The results are organized based on the conceptual model found in Fig. 2, which is a synthesis of the analysis. The FGDs all began with discussions around the inherent relationships between sex and contraceptive use, and how support for both behaviors was restricted by the character’s age and marital status. Participants expressed concern around the potential side effects of using contraceptives and believed that the preservation of fertility should be a priority. These perspectives created a picture of what the participants believed the character should do based on the approved social context. However, participants also acknowledged that these actions would not always align with what the character would do, with education being presented as one potential motivator for this deviation from the established social norm. Finally, the participants described those identified as influencers in the character’s decision to seek care, including peers, parents, and partners.
Appropriate context—age, marriage and sex
Participants grounded their discussion of the character’s contraceptive use initially by expressing resistance to the character’s choice to have sex due to her age and marital status. Participants in each of the FGDs began with statements in opposition to the character’s sexual activity, frequently describing the character as wayward or a prostitute due to this behavior. This discussion of sex was initially separated from the character’s desired contraceptive use, as the participants quickly established that due to cultural and religious norms her decision to have sex was not supported. Resistance most commonly related to the girl’s age, with many sharing the sentiment of an unmarried, Christian woman from Kaduna who said, “She is 16, I think she is not up to that age.” For participants, there was clear resistance to sexual behavior at 16 specifically, but there was very little discussion about the specific age at which these behaviors would be approved. One statement that alluded to this idea was made by an unmarried, Christian woman from Ilorin who said,
“The community view will be like, what is she looking for because her community here feels under-19, under-18, are still kids so what is she looking for. The advice they will give her will be to prevent sex or to even stop dating.”
Here, we see the participant grappling with the idea of the age at which this character would be considered an adult or able to have sex and make her own decisions. Whether a legal or perceived definition of adulthood, this quote relays that there is a norm established around the age of adulthood.
The resistance to sex was also compounded by the character’s marital status, as participants frequently put this forward along with age as a reason against her choice to have sex, as one married, Christian woman from Kaduna stated below,
“Now she can marry sixteen, seventeen; they can marry now, in this generation now she can marry. Let her just make up her mind now to be married because if anything happens now, she will be married.”
In this quote, we see the woman suggesting that if the character were to be married, then the decision to have sex would be acceptable, even at the otherwise unacceptable age of 16.
While the participants established that the character was not at the “right” age or marital status to have sex, they similarly attached her contraceptive use to her sexual activity, thus requiring the same prerequisites. The idea of contraceptive use was inherently attached to sex so the two ideas were frequently combined, as exemplified by an unmarried, Christian woman from Ilorin who said,
“I'm not sure they are going to accept it [contraception] because someone at the age of sixteen is not even meant to be having sex in Nigeria. That's all we believe.”
Discussions of age as a criterion for contraceptive use occurred in all of the FGDs, aligning with the above belief that this is a norm across Nigeria. Similarly, participants identified marriage as a criterion for support of contraceptive use, as an unmarried, Christian woman in Jos stated,
“…others will feel ah this girl is still a teenager, why will she start looking for family planning and all that when she is not married.”
Statements establishing the appropriate social context in which the character’s contraceptive use was supported by the community were identified across all the FGDs. Based on the results of the coding process, Muslim participants were twice as likely as Christians to raise marital status as a concern for both sex and contraceptive use. The lack of acceptance of sexual behavior outside the context of marriage within the Muslim population was discussed widely by participants from both religions, with one married Muslim woman from Jos sharing,
“Even if she meets her friends, it’s not like they know the side effects nor do they know if there are varieties [of methods] in order to give her advice. So, it is expected she tells her parents the truth…It is better they get her married. That is the better [way] that will protect the community from being totally ruined.”
Generally, the FGDs with the Muslim participants made it clear that they would prefer that the character get married instead of using a contraceptive method.
Despite these established norms, there was also an acknowledgement by all participants that adolescents in the community are having sex and accessing contraceptives, a sentiment which is best encapsulated by an unmarried, Christian woman from Ilorin who said,
“I heard that family planning prevents pregnancy and it's used for women, married women, who want to stop giving birth. But girls of nowadays are already doing it.”
