My internship placement has been at the Alliance for Reproductive Health Rights (ARHR), a Ghanaian NGO working to ensure that health rights of all people, especially vulnerable groups such as the poor, marginalized, and women of reproductive age, are protected and fulfilled. While much of their work is centered around reproductive and sexual health issues, I have learned that their projects are expansive and address many health issues which support the organization’s ultimate goal to support achieving Universal Health Coverage (UHC), a commitment the government of Ghana has set to reach by the year 2030.

Prior to coming to Ghana, I had an interest in learning more about recent Comprehensive Sexuality Education (CSE) guidelines released by the Ghana Education Service and UNFPA in November of last year; thus, I was very excited to be working with ARHR for the five weeks of internship as they are one of the organizations working to implement CSE in Ghana. One of their current projects is focused on providing CSE to out-of-school adolescent girls between the ages of 10-19. Teenage pregnancy is a pertinent issue in Ghana. National data collected by the Ghana Ministry of Education in 2018 indicate that 7,575 girls in basic and senior high schools truncated their education due to unplanned pregnancy (Ghana Web, March 2019). Out-of-school girls in impoverished communities are also more susceptible to sexual abuse. Thus, having a CSE program to help empower these adolescent girls through gender-responsive comprehensive sexuality education is extremely important.

In the last two weeks, I have been fortunate to go on two monitoring field visits in communities currently implementing the CSE project to reach out-of-school adolescent girls. The project utilizes a system of peer-to-peer education through “adolescent health champions”- adolescent girls who are recruited and trained to go out in their communities and educate their peers on various topics including sexual health and contraception use but also personal hygiene, assertiveness and negotiation skills, and the issue of gender stereotypes and gendered-based violence. Adolescent girls from the community who speak the community language are trusted by parents and adolescents and thus get access to girls that is unattainable to other educators.

The first community I visited was the Gbese community, a dense urban neighborhood located within the Jamestown district at the heart of Ghana’s capital city, Accra. Most members of this community are from the Ga ethnic group and speak the dialect Ga. The very minimal amount of Twi I learned was of no help in this community and many of the community members speak little to no English. After first meeting with the director of this project and getting a good background understanding of how the project functions, I met with five adolescent champions. Like most teenage girls, they were excited to have someone new interested in them, but they were hesitant to open up to a stranger about sex, understandably as sexuality is still a very taboo topic nationally. Their answers were short and I had to dig a bit, but it was clear they enjoyed the work they were doing and were comfortable going out and speaking with their peers about sex-related issues. When I asked one girl whether she talked to her peers about condom use, she immediately said yes and showed me the condoms she carried in her bag on visits. The program director and the adolescent girls then led me deeper into the neighborhood to meet some of the girls’ mothers. The director had to translate these interviews entirely, but the mothers were open to telling us how they felt and the four moms we spoke to were unanimous in their praise of the program and described seeing an impact among the adolescent girls already.

My second community visit setting was much different in the rural community of Peki located about 3 hours outside of Accra in the eastern Volta region of Ghana. During this visit, I was joined by two new ARHR interns who are friendly Ghanaian medical students. I was happy to have the company on the long trip and even more thankful to have them when we approached the large group of around twenty adolescent girls- six of them holding their infant children, most of the other girls had little ones back home. It would have been difficult to try to engage this many girls in conversation while taking notes and photos. It turns out that even between the three of us, getting a conversation going was a bit like pulling teeth. After having each of the girls introduce themselves, we had to employ the tactic of calling on specific girls to demonstrate to us how they would interact with a peer during a CSE visit. Slowly the girls warmed up to us and began to share their experiences. It was evident that this group was comfortable talking about personal hygiene but had many questions and concerning misconceptions regarding contraception. One girl asked, “Does family planning cause sickness?” Another cited knowing a girl that had used an implanted contraceptive and couldn’t have more children after it was removed as evidence that all birth control caused infertility. I felt out-of-place addressing their questions and concerns as someone with no formal medical background but also felt like I had no other option but to try my best to remedy their misunderstandings, especially knowing these girls will be educating future peers with these fallacies.

These field trip experiences were simultaneously enriching and challenging. It was exciting to see an innovative program strategically addressing a great need for adolescent girls in action. In the Gbese community, the impact of the project was evident and positive. Everyone we spoke with was openly enthusiastic and confident in the program and its mission. This was not the case in Peki, as reflected by both the insecurities of the adolescent champions and a list of concerns we gathered from a community health facility worker engaged in the program.

In both communities, the need for out-of-school boys to receive CSE was brought up on a couple of occasions. A group of four older adolescent boys who had helped with a community-wide event put on for the Gbese CSE project was also at the small stall where I met the adolescent champions. Their objective was to share their interest in the program with me in addition to their desire to participate in a similar project focused on adolescent boys. As one boy told me, “We are the ones causing a lot of the problems!” I chuckled but immediately commended their awareness and eagerness to get involved and encouraged them to stay engaged should such an opportunity develop.

Child marriage is another associated issue in some communities in Ghana. Educating young girls about decision-making and assertiveness is wonderful and worthwhile; however, if a girl’s parents decide to give her to a man as a wife, her training on these topics will not empower her to stop that process. Comprehensive change often must engage all the stakeholders involved, and in the case of empowering young girls, reaching and educating boys and parents is also necessary.

The fact that homosexuality is illegal in Ghana, and discussion around homosexuality practically forbidden, is a clear hindrance to CSE. The new CSE curriculum for in-school children is still being finalized, but it will absolutely not include any discussion of sexuality outside of heterosexuality and is currently not included in this out-of-school programs either. This means these adolescents’ education will discernibly not be fully comprehensive, which is frustrating for a person coming from my background and perspective. Despite these concerns, the work of ARHR to provide this vulnerable population with essential CSE knowledge is both promising and admirable.

As a graduate student who classifies primarily as a qualitative researcher, I have contemplated the benefits and difficulties that come with research which requires the researcher to be the mechanism gathering the data. Conducting interviews is often a more in-depth and effective research method than others. As an interviewer, your personal identity is a critical factor. Who you are can open some doors and close others. Going into these communities provided a clear reminder of this. I can’t recall another time I felt more like a spectacle as I drew attention from every person I passed. As an obvious outsider who possess identity characteristics with significant cultural and historical significance, I wasn’t the ideal person to have a conversation on this topic with this group of people. This was painfully obvious in Peki when one of the girls refused to answer a question after being called on multiple times by the other interns; finally another girl shouted, “She’s afraid to speak in front of the Oburoni (white person)!” The health facility worker also had a difficult time understanding my English, despite my greatest efforts to speak as clear as possible. The other Ghanaian interns’ English seemed to not be an issue so we got through the interview, but I couldn’t help but feel discouraged with my inability to have the conversation on my own.

My internship work with ARHR has given me many important lessons in strategic health communication, especially related to CSE. I further appreciate the crucial need for CSE development in Ghana, the U.S., and around the world. Learning about the other work ARHR and other NGO’s are doing to achieve UHC, which surpasses current efforts in the U.S., has also been eye-opening and inspirational. Ghana’s efforts to ensure all citizens have a right to quality primary healthcare should serve as a helpful example to other nations. I will leave Ghana at the end of this week with much to reflect on and valuable experience that will improve my future research and teaching.