in Limpopo Province within Polokwane Municipality
by
NOMFUNDO THOKOZILE SINGWAYO
THESIS PRESENTED FOR THE DEGREE OF
MASTER OF SOCIAL WORK
IN THE FACULTY
OF ARTS AND SOCIAL SCIENCES
AT
STELLENBOSCH UNIVERSITY
SUPERVISORS: DR TASNEEMAH CORNELISSEN-NORDIEN
DR ILZE SLABBERT
DECLARATION
By submitting this thesis electronically, I, Nomfundo Singwayo, declare that the entirety of the work contained therein is my own, original work, that I am the sole author thereof (unless to the extent explicitly otherwise stated), that reproduction and publication thereof by University of Stellenbosch will not infringe any third party rights and that I have not previously in its entirety or in part submitted it for obtaining a qualification.
DECEMBER 2020
Copyright ©2020 Stellenbosch University All rights reserved.
ABSTRACT
Adolescence is a difficult life phase is marred by various challenges. One such challenge is an unplanned and unwanted pregnancy. It is particularly difficult for the teenage mother who is more likely to face critical social issues such as poverty, poor education and engage in risky behaviour which may lead to poor health issues and dependence on social services. The financial cost of teenagers having babies is devastating. Educational attainment is difficult for the teen mother which may lead to decreased economic opportunities and a lack of income throughout their lifetime. These issues become exacerbated if the teenage mother is also HIV positive.
The goal of the research study was thus to gain an understanding of the views of social service providers regarding the services available to HIV-positive teenage mothers within Polokwane Municipality in Limpopo province. This goal was achieved the following objectives:to explain the effect of socio-cultural and educational factors on HIV-positive teenage mothers and their needs in this regard, to describe the social support available to HIV-positive teenage mothers from an ecological perspective, to investigate the perceptions of social service providers on support services available for HIV-positive mothers. This study used a qualitative research approach. The research utilised an exploratory and descriptive design. Purposive sampling was used to select the 20 participants who participated in the study. Data was collected by means of semi-structured interviews with guiding questions, formulated based on the literature review. After data collection and analysis, various sub-themes and categories emerged.
The findings of the study reveal that HIV-positive teenage mothers living in Limpopo Province have different needs, which include the need for support from their families, friends, teachers and the community. Socio-cultural factors such as early marriage, lack of parental guidance, gender power imbalance and peer pressure influence teenage pregnancy in Limpopo province, also became apparent.
The findings further indicate a gap in the social, instrumental and informational support provided to HIV-positive teenage mothers. Based on these findings relevant conclusions and recommendations are made.
Adolessensie is ʼn moeilike lewensfase gekenmerk deur verskeie uitdagings. Een van hierdie uitdagings is ’n onbeplande en ongewenste swangerskap. Dit is veral moeilike vir ʼn tienermoeder wie meer geneig is om kritieke maatskaplike kwessies soos armoede, ʼn lae opvoedingspeil en eksperimentering met risiko gedrag te ervaar wat kan lei tot swak gesondheid en afhanklikheid aan maatskaplike dienste. Die finansiële uitdagings vir tieners om babas te kry is oorweldigend. Om opvoedkundige kwalifikasies te verbeter is moeilik vir die tienermoeder wat kan lei tot beperkte ekonomiese geleenthede en ʼn gebek aan inkomste regdeur hul lewensduur. Hierdie kwessies vererger as die tienermoeder HIV-positief is.
Die doel van hierdie studie was dus om ʼn begrip te verkry van die sienings van maatskaplike diensverskaffers oor beskikbare dienste vir HIV-positiewe tienermoeders in die Polokwane Munisipaliteit distrik in Limpopo. Die doel was bereik deur die volgende doelwitte: om die effek van en behoeftes aan sosio-kulturele en opvoedkundige faktore op en van HIV-positiewe tienermoeders te verduidelik; om die maatskaplike ondersteuning wat beskikbaar is vir HIV-positiewe tienermoeders te beskryf; om die persepsies van maatskaplike diensverskaffers op die dienste wat beskikbaar is aan HIV-positiewe tienermoeders te ondersoek en; om relevante gevolgtrekkings en aanbevelings te maak. Daar is gebruik gemaak van ʼn kwalitatiewe navorsingsbenadering met ʼn eksplorerende en beskrywende aard. Doelbewuste steekproeftrekking is gebruik om die 20 deelnemers te werf wat deelgeneem het aan die studie. Data is ingesamel deur gebruik te mak van ʼn semi-gestruktureerde onderhoudskedule. Die literatuur oorsig is benut om die onderhoudskedule saam te stel. Na die data ingesamel is en geanaliseer is, is verskeie temas en sub-temas geïdentifiseer.
Die bevindinge van die studie toon dat HIV-positiewe tienermoeders wat in die Limpopo distrik woonagtig is, verskeie behoefte het, onder andere die behoefte aan ondersteuning van hul gesinne, vriende, onderwysers en die gemeenskap. Sosio-kulturele faktore soos jeugdige huwelike, gebrek aan ouerlike leiding, wanbalans in geslagsmag en portuurdruk beïnvloed tiener-swangerskappe in Limpopo. Die bevindinge dui verder dat daar ʼn gaping is in die maatskaplike, instrumentele en informele ondersteuning wat voorsien word aan HIV-positiewe tienermoeders. Gebaseer op hierdie bevindinge is relevante gevolgtrekkings en aanbevelings gemaak.
Acknowledgements
I would like to acknowledge and express my gratitude to God for being there for me throughout this research journey.
To Dr Cornelissen-Nordien and Dr Slabbert, for their professional guidance, encouragement, patience and support by all means.
To my husband, thank you for your support throughout my journey.
To all the participants who took part in the study.