Being young themselves, participants frequently discussed what the character should do within the established social norms, while also acknowledging that what she would do would not always conform to these guidelines. Participants referred to the character as being ‘determined’ and shared sentiments like the one said by a married, Muslim woman from Kaduna,
“Even if they talk, she has already made up her mind…So what anybody can say or would not say, she will do what is in her mind because she has already set her mind.”
Though mentioned across the FDGs, unmarried participants more frequently acknowledged this separation between the character’s likely actions compared to established norms; most mentions of this ‘determined’ mindset were made by unmarried participants.
Future fertility and contraceptive side effects
While established cultural norms influenced the perceived appropriate context for a girl to use a contraceptive method, side effects and the preservation of fertility served as tangible concerns that support the reasoning behind these norms. Concerns around side effects were discussed universally across all FGD in all regions, with slightly more mentions among unmarried participants. Comments commonly mirrored ones like this sentiment expressed by an unmarried, Muslim woman in Ilorin who said,
“It is not good for a 16 year old to use modern contraceptives because it could have side effects when she’s grown up.”
Like this woman, other participants commonly discussed fertility concerns in connection with social norms, almost as a justification for why the norms exist. Participants discussed the threat that infertility could place on a future marriage, a concern that made using contraceptives not worth the risk. One married, Christian woman from Kaduna touched on the intersection of age, parity and fertility protection when she said,
“To me, the age of sixteen is too early for her to take family planning because at times that family planning, I think it has its own side effect, (it) is when you finished giving birth to your children that’s when you have family planning.”
Like this woman, participants indicated that contraceptives should not be used until a woman reaches her desired parity to avoid the potential physical effects of using a method. Participants talked about side effects through sharing stories of friends or family who had suffered short- or long-term side effects from using a method. Side effects unrelated to fertility like weight gain were mentioned, though most of the discussion centered on fertility concerns. While these concerns were presented as a reason the character should not use contraceptives, participants still acknowledged that this information may not fully impact her decision. For example, while some women might consider side effect information as a deterrent to contraceptive use, those accessing a contraceptive would use this information to select a safer method and avoid potentially riskier methods while still preventing pregnancy.
The character’s educational pursuits were discussed as a motivator for contraceptive use among adolescents, as well as a reason to support contraceptive use among those previously opposed. Discussions of education were particularly common among participants in Ilorin, who mentioned it as a supportive factor twice as often as participants in Kaduna or Jos. Regardless of the city, education was an alternative motivator for contraceptive use besides early sexual behavior. An example of this idea occurred when one unmarried, Muslim participant from Ilorin acknowledged that opinions on the girl’s behavior would not prevent her from using a method, the moderator probed on why she thought this, to which she replied:
“Participant: Since she will not continue with it forever because she would still want to give birth.
Moderator: Oh, you think it is just for a short while so as to prevent pregnancy.
Participant: Yes. She may want to further her education or learn a trade.”
In this example, the participant viewed contraceptive use as temporary so the character could complete her education, while understanding that she may still want children in the future. Education was understood by some participants as something that should be protected and pursued and was given as a reason why the participants should avoid sex. However, with acknowledgment that sex was occurring, education was also one of the few factors that could negate pressures around age or marital status to generate support for accessing a method among community members.
Throughout the contraceptive decision-making process, the girl’s parents and peers were identified as the most likely people to influence her decision. Mentions of her partner were much less common, and the role of a provider was mostly discussed in connection with the decision around her choice of method, not the decision to use contraception.
Participants described peers as being people girls looked to for modeled behavior around sex and contraceptives, as well as a source for contraceptive information. Though discussed throughout, the most frequent mention of peer influence occurred in Ilorin, and Christian participants across all FGDs were over twice as likely to discuss the influence of peers compared to their Muslim counterparts. Unlike some of the other influencers, participants believed that the character would turn to her peers, and that those who the character surrounded herself with would dictate how she moved forward. Participants pointed to the character’s friend’s pregnancy as evidence that the character would see sex as normal. For some participants, this was a reason to recommend keeping girls away from certain peers, to prevent exposure from sexual behavior before she is considered old enough, especially outside of marriage. For example, one married, Christian woman from Kaduna introduced this idea by stating,
“She is sixteen, she won’t see her friend doing something, let her avoid it. The more she sees her friends, they are flirting, doing some things and all that, she too will like to put herself there.”
