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Background: Adolescent pregnancies present a great public health burden in Kenya and Sub-Saharan Africa (UNFPA, Motherhood in Childhood: Facing the challenge of Adolescent Pregnancy, 2013). The disenfranchisement from public institutions and services is further compounded by cultural stigma and gender inequality creating emotional, psychosocial, health, and educational problems in the lives of vulnerable pregnant adolescents (Int J Adolesc Med Health 15(4):321-9, 2003; BMC Public Health 8:83, 2008). In this paper we have applied an engagement interview framework to examine interpersonal, practical, and cultural challenges faced by pregnant adolescents. Methods: Using a qualitative study design, 12 pregnant adolescents (ages 15-19) visiting a health facility’s antenatal services in Nairobi were interviewed. All recruited adolescents were pregnant for the first time and screened positive on the nine-item Patient Health Questionnaire (PHQ-9) with 16% of 176 participants interviewed in a descriptive survey in the same Kangemi primary health facility found to be severely depressed (Osok et al., Depression and its psychosocial risk factors in pregnant Kenyan adolescents: a cross-sectional study in a community health Centre of Nairobi, BMC Psychiatry, 2018 18:136 https://doi.org/10.1186/s12888-018-1706-y). An engagement interview approach (Social Work 52(4):295-308, 2007) was applied to elicit various practical, psychological, interpersonal, and cultural barriers to life adjustment, service access, obtaining resources, and psychosocial support related to pregnancy. Grounded theory method was applied for qualitative data sifting and analysis (Strauss and Corbin, Basics of qualitative research, 1990). Results: Findings revealed that pregnant adolescents face four major areas of challenges, including depression, anxiety and stress around the pregnancy, denial of the pregnancy, lack of basic needs provisions and care, and restricted educational or livelihood opportunities for personal development post pregnancy. These challenges were related both to existing social and cultural values/norms on gender and traditional family structure, as well as to service structural barriers (including prenatal care, mental health care, newborn care, parenting support services). More importantly, dealing with these challenges has led to negative mental health consequences in adolescent pregnant girls, including feeling insecure about the future, feeling very defeated and sad to be pregnant, and feeling unsupported and disempowered in providing care for the baby. Conclusions: Findings have implications for service planning, including developing more integrated mental health services for pregnant adolescents. Additionally, we felt a need for developing reproductive education and information dissemination strategies to improve community members’ knowledge of pregnant adolescent mental health issues.
Our study was informed more broadly by a grounded theory method. Grounded theory approach does not presume existence of a theory from the outset but uses the participants’ data to create meaningful categories and theoretical thrust [37]. We embedded an ‘engagement stance’ shown by the interviewer which was meant to elicit experiences around pregnancy, emotional support, and quality of interpersonal relationships. We had a broad framework which provided us with three registers to probe our participants in: a) practical (e.g., resources, access) b) interpersonal (e.g., support from spouse/partner, parents, health centre), and c) cultural barriers (e.g., stigma from family, community, discrimination in school, clinics). The conceptual foundation of this interview is a combination of ethnographic and motivational style probing designed to identify barriers to uptake of services [23], investment in treatment, and tapping into experiential components around the mental health problem namely, depression. It specifically identifies participants’ practical constraints such as food insecurity, lack of funds to access healthcare, and help in ascertaining the challenges that will interrupt therapeutic engagement and progress. As a team, we got beginner’s training in the use of G-IPT (with the exception of NG who is already a trained supervisor of IPT by International Society for IPT) adapted for adolescents in perinatal spectrum in the Kenyan context. We went with the interview with the expectation that our adolescent participants will generate a theory about psychological distress associated with being pregnant at a vulnerable age and that we will learn about the severity and interpersonal challenges around being pregnant and depressed. Whilst we had these registers to probe the adolescents on, we did not start the interview process with assumed categories within these broad registers and expected our interview data to generate themes and sub-themes that would highlight these. See Table 1 which presents the interview domains and Table Table22 which presents the interview themes and corresponding case vignettes. Sample Characteristics and Interview focus Interview themes and corresponding case vignettes from adolescents who visited health facility for maternity care We worked in one of the Nairobi county health center that is typically headed by a nursing officer-in-charge. The