CHAPTER 1
1. INTRODUCTION………..1
1.1 PRELIMINARY STUDY AND RATIONALE………1
1.2 PROBLEM STATEMENT………..5
1.3 RESEARCH QUESTION………..6
1.4 GOALS AND OBJECTIVES……….6
1.4.1 Goals……….6
1.4.2 Objectives……….6
1.5 THEORETICAL POINTS OF DEPARTURE……… 6
1.5.1 Sub-levels of the ecological system……….7
1.5.1.1 Micro-level………... 7
1.5.1.2 Meso-level………...8
1.5.1.3 Exo-level………8
1.5.1.4 Macro-level………9
1.6 CONCEPTS AND DEFINITIONS……….9
1.6.1Social Support………9
1.6.2 Social service provider………9
1.6.3 HIV/AIDS………...9 1.6.4 Teenage mothers………...10 1.7 RESEARCH METHODS……… .10 1.7.1 Research Approach………...10 1.7.2 Research Design………...10 1.7.3 Research Methodology……….11 1.7.3.1 Literature Review………11 1.7.4 Sampling……….11
1.7.5 Method for Data Collection………..12
1.7.5.1 Research Instrument……… 12
1.7.5.2 Analysis and Interpretation of Data……….12
1.7.6 Data verification……… 14
1.8 ETHICAL CONSIDERATION……….. 15
NEEDS OF HIV-POSITIVE TEENAGE MOTHERS….………16
2.1 INTRODUCTION……….……….16
2.2 Needs of HIV-positive teenage mothers ……….……….17
2.2.1 Basic of needs of HIV-positive teenage mothers.…..….…………...………...18
2.2.1.1 Physiological ……..………..19
2.2.1.2 Safety………...19
2.2.1.3 Love and belonging ……...………...20
2.2.1.4 Esteem………22
2.2.1.5 Self-Actualisation ……….24
2.2.2 SOCIO CULTURAL AND EDUCATIONAL INFLUENCES ON TEENAGE MOTHERS………..………25
2.2.2.1 Lack of parental guidance………..……….25
2.2.2.2 Gender power imbalances ……….………..………..26
2.2.2.3 Early marriages...27
2.4 EDUCATIONAL INFLUENCES ON TEENAGE MOTHERS....………28
2.5 CONCLUSION………..………..29
CHAPTER 3: SOCIAL SUPPORT AVAILABLE TO HIV-POSITIVE TEENAGE MOTHERS FROM AN ECOLOGICAL PERSPECTIVE……….……..………..31
3.1 INTRODUCTION……….………..31
3.2 ECOLOGICAL PERSPECTIVE ……….32
3.2.1 Sub-levels of the ecological perspective ………..33
3.2.1.1 Micro-level……….…...35 3.2.1.2 Meso-level………..36 3.2.1.3 Exo-level……….….36 3.2.1.4 Macro-level…..………..…..37 3.3 ECOLOGICAL CONCEPTS……….39 3.3.1 Life stressors………40 3.3.2. Coping measures………...41 3.3.3 Self-esteem ………...41
3.3.4 Habitat and niche……….42
3.4 SOCIAL SUPPORT AVAILABLE TO HIV-POSITIVE TEENAGE MOTHERS………..43
3.4.1 Emotional support ……….…………..43
3.4.1.3 Exo-level………..………..45 3.4.1.4 Macro-level………46 3.4.2 Instrumental support ………..47 3.4.2.1 Micro-level………..47 3.4.2.2 Meso- level……….………47 3.4.2.3 Exo-level……….48 3.4.2.4 Macro-level……….…………48 3.4.3. Informational support ………..………..49 3.4.3.1Micro-level……….……….49 3.4.3.2 Meso-level……….49 3.4.3.3 Exo-level ………...50 3.4.3.4 Macro-level………..……….51 3.5 Conclusion………...51
CHAPTER 4: EMPIRICAL INVESTIGATION ON THE VIEWS OF SOCIAL SERVICE PROVIDERS REGARDING SERVICES AVAILABLE TO HIV-POSITIVE TEENAGE MOTHERS……….…….……52
4.1 INTRODUCTION………..………52
4.2 Summary of the research method……….52
4.2.1 Research methodology………..….……….52
4.2.1.1 Research question……….52
4.2.1.2 Goals and objectives……….52
4.2.1.3 Research Approach………..…53
4.2.1.4 Research design………...53
4.2.2 Literature review………53
4.2.2.1 Sampling……….54
4.3 METHOD FOR DATA COLLECTION………...54
4.3.1 Research instrument………..…..54
4.3.2 Analysis and interpretation of data………55
4.3.3 Ethical considerations………..……55
4.4 IDENTIFYING DETAILS OF PARTICIPANTS………..…..56
4.5 THE VIEWS OF SOCIAL SERVICE PROVIDERS REGARDING SUPPORT SERVICES AVAILABLE TO HIV-POSITIVE TEENAGE MOTHERS ……..……58
4.5.1 Theme 1: Micro-level………...60
4.5.1.1 Sub-theme 1.1 The basic needs of HIV-positive teenage mothers……..61
4.5.1.1(c) Category: Love and belonging needs………...64
4.5.1.1(d) Category: Esteem needs………..……….………….65
4.5.1.1(e) Category: Self-actualization………...66
4.5.1.2 Sub-theme 1.2. Socio-cultural factors………67
4.5.1.2(a) Category: Lack of parental guidance….…………..……….67
4.5.1.2 (b) Category: Gender power imbalances…..………69
4.5.1.2(c) Category: Peer pressure……….70
4.5.1.2 (d) Category: Early marriages…...………..71
4.5.1.2 (e) Category: Education……..……….73
4.5.2 Theme 2: Meso-level………...73
4.5.2.1 Sub-theme 2.1: Educational programmes……….74
4.5.2.1 (a) Category: Health education………74
4.5.2.1 ( b) Category: HIV/AIDS prevention programmes in schools……….76
4.5.2.1 (c) Category: Lack of education………..77
4.5.2.1(d) Category: Other needs experienced by HIV-positive teenage mothers in school.………..78
4.5.2.2 Sub-theme 2.2 Religion………...80
4.5.2.2 (a) Category: The role of churches………80
4.5.2.3 Sub-theme 2.3 Support groups……….….81
4.5.2.3 (a) Category: Challenges with support groups………..….83
4.5.3 Theme 3: Macro level…….………84
4.5.3.1 Sub-theme 3.1 Implementation of policy and legislation………84
4.5.3.1 (a) Category: Support offered by government……….85
4.5.3.2 Sub-theme 3.2 Employment and economic assistance……….87
4.5.3.2 (a) Category: Availability and accessibility of employment..……….89
4.5.3.3 Sub-theme 3.3 Effectiveness of support available to HIV-positive teenage mothers…..………..90
4.5.3.3 (a) Category: Social support ………..……92
4.5.3.3 (b) Category: Instrumental support ………..94
4.5.3.3 (c) Category: Informational support ………..………95
4.5.4 Theme 4: Obstacles experienced by social service providers rendering services to HIV-positive teenage mothers……….……….…..…………..97
4.6 CONCLUSION……….…………98
CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS 5.1 INTRODUCTION……….99
5.2.1 Identifying details of participants……….100
5.2.2 Theme 1: Micro-level……….101
5.2.3 Theme 2: Meso-level……….103
5.2.4 Theme 3: Macro-level………105
5.3 CONCLUSIVE RECOMMENDATIONS FOR FUTURE STUDIES………109
5.4 CONCLUSION……….…..110
REFERENCE LIST..……….……..111
ANNEXURE 1: INFORMED CONSENT FOR PARTICIPANTS………...133
ANNEXURE 2: INTERVIEW SCHEDULE FOR SERVICE PROVIDERS………..136
ANNEXURE 3: RESEARCH BUDGET………..………..140
ANNEXURE 4: REC NOTIFICATION LETTER……….141
LIST OF FIGURES Figure 2.1: Theory of human motivation……….………..18
Figure 3.1: Bronfenbrenner Ecological Perspective……….…………..34
LIST OF TABLES Table 4.1 Profile of social service providers……….55
Table 4.2 Themes, sub-themes and categories identified in this research study………..59
CHAPTER 1
1. INTRODUCTION
1.1 PRELIMINARY STUDY AND RATIONALE
Teenage pregnancy, can is perceived in many industrialised countries as both a social and health related problem (Lawlor, Najman & Shaw, 2006; Carter & Spear (2002), add to this the issue of sexually transmitted infections (STI) and Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS); and the problem becomes exacerbated, thus warranting even greater attention. Teenage pregnancy, STIs and HIV/AIDS are both social and health related issues faced by adolescence, as an estimated 11.8 million young people aged 15-24 were living with HIV by mid-2002. About half of all new HIV infections worldwide, or approximately 6,000 per day, occurred among young people (Kirby, 2002). By 2008, every other woman of at least age seventeen who was pregnant was also HIV positive (Harrison, 2008). This is thus indicative of HIV infections being driven among young people (UNAIDS, 2004).
