier in accessing health services. Respondents indicated that maternal and reproductive health services were extremely limited at facilities. This finding is supported by other literature that has assessed aspects of South Sudan’s health infrastructure [1].
When asked about services from community health workers, the participants mentioned that there were no community health workers regularly operating in their communities, although they were seen during specific outreach activities such as immunization campaigns.
Sources of health services used by participants included small private clinics and medicine shops, and local herbalists and traditional healers. In cases of serious illness (especially of children), participants indicated that they travel to a health facility. They noted that the responsibility of taking children to health facilities rests mainly on women.
In terms of the dissemination of health-related information, participants noted that health messages are broadcast on popular FM radio stations, but messages are in English, a language most villagers do not understand. Recognizing this as inadequate, participants noted that schools had the potential to be an important source of health education and information.
Child Bearing
Getting pregnant at a young age before marriage was found to be common and socially acceptable. Some women mentioned that getting pregnant at an early age is an obvious sign of proving their fertility to their communities. As one participant stated, “If a girl does not get pregnant at early age, people think she is a barren woman”. When asked how many children a woman should have, a majority of participants said that a woman should give birth to eight to twelve children and, therefore, should start giving birth early.
Various social norms in these communities encourage young women to have sex and bear children. For example, participants in focus groups mentioned that young girls and women are known to get drunk at funerals, participate in local dances, and have sexual intercourse. This practice is culturally encouraged, as these communities believe in compensating for a death by giving birth.
Early marriage is common in these communities; the ideal age for women to get married is thought to be between 13 and 16 years old. A dowry, paid in cattle, is an important source of wealth, and families are motivated to marry their daughters at an early age to acquire more cows.
Family Planning
Participants were not generally knowledgeable about family planning methods. Some women mentioned that their male partners did not want them to use contraceptives. A male participant felt that “People use condoms when they do sex with sex workers, not wives”. Participants from both male and female focus groups said that one of the reasons they would not use contraception was because they were afraid of perceived side effects such as “getting infertile,” or making the menstrual cycle irregular.
Other Findings
Almost all of the participants were found to be generally informed about HIV/AIDS. When asked to specify how someone could become infected with HIV, a majority of the respondents mentioned sexual intercourse, needles, used razor blades, and blood transfusions. However, the stigma towards those infected with the virus remained high.
Participants also noted that violence against women is high in their communities. In most of the cases, community leaders and family try to solve the issue at their own level; however, in some extreme cases of violence, the offenders are also reported to police and the courts.
Discussion and Conclusion
The findings from this qualitative study are relevant for the Ministry of Health and other NGO health programmes, and are consistent with other research. [8] Study findings and recommendations are summarized as follows:
- The rural communities in South Sudan have cultural norms that adolescent girls should begin to bear children at an early age (13–16 years old) and bear many children during their lifetime (8–12).
- There are widely held misconceptions about the use and side effects of contraceptives, leading to reduced use.
- Heath programmes targeted to improve adolescent sexual and reproductive health of women in South Sudan should take the local cultural context in consideration.
- Education relating to how HIV/AIDS is transmitted seems to be relatively effective. HIV/AIDS awareness raising and education techniques should be examined to determine techniques that could be used to similarly improve education on issues related to contraception, and delaying marriage and childbirth.
To be effective in South Sudan, adolescent sexual and reproductive health programmes must take the current social norms and practices into account and learn from the successes of HIV/AIDS education programmes.
References
- South Sudan Ministry of Health and National Bureau of Statistics. South Sudan household survey 2010 Final Report, South Sudan Ministry of Health and National Bureau of Statistics, Juba; 2013.
- Rai RK, Ramadhan AA, Tulchinsky T H. Prioritizing maternal and child health in independent South Sudan. Maternal and Child Health Journal 2012;16(6):1139–42.
- Jensen R. Do labor market opportunities affect young women’s work and family decisions? Experimental evidence from India. Quarterly Journal of Economics 2012;127(2): 753–92.
- Heckman JJ, Mosso S. The economics of human development and social mobility. Annual Review of Economics 2014; 6: 689–733.
- Bandiera O, Buehren N, Burgess R et al. Empowering adolescent girls: evidence from a randomized control trial in Uganda. World Bank, Washington, DC; 2012.
- Sudan National Bureau of Statistics. Sudan Household Health Survey 2006, Sudan National Bureau of Statistics, Juba; 2007.
- Beesley ME. Off the road: the mapping of health training facilities in Southern Sudan, Ministry of Health, Government of Southern Sudan in collaboration with the Liverpool Associates in Tropical Health, Juba; 2010.
- Tariquazzaman S, McKague K. Knowledge, Attitude and Practice and service barriers in a tuberculosis programme in Lakes State, South Sudan: A qualitative study. South Sudan Medical Journal 2018;11(1):4-7.
Disclaimer: The views expressed in this paper are those of the authors and do not reflect the views of the World Bank or BRAC.
