“Seeing Is Believing”: Identifying the Sexual and Reproductive Health Priorities of Adolescent Girls and Young Women in Freedom Park, South Africa Through an Adapted Body Mapping Approach

Abstract

Objectives

This study uses a decolonized research approach to identify the sexual and reproductive health (SRH) priorities of adolescent women living in Freedom Park, Cape Town, South Africa. The history of colonialism and apartheid has a significant ongoing impact on the SRH of women in the community. The objectives of the research were for adolescent women to create a shared definition of SRH and identify SRH needs and priorities.

Methods

A qualitative, participatory action design guided by decolonized methodologies was employed. Community members co-developed a modified body mapping exercise, ensuring cultural appropriateness and participant privacy. This participatory tool was used to explore SRH issues, leveraging its ability to foster dialogue and self-expression in a safe and collaborative environment. Seven workshops were conducted, engaging 54 adolescent girls and young women (AGYW) aged 16–25. Participant body maps and narratives were analyzed with the community through thematic coding and visual interpretation.

Results

Participants defined SRH, and illustrated SRH body parts, outcomes, and priorities on their body maps. Five themes were identified when discussing priority SRH issues: reproductive health and sexual wellness, abuse and violence, mental health, support and knowledge, and social pressures. Participants identified the two SRH issues they most wanted to address in their community as gender-based violence (GBV) and adolescent pregnancy. The body mapping methodology fostered open discussion and provided insight into personal lived experiences.

Conclusions

This study highlights socio-economic factors, cultural context, and historical influences as intersecting root causes of SRH outcomes in Freedom Park. The participatory body mapping approach empowered AGYW to express their SRH needs and identify community-driven priorities. Findings underscore the importance of contextualized, culturally sensitive research methods in addressing complex health challenges. Future interventions should address GBV and adolescent pregnancy through community-led strategies to foster sustainable change.

Background

There is a significant history of imperialism and coercive control stemming from a long legacy of colonialism in southern Africa. Colonizers used medical practices as a strategy for control, committing violence, and experimenting on Indigenous bodies. Reproductive control was a strategy for oppression and exploitation of populations (in particular women) (Kuumba, 1993). This history of control through sexual and reproductive health (SRH) services was exacerbated in South Africa during apartheid. The regime heavily policed sex and sexuality (Posel, 2011), including making abortions illegal, which disproportionately negatively affected non-white populations (Klausen, 2015). Apartheid rule politicized family planning measures as a method for controlling the Black and Coloured populations, seeding a long lasting distrust of the healthcare system (Kaufman, 2000). Despite the introduction of more progressive contemporary legislation regarding women’s SRHR after the end of apartheid in 1994, the context of colonialism and apartheid in South Africa continues to affect SRH delivery and outcomes.

Adolescence into young adulthood is a critical developmental period, particularly in regard to sexual health. Adolescent girls and young women (AGYW) in South Africa experience high rates of coercive sex, gender-based violence, and sexually transmitted infections, including an ongoing HIV/AIDs crisis (Pillay et al., 2020). Rates of adolescent pregnancy are significantly higher than in other LMICs, especially in under-resourced communities, such as townships. These rates have only increased since the start of the COVID-19 pandemic (Smith et al., 2024).

Current approaches to sexual and reproductive health research directly stem from the historical politicization of sexual health and carry with them the weight of an oppressive history. A decolonized approach to research and data collection is therefore key when discussing sexual health in southern Africa. It is imperative to center community voices in research practices, acknowledge systemic power imbalances influencing research topics, and develop an approach that critiques the application of traditional Western research methods (Stevens-Uninsky et al., 2024).

The decolonized approach asks researchers to reconsider the methods and methodologies traditionally applied to community research and identify an approach that is culturally relevant and appropriate so that AGYW are empowered to claim ownership of their own knowledge and experiences. Recognizing context, acceptability, and local knowledge in research design and data collection methods is critical in identifying and interpreting new knowledge (Pienaar, 2023). Adapting existing data collection methods or community knowledge sharing traditions, and the creation of new data collection methods is an important component of this decolonized approach (Woodbury et al., 2019).