facility offers community level care services to include maternal and child health services, HIV counselling and testing, and anti-retroviral therapy. A small cubicle was provided by the health facility to conduct these interviews. This study is part of the larger initiate of prenatal depression project (which aims to study prevalence of depression and mechanisms for depression in pregnant adolescents). We were given IRB clearance from Kenyatta National Hospital and University of Nairobi Ethics Review Committee (ERC Approval No. P499/07/2015). We carried out data collection after receiving authorization from Nairobi County Directorate. In the larger study, 174 pregnant adolescents were recruited, 32.9% were identified with depression (using PHQ-9 cut off of 15 and above) [38]. We used a convenience sample to recruit 12 out of the larger cohort we had interviewed for our cross-sectional survey study. We made a decision to recruit a sample of 12 participants who screened positive for depression with at least 5 participants with severe depression symptoms on PHQ-9 and the remaining participants (these 7 participants scored mild to moderate depression severity on PHQ-9) were identified through their responses to the sociodemographic questionnaire which sought to identify 5 domains of psychosocial risk factors namely, lack of perceived social support, living with HIV/AIDS, domestic and sexual violence, substance abuse, and poverty. Two participants declined to give consent for in-depth interviews due to reluctance expressed by their family member who had accompanied them. All the adolescents were provided referrals (to KNH Department of Mental Health or to the Psychiatry clinic that runs in the health center in cooperation with the University of Nairobi) after the interview. See Table Table11 for more information. We interviewed 3 caregivers and 1 partner who accompanied the adolescent for check-up to get a sense of the family’s experiences and perspective around the developing pregnancy. Several of our participants mentioned not having enough monetary support for a caregiver, partner or a boyfriend to accompany so we were only able to interview a few caregivers we could manage to find in the clinic. Informed by grounded theory and engagement interview approach, we developed an interview guide for the adolescents and a separate guide for caregivers and partners (see Additional files 1 and 2). The study entailed questions of sensitive nature, and it was imperative to protect participants and their caregivers’ identities. We interviewed the 12 adolescents separately in an in-depth semi-structured interview format. Sample 1 (pregnant adolescents) and 2 (caregivers/partner) interviews were both key informant interviews and therefore done on a one-on-one basis. We used the interviews without identifiers for adolescents (Additional file 1) and for caregivers and partners (Additional files 2) to elicit experiences of pregnancy, depression, and barriers to care. The interview was carried out by a trained researcher who was the first author in this case. Consent form was signed by participants prior to the interview. Interviews were carried out in Kiswahili or English based on the preference of the participants and using the procedure that was sensitive to participants’ level of distress (e.g., provided additional referrals or social support as needed after individual interview). The same procedure was followed with the 4 caregivers: 3 mothers and 1 partner and the researcher gave time to address any questions the adolescents and caregivers had about mental health issues. Audio tape data from interviews were transcribed and then analyzed by a team of 3 individuals. The first author read each transcript and developed themes per interview. The second author who is a native Kiswahili speaker reviewed the interviews to check quality of translation and transcription. These interviews and the preliminary themes were then reviewed by second and last authors who were the primary researchers’ supervisors. This team then shared key interview vignettes, themes, and codes to other members of the team for their feedback and deliberation. Two sample interviews were then read by the other members of the team. The first and last author then triangulated and collated interview themes from these deliberations and these were then categorized into core themes. Key themes and the corresponding codes and relevant vignettes from all transcripts were compiled in to MS word documents by the primary researcher and reassessed by the co-authors for accuracy, authenticity, and synergistic links with our epidemiological framework. We have tried in our analysis to keep closer to our participants’ lived experience and presented their vignettes to exemplify their feelings and thoughts. Table 3 elucidates the core themes and presents representative vignettes on the right column. The table’s first section is devoted to the adolescent participants and the second section focuses on the 4 caregivers we interviewed. Emerging Themes and illustrative quotes on challenges experienced by caregivers living with adolescents The parents and/or guardians of the minors in this study provided informed consent to participate. We would like to highlight a few caveats that underpin our experiences of engaging with the pregnant adolescents:
