Decision making and contraception: Perceptions and experiences of Thai-Isan adolescents
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Adolescent pregnancy became a nationally recognised public health priority in Thailand in 2008, at first National Health Assembly of Thailand. The prevalence of contraceptive use by Thai adolescents still remains low, compared to adults. Contraceptive use could significantly reduce the physical, emotional and financial risks associated with early life pregnancies for Thai adolescents. Many previous studies have recruited female participants aged 18–49 years, but little is known about how adolescents in the 15–19-year-old age group make their decisions about contraceptives and what factors influence their choices. Furthermore, few published studies have described what adolescents expect or need in order to meet their sexual and reproductive health needs to make informed decisions. The issue of human rights has not been explored, either. This research used a qualitative approach to explore perceptions and experiences of Thai adolescents during the contraceptive decision-making process and factors that influenced those choices. This approach allowed me to hear the previously unheard opinions of Thai adolescents regarding their sexual and reproductive health, and their rights. Thirty-eight secondary school-age adolescents participated in the study; 29 took part in focus group discussions (FGDs), and 11 consented to in-depth interviews. Another nine teenagers who were not part of FGDs also engaged in in-depth interviews. Audio-recordings were transcribed verbatim in Thai. Data was analysed using thematic analysis. Regardless of initial contraceptive discussions and decisions made before initiating sexual relationships, final contraceptive decisions made were unplanned and happened just before each sexual encounter. Typically, males were expected to provide condoms, and girls were expected to request condoms though males were likely to negotiate for no condoms. When the female failed to negotiate or willingly allowed her boyfriend to have sex with no condoms, withdrawal rules were likely to apply. Emergency pills were used when the female was uncertain about successful use of the withdrawal method and when one or both partners had drunken unprotected sex. Long acting hormonal implants were used after abortion on parental demand. Fear of the negative consequences of pregnancy, such as burdening parents and being punished by parents, was a factor influencing prevention of unplanned pregnancies. Condoms were likely to be their first choice. All participants knew that condoms were more effective than the withdrawal method, but many were ill-informed about hormone pills. Accessibility and cost of condoms affected adolescents’ choice of method. Female’s negotiation skills affected contraceptive decisions. Interestingly, having an older girlfriend or fear of HIV/AIDS infection could lead young males to use condoms. Young females’ fears of being in social and financial difficulties, or of being unable to fulfil cultural expectations as the firstborn daughter, affected their decisions. The sexual and reproductive needs and the human rights requirements of adolescents in Thailand have not yet been met. Participants suggested that allowing them to express their views might help increase understanding between adolescents and previous generations. They felt that people in their age group should have an understanding of their own sexuality, and should be consulted about sex and contraceptive use by older adults. Participants felt that some social beliefs/values should be changed to increase accessibility to condoms and other effective contraceptive methods. Confidentiality and privacy were recurring issues in discussions about youth-friendly sexual health services currently provided in Thailand. The findings of this study suggest that applying a holistic approach to improve adolescents’ decisions about contraception would benefit Thai society as a whole. It is recommended that policy-makers in Thailand should integrate morals-cultural based, rights-based and gender-based public health interventions to increase adolescents’ knowledge about contraceptives, to help them access effective contraceptive methods, and to allow them to make informed decisions about their reproductive health.