Body mapping, the data collection method used in this research, allows the voices of those who have been oppressed and overlooked to speak freely, often in ways distinct from, or in opposition to, dominant narratives (Jager et al., 2016). The visual nature of body mapping often allows for participants to communicate experiences that they may find challenging to express verbally (Naidoo et al., 2021). It is an effective methodology for reducing barriers to participation, empowering participants to discuss challenging topics, and is an effective method to build comfort amongst participants in speaking openly around culturally taboo, or sensitive topics, such as SRH (Hartley et al., 2023). Body mapping is relatively well-known in South Africa, as the technique originated as an art therapy method for women living with HIV/AIDs in South Africa in 2002 (Lys et al., 2018).

Study objectives

This research applies decolonized research methodologies and methods to identify and engage with AGYW’s sexual and reproductive health priorities, and develop a deeper understanding about the application of decolonized methodologies. A central goal of this work was to demonstrate whether these methodologies are an effective approach in allowing AGYW to identify their own sexual health priorities. This self-identification represents the first step in a participatory action research approach to addressing these issues in a relevant, appropriate, and accessible manner.

This research explores two critical SRH questions:

1. How do AGYW define sexual and reproductive health as it applies to them?

2. What are the sexual and reproductive health needs and priorities of AGYW in Freedom Park, Mitchells Plain, as they identify them?

The findings of this study will support ongoing research and interventions with an under-served and high-needs population, as well as sharing learnings with researchers regarding the application of decolonized research methodologies in SRH research.

Methods

Study setting

This study took place in Freedom Park, a community in Mitchells Plain township, Cape Town, South Africa. Townships like this one emerged under apartheid in South Africa, as segregated government-sanctioned settlements for “Coloured,” “Black,” or “Indian” communities (Donaldson, 2024).¹ Racial segregations, inequalities, enforced geographic isolation, and the socioeconomic disadvantages created by apartheid remain in effect today, and continue to have adverse ramifications in terms of quality of life. Challenges in accessing education due to geographic distance, inadequate school infrastructure, lack of resourcing, or school fees mean that only 27% of Mitchells Plain residents matriculate secondary school, with almost 50% leaving school sometime during their secondary education (Strategic Development Information and GIS Department, 2013). Educational attainment, in conjunction with inequities in hiring, geographic distance from the city center, transportation costs, and limited employment opportunities in turn contribute to an unemployment rate of over 30% (Gardiner, n.d.). Mitchells Plain covers a large geographic area, where public services are sparsely available. Residents of the township travel long distances, on average over 19 kilometers, to access primary care hospitals (Richards et al., 2024), and face similarly lengthy journeys to access other public services, many of which are under-resourced (Development Action Group, 2009). Additionally, apartheid era policies continue to contribute to the significant levels of gang violence present in Mitchells Plain, which has in turn exacerbated levels of sexual violence, amongst other risks (Ndhlovu, 2024).

Freedom Park neighborhood was formally recognized as a community in 1998, following tenants’ collective action in protesting poor living conditions and extensive wait times for government-supported housing. The leaders of this community action remain active in Freedom Park, are well respected for their role in promoting the area’s development, and both supported and participated in this research.

The neighborhood has a predominantly young population, with over 60% of residents below the age of 30 (Development Action Group, 2020). Unemployment, crime, and negative sexual health outcomes are higher in this neighborhood than on average across Mitchells Plain. There are a substantial number of AGYW in this community experiencing negative sexual and reproductive health outcomes, including high prevalence of HIV and STIs, adolescent pregnancy, and high rates of gender-based violence(GBV) (Merrill et al., 2023). These health outcomes are exacerbated by unemployment rates over 70%, violence, crime, and poverty- around 25% of households have no source of income (Development Action Group, 2020). In addition, AGYW have limited access to resources and supports that might help address these issues, due to geographic distance, and limited access to public services. Given these conditions, this research was designed to support the AGYW of this community, providing an accessible, non-judgmental environment for openly expressing their own sexual and reproductive health needs.

Study type

The study employs a qualitative exploratory design, integrating community-based and participatory action research approaches. It utilizes a decolonized methodology and incorporates an adapted body mapping technique.