Teenagers are therefore particularly vulnerable to STIs and HIVAIDS. HIV/AIDS does not only affect the health of adolescents, but also their psychosocial wellbeing and their economic status (WHO, 2005). Although, Lloyd and Mensch (2008) argue that the percentage of girls dropping out of school because of pregnancy or early marriage has declined, at least in West Africa, the numbers of teenage pregnancies are still high. In 2007, nearly 50000 learners became pregnant while at school, with higher rates in poorer provinces such as KwaZulu-Natal and Limpopo (DOE, 2010). In South Africa, teenage pregnancy is driven by many factors, which include, but are not exclusive to:
• Gender inequality
• High incidences of gender-based violence
• Belief systems of varying behavioural expectations of how boys and girls should act
• Certain sexual prohibitions (for girls) and sexual tolerance (for boys) • Poverty
• Insufficient access to contraceptives and termination of pregnancies • Incorrect and unreliable contraceptive use
• Condemnatory attitudes of many health care workers
• Inadequate sex education (Bearinger, 2007; Chetty & Chigona, 2007;
Christofides, 2009; Jewkes, Christofides & Morrell 2009; MacPhail, Miller, O’Brien, Pettifor & Rees, 2005).
Collectively these factors place teenage girls at high risk of either contracting a STIs/HIV, becoming pregnant or both. South Africa has however taken various steps to safeguard girls. One such step is to safeguard a young mother’s right to education. Even before the advent of democracy and an official policy, pregnant adolescents were permitted to attend school and to return to school after the baby was born (Letsoalo, Makiwane, Panday, & Ranchod, 2009). Bhana, Morrell, Ngabaza and Shefer (2010) affirm that since 1994 and the first democratic election, South Africa has developed an extensive body of law and policy that incorporates the Constitution’s Bill of Rights (RSA, 1996) and develops a human rights culture. Bhana et.al. (2012) further mention that the South African Schools Act No 84 of 1996 (SASA) brought about notable changes within the school system within several areas, including banning corporal punishment, developing democratic school governance structures and extending the rights of learners so that they no longer had to suffer the fate of arbitrary exclusion.
Letsoalo, Makiwane, Panday and Ranchod (2009) mention that the introduction of the Constitution in 1996, together with the Schools Act, No. 84 of 1996 in the same year, formalized this practice. During July 2000, The Council of Education Ministers took a decision in July 2000, that pregnant adolescents would no longer be expelled from school, but rather given an equal opportunity to attain an education (DoE, 2007). According to the Department of Education (2007), the motivation for specific guidelines regarding the management of teenage pregnancy came from the increase in the phenomena observed in schools.
These guidelines recognize that “unplanned pregnancies do occur, and that the education system requires policies and procedures to manage these events appropriately” (DOE, 2007:13). The guidelines further recognize “the responsibility
and influence that the education system shares with the larger community to prevent and manage teenage pregnancy, emphasizing a prevention focus to reduce teenage pregnancy, HIV and other sexually transmitted infections” (Letsoalo, Makiwane, Panday & Ranchod, 2009: 15). This can be accomplished by providing adequate sex education as part of Life Orientation, HIV/AIDS and peer education programmes. However, the guidelines do ascribe some of responsibilities on learners. These include, obligating a pregnant girl to inform a teacher about the pregnancy (DoE 2007). Although schools cannot provide the necessary medical care, they are obligated to call on the local health services for pre- and post-natal support (Bhana, Morrell & Shefer, 2012).
There are many strategies directed to lessen and stop teenage pregnancy, there are however, fewer policies and strategies to manage adolescent girls who are already pregnant (DOE, 2007). The White Paper on Population Policy (Department of Welfare and Population Development, 1998), for example, is a policy which aims to address adolescent pregnancy. This is particularly relevant as unprotected sex and early marriage, can lead to pregnancy, sexually transmitted infections and HIV/AIDS, thus carrying many risks for young people, including the risk of school dropout and suffering from poor health.
The potential for poor health which an adolescent may be faced with can be as a result of collective factors. These may include diseases within the environment, family circumstances and personal vulnerability and is exacerbated by risky behaviour. This is particularly relevant to adolescents, who are at a life phase where risk taking is prominent (Erikson, 1959). Teenage pregnancy is thus complicated by personal, social, economic and environmental factors. Crawford, Cribb and Kelly (2013) therefore highlight that adolescent girls, most at risk of pregnancy are those who have unfulfilled basic needs, such as food (Maslow, 1954). These girls are also persistently absent from school when they reach grade nine and showed slower than average academic progress. They are also often in residential care facilities and may have been exposed to sexual abuse (Crawford et al., 2013). Furthermore, Jewkes et al. (2009) point out that sex is often coerced, condom use hard to negotiate, contraception inaccessible and girls very vulnerable to pressure from their male partners and others.
Adolescents is a phase marred by various factors such as role confusion (Erikson, 1954). For this reason, adolescents are identified as an at risk group for sexually transmitted infections by the Department of Health’s, National Strategic Plan on HIV/AIDS and Sexually Transmitted Infections (National Strategic Plan for HIV, STis and TB, 2012-2016), as they often engage in risky sexual behaviour as they seek to find their identity. Furthermore, the plan identifies adolescent girls as one of the key target groups for intervention.
The intervention programmes of the NPS at schools, according to Berry and Hall (2009) ought to include parenting programmes to promote positive communication with adolescents on sexuality and HIV and increase access to youth-friendly public health services. The efficacy of these programmes should be evaluated in order to determine if it is able to successfully transfer knowledge and alter the attitudes of adolescents. However studies have shown that special teacher training or through in-school lectures by outside experts have some effects on knowledge and attitudes but rarely effects on self-reported behaviour or biological outcomes such as HIV status by adolescents (Colvin, Magnani & Speizer, 2003; Gallant, Maticka & Tyndale 2004; NRC/IOM, 2005).
Moreover, the prevention strategies of the NSP promotes abstinence, delaying the first sexual encounter and safer sex practices (Berry & Hall, 2009). Adolescents are increasing recognising the need to attain an education throughout the developing world. In light of the change in view of educational needs, Lloyd (2008) suggests that sexual and reproductive behaviours of adolescents are changing and the need for education in terms of health care services, fertility inclinations, postponement of marriage and increased opportunities for education and employment are needed. The role of schools is therefore, increasingly relevant in educating adolescents particularly in relation to reproductive health and sexual education.
Duflo, Michael, Pascaline and Samuel (2006) (cited in Llyod, 2006), thus argue that health clubs in schools could bridge the gap in social service delivery between the education and health care sectors with potential benefits to adolescent reproductive health. It is particularly relevant for this gap to be filled as teenagers continue to be infected with HIV, despite the overall decline in new infections and therefore still
leaving adolescent girls at risk to become HIV-positive and pregnant (Jooste, Labadarios, Onoya, Rehle, Shisana, Simbayi, Zuma & Zungu, 2009; NDOH, 2013; SANAC, 2011a). What is however positive is that South Africa has managed to increase the number of people on antiretroviral treatment (ART), which has led to a decrease in AIDS-related mortality and increased life expectancy (UNAIDS, 2012). HIV positive teenage mothers therefore no longer have to live with the fear of a death sentence hovering over them or a fear of their baby being left orphaned.
