Perceptions of Adolescent Pregnancy in Rural Contexts: An Approach based on Social Determination of health inequities


 Background: The phenomenon of teen pregnancy as a social process in rural areas within settings of violence and peacebuilding are not well understood. The purpose of this study was to inquire into the perceptions of lived experiences in Colombian rural areas on the social forces and social determination of adolescent pregnancy. Methods: Qualitative study using semi-structured interviews and focus groups. Data triangulation included young people and other social actors from the Amaime river basin (municipalities of Palmira and El Cerrito in Colombia). Perceptions about the social conditions, specific ways of living, and lifestyles, were analyzed with approximations from phenomenology with the theoretical approach of social determination of health inequities. Results: Living conditions with strong social stigma and demand for social, political, and cultural opportunities were found. Regarding the way of living, an isolated young person is perceived with emotional gaps, sanctioned by the social group, and with little communication and information on sexual education. Regarding lifestyles, there are standardized youth behaviors that affect a person’s life plan and sexuality with precarious gender relations and with various types of violence that limit exercising peacebuilding. Conclusions: This study contributes to a pressing topic in sexual and reproductive health, with a novel approach that generates conclusions that contribute to comprehensively expanding the required interventions.

There have been few studies interested in approaching the phenomenon of teen pregnancy as a social process in rural areas within settings of violence and peacebuilding. Qualitative methods are appropriate in this sense to approach the knowledge of the representations, meanings, and perceptions from the perspective of individuals. 2,5,9 The need to understand and positively transform adolescent health paradigms is presented. To do so, comprehensive views based on adolescents' perceived needs are required to improve sexual health promotion and prevention actions. Studies on perceptions seek to obtain information about the values, traditions, experiences, prejudices, ways of thinking, and knowledge that adolescents have in their family contexts and in their socioeconomic and cultural environment. 2,5,10,11 The research question was: What are the perceptions from the lived experiences of young people and social actors in the Amaime river basin regarding the social forces and dimensions of social determination involved in adolescent pregnancy in settings of violence and peacebuilding?
The research framed the exploratory analysis of the adolescent pregnancy issue in the challenges of promoting health using an approach that highlights the social aspects in the disease-health process. This contributes to a broader view in relation to traditional epidemiological approaches to focus on characterizing the social context and perceptions where problems are reproduced, and social inequities arise. 12.13 Methods An exploratory qualitative study was conducted using semi-structured interviews and focus groups (FG) with the support of a eld notes to draft reports. These techniques made it easier to approach a design with elements of phenomenology, 14 allowing the development of analytical categories according to the dimensions of the social determination approach. 13 The area of study focused on the rural area of the Amaime river basin, the municipalities of Palmira and El Cerrito in Colombia. Triangulation was used to gather information as participation by various social actors involved in the phenomenon of adolescent pregnancy was considered. Thus, young men and women with experience in pregnancy at an early age (when they were between 14 and 18 years old) were invited to participate in the research project. The call and enrollment of the project was carried out in two non-formal training centers where young people and adults from the families of the Amaime basin participate in permanent training with an international foundation. The participant age range was between 14 and 30 years old at the time of study, and the history of experience in pregnancy at an early age was used as inclusion criteria. These key informants were included in focus groups and some of these were also involved in the study through semi-structured interviews. Leaders from the areas studied, aged between 30 and 60 years, were also convened and participated in the focus groups. Additionally, local health representatives and health authorities from the municipalities of Palmira and El Cerrito were involved in the study and participated in semi-structured interviews. Overall, 3 FG with 25 participants (See Table 1) and 12 semistructured interviews were conducted (See Table 2).  Information was collected between the months of February and March 2019. This project was approved by the institutional ethics committee to which the main researcher was a liated as a student of a master´s program (approval certi cate No. 021 − 18), and informed consent from the participants was obtained.
The initial analytical categories corresponded to prede ned dimensions of a matrix of social determination elements, 13 which were addressed using a semi-structured interview guide and focus groups. The topics that served as categories were living conditions, social forces, perception of pregnancy, and violence (Table 3). Key elements in constructing identity, such as community and diversity, were characterized in perceptions. Positive and negative aspects in the experience of early pregnancy and the relationship of the phenomenon with violence were described in the changed perception of the actors in the peacebuilding stage. 3. Symbolic violence.

Peacebuilding.
The theoretical saturation technique was used to collect and process information, considering the contribution of new data based on intuition or experience, particularly related to community beliefs, perception of the phenomenon, and topic of social networks. Additionally, emerging information categories were constructed to be analyzed and interpreted and nally to generate discussion. These categories were included in a table and were subject to analysis on social determination and its conjunctions, 13 thus expanding the understanding, comprehension, and interpretation of the phenomenon.
