Understanding Conceptualizations and Structural Environment for Improving Pre-Pregnancy

220 Pages·2017·3.62 MB·English

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Theses and Dissertations
6-30-2016
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Chiwoneso Beverley Tinago
University of South Carolina
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Tinago, C. B.(2016). Understanding Conceptualizations and Structural Environment for Improving Pre-
Pregnancy Planning for Adolescent Girls and Young Women in Harare, Zimbabwe. (Doctoral dissertation).
Retrieved from https://scholarcommons.sc.edu/etd/3515
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UNDERSTANDING CONCEPTUALIZATIONS AND STRUCTURAL ENVIRONMENT
FOR IMPROVING PRE-PREGNANCY PLANNING FOR ADOLESCENT GIRLS
AND YOUNG WOMEN IN HARARE, ZIMBABWE

by

Chiwoneso Beverley Tinago

Bachelor of Science
William Carey University, 2009

Master of Public Health
University of Southern Mississippi, 2010

Submitted in Partial Fulfillment of the Requirements

For the Degree of Doctor of Philosophy in

Health Promotion, Education, and Behavior

The Norman J. Arnold School of Public Health

University of South Carolina

2016

Accepted by:

Lucy Annang Ingram, Major Professor

Edward A. Frongillo, Committee Member

Christine E. Blake, Committee Member

David Simmons, Committee Member

Barbara Engelsmann, Committee Member

Lacy Ford, Senior Vice Provost and Dean of Graduate Studies
© Copyright by Chiwoneso Beverley Tinago, 2016
All Rights Reserved.
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DEDICATION
I dedicate this research to my family. To my dearest mother, Gloria Chiedza
Tinago for being my rock throughout this process. I appreciate all the sacrifices you make
for me and my sisters and for believing in us and our capacity to break through barriers as
women and girls. You are my greatest advocate and I share this accomplishment with
you. To my dearest father, Brian Alphabet Tinago, I thank you for believing in educating
the girl child and for sacrificing to send all your girls to the best schools so that we could
realize our dreams through a sound education. To my older sister Chidochashe, I’ve
always thought you could do anything you put your mind to and I am truly appreciative
for your encouragement and support throughout this process. To my loving twin sister
and womb-mate Chatinoda, you are the constant in my life. A constant source of support,
guidance, encouragement, and laughter. You always say, “We are built for teamwork”,
and I agree. Thank you for always standing by me because together we are stronger. To
my youngest sister Chamapuwa, I thank you for being a light in my life and for
reminding me to see the good in all things. It’s your turn now. To my maternal
grandparents Leonard Chipindu and Loice Mukwenga, and paternal grandparents David
and Enesta Tinago, your granddaughter is getting a PhD! I hope you’re celebrating in
heaven. My final dedication is to the research participants. Thank you for trusting me to
share your stories and for reminding me to continue in sincerity and fortitude because
there is still work to be done.
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ACKNOWLEDGEMENTS
First and foremost, to God be the glory. Your love and grace has sustained me
throughout this doctoral program. To my fearless and dedicated committee chair and
advisor Dr. Lucy Annang Ingram, you inspire me and are always there to challenge and
support me in my educational and professional endeavors. I cannot thank you enough for
always being there for me and for believing in me. Dr. Edward Frongillo, thank you does
not seem sufficient to express the immense gratitude I feel towards you. You’ve been a
reliable source of guidance and inspiration, and I am honored to have you as a mentor.
Dr. Christine Blake, you were the first to ignite my passion for qualitative research and
you always challenge me to dig deeper and unpack my thoughts. I am truly grateful for
your mentorship and support. Dr. David Simmons, you inspired my choice to enroll in
the doctoral program at USC and I am so grateful for your mentorship throughout my
tenure at USC. Dr. Barbara Engelsmann, you inspired the conception of this dissertation
research and you provided much needed guidance and support throughout the process and
for that and so much more, I am deeply thankful. I would also like to thank my other
mentors; Dr. Daniel Schabot, Jennifer Talbert, Dr. Andrew Reid, Dr. Carolyn Parks-Bani,
Dr. James McGuire, Mr. Grant Guthrie, Professor Rose Kambarami, Dr. Heather Brandt,
and Dr. Casey Goldston-Giraudy. Thank you also to my dearest friends in the Circle and
the Sistrens, Chineme, Helen, Chati, Oddessy, Odelia, Monalisa, Rumbi, Tanyaradzwa,
Tanya, and Dosithe for being an amazing support system. Thank you to my extended
family, amazing cohort and friends Stephanie, Tiara, Deeonna, Gabby, Caroline, Jessica,
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Ann, Andrea, Sarah, Shaun, Rudo, Maggie, and the staff and residents of Preston
Residential College. Finally, a huge thank you to the Sackler Institute for Nutrition
Science for funding this dissertation research.
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ABSTRACT
Zimbabwe has a high maternal mortality with adolescent girls and young women
facing disproportionately high risk of maternal morbidity and mortality. Current
approaches to reducing maternal mortality in Zimbabwe focus on the pregnancy period
with antenatal care, obstetric care, and micronutrient supplementation during pregnancy.
Although important, these approaches are not reaching a large number of women and
may benefit from integration with pre-pregnancy approaches. The importance of pre-
pregnancy interventions to promote young women’s health has been emphasized, yet
many young women in developing countries like Zimbabwe do not have access to pre-
pregnancy care because little is understood about the concept of pre-pregnancy planning.
Furthermore, it is unknown which interventions will have the greatest impact on maternal
outcomes of women in these countries. The purpose of this research was to work
collaboratively with adolescent girls, young women, and key stakeholders in Harare,
Zimbabwe to bridge the knowledge gap around pre-pregnancy planning and to inform the
development of a pre-pregnancy planning intervention. Interview data were collected
from June-August 2015 from adolescent girls and young women (14-24 years) (n=48)
and key community stakeholders (n=24) from two low-income high-density communities
in Harare. Sixteen focus groups were also conducted in November 2015 with females
aged 14-24 years, healthcare workers, and partners of females aged 14-24 years (n=134).
Qualitative analysis with Nvivo 10 software indicated that adolescent girls and young
women conceptualized pregnancy across 8 themes: carrying a child, motherhood, the best
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time for pregnancy, pregnancy decision makers, who is responsible for the pregnancy,
pregnancy burden, pregnancy dangers, and increase in social status with pregnancy.
Participants expressed mixed views concerning the possibility of planning a pregnancy
and described pregnancy planning across the pre-pregnancy, pregnancy and post-
pregnancy phases. Key community stakeholders described a physical environment related
to pregnancy and planning for pregnancy that was limited in programming targeting
adolescent girls and young women and a social environment that was deeply rooted in
culture and cultural practices. Focus group participants described potential pre-pregnancy
efforts that included clinic programs, community outreach, edutainment, empowerment
of young women, parent and partner involved or targeted programs, peer education,
school programs, technology programs, and youth friendly environments. Findings
suggest that considering the socio-sociocultural influences on pregnancy will be
beneficial in developing pre-pregnancy efforts to improve maternal and child health in
Zimbabwe.
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TABLE OF CONTENTS
DEDICATION ....................................................................................................................... iii
ACKNOWLEDGEMENTS ........................................................................................................ iv
ABSTRACT .......................................................................................................................... vi
LIST OF TABLES .................................................................................................................. xi
LIST OF FIGURES ................................................................................................................ xii
LIST OF ABBREVIATIONS ................................................................................................... xiii
CHAPTER 1: INTRODUCTION ..................................................................................................1
1.1 OVERVIEW OF STUDY ............................................................................................3
CHAPTER 2: BACKGROUND AND SIGNIFICANCE ....................................................................7
2.1 SETTING ................................................................................................................7
2.2 MATERNAL HEALTH, MORBIDITY, AND MORTALITY IN ZIMBABWE ......................8