1.2 PROBLEM STATEMENT
Despite the many strategies which are in place aimed at preventing teenage pregnancies, (DOE, 2007), the risks continue to exist and for this reason South Africa continues to battle with high rates of teenagers falling pregnant. According to the DOE (2014), 20 000 learners were reported to be pregnant. This is thus indicative of the risk of exposure to HIV infections due to having unprotected sex. Hence the need for support to HIV positive teenage mothers (Evans, Holgate & Yuen, 2007).
These services are particularly necessary as the teenage mother is in a particularly difficult life phase, marred by identity and role confusion (Erikson, 1954) and now has the added burden of being pregnant and on top of also being HIV positive. For the HIV teenage mother her burdens are exacerbated by multiple factors which are have a direct negative impact on her baby and how she cares for her/him. It is thus fundamental that support services should be made available to this vulnerable group. However, according to Payne (2005) there are not much support services available to HIV positive teenage mothers.
Despite various programmes to educate adolescents about HIV and safer sex practices, environment factors such as poverty and a lack of access to education are teenage pregnancies and HIV among young people in Limpopo Province continue to rise (Musetha, 2013). According to Musetha (2013) the District Health Barometer, states that most mothers who give birth to babies in the Limpopo health facilities were adolescent girls. Long (2009) further, points out that those teenage mothers experience high rates of depression, lack education and employment skills and live in poverty more frequently. This is often the case as poverty is a risk factor for teenage pregnancy Additionally, Hallman (2004) affirms that living in a poverty stricken area with little if any education, reduces the teenage girl’s chance of accessing information
about pregnancy and safer sexual behaviour, particularly with regards to family planning information.
1.3 RESEARCH QUESTION
What are the views of social service providers regarding support services available to HIV-positive teenage mothers?
1.4 GOALS AND OBJECTIVES 1.4.1 Goal
The aim of this research was to gain an understanding of the views of service providers regarding support services available to HIV-positive teenage mothers in Limpopo within Polokwane Municipality.
1.4.2 Objectives
• To provide an overview of the effects of socio-cultural and educational factors on
HIV-positive teenage mothers and their needs in this regard.
• To describe the social support available to HIV-positive teenage mothers from an
ecological perspective.
• To investigate the perceptions of social service providers on the support services
available for HIV-positive mothers through an empirical study.
• To draw conclusions and recommendations based on the findings of the study.
1.5 THEORETICAL POINT OF DEPARTURE
An ecological metaphor for social work was introduced by Germain (1973) as a practice perspective over 40 years ago. This ecological perspective, according to Germain and Gitterman (1996) address life transitions and recognise these transitions sources of stress. Life changes occur with biological influence that interact with psychosocial, social and cultural factors, as well as physical settings which may cause increasing demands. This is particularly relevant to HIV-positive teenage mothers who are vulnerable to the difficult life phase of adolescents (Erikson, 1954) and a lack of support services and relevant programmes to provide support.
The ecological perspective thus offers the opportunity to view the HIV positive teenage mother within the context of her environment, considering the particular cultural and historic context in which she functions (Germain & Gitterman, 1996). The HIV positive teenage mother and the environment in which she lives are in a reciprocal relationship, continuously influencing the other, specifically in relation to her pregnancy and HIV positive status (Germain & Gitterman, 1996). Thus, within the context of the ecological perspective, support services for HIV positive teenage mothers should consider the relationship she has with her immediate environment, which may include her family, the school and health care services, which are available. Support services for pregnant teenage mother may include counselling and primary healthcare, which also include testing for HIV/AIDS and providing the necessary psychological health services, required, particularly if the teenager tests HIV positive. The ecological perspective applies elements of the systems theory to understand the person in their environment (Payne, 2005). These systems are on various levels which include the micro, meso and exo level (Bronfenbrenner, 1994).
1.5.1 Sub-Levels of ecological perspective
To understand human functioning in various developmental phases it is important to consider it from an ecological perspective Bronfenbrenner (1994). The socially organised levels (micro, meso, macro and exo) provide insight into the individual’s development, and the case of this study, the HIV positive teenage mother. Understanding her context would enable support and guide the array of needs from the micro-level, including relationships with parents and at school and on the macro-level, which include relevant policies related to teenage pregnancy and HIV.According to Bronfenbrenner (1997), the ecological environment is envisioned as extending beyond the immediate situation that directly affects the developing person.It is thus relevant that in providing support services for teenage mothers, the social service provider should be cautious of the teenage mother’s HIV status, social roles in the family and economic status of the family as these may impact on their lives.
1.5.1.1 Micro-level
For teenage mothers, support on the micro-level begins from family, friends and partners. Barnfather, Letourneau and Stewart (2004) however point out that teenage
mothers’ gain informal support from friends and sometimes professional support is sort. The social support which the teenage mother does gain is usually aimed at minimising the stress caused by the pregnancy (Ballard, Cahoon, Devereux, Leigh and Weigel, 2009). This support would be even more relevant for a teenage mother who has the added burden of being HIV positive. Therefore, creating support networks around HIV positive teenage mothers is a good way to prevent stress and the deleterious effects of unplanned pregnancy. According to Crase, Hockaday and McCarville (2007), HIV positive teenage mothers appreciate the support that they receive from their family and particularly their mothers.
1.5.1.2 Meso-level
According to Bronfenbrenner (1979) the meso level is made up of the interaction of the micro system. The meso-level may have an effect on the individual, same values are taught across all systems are shared (Nash et al., 2005). One of the most productive ways to teach adolescent girls and HIV positive teenage mothers’ values is thus through educational programmes at school. Panday et al. (2009) states that the most effective curriculum-based programmes are based on designing activities that are consistent with community values. Panday et al. (2009) further point out that educational programme can be even more productive when they are presented by peers, as this makes it easier for the adolescents to relate to what is being taught at school, especially in the Life Orientation class.
1.5.1.3 Exo-level
For the purpose of this study, the exo-level includes social, medical, educational and recreational resources available to HIV-positive teenage mothers. These are the most significant resources to meet the immediate needs of the HIV positive teenage mothers, which include, access to counselling, support groups, clinics, doctors and parenting classes (Visser, 2007). Some of the HIV positive teenage mothers are inexperienced and lack knowledge in organising their own health care and seeking support services. They depend on local service providers to receive contraceptives, support, advice and information. Teen Outreach Program can also assist in the reduction of teenage pregnancy (Elder, 2013).
1.5.1.4 Macro-level
The macro-level, according to Visser (2007) includes people’s attitudes and values and relevant legislation and policies. In the context of this research, the ecological perspective (Germain and Gitterman, 1996) can be utilised as a framework to assess the needs of HIV-positive teenage mothers, particularly in relation to the social support needed.
1.6 CONCEPTS AND DEFINITIONS
1.6.1 Social support
Support can be defined as “providing help, encouragement or approval to an individual and showing an active interest in them” (Reber & Reber, 2001:16). Barnfather, Letourneau and Stewart (2004:18) further describe support as “the interactions with family members, friends, peers and health professionals that communicate information, understanding and respect for the individual.”
1.6.2 Social service providers
Social service providers refer to practitioners who link clients with different resources. They help clients to access much-needed resources to which they are entitled (Patel, 2005).
According to the Department of Social Development (2005) and UNICEF (2009), the term “service providers” includes the following civil society organisations: Non-Profit Organisations (NPOs) also known as Non-Governmental Organisations (NGOs), Faith-based Organisations (FBOs) or Church-Based Organisations (CBOs), and Community-Based Organisations (CBOs) which operate in the non-profit sector or voluntary sector (Department of Social Development, 2009b). For the purpose of this study, social service providers such as social workers, social auxiliary workers and community workers will be included.