Ethics approval

This research project received ethical approval (Protocol No. 16889/Protocol No. 2957) from the Hamilton Integrated Research Ethics Board in Ontario, and the Stellenbosch University Health Research Ethics Committee in South Africa.

Study team

This study was designed and implemented in collaboration with community members from Freedom Park and a North American researcher. The researcher had previously worked with these individuals and within the Freedom Park community.

The research team consisted of four stakeholder groups: (1) The Community Advisory Committee (CAC) consisted of five community leaders, aged 19–60. They offered guidance and direction at every phase of the study, from defining research and data analysis to logistics and support; (2) Nine Research Assistants (RAs), women aged 18–25, worked in pairs to support the implementation of research, facilitating recruitment, supporting workshop implementations, and discussing findings; (3) The Neighborhood Watch, an informally organized neighborhood security team, established to provide their community with security in the face of gang violence. Five members provided security to the researcher, team members, and participants, and were present outside the facility at all workshops and events; and (4) the researcher. The North American researcher worked to provide funding and support for the research, as well as ethics approval, and institutional relationships. Her role consisted of workshop management and facilitation, logistics and supplies, and knowledge management. CAC members and RAs were compensated at an hourly rate, and Watch members at a daily rate.

Study team members were engaged as equal partners from the conception of research through analysis and completion. This collaborative process involved the CAC in research topic identification, design, implementation, and analysis, to ensure relevance and appropriateness of the work. RAs and neighborhood watch members were also engaged in implementation and interpretation to ensure a broad scope understanding.

Eligibility and recruitment

Participants were eligible to participate in this research if they: self-identified as women; were aged 16–25; and lived in Freedom Park full time. Recruitment methods included word of mouth, door-to-door outreach, and digital outreach using WhatsApp, conducted both in advance of workshops, and same-day.

RAs used a word of mouth and snowballing approach to invite both those who had already expressed interest, and others, to join. Eligibility was assessed as participants entered the workshop space. At each session, participants were asked to sign written consent forms, with different written forms available for children under the age of majority (18 in South Africa), and their parents. Participants were offered snacks, drinks, lunch, and an airtime voucher for 50 Rand (just under $4 CAD).

Method design

The CAC focused on formulating a data collection method that addressed concerns such as privacy, and willingness to discuss sensitive SRH issues, while simultaneously prioritizing collaboration, activity, and creativity in the data collection process. CAC members were familiar with body mapping and identified it as an initial framework to work from. The CAC developed an adapted group body mapping method that would address privacy concerns and ensure a collaborative approach. The adaptation was rooted in the desire to ensure that it met the criteria of (1) prioritizing personal perspectives and providing an opportunity for self-expression which was not often offered to AGYW; (2) collaborative and participatory, as a reflection of community communication norms; (3) gave the opportunity for action oriented strategies; (4) creative and engaging to further empower AGYW in discussing challenging topics; (5) provided privacy in their communications to reduce risk of gossip; and (6) reduce discomfort talking about personal topics.

In typical body mapping processes participants, either alone or in groups, illustrate personal experiences that are directly attributed to the individual (Lys et al., 2018). In this adapted approach, participants would work in pairs and create a “third person” body map, on which the generalized experiences of women in Freedom Park, or the personal experiences of the participants could be mapped, according to participant preference.

Data collection

Seven 3 - hour workshops, designed by the CAC, were held in April and May of 2024. Each workshop began with an icebreaker exercise, led by RAs and the researcher. The first set of prompts guided participants to collaboratively develop a shared definition of SRH by asking “what does sexual and reproductive health mean to you?” The group next discussed how to approach body mapping, including the range of illustration options, art techniques, and creative approaches that could be applied to their body maps, as well as the importance of colors and their meanings, which are defined in Table 1. Participants then divided into pairs and outlined their body maps.

Table 1.

Common interpretations of colors.

Once body maps were drawn, participants received 3 prompts. First, they were asked to “draw on their body maps the parts of the body that have to do with sexual and reproductive health.” Next, they were asked to “add to the body map the most commonly seen issues in sexual and reproductive health in Freedom Park.” Finally, they were prompted to “highlight the primary SRH issue that they would like to see addressed in their community.” While participants were drawing, the researcher and RAs visited each group, answering questions and asking participants to provide descriptive narratives or explain elements of their drawings in greater detail.