Participants across FGDs acknowledged that the girl’s actions could be influenced by what she believed her friends were doing, though this can depend on who her friends are. This applied to both sex and seeking contraceptives, as an unmarried, Christian woman from Jos said,
“So, if she has positive thinkers as friends they will be able to at least change her mind against doing it [using contraceptives]. And if her friends are just the way she is, they can even strengthen her more, and even expose her to more contraceptives that she can use.”
The influence described here was a perspective shared by many participants, though this participant also suggested that peers could change her mind against contraceptive use if they did not agree with her actions. This type of verbal influence or resistance was not widely discussed, with the majority of mentions of peer influence referenced as a mirroring of behavior instead. Where participants did see more of this verbal influence was in the sharing of stories between peers about contraceptive methods, particularly about which methods had produced side effects.
Parental influence on a girl’s contraceptive use was complex, as parents were seen as the expected enforcer of social norms around sex and contraceptive use. Participants placed the responsibility on parents to start conversations to establish what the character should do, and several participants even placed blame on the character’s parents for her decision to have sex and seek a contraceptive. For example, in referencing what the community would think of the character’s actions, one unmarried, Muslim woman from Ilorin said,
“It could be traceable to a family member or parents. Community members would probably think she is following the footsteps of her parents…most likely her mum.”
The pressure put on parents disincentivizes them from supporting a daughter’s access to a safe method. The participants explained that this pressure would make a girl’s decision to approach her parents for advice challenging. The influence of parents was more frequently discussed as something the character should seek, rather than what she would seek, suggesting that community pressures prevent adolescents from actually turning to this relationship.
Despite the social pressure that challenges this relationship, participants did identify parents as a source where girls could access accurate information. Most commonly, parents were perceived as the ones to explain the disadvantages of contraceptives and early sex. Though a few participants also suggested that parents can be a source of method-related information. As a married, Christian woman from Jos said:
“Is (it) better for us to tell the child the truth? Let’s look at it this way—if we should tell her the truth, abstinence is not (for) all of us, or not everybody can do it. To some extent, we have, they have friends definitely, so if you as a parent will tell her not to do this if she goes out it will be another thing. So we should just advise them in a way that they will understand, and (it) is good to some extent is good for her to use the contraceptive.”
This woman reflects a dilemma mentioned by others that parents should be a resource in order to ensure that girls are getting accurate information. Yet, we still see hesitance in fostering that communication line. Participants grappled with the need to expose the character to information about sex and contraceptives to promote safe practices, while also connecting this exposure through peers’ to mirrored action that may not be safe.
Though discussed the least frequently, participants described partners as an important source of influence, particularly when choosing a method. While the character decided whether to follow her peers or turn to her parents, participants described the partner as a critical player in the decision to use a method and which type of method to use. This is clear in one quote from an unmarried, Christian woman from Jos who said,
“For me, the person that I think will influence her is her boyfriend, because definitely before she starts thinking of that she talked to him about it, so she will go and do [access contraception], leave everything unto him to choose.”
When discussing the influence of partners, participants commonly described partners in a decision-making role, as indicated above. Further, a few participants also relayed a high level of mistrust in the character’s partner and thus may not expect the partner to be involved in the decision-making. Several participants recommended that the character avoid sex because her partner would leave her if she became pregnant, again, illustrating some level of distrust of partners. Alternatively, participants also suggested that partners could help remove barriers for the character, particularly by covering the cost of a method. When, partners were discussed, it was most frequently by married participants, though there were no regional or religious differences. Overall, the partner was described as an important influence throughout the contraceptive seeking process, and someone who would play a large, positive or negative, role in the decisions that were made along the way.