1.6.3 HIV/AIDS
Acquired immunodeficiency syndrome (AIDS) is a disease in which the body’s immune system breaks down and is unable to fight off infections, known as opportunistic infections, and other illnesses that take advantage of a weakened immune system (Evian 2005). Human immunodeficiency virus (HIV) is the virus that causes AIDS. A member of a group of viruses called retroviruses, HIV infects human cells and uses
the energy and nutrients provided to the cells for them to grow and reproduce (Evian, 2005).
1.6.4 Teenage mothers
According to UNICEF (2008), teenage pregnancy is defined as a teenage girl, usually within the ages of 13-19, becoming pregnant.The term in everyday speech usually refers to girls who have not reached legal adulthood, which varies across the world, who become pregnant (UNICEF, 2008).
1.7 RESEARCH METHODS 1.7.1 Research approach
This study explored the views of social service providers on the social support services available to HIV-positive teenage mothers. A qualitative research approach was adopted in order to interact directly with the social service providers (Delport, De Vos, Fouché & Strydom, 2011). Qualitative research gives researchers the experiences of participants, to determine how meaning is created through and in culture, and to discover rather than test variables (Corbin & Strauss, 2008).
1.7.2 Research design
Research design is the plan according to which research participants are recruited and information is collected from them, as stated by Kruger, Mitchell and Welman (2005). The research design describes how answers were sort Kumar (2005) in relation to support services available for HIV positive teenage mothers.
An exploratory design was used in this study. As stated by De Vos et al. (2011) the exploratory research carried out allowed the researcher to develop insight into the support services available to HIV positive teenage mothers in the Limpopo Province, as there was lack of information in this regard (Bless et al., 2009; De Vos et al., 2011). The exploratory mode of inquiry thus allowed the researcher to explore the support services available to HIV-positive teenage mothers, focusing on the needs and impact of socio-cultural and educational factors on HIV-positive teenage mothers (Neuman, 2010).
1.7.3.1 Literature review
For the purpose of this study, a literature review was completed prior to empirical study. The literature review offered a clearer understanding of teenage pregnancy in relation to the HIV status of the teenage mother (De Vos et al., 2011). Furthermore, a comprehensive literature study provided a theoretical framework for the study; secondly, it highlighted existing literature; thirdly, it substantiate the importance of the study against the backdrop of previous research; and lastly, it gave a comprehensive understanding of the nature of support services available to HIV positive teenage mother (De Vos et al,. 2011).
1.7.4 Sampling
A sample is a subdivision of the population in which the researcher is interested (De Vos et al., 2011). For the purpose of this study, purposive sampling was utilised. This is a method of non-probability sampling. In non-probability sampling, the selection of a particular individual is not known since the researcher does not know the exact population size (De Vos et al., 2011). Purposive sampling is, according to De Vos et al. (2011), based entirely on the judgement of the researcher. In the present study, researcher selected a sample from the population that was composed of elements that contained the most qualities or typical attributes that best served the purpose of the study. The population of this study comprised all social service providers rendering services to HIV-positive teenage mothers in Limpopo within Polokwane Municipality. Purposive sampling was utilised in qualitative research and therefore correlated with the research approach selected (De Vos et al., 2011). The researcher physically approached the head of various welfare organizations to make appointments for permission to interview the service providers.Throughout this process, the researcher introduced herself as a social worker doing her Master’s studies in Social Work at Stellenbosch University and produced a student card. After giving their permission, the participants were informed about the confidential nature of the study in relation to the recording and transcription of the interview. The researcher informed the participants that they would be required to sign a consent form as an indication that they have decided voluntarily to participate in the study. If the participants wished to terminate the interview, they would be allowed to do so since they were not under any obligation. Throughout the interviews, none of the participants left; they all participated until to the end. Twenty participants were selected for this study, with the following criteria:
• Social workers, social auxiliary workers, community health workers, lay
counsellors, mentor mothers, child and youth care workers working in the field of social welfare in Limpopo within Polokwane Municipality
• Render support services to HIV-positive teenage mothers • Conversant in English.
1.7.5 Method for data collection 1.7.5.1 Research instrument
For the purpose of the study, an interview schedule was used as a research instrument for collecting data, and face to face interviews were conducted (Kumar, 2005). a semi-structured interview schedule offered flexibility to the interviewed which allowed the researcher to asked in a different order (Dudley, 2010).
A pilot study was conducted to test the interview schedule (Delport & Strydom in De Vos et al., 2011). This allowed the researcher to have an opportunity to determine if the interview schedule was viable, which it was.
1.7.5.2 Analysis and interpretation of data
Neuman (2011) states that data analysis begins with gathering data and systematically organising, integrating and examining the data by looking into patterns and relationships among specific details. The data analysis method proposed by Creswell (1998) as cited in De Vos et al. (2011) was applied in this study. The analysis included the following steps:
Step 1: Planning for recording of data
The researcher recorded data in a systematic manner that was appropriate to the setting and participants, with a digital recorder. This enabled the researcher to listen attentively to the participants without having to take any notes.
Data analysis is a qualitative enquiry that necessitates analysis at the research site during data collection. In this study, the transcripts of the interviews were done after every interview conducted.
Step 3: Managing (organizing data)
De Vos et al. (2011) mention that, all data collected should be properly organized. The recorded interviews were saved to a laptop and two computers afterwards. The recorded interviews were marked from one to 20, as were the transcripts. This was done to ensure that none of the interviews were misplaced. In order to maintain the security of the information, the laptop and the two computers had passwords and were accessed by the researcher only.
Step 4: Reading and writing themes
De Vos et al. (2011) emphasize the value of re-reading the data several times. After the organization and conversion of the data, the researcher listed themes according to the data that was provided by the participants and in terms of the review of literature.
Step 5: Generating categories, themes and patterns
De Vos et al. (2011) indicate that this step is at the heart of qualitative data analysis. The researcher categorized the questions according to the themes which related to the needs of HIV-positive teenage mothers, support services available and the effect of socio-cultural and educational factors on HIV-positive teenage mothers.
Step 6: Coding the data
According to Punch (2015), coding is the starting activity in qualitative analysis and the foundation for what comes later. Codes are tags, names or labels, and coding is therefore the process of putting names or labels against pieces of the data (Punch, 2015). For the purpose of this study, the data which the researcher has collected from the participants was coded in terms of different labels.
Step 7: Testing emergent understanding
This step emphasised the importance of ongoing evaluation. Once the themes, sub-themes, categories and coding were well under way, it was important to evaluate the data for usefulness. This was done in consultation with the supervisor in order to
determine which themes, sub-themes and categories fitted best with each other (De Vos et al., 2011).
Step 8: Searching for alternative explanations
As the researcher discovered categories and patterns in the data, the researcher engaged in critically challenging the very patterns that seemed so apparent. The researcher searched for other plausible explanations for these data and the linkages among them (De Vos et al., 2005).
Step 9: Writing the report
According to Delport and Fouché (2002), the qualitative report is less structured, more twisted together with the total research process, and usually longer and more descriptive than the quantitative report. This was the final phase of the spiral; the researcher presented the data as well as packaging what was found in the text in tabular form.