The emerging categories correspond to unexpected elements or information not considered in the initial design and that the informants expressed and attributed to the studied phenomenon. Additionally, repetitive elements in terms of similarities and differences were considered, both in the interviews and the focus groups, with continual comparison processes that are considered and synthesized in the discussion.
The analysis was framed regarding social determination context with the qualitative paradigm of social research. It began with transcription of audio recordings of the interviews and focus groups of young people and adult actors, creating a le using Microsoft O ce's Professional Plus 2013 Word program to code. Then, the commenting tool was used to identify the analytical categories. Thus, the information organization process was conducted separately for young actors who experienced adolescent pregnancy and social actors by employing differential codes. Subsequently, the information was processed and added to categories and subcategories according to the perceptions, conditions, circumstances, or situations in the proposed social determination model. They were then grouped into the general domain, the speci c domain, and the singular domain.
When drafting the ndings and discussion of results, informant con dentiality was preserved using previously de ned alphanumeric codes. The information was extracted for the discussion, applying processes and strategies of academic rigor that are typical of qualitative methods. 15 Thus, in a nal step, the triangulated data obtained from the collection techniques (focus groups and semi-structured interviews) was used, and the results for socialization were returned to the participants to nd similarities, agreement, or disagreement among the perspectives of the social actors and to complete the exploratory analysis of the phenomenon. 16

Results
The research results below are grouped into the categories of living conditions, way of living, and lifestyle. The various domains proposed by Jaime Breilh on the theoretical approach of social determination were also analyzed (See Table 4), such as the general, speci c, and singular domains.  Table 5). For them, opportunities depend on the social relationships of land production and the precarious conditions that it generates, affecting their way of living with an early start in their sexual lives, dropping out of school, and the tradition of adolescent pregnancy with a high level of responsibility for women and not for men. In terms of the economy, many young people are forced to migrate from their homes to cities such as Cali and Palmira to seek employment, as opportunities are limited to the agricultural sector, and many young people do not want to work as cheap labor in planting and processing sugar cane, an activity located in Valle's plains, nor want to perform horticultural work on the hillsides of the Amaime river basin.
""Economically there are de ciencies since it depends on what they sow and how much they can get for that, they cannot set the price; they depend on how much others want to pay". (Interview, Young1) "The people of the Amaime River are a bit humble; it is quite complicated in the eld of education because there are areas that are very remote, and it is di cult for them to get around. Many do not have the possibility of being well due to lack of work or lack of opportunities". (Interview, Young2) "There is no help for everyone in health, education; the peasant is unprotected." (Participant FG 3).
"The living conditions of the communities are negative due to the lack of work, and the problem of education. For example, I was studying, and now more than anything, the issue of education has become di cult for me. I have not focused on thinking about pregnancy as a teenager, my goal is that I have to educate myself". (Interview, Young3) Regarding political opportunities, young people feel that their parents are used in the electoral process and that politicians are not interested in their voice, generating a type of symbolic violence or State neglect.
The study results indicated that families remain employed in domestic and horticultural work in rural areas, while those who inhabit the plains closest to Palmira and El Cerrito generally work in various labors. In this case, many of the young people remain alone in their homes for much of the time, except when they are at school. Young people demand cultural and sports spaces, claiming they need to use the streets to socialize and interact with others. Many state that there are few cultural offerings, and that parties and consuming alcohol are promoted.
For their part, social leaders express social resentment because of the State's lack of presence as an institution that solves socioeconomic de ciencies and as an entity that participated in the war against FARC-EP without making social investments in the area. They also perceived the existence of high social stigma for having been in the middle of the armed con ict.
As for the way of living (See Table 6), young people are characterized by their simplicity and humility, particularly determined by the shortcomings of their environment and limitations in achieving their dreams. With regard to perceptions about the community, family, and institutional framework, we found that they act as negative social forces because they repress young people's freedom in terms of being informed, educating themselves, and being able to experience the right of sexual and reproductive life in an enjoyable manner. Young people enjoy partying, going out to dance, going to the movies in Palmira, or going out to eat, as well as walking, swimming in the river, playing soccer or riding horses, and in some cases, standing along the sides of the main roads.
Among families, there is a lack of knowledge about how to approach the subject of sexual education, and it is considered a taboo subject, which is discussed after the pregnancy has already occurred.
"Today, teenage pregnancy is a re ection rather of going out to dance; because before one used to get together with friends to share, now it's going to dance. Before the neighbors met, they were more concerned with sharing and uniting in community; now they have been more inclined to communicate with technology". (Interview, Social Leader 1).