After all participants were satisfied that their body maps were complete, participants came together in a group discussion to agree on one or two issues they believed were the priority need in the community and provide context on these SRH issues.

Data analysis

The research team analyzed deidentified transcripts from the workshops, alongside a visual analysis of the body maps. The analysis was done in several stages. First, an oral discussion with RAs was conducted immediately after the workshop, to identify points of interest and themes, which were recorded in field notes. Second, a visual analysis of the body maps was conducted with the CAC, to identify themes, and provide culturally and linguistically specific interpretations. Third, the transcripts and notes from the CAC analysis meetings were used to create an initial codebook for the primary researcher, which was the basis for coding and data analysis. Transcriptions were facilitated through the use of DeScript, and coding was conducted using NVivo. This 3-step process incorporated the critical insights of the research team and allowed for both an inductive and deductive approach to qualitative data analysis. Visuals of the body maps and illustrative quotes are shown throughout this study. Findings were shared back with the CAC for review and approval.

Results

In total 54 AGYW, aged 16–25 participated across the seven workshops. Sixteen of the participants (30%) were under the age of 18. Workshops ranged from 6 to 10 participants each. All participants identified as women and lived in Freedom Park full time. Participants represented many populations, including young mothers, school attendees, pregnant women, married, single, or dating. All participants were comfortable in both English and Afrikaans. The researcher communicated in English, but if there were words or topics participants found easier in Afrikaans, translation was provided by the RAs. At the end of the workshops, there were a total of 24 body maps available for analysis (Table 2).

Table 2.

Summary of key themes.

Question	Themes	Brief description
Most common SRH issues	Reproductive and sexual wellness	Pregnancy, puberty, STIs, STDs, HIV, contraception and lack of consent for sexual activity
	Abuse and violence	Instances of sexual violence, closely linked with drug and alcohol use, and gangsterism
	Support and knowledge	The need for financial and emotional support from partners and families, and greater knowledge on SRH topics
	Mental health	Depression, suicidal ideation, stress, anxiety, and regret associated with SRH, as well as desire for safety and affection
	Social pressures	External societal pressures and norms, such as fear of judgment, peer-pressure, and self-esteem affecting SRH
Key SRH issues to address	GBV	High rates of intimate partner violence and sexual abuse identified as priority issue, closely linked with high rates of adolescent pregnancy
	Adolescent pregnancy

Question 1: A shared definition of sexual and reproductive health

At the start of each workshop, participants created a “dictionary” of terminology that they felt applied to SRH. This activity identified the important elements of SRH according to participants, helped create a shared understanding of the phrase, and facilitated discussion of the broad range of topics that could be discussed over the course of the workshop. The identified topics and their frequency across the seven workshops can be seen in Table 3.

Table 3.

Frequency with which common SRH topics were referenced.

Commonly referenced SRH elements	# Workshops	Frequency (%)
Abortions, HIV, periods, rape	7	100
Clinics/testing, condoms, miscarriage, pregnancy, puberty, STIs/STDs	6	86
Abuse/violence, breastfeeding, contraception, love/affection, peer pressure	5	71
Communication, intercourse, pleasure/desire, self-esteem/shame	4	57
Drug and alcohol use, PrEP, sleeping around, stillborn baby	3	43
Anxiety, depression, family planning, judgment, kissing, premature birth	2	29
Adoption, affection, consent, divorce, fertility, gang bang, gossip, guilt, healthy babies, inappropriate touching, jealousy, overthinking, ovulation, pain, pap smear, privacy, selfishness, sexism, sperm, SRH rights, stress, suicide, support system, teen pregnancy, unprotected sex, yeast infection	1	14

Question 2: What body parts relate to sexual and reproductive health?

Once the outline of a body map had been drawn by each group, participants fleshed them out to create a more complete image of a person. This included portrayals of faces, clothing, fingernails, and hair, as well as identifying specific body parts they believed were related to SRH. This created greater nuance and understanding of what SRH meant to participants. The frequency with which body parts were identified as components of SRH across all body maps can be seen in Table 4.