1.7.6 Data verification
Regarding data verification, the validity and reliability of the study were taken into consideration by ensuring as far as possible that the norms of credibility, transferability, dependability, and conformability were applied (De Vos et al., 2011). Regarding the credibility of the study the researcher transcribed the interviews as accurately as possible, thus ensuring that the transcriptions were accurate and precise. The transferability of the study was managed by providing two literature chapters, describing the needs of HIV-positive teenage mothers and the social support available to them from an ecological perspective as well as a description of the research methodology.
Dependability refers to the logical and sound documentation of the research process (De Vos et al., 2011). The researcher described the research process earlier in the chapter as well as meeting the objectives of the study (Chapters 2-5). De Vos et al., (2011) indicate that in terms of the conformability of a study, the findings should be confirmed by other studies. The researcher made use of literature control in the empirical investigation (chapter 4) in order to ensure the conformability of the study.
1.8 ETHICAL CONSIDERATIONS
Ethics is a set of moral principles which is suggested by an individual or group and is subsequently widely accepted. It offers rules for behavioural experimental subjects and respondents, employees, sponsors, other researchers, assistants, and students (Babbie, 2007). Ethics refer to the moral responsibility that the researcher bears towards those who participated in research, those who sponsor research and those who are potential beneficiaries of the research (Monette et al., 2008). The researcher is a registered social worker with the SACSSP (Registration no.1040733). Permission was acquired from the Departmental Ethical Screening Committee (DESC) of the Department of Social Work at Stellenbosch University before the research was carried out. This research was classified as low risk, as mentioned in the Stellenbosch University guidelines for DESC of September 2012. For the purpose of the study, all records and transcribed documents from the participants are stored in a lockable storage. The information on the PC, was password protected.
1.9 LIMITATIONS OF THE STUDY
Various limitation are relevant to this study, these include that:
the findings of the study cannot be generalised, as this was a qualitative study, the sample of this study was small, although the data collected was rich,
the study was limited to the Polokwane Municipality, Limpopo Province and no other regions in the Republic of South Africa,
although, the exo-level was discussed within the literature study, it was not identified as a separate sub-theme within the empirical data.
CHAPTER 2
SOCIO-CULTURAL AND EDUCATIONAL EFFECTS ON AND NEEDS
OF HIV-POSITIVE TEENAGE
This chapter looked at the first objective of the study, which focuses on the socio-cultural and educational effects on HIV-positive teenage mothers.
The needs of HIV-positive teenage mothers are vast as they need love, care and support from families, friends and the communities in which they live (Adedeji, Ayegboyin & Salami, 2014). Teenage mothers also need to get information about contraceptive methods, HIV and STIs from teachers, health care providers and the mass media (Boonstra, 2007). Culture also plays a role in the lives of teenage girls. According to Chen and Farruggia (2002), culture is a system of beliefs, values, languages, behaviours, and human-made aspects of the physical environment that vary from one group to another. These cultural systems are interactive and have a direct impact on the adolescent development. This impact is mainly relevant on HIV-positive teenage mothers who are not only at a sensitive phase of the development (Erikson, 1954), but also having to cope with the pressures of motherhood and the trauma of being HIV positive.
These cultural systems have a substantive impact on the lives of females in South African rural communities, where women have no power as these communities are characterised by male dominance (Bhana 2006; Jewkes, Junius & Kekana, 2005). UNICEF (2006) indicates that South African society is to a large extent patriarchal, as females have a lower social status than their male counterparts. Girl children are raised to become home keepers and child-bearers, with little or no regard for attaining an education. In response to this disregard for girls getting an education, the South African Minister of Education launched the Girls’ Education Movement (GEM) in Parliament, in 2003 (UNICEF, 2006). GEM aims to make a positive difference in the lives of African children, particularly girls by:
• offering girls equal access to education,
• improving the quality of education in rural schools,
• making the school curriculum and books gender inclusive, • building schools that are safe, especially for girls,
• interacting with boys as strategic partners in education,
• focussing on addressing cultural practicing which are harmful, specifically to girls, such as early marriages (UNICEF, 2006).
These aims form the basis for the exploration of the needs, socio-economic circumstances and education of girls, which will thus be addressed in this chapter.
2.2 NEEDS OF HIV-POSITIVE TEENAGE MOTHERS
Adolescents are at a vulnerable stage within their development as they battle through role confusion (Erikson, 1954). For teenage mothers this phase of role confusion becomes an ever-increasing burden, as her body has experience tremendous hormonal changes. These factors contribute greatly to the unique needs of teenage mothers at this developmental stage, and this is exacerbated even more when the teenager tests positive for HIV.
Much focus is often placed on teenage pregnancy prevention in order to reduce teenage pregnancy with little or no focus on providing services for teens that are already pregnant or have become parents (NACCHO, 2009). As part of the prevention programmes, family planning and reproductive health services, which include contraception and condoms are made available to teenagers (Letsoalo et al., 2009). However according to Newman and Newman (2006) contraceptives are used inconsistently and, in some cases, incorrectly. The incorrect usage thereof may thus lead to tears in condoms and missed doses of birth control pills can lead to ovulation (Letsoalo et al., 2009), resulting in teenage pregnancy and/or HIV.
These factors collective increase the vulnerability of the teenager as she is more likely to give birth to an unhealthy, low birth weight infant because her body may not be ready to support pregnancy, consequently requiring extra support services (Martin, 2003). The risks and need for medical and social support services then further increase as the pregnancy is unplanned and more so if the teenage mother tests HIV positive. Evangelisti (2000) points out that as a pregnant teenager, more challenges experienced in comparison to an adult who has an unplanned pregnancy, because the life changes and adaptations are greater; and the adolescent does not have the life experience to navigate successfully through the challenges.
2.2.1 Basic needs of teenage mothers
Human needs arrange in a hierarchy of potency and priorities according to Maslow (1954). Lower needs are more potent and take precedence over the higher needs in the hierarchy of need satisfaction, as illustrated in Figure 2.1 below.
Figure 2.1 A theory of human motivation (Maslow,1970)
Figure 2.1 illustrates the basic human needs according to Maslow’s hierarchy (Maslow, 1970). These needs are relevant but not exclusive to HIV-positive teenage mothers. According to Mogotlane, Van Niekerk and Young (2007), teenage mothers, like everyone else, have basic needs, which include the need for food, water, shelter and air. The needs do not end with the teenagers themselves because as mothers, they need to provide food, shelter and clothes to their children.
The needs of HIV-positive teenage mothers are unique in that they find themselves in a difficult to the developmental stages of adolescence (Erikson, 1954) and have the added burdens of motherhood and being HIV positive. These needs include, but are not exclusive to having proper, healthy food and potable water as they need to take medication in order to keep healthy (Boeree, 2004). For the HIV positive teenage mother these basic needs are not exclusive to her but must be inclusive of the needs of her baby, which can be seen as extra or special needs required for survival (Mogotlane, Van Niekerk & Young, 2007). However, teenage motherhood occurs outside of marriage, it is unplanned, and it occurs in unstable relationships (Jewkes, Jordaan, Maforah & Vundula, 2001, cited in Mkhwanazi, 2010). The needs of HIV-positive teenage mothers will be discussed below, following the pyramid of Maslow’s hierarchy of needs, and the figure will be explained from the bottom up.