"I speak from my own experience, I got pregnant when I was 14 years old, my parents supported me and then they told me to take care of myself from now on. I stopped studying, and they continue to help me; I work and live with my parents; the father did not answer, the boy is 10 years old and little by little I am taking him forward". (Participant FG 3).
The accounts of the study's informants indicated that youth health services do not provide adequate coverage by health authorities in El Cerrito and Palmira, as the area has a highly dispersed population throughout the Amaime river basin. Therefore, there is no access to information and education. Thus, this becomes an additional burden that is dependent on the will and discretion of teachers within educational institutions.
According to the participating social leaders, the community is ignorant of health issues and adolescent pregnancy issues, and it is not interested in young people. These communities come to play a leading role when pregnancy appears, developing opinions from their prejudices and especially from the beliefs of assuming the issue as a tragedy and, particularly, recriminating women.
The research study revealed that the issue of community organizational support is weak because of the dispersion of the area that prevents closer relationships among neighbors, and because it could have become fractured in the armed con ict.
Regarding the characteristics of the area to understand diversity and identity, the study's participants consider that the territory provides them with water and very good land, as it is a moorland zone. Nevertheless, the geographical characteristics, limited access due to public transportation shortcomings, a political-administrative division between two municipalities, and scarce institutional governmental presence determine the presence of adolescent pregnancy.
As for the lifestyle category (See Table 7), there is a more singular determination appropriately related to the affective eld and self-con dence. Many young people showed emotional gaps and lack of communication at the family level. Many remain isolated and are distrustful of engaging in sex education topics with families, teachers, or friends. Table 7 Key ndings and testimonies by dimension: Category of lifestyle.
Pregnancy at an early age is conducive to this rural context, as it begins with friendship, courtship, recognition of one's body, and young people are not aware of the risks of pregnancy, highlighting the fact that both men and women agree that it is the man who applies the most pressure to have sex.
"… Many young people… on the subject of sexual health are very open, it has been presented that the rst time they see each other they are already dating, and everything happens. On the sexual issue there are more things; some are very cautious, other people are responsible; but there are others who are not, mainly men." (Interview, Social leader 2).
Thinking about a life project creates challenges for young people in the rural Amaime river basin area because of the limitations and restrictions that prevent them from having a strong self-concept. Communication problems do not allow the self-determination process to appropriately take place in young people so that they can handle the circumstances of sexuality and adolescent pregnancy, and of sexuality and non-pregnancy. Thus, sexual activity occurs in a physiological moment, where an existential vacuum emerges. Conversely, a couple that has sexual activity more consistently allows the affective aspect between them to develop. Moreover, lifestyle is globally determined by standardized forms of interaction typically marked by online social networks as rural areas are not left out of this phenomenon. Additionally, other domains that mark social behaviors with trends, gender, and sexual life distortions are created.
It is noteworthy that, from an early age, many young people envision their life project as a couple. This is related to the lack of encouragement of family and people in the context. Thus, in many cases, adolescent pregnancy is culturally determined by a rural tradition of dropping out of school and couples beginning at an early age, where women postpone their life plan for the ideal image of life as a wife.
Thus, early pregnancy is considered to be determined by a social assignment of the role of being a woman as many men in the Amaime river basin abandon their responsibility of fatherhood, establishing a practice in which it becomes di cult to understand gender equity and equality relationships, where the family forces the woman to assume that responsibility, with a low occurrence of cases in which responsible fatherhood is constructed. Once again, families end up raising grandchildren who are the result of their daughters' pregnancies, considering it a normal or routine way of living.
Regarding the issue of the perception of pregnancy as such the participants, and especially those with personal experience, highlighted positive and negative aspects. More positive aspects are reported in rural areas as compared with areas near the cities of Palmira and El Cerrito. For example, they state that it depends more on youth culture, and in rural areas it is determined by the tradition of patriarchal culture, in many cases through deception and by idealizing pregnancy. Pregnant women are perceived by the community as strange individuals, who experience changes in their bodies, emotional problems, and who are isolated.
From the perspective of health representatives, this is determined by the elements of culture, education problems, poverty, and social resentment. When women become pregnant, they look to meet other pregnant women when they begin stages of medical oversight. They consider each other peers and experience the instinct of being mothers, building the bond between mother and child, downplaying the issue of fatherhood in the midst of sadness, fear, and the challenge of giving birth with various risks. This is where the connection of responsible fatherhood is lost.