Table 4.

Percentage of body maps in which a body part was identified.

The body map imagery ranged from anatomically correct body parts (as can be seen in Kechia and Kiki, Figure 2), as well as more abstract depictions (Adeelah, Figure 1), and written words (Ruwayda, Figure 3). Other body maps contained additional illustrations external from the body itself, such as in Zoë, in Figure 1.

Figure 2.

Body maps of Kechia, Kiki, Tamia, and Naeelah.

Figure 1.

Body maps of Zoë, Devil/Drea, Jessy, and Adeelah.

Figure 3.

Body maps of Mishka, Zoey, and Ruwayda.

Question 3: What are the most common sexual and reproductive health issues?

Once SRH body parts were included in the body maps, participants were prompted to illustrate “the most common sexual and reproductive health topics seen in Freedom Park.” This invited participants to apply their definition of SRH to their experiences of common issues within their community.

Reproductive and sexual wellness

Sexual health issues related to the reproductive life cycle and the sexual wellness of women were some of the most common SRH issues identified by participants on their body maps. The reproductive life cycle represents the biological changes of the female reproductive system, from puberty and periods through pregnancy, childbirth, and menopause (Hoyt & Falconi, 2015). The most common SRH issue identified in the reproductive life cycle was pregnancy, often depicted as a product of abusive relationships and a source of concern for AGYW. Many participants illustrated feelings of sadness or concern about the pregnancy, as can be seen on Kechia in Figure 2, and Zoey in Figure 3. Participants also identified topics related to periods and puberty, such as blood flow, period cramps, hormonal shifts, and crushes on boys, as can be seen on Zoë (Figure 1).

Participants also identified STIs, STDs, and HIV as common SRH issues in their community. Risk factors for STD transmission were unprotected sex and “sleeping around,” or having multiple partners. In Figure 1, Devil/Drea additionally identifies mother to child transmission of HIV as a risk. Condoms and Pre-Exposure Prophylaxis (PrEP) were identified as modes of protection, as were other forms of contraception, such as the 3-month injection (visible on Zoë in Figure 1), birth control pills, and the implant.

Participants identified contraceptives as strategies for preventing both infection and pregnancy but also mentioned many reasons why a woman might not use them, including pressure from a partner, or a desire to get pregnant. The identified benefits of condom use can be seen on Jessy, in Figure 1, who represents the ideal outcome of good sexual health.

“Sure, in theory, not wearing a condom can get me pregnant, but I’m not going to believe it until it happens. I must try it for myself to see. Seeing is believing.” (Committee Member 1, CAC Meeting)

Younger women in particular spoke about consent as a component of their SRH, as can be seen on the mouth of Adeelah (Figure 1). Issues of consent frequently intersected with participants feeling that they were not yet ready for sexual interaction. Other participants spoke about attraction and desire as a component of SRH.

“Sometimes you don’t feel like you want to do it. Sometimes you don’t. Sometimes you feel to do it, but your heart and your mind tells you. So like, unsure.” (Participant 3, Workshop 2)

Abuse and violence

Themes of abuse and experiences of violence were woven throughout the body maps and narratives of the participants. Representations of abuse, such as bruising (Kechia and Kiki, Figure 2), bloody noses, and black eyes (see Tamia and Naeelah, Figure 2), were common. Participants used a range of terminology, including sexual violence, abuse, domestic abuse, rape, sexual abuse, and mental abuse to describe what is best summarized as intimate partner violence. Rape in particular was identified as one of the most prevalent SRH issues in the community. Levels of extreme violence and pain were associated with rape, as can be seen on Tamia (Figure 2) who was “beaten up and raped. She is not having her period, that is part of the rape. She’s…she’s been hurt, she is actually 16 years old, and she has bruises on her arm.” (Participant 8, Workshop 6).

Abuse was most often depicted as being perpetrated by boyfriends or fathers. In one instance, a participant shared a poignant story of a woman using violence as a form of self-defense.