2.2.1.1 Physiological
The most basic of needs according Maslow’s hierarchy, are everyday physiological needs which are required for survival, including food, drink, breathing and rest (Maslow, 1970; Poston, 2009). For teenage mothers, according to, Kristin and Kristine (2011) these basic needs include the need for stable homes, which is often not fulfilled as, many teenage mothers are not able to remain at home with their parents because of overcrowding in the home, abuse, neglect, or financial difficulties. As a result, basic needs are often not met. The constitution of South Africa (1996) emphasises that all people have the right to food, housing, health care, food and water, but is often not fulfilled, particularly so for teenage mothers in rural areas of South Africa. HIV positive teenage mothers would be able live healthier lives for longer if they receive the necessary care and support. Their immune systems could also be strengthened by having access to health food, exercise, rest and adequate medical treatment, in this way they may be able to cope better, be happy and feel productive (Education and training unit, 2017).
Often, however, HIV-positive teenage mothers come from low socio-economic areas and often have to rely on social services for support which include medical and/or financial assistance (Burger, Gouws & Kruger 2008). They therefore experience difficulty in accessing the most basic needs, as described by Maslow (1970), met. For teenagers these basic needs are usually fulfilled by parents, however, in poverty stricken areas of rural South Africa, parents are often unable to meet these needs and as a result the teenage mother may also not be able to meet the basic needs of her baby, perhaps not even understand these needs.
2.2.1.2 Safety
If basic physiological needs are met, safety needs are prioritised (Maslow, 1970). According to Bremmer and Slatter (2011) safety needs can be defined as a space which is safe and secure, health care, a home and family are sort after. For HIV-positive teenage mothers the need for a home in order to feel safe as they are helpless, defenceless and dependent on others (Meyer, 2004). Kristin and Kristine (2011) are of the opinion that teenage mothers need better homes to feel safe, implying that security needs may not be met. This stress of safety is then exacerbated as the teenage mother is not in a position to fulfil her own needs and now has to meet the
needs of her baby (Mofokeng, 2005). She therefore needs help from her family in taking care of the child and herself.
For safety purposes, family planning services are provided to HIV-positive teenage mothers with the purpose of making reproductive health services available, providing contraception including condoms, and improving their knowledge and skills to use them (Letsoalo, Makiwane, Panday & Ranchod, 2009).
UNICEF (2011) calls on donors who contributions to HIV and AIDS prevention and treatment initiatives to recognize that condoms, testing sites, ARVs and vaccines must be accompanied by education in an attempt to address stigmas and gender constructs which contribute to the spread of HIV-positive in young adolescents. Systemic changes are required on all levels to create an environment where HIV-positive teenage mothers and their children have the greatest chance of thriving (UNICEF, 2011).
The need for love and belonging, which should be met through satisfactory relationships with family members, friends, peers, classmates, teachers, and other people with whom individuals interact form part of the third level of the pyramid (Maslow, 1970).
It is important to take note that teenage mothers, like any other teenagers, need to be protected and feel safe all the time. Being teenage mothers does not make them adults.
2.2.1.3 Love and belonging
After physiological and safety needs are met, the need for love and belonging takes precedence (Maslow, 1943). HIV-positive teenage mothers particularly require a sense of belonging and have a need to be loved, which includes being appreciated, feeling safe and comfortable, and being supported, factors which usually result in long-term survival (Mofokeng, 2005). A lack of love and belonging is often portrayed in the form of neglect, shunning and ostracism. For the HIV positive teenage mother ostracism can be particularly harmful as their ability to form and maintain emotionally significant relationships, which include family and friendships are negative impacted (Mofokeng, 2005).
Needing to belong is significant; and particularly so for adolescence (Erikson, 1954). According to Maslow (1943) this sense of belonging and acceptance among their social groups, regardless of whether these groups are large or small, is important to fulfil the need for love and belonging. For HIV positive teenage mother this need is sometimes not fulfilled as they are shunned by family and the community (Mofokeng, 2005). Humans need to love and be loved – both sexually and non-sexually – by others. The risk of becoming susceptible to loneliness, social anxiety and clinical depression in the absence of this love or belonging (Singh, 2017), thus becomes a particularly significant risk factor for HIV positive teenage mothers, who may become isolated by family and their community. The need for belonging may thus overcome the physiological and security needs, due to peer pressure (Maslow, 1943).
Improved quality of life can be related to the level of social support available to teenage mothers living with HIV (Migliardi, Mignone & Roger, 2012). This includes a sense of belonging and feelings of being loved by family and friends Migliardi et al. (2012), better life is also influenced strongly by one’s views of social and family support. Besides other people’s views, if HIV-positive teenage mothers believed that their social support was sufficient, improvements in individual resilience could be attained (Migliardi et al., 2012).
According to the WHO (2007), it is important that social support at community-based organisations are promoted for HIV positive teenage mothers as this may improve the physical and emotional health. HIV-positive teenage mothers and their babies need care during pregnancy, during childbirth and after birth. There a continuum of care that starts in the household and community and extends into the healthcare system, including care for complications, can contribute to healthier pregnancy outcomes (WHO, 2007).This continuum of care for the teenager, should however begin, before pregnancy. Dittus and Jaccard (2000) state that parents with permissive attitudes about sex or premarital sex, or those that have negative attitudes about contraception, have teenagers who are more likely to have unsafe sex and become pregnant. It is thus important that parents engage in sex education with their children in order to mitigate the risk of teenage pregnancy and HIV/AIDS (Dailard, 2001). Letsoalo, et al., (2009) are in agreement and state that parent-adolescent communication on issues of
sexual behaviour and childbearing is very important. Aboagyewaa (2013) further adds that lack of sex education in schools and at home has been identified as a major contributory factor to the high rate of teenage pregnancy, HIV and unsafe abortion.
2.2.1.4 Esteem
Higher up in the hierarchy of needs according to Maslow (1954), is the need to develop positive feelings of self-worth and self-esteem and act to foster pride. This aspect can be hindered dramatically in adolescents, particularly for girls who fall pregnant. Before the teenage mothers can work toward self-esteem, they must feel safe, secure, and part of a group such as a class in school, which is often not the case. McCoy (2016) points out that parents need to exemplify assertiveness and confidence in their everyday engagements with their daughters but also show that even as adults, they do make mistakes. By acknowledging the importance of forgiving themselves and moving forward, parents will assist teenage mothers to realize that life still continues they only need to be assertive and positive about life.
McCoy (2016) further points out thatit is important for girls’ for their parent to reinforce their belief in them, to support them unconditionally, even when making mistakes This is however, so far removed from the reality of the young girls living in poverty-stricken areas, as parents have significant difficult in meeting just their basic needs. Self-esteem needs to be nurtured through mutual respect and good human relations (Maslow, 1943), something which is often absent in the lives of HIV positive teenage mothers. Furthermore, Germain and Gitterman (1996), point out that self-esteem is about the extent to which a person feels capable, important, effective and valuable. It is the most significant dimension of self-concept and is a major influence in human thinking and behaviour as it is about recognition, achievement, setting goals and achieving them (Maslow, 1943). According to Poston (2009), esteem needs are at the highest point in the hierarchy of needs. It is also a need which developed over a period time.