When asked about violence, the actors focused on the issue of the armed con ict, con rming demobilization as a factor that makes them feel more secure to move freely through the area nowadays. They feel like they were manipulated by the various agents of the armed con ict. It is evident that they have experienced other forms of violence, such as theft, verbal violence through the misuse of vocabulary in soccer matches, and consumption of psychoactive substances among young people.
It is easier for young people to talk about peace than for adults, particularly for women. However, as actors who were related to the war, they have proposals for building a culture of peace. While there is a potential decrease in the anxiety of living with armed actors, there are still emotional gaps arising from the war, with expressions of sadness and pain in the midst of a negative perception of a true peace agreement and real compliance with the agreements being far off. In both men and women, there is a need for mourning processes, in which psychosocial care is required to recreate violent situations.
Based on their perception, people experienced the symbolic violence exerted from invisible barriers in times of armed con ict between the middle rural area and the upper area, which made communication with each other impossible, in addition to invisible borders in the populated areas near Palmira and El Cerrito as a result of urban violence.
Cultural violence issues in terms of gender violence remain hidden, and there is a lack of awareness and a need to educate people on the subject. The participants recalled gender-based situations of violence with horror. They consider these to be isolated cases, and, in their perspective, they do not see adolescent pregnancy as a product of this issue. They focused more on topics related to psychological and cultural violence because of gossip, a result of the judgments and prejudices among people, especially in the areas closest to the cities of Palmira and El Cerrito that lead to discussions and entanglements.
There is denial of adolescent pregnancies caused by actors in the armed con ict. The community claims that the pregnancies occurred between armed actors and women of legal age. The actors' perceptions show fears and memories of the armed struggle for the control of bodies and the area. Despite the demobilization process, there is distrust in the peace process that results in uncertainty regarding the ful llment of agreements and subsequent investment that is necessary from the State. The peace process's contribution to peace in the area is acknowledged, although they consider it an imperfect peace as a stronger presence of government institutions in rural areas is necessary. The peace imagined by the key actors in the research study involves transforming complex con icts, such as drug tra cking, reincorporating ex-combatants, and security for the entire population, and increasing opportunities and continuing education in the culture of peace.

Discussion And Conclusions
This study shows that public health interventions must use theoretical frameworks that include the matrix of social health determination to manage complex phenomenon, such as adolescent pregnancy, overcoming the idea of an isolated or individual analysis event, to improve and analyze it through categories involving conditions, ways of living, and lifestyles, which involves understanding and intervening in it as a social phenomenon. 12,13 In the rural area of the Amaime river basin, adolescent pregnancy is present as a phenomenon linked to different social determinations that have been grouped into the various categories analyzed. Here, it is necessary to continue with the process of researching and intervening to join efforts of the social group with a broad and inclusive concept of public health to create an organized response to transform needs and bring about collective action.
With regard to the phenomenon of adolescent pregnancy, there are diverse studies that analyze gender violence, contexts of poverty, and the predominance of patriarchal culture. [1][2][3][4][5] Thus, those suggest that is necessary to consider childhood history, adolescence, and cultural context as dimensions that determine motherhood and fatherhood. Additionally, the timeline must be considered to analyze inequality. 3,4 Under the premise of disapproval of sexuality, access to information, education, and exercising pleasurable and responsible sexuality, sexuality has been impeded as adult society has established a speci c way of understanding, interpreting, and managing sexuality in social, educational, religious, and cultural institutions. 1,5 Notably, adolescents tend to request information and medical attention on planning. Data shows that a high percentage of these health services are concentrated in the group of adolescents aged between 10 and 14 years, which is contradictory to the studied phenomenon of pregnancy in these population groups. 1,17 It is worth noting that many adolescents are identi ed as having couples that are older than their age ranges. 2 In this sense, it becomes necessary to look toward health promotion actions, by the entire society, involving both government and non-government actors, as well as involving the different ways in which civil society expresses itself. 2,3 Thus, health promotion should be included as a local response-generating mechanism to the set of needs expressed by actors in the categories of living conditions, ways of living, and lifestyle. 13 This includes social gaps among these groups, which demand inclusion and improving their health status.
Additionally, the phenomenon of adolescent pregnancy as a component of sexual and reproductive health policies, which is considered a priority at the national and international level, requires greater emphasis from sectoral, crosssector, and community responses in coordinating measures that are combined and adapted to speci c territorial contexts; for example, a comprehensive model of Primary Healthcare with the renewed approach mentioned by PAHO should be considered. 18 It is clear that in rural communities, such as those studied, there is a need for strategies that allow more progress in transforming social gender relations, promote equity, and are conceived as part of sexual and reproductive health programs available for the entire population. The research ndings indicated that actors perceived that poor education in gender construction has led to speci c risks such as early pregnancy. Men were found to have internalized archaic forms of behavior and attitudes that put women at a disadvantage when it comes to issues such as self-esteem, using their bodies, abandoning their children in the womb, and sexual relations at an early age.