“Most of the time it is men, sometimes it can be a woman. There was a case like that…one woman I knew was beating her children. And then there was my friend, was in an abusive relationship. The, the boyfriend always used to beat her up. She came with her friend, kind of blue eyes already, with bruises. At the end of the day, she stabbed him to death in front of the kids and planned to leave. Cause she just had enough. She stabbed him to death with a fork.” (Participant 1, Workshop 1)

Participants also referenced drug and alcohol use as a common SRH issue, and closely linked it to violence. As can be seen in Figure 3, Mishka, a direct connection is made between drinking alcohol and violence, as she is being beaten with a bottle of 8 PM, a local brand of whiskey. Similar connections were made between substance use and the spread of STIs/STDs, the health of pregnant women and their unborn children, and as a coping mechanism for stress or depression.

The body maps also contained mentions of gangsterism, which is very prevalent in Freedom Park, suggesting that the life of a gangster, or as the girlfriend of a gangster, might present a greater risk of violence and abuse. Participants stated that gang members often provide financial security, physical protection, support, and social standing, which were identified as a necessity for survival. Participants also linked the gang lifestyle, and drug and alcohol use, with gender-based violence. Leaving a partner who is a gang member was identified as challenging, due to loss of financial security and protection, and risks of further violence, particularly if parents had distanced themselves from their children, for example due to an adolescent pregnancy. Further, there is a cultural context of male partners as financial providers.

Support and knowledge

The body maps and participant narratives frequently mentioned a lack of support as a common SRH issue, ranging from housing and finances to sexual health information, and access to resources. Participants shared a desire for such support in their intimate partnerships. Limited support was linked with pregnancy, in particular partners who had left a pregnant partner with no emotional or financial support. Concerns over the availability of essentials, such as food and shelter were frequently connected with having sex for money, returning to abusive partners, or falling pregnant with the expectation that their partners would then provide for them. Participants stated that this strategy was often ineffective, and could in turn lead to loss of support from their parents.

As can be seen on Zoey and Ruwayda (Figure 3), knowledge of sexual activity or adolescent pregnancy often resulted in the loss of parental support. “For the girl sometimes the family don’t want her and they will kick her out.” (Participant 6, Workshop 5). Participants also expressed a desire to learn more about SRH from their parents, in particular from their mothers, and wished parents supported them by providing information on SRH topics.

Knowledge sharing from family and elders around sex and sexuality in the community emerged after sexual activity had begun. Participants identified that once young women are married, or visibly pregnant, even if they are adolescents, the acceptability of discussing SRH increased. Many participants who were already adolescent parents were more comfortable sharing SRH information and experiences.

Other sources of SRH support and knowledge mentioned were clinics and counseling. Participants identified accessing checkups, clinics, and hospitals, as important forms of support, especially after abuse, or during a pregnancy. One participant said of her body map “She must go to clinics, counseling. I think she do, she do have a support system. When she was raped, obviously she needed to go to the hospital, which means then, because she’s under age also, that’s where she got a support system.” (Participant 9, Workshop 6).

Mental health

Participants frequently mentioned mental health as a component of their SRH, with negative emotions mentioned more than four times more frequently than positive emotions. Depression was referenced frequently, often as the consequence of unintended adolescent pregnancy. One participant explained “She’s depressed because she is pregnant. She’s a teenager, she’s too young.” (Participant 2, Workshop 1). Participants also closely related depression to the absence of a partner, or violence and abuse from their partner, as can be seen on the body map of Kechia (Figure 2). Many body maps depict depression and sadness through tears and frowning faces, as can be seen on Mishka in Figure 3, and Zoe and Zanie (Figure 4).

Figure 4.

Body maps of Zoe and Zanie.

Depression was also closely linked with suicidal ideation. During analysis, CAC members and research assistants identified the phrase “overthinking” as synonymous with suicidal ideation, as seen on Tamia (Figure 2). Body map references to overthinking and suicidality were frequently attributed to instances of rape and abuse, especially among body maps representing younger women.

Feelings of stress and anxiety were also identified throughout the workshops. Stress was often linked to an unintended pregnancy, or resource availability post-partum. References to stress and anxiety were also occasionally accompanied by feelings of fear, sometimes regarding the pregnancy itself, or fear of the reaction from parents.