The bottom level of esteem is met when an individual has acquired a level of status, recognition, fame, reputation and appreciation, to name just a few. These areas in a teenager or teenage mother’s life take work to maintain. Being diagnosed with HIV often may bring about low self-esteem in teenage mothers and may also have a negative impact on their reputation (Education Training Unit, 2017). This low
self-esteem or an inferiority complex for HIV positive teenage mothers may be a reality as they are experiencing imbalances in their developmental stage, due to pregnancy, motherhood and positive HIV status. (Maslow,1943). Psychological imbalances such as depression can become hinderances in obtaining a higher level of self-esteem or self-respect and could therefore lead to teenagers falling pregnant, contracting HIV, poor school performance and emotional instability (Richter, 2000).
Some people have a need for stable self-respect and self-esteem. Maslow (1943) refers to two versions of esteem needs: a "lower" version and a "higher" version. The "lower" version of esteem is the need for respect from others and may include a need for status, recognition, fame, prestige, and attention. The "higher" version manifests itself as the need for self-respect. For example, the person may have a need for strength, competence, mastery, self-confidence, independence, and freedom. This "higher" version takes precedence over the "lower" version because it relies on an inner competence established through experience. Deprivation of these needs may lead to an inferiority complex, weakness, and helplessness. Teenagers who lack self-confidence easily fall into peer pressure, resulting in teenagers getting involved in unhealthy relationships and teenagers getting involved in sexual activities carelessly and without any knowledge because others in their friendship groups are in relationships. This may be because parents do not give full support and time to their teenagers, especially their daughters (Kochrekar, 2017).
A teenage mother infected with HIV does not only have to face the judgment of society but also her own conscience and self-acceptance. As a result, she may not respect herself and seek the acceptance of others by stopping ARV medication and claiming she was misdiagnosed and does not have HIV (Education Training Unit, 2017).
Adolescent mothers should be provided with life skills (including vocational training) and sexuality education to increase their autonomy, mobility, self-esteem, and decision-making abilities. Adolescents who participate in one or other form of risky behaviour often partake in other high-risk behaviour (Essau, 2004, in Letsoalo et al., 2009). For the purpose of this study, the examples of high-risk behaviour include substance abuse and engagement in unsafe sexual behaviour which may result in HIV and unwanted pregnancy (de Guzman & Pohlmeier, 2014).
An intoxicated teenager may find herself having unprotected sex, which may result in pregnancy and/or HIV (Our World Today, 2008). This according to Brook, Kachieng’a and Morejele (2006) as cited by Letsoalo et al. (2009), is a psychoactive effect of alcohol and drugs as it increases sexual arousal and desire, decreases inhibition and tenseness, diminishes decision-making capacity, judgment and sense of responsibility, therefore disempowering teenagers to resist sex.
Nevertheless, teenagers often drink or use other drugs when they engage in sexual activity, despite the apparent risks, therefore it is common that adolescents lose their virginity while drunk. Unfortunately, this may result in pregnancy and contracting HIV because using protection is not a priority while intoxicated (National Campaign to Prevent Teen Pregnancy, 2002).
2.2.1.5 Self-actualization
At the very top of Maslow’s hierarchy, lies self-actualization. This level of need refers to what a person's full potential is and the realization of that potential. Maslow (1943) describes this level as the desire to accomplish everything that one can, to become the most that one can be. He believed that to understand this level of need, the person must not only achieve the previous needs but master them as well. According to Bremmer and Slatter (2011), the final level of self-actualisation is reached by very few people.
De la Rey, Duncan, O’Neill, Swartz and Townsend (2011) agree, stating that self-actualization is the top level of need. It refers to the complete growth of the self and becoming the best person one can be. Circumstances necessary to satisfy this need include not being disturbed by lower-level needs, being able to love and be loved, being free of self-imposed and societal constraints, and being able to recognize one’s own strengths and weaknesses (Maslow, 1943). In order for teenage mothers to realise their potential, their parents and teachers should provide them with guidance towards self-discipline and in realistic goal-setting, for example, encouraging them to continue with school in order to learn about a vast variety of careers in the modern world. This can help them to choose a career most suitable to their own talents and personalities (Panahi, 2015).
This section discussed the needs of HIV-positive teenage mothers following Maslow’s Pyramid. The next section will discuss the impact of socio-cultural issues on HIV-positive teenage mothers. The section will specifically focus on the lack of parental guidance, gender power imbalances and early marriages.
2.3 SOCIO CULTURAL INFLUENCES ON TEENAGE MOTHERS
This section will discuss cultural influences on teenage mothers. The socio-cultural factors that are relevant to this section include lack of parental guidance, gender power imbalances and early marriages.
2.3.1 Lack of parental guidance
UNDPA (2013) describes a dysfunctional family as one in which there is little or no love offered to the teenagers, for this reason they tend to seek love and affection elsewhere. Often resulting in sexual relationships which result in pregnancy and/or HIV (Thobejane, 2015). Parents who fail to provide for their families, thus contribute to the situation of their teenage girls falling pregnant at an early age. Parents play an important role in the lives of teenage mothers; a lack of parental support and monitoring may thus be a significant factor in adolescent substance abuse as well as engaging in sexual activities with multiple partners (Breiner,Ford & Gadsden, 2016).
According to Thobejane (2015), teenage mothers who are not shown love and affection by parents or partners will seek it out from their peer group. A lack of parental guidance does have a major effect on teenage pregnancy because some parents do not have time to discuss sexual matters with their teenagers.
If parents can approach their role as sex educators in positive, affirming ways, teenage mothers will be able to live healthy, make better decisions about sex and build loving relationships (Huberman, 2002).
2.3.2 Gender power imbalances
Gender roles are a dynamic concept which changes over time and presents differently in different regions. In some countries, for example the age disparity in the period of sexual initiation between the two sexes has been decreasing, while in other more
developed countries, there the opposite is observed (World Health Organization, 2007).
Teenage pregnancy is an example of one such gender power imbalance. It often makes teenage mothers economically vulnerable and reliant on male partners (UNFPA, 2007). Traditional constructions of gender are still operating and constrain teenage girls (Adams et al. 2009). In rural areas, where culture is mostly respected, men maintain power over females and are regarded as heads of households (Adams et al., 2009). Teenage boys are likely to pressure teenage girls into unwanted or unprotected sexual relations (Rathus, 2008). According to Harrison,Kunene and Xaba (2001), a lack of decision-making autonomy within relationships constrains girls’ ability to practice safe sex.
In Limpopo province, gender still has an impact on teenage girls being sexually abused by older men. Teenage mothers are abused and no one raises a concern about the abuse (Jewkes, Jordaan, Maforah & Vundule 2001). Moore and Rosenthal (2006) agree that sexual and physical violence have come to characterize relationships between females and males in some communities in South Africa. In many instances, teenage mothers have less power over their own bodies than men and are often required to be more accountable for their actions than young men (Naidoo, 2005). According to Moore and Rosenthal (2006), physical abuse by a partner and current involvement in a physically abusive relationship were associated with becoming pregnant.
2.3.3 Early marriages
According to Ehler and Ziyane (2006), teenage pregnancy is a practice that conforms to societal expectations. These societal expectations are sometimes linked to cultural practices. Cultural beliefs often impose higher risks on females due to male dominance and the lack of female decision-making capacity in this regard (WHO, 2007). Thus, an adolescent girl growing up in a society that has cultural practices such as early marriage or arranged marriage is likely to succumb to the pressure to fall pregnant. Cultural practices such as early marriage and adolescent pregnancies cause girls to drop out of school at early age, thereby undermining their economic status (UNFPA, 2017).