It is increasingly necessary to understand the characteristics of adolescent men in their role as fathers to determine how many there are and how their location is in uential as a rst step in guiding public policies that make them participate in the process of reducing adolescent pregnancy indicators. This is signi cant as data indicates that for every adolescent man who is a father, there are four adolescent women who are mothers. Another relevant nding is that young people continually engage in risky sexual practices. These ndings are in line with previous research ndings. 10,11 Additionally, in the Amaime river basin, the coexistence of different roles for women regarding work, economic, and environmental contributions, it is recognized in terms of their relationship with the land and domestic tasks. It is necessary to make progress in reconciling family and greater institutional support, as the existence of unfavorable conditions for women, lack of protection, and inequality in terms of gender relations and power-a phenomenon that generally occurs in determinations and social reproduction-is demonstrated.
Moreover, parents become extremely important actors who must be involved in new guidelines on caring for adolescents. Parents must be sensitized to the new risks that children and young people are currently exposed to (such as those associated with the use of social networks with new information technologies that can lead to early sexualization, addiction, suicide, etc.). Simultaneously, it is necessary to involve caregivers and relatives to resolve the di culties in generating empathetic, affective, or assertive communication precisely in the pregnancy experience and romantic relationships at an early age. Thus, many young people said they felt alone due to depressive disorders developed as a result of their family, community, school environment, and the experience of adolescent pregnancy and construction of their young identity.
Young people must be able to express themselves to achieve an effective intervention. Some leaders are already promoting this, but more institutional support is needed. For example, one option is through an alliance between the governments of Palmira and El Cerrito, Universities, and NGOs in the area, which can come together and promote education through art workshops for peace, theater, music, dance, and photography. It is also necessary to strengthen entrepreneurship and business opportunities that motivate young people, based on the role of a training school and not as isolated activities, where the desire to learn and discipline are combined, which would contribute to new spaces to prevent adolescent pregnancies from other perspectives. It is critical to reiterate that in the rural area, government efforts and social participation should be combined to overcome geographical and political delimitation. For this to be achieved in the Amaime river basin, leadership from the Municipal Departments of Health in El Cerrito and Palmira is required to push forward a strategy with the help of the Department's Health O ce and to involve leaders in these places, as the populations that inhabit this area are in fragile environments, because of the prolonged con ict between the Colombian government and illegally armed groups.
In terms of the knowledge gap, this study nds that it is relevant to develop a research policy with a concerted agenda with the area's social actors and agents to respond to speci c needs. This agenda should be adapted to each community's speci c characteristics. Thus, in relation to the topics covered in this research study, questions must be asked according to the context, so that it can be tied to the results, attempting to attract attention for decision-making and public agenda. New research studies should be developed in the future. These studies should involve actors such as the owners of land and of large economic sugar capital in the region, teachers from educational institutions, and participation by young men and representatives of non-governmental organizations, which may complement the understanding of the phenomenon and contribute to analyzing the interventions required to address it.
Based on actors' perception of the violence and demobilization of the FARC-EP, we found that although there is a feeling of freedom, the inhabitants' anxiety persists regarding the topics of potential incursion by other armed actors in the area. It is important to recognize international efforts to demobilize armed actors and the effort of the previous administration and the FARC-EP's Secretariat for building peace. Today, more than ever, it is crucial for Palmira and El Cerrito to be part of the municipalities that the State recognizes as places where human rights violations have occurred. It is also appropriate to provide psychosocial and humanitarian care and to participate in productive projects in accordance with the Havana agreements from the perspective of the territorial peace model. 19 Therefore, it is necessary that the health sector considers that intervening in the post-con ict is both a right and an obligation. The health sector should also consider that the con ict has provided an opportunity to acknowledge other types of violence, such as intra-family violence and gender violence, which are related to sexuality, and other con icts concealed in the culture that arise from the conditions, ways of living, and lifestyle-with the economic and political structures-as has been demonstrated with regard to early pregnancy in this area under study and in other related studies. 2,3 Finally, the political issue as one of the dimensions of living conditions explained by young people is concerning, particularly because of apathy and depoliticization that undermines the role and responsibilities of citizens because politics is perceived as elitist. Civil society's capacity to empower itself and solve local problems is not apparent either. In other words, it is not an actor capable of generating political militancy and claiming rights. Consequently, it is necessary to rethink processes to generate community and social participation, which are not related to partisanship or electoral activities with individual interests.