Many of the body maps and participant narratives discussed regret, frequently in relation to unintended pregnancy, and while pregnancy is regarded as generally a positive event, the value of family planning was also recognized.

“Okay, people are having these babies without thinking of their futures. For teenage pregnancy, they must come out of school, they may stop their lives. You can feel depressed, and you might not be able to care for it. [If her boyfriend leaves] she is going to blame the baby.” (Participant 11, Workshop 7)

Participants also drew depictions of positive emotions in regards to their SRH, although often framing them as ideals not as present realities. Participants spoke of having comfort and security, partners present during pregnancy, romance, and love as emotions that influenced their sexual and reproductive health positively. As one participant demonstrated on her body map, “She’s happy. She can feed her baby. She don’t have to worry because the father is working every day. And she is working. [She’s not worried about being pregnant.] She’s good.” (Participant 4, Workshop 3).

In most workshops, there was one body map that focused exclusively on positive outcomes. An example is Jessy in Figure 1. Jessy depicts positive emotions surrounding SRH. Her face is smiling and drawn in the color pink which was equated to happiness and love. She represents a young woman who feels protected, safe, and hopeful.

Social pressures

Participants also referred to the influence of external societal stressors as a key component of their SRH. This included mentions of peer pressure, judgment, and self-esteem. Peer pressure from friends was discussed as a strong impetus for sexual activity, due to the desire for shared experience with their cohort. Participants also identified pressure from male partners to engage in sexual behaviors, even if they did not feel ready. Sometimes, the pressure from peers was not because the peers themselves were actually engaging in the behavior themselves,

“Sometimes their friends, they are not actually sexually active. And they just tell you that, you can do it. Like they want to do it. But then, you think that they are sexually active. Now you also want to do it. And you are actually getting pregnant.” (Participant 10, Workshop 6)

Participants also frequently raised concerns around being judged by the community, family, and friends. Freedom Park is a very small and tightly knit community, and participants feared that if they asked for support, then they would be judged, and gossip would spread about their sexual behaviors. One participant explained “When you have intercourse now with someone, and then you tell your friend, that’s a secret, and then your friend can tell everyone…And that can lead to people judging.” (Participant 7, Workshop 5).

These social norms put pressure on participants to not reveal vulnerability in instances of abuse for fear of similar judgment. Many participants referenced that they felt that if they reported instances of abuse, they would not be supported by family or the community, in seeking safety or justice. Body maps, such as Tamia and Naeelah (Figure 2), Ruwayda (Figure 3) and Tina (Figure 5), depict abuse and tears, accompanied by a smile.

Figure 5.

Body map of Tina.

“A lot of people judge one another. That’s why you must put a smile on your face. Because now I’m going to tell you what did happen with me. And now you’re going to judge me, you’re going to tell, you’re going to tell him.” (Committee Member 2, CAC Meeting)

The theme of social pressures regarding SRH also included references to self-esteem. Participants emphasized that low or high self-esteem affected sexual behaviors, as can be seen on the body maps of Devil and Adeelah (Figure 1).

“Holding up that self-esteem, that’s actually what the kids are lacking at. You know, they’re not, they’re not intrigued of knowing themselves as to what they can do or what they could not do. They’re not asking themselves ‘is this right for me, is this wrong for me’. They’re not challenging themselves. They’re more challenging their friends and not realizing it’s hurting themselves.”(Committee Member 1, CAC Meeting)

Question 4: What sexual and reproductive health issue should be addressed?

Finally, participants were asked, out of all the common SRH issues they had identified, which was the priority need to be addressed in Freedom Park. All workshop participants came to a consensus on one or two SRH topics. Across all workshops, the two priority issues between all groups emerged as gender-based violence (GBV) and adolescent pregnancy.

Gender-based violence

Participants identified the frequency of violence against women as a key SRH issue that needed to be addressed in their community. For the purposes of this study, the term GBV is inclusive of the many terms participants used to describe gendered abuse and violence. Typically, participants referred to the issue as “abuse” or in two instances, “violence against women,” as can be seen in Figure 6. After selecting this as a priority issue, participants created a definition of abuse that included sexual violence, rape, physical, verbal, emotional, and financial abuse, amongst others, as can be seen in Figure 6.