2.3 FACTORS THAT CONTRIBUTE TO MATERNAL HEALTH IN ZIMBABWE ..................15
2.4 NATIONAL STRATEGY AND INTERVENTIONS TO PROMOTE MATERNAL HEALTH IN
ZIMBABWE .................................................................................................................27

2.5 A NEW APPROACH FOR IMPROVING MATERNAL HEALTH IN ZIMBABWE: PRE-
PREGNANCY HEALTH .................................................................................................29

2.6 GAPS IN THE LITERATURE....................................................................................39
2.7 STUDY SIGNIFICANCE ..........................................................................................40
CHAPTER 3: METHODOLOGY ..............................................................................................42
3.1 OVERVIEW OF RESEARCH DESIGN .......................................................................42
3.2 STUDY SETTING ...................................................................................................44
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3.3 CONCEPTUAL MODEL ..........................................................................................44
3.4 SAMPLING ...........................................................................................................50
3.5 PARTICIPANT RECRUITMENT ...............................................................................51
3.6 DATA COLLECTION..............................................................................................52
3.7 DATA MANAGEMENT ..........................................................................................53
3.8 DATA ANALYSIS ..................................................................................................54
3.9 ETHICAL CONSIDERATIONS AND ETHICAL APPROVAL MECHANISM ....................57
3.10 DISSEMINATION PLAN .......................................................................................57
CHAPTER 4: RESULTS ..........................................................................................................59
4.1 UNDERSTANDING CONCEPTUALIZATIONS OF PREGNANCY AND PLANNING FOR
PREGNANCY AMONG ADOLESCENT GIRLS AND YOUNG WOMEN IN HARARE,
ZIMBABWE .................................................................................................................60

4.2 UNDERSTANDING THE SOCIAL ENVIRONMENTAL INFLUENCES ON PREGNANCY
AND PLANNING FOR PREGNANCY IN HARARE, ZIMBABWE .........................................88

CHAPTER 5: SUMMARY, IMPLICATIONS AND RECOMMENDATIONS ...................................113
5.1 SUMMARY OF MAJOR FINDINGS ........................................................................113
5.2 PUBLIC HEALTH SIGNIFICANCE .........................................................................125
5.3 STUDY LIMITATIONS .........................................................................................127
5.4 CONCLUSION AND IMPLICATIONS FOR FUTURE RESEARCH ................................127
REFERENCES .....................................................................................................................131
APPENDIX A – STUDY FLIERS ...........................................................................................143
APPENDIX B – SEMI-STRUCTURED INTERVIEW GUIDE ......................................................149
APPENDIX C – FOCUS GROUP DISCUSSION GUIDE ............................................................156
APPENDIX D – INTERVIEW AND FOCUS GROUP SOCIO-DEMOGRAPHIC SURVEYS .............159
APPENDIX E – STUDY CONSENT AND ASSENT FORMS ......................................................170
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