Same Behaviors, Different Outcomes: The Role of Perceived Barriers and Risk on Sexual and Reproductive Health Practices among Youth in Ghana Open Access
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Background: Addressing the sexual and reproductive health (SRH) needs of young people has been identified as a priority for global health investments. The present research examines how barriers to services and perceived risk may influence sexual and reproductive health behaviors among youth in Ghana. Methods: Cross-sectional and longitudinal analyses were used to identify barriers to various services, explore how perceived risk predicted subsequent behaviors, and further understand how measures of risk can influence the way perceived risk is understood and reported. Results: Our first analysis revealed that while embarrassment continues to be a commonly reported perceived barrier to accessing most SRH services, it was a significantly greater barrier for contraception and HIV/STI testing compared with abortion. Structural barriers like cost and safety were greater barriers for abortion services. There were no differences in barriers reported by girls or boys or by those living in high versus low HIV prevalence communities. Using longitudinal data, our second analysis found that despite being integral to many behavior change theories, perceived risk did not predict subsequent behaviors as expected. There was no effect of perceived risk on having an older partner, multiple partners or unprotected sex. And, surprisingly, those with high perceived risk of HIV or pregnancy exhibited an increased odds of sexual initiation 18 months later. There was a significant main effect of self-efficacy on risk perception and behavior but no effect of perceived benefits on risk perceptions or behaviors. Finally, the third analysis revealed that despite being different outcomes, youth perceive their susceptibility, severity, and worry about both pregnancy and HIV in a similar ways using both cognitive and emotional measures. Youth perceived their own susceptibility of both HIV and pregnancy as significantly lower than the likelihood among others in their community indicating a perceived optimism bias among this population. Discussion: Though contraception is a key intervention to preventing unintended pregnancy and subsequent unsafe abortion, youth report being more embarrassed about seeking contraceptive services than abortion services. Efforts to understand why the stigma around contraception exists should be explored in addition to identifying ways to ensure access to safe abortion services for youth. In addition, these results highlight the need to consider other factors when trying to understand influences on behavior change among youth such as self-efficacy. And, cognitively based behavioral theories may not be the most accurate when trying to understand motivations for behavior change among youth. Results also suggest that emotional constructs and factoring optimism bias should be considered when trying to understand the way young people perceive their risk of sensitive outcomes like HIV and pregnancy and how these perceptions can influence behaviors.Conclusion: Youth are complex and so are the services they seek, their motivations for behavior change and how they perceive and understand risk. Researchers, program implementers and policy makers should consider this diversity when developing reproductive health programs and policies aimed to support young people.