Figure 6.

Participant definitions of gender based violence.

From participants’ perspectives, those responsible for perpetrating the abuse were largely men. While female family and friends could be perpetrators, the bulk of the abusers were identified as boyfriends, husbands, or other male relatives.

Adolescent pregnancy

While many of the body maps depicted pregnancy, participants identified the high rates of adolescent pregnancy as a specific priority for Freedom Park. The underlying issue was identified as the impact adolescent pregnancy can have on both the individual and their community, as can be seen in Figure 7.

Figure 7.

Participant determinations of underlying issues regarding adolescent pregnancy.

Participants emphasized that “every baby was a blessing,” however there is a time and a place to bring that child into their lives. The underlying issue was more about choice and options, than about pregnancy itself. They detailed that the underlying risks were to the health of adolescents, their financial stability, and their educational achievements, in particular when they lacked familial support and SRH knowledge.

Of note is the link between GBV and adolescent pregnancy. Participants regularly identified GBV, in particular rape, as a cause of adolescent pregnancy in their body maps, as can be seen at the base of Tamia’s body map (Figure 8). Participants also referenced this interaction in their narratives, saying “She’s –- she was raped also and is pregnant from the rape. She’s confused. she’s only 17. She’s confused. She doesn’t know anything.” (Participant 5, Workshop 4).

Figure 8.

Body map of Tamia, and interaction of priority issues.

Discussion and implications

This research aimed to understand AGYW’s lived experiences around SRH, by giving them an opportunity to express their feelings and experiences in a way that was culturally appropriate, adaptable, and private enough to share their stories. We sought to explore how AGYW defined their SRH, their SRH priorities, and how this fit in the greater socio-economic, cultural, and political system in which they reside.

The AGYW of Freedom Park identified GBV and adolescent pregnancy as the issues they most wanted to see addressed in their community. Participants positioned these needs in the overarching context of their everyday environment, using SRH outcomes as a vehicle to describe the underlying need for change. The socio-economic and cultural risk factors, and historical trauma experienced by the community were identified as a key component of their SRH needs - significantly contributing to or causing the identified issues. This provided a clear message; AGYW in Freedom Park identify the interplay of socio-economic, cultural, and historical elements as both components and root cause of their SRH needs.

Contextual components of SRH priorities

Socio-economic status

Socio-economic conditions, such as high rates of poverty, hunger, housing insecurity, and unemployment, affected women’s well-being and SRH. These stressors, which are common in the community, influenced choices to stay with abusive partners, or to have children. Low SES is a risk-factor for GBV, as are depression, experiences of childhood abuse, and youth (Muluneh et al., 2021).

Participants also identified a lack of personal safety within Freedom Park as contributing to AGYW’s sense of limited options regarding their SRH, and the prioritization of physical survival. Gangsterism and low SES are closely linked, as gangs provide financial opportunity and social connection (Hesselink & Bougard, 2020). In the small neighborhood of Freedom Park (which is only a few square blocks) there are at least eight conflicting gang territories, as identified by participants and the CAC. The Hard Livings, Fancy Boys, Americans, Mongerels, Hustlers, 28’s, Spoiled Brats, and the K-Ways recruit young men, often pre-teens, to participate in illegal drug trade, robbery, and other acts of violence. Instances of gun violence and death are extremely high within the community. During the course of this study alone, there were at least 3 shooting deaths of people connected to participants.

Participants’ survival in this challenging environment superseded any resulting negative SRH outcomes. Addressing these socio-economic conditions, and by extension gangsterism and violence in the community was expressed as a fundamental component of addressing the identified SRH priorities.

Cultural context

AGYW reported limited community support, low levels of social cohesion, and sparse SRH knowledge translation in Freedom Park as another component of the identified SRH outcomes. A lack of shared community values and interconnectedness results in a reduction in “mutual care,” or the sense that community members are alienated, and will not care and support one another. As the Freedom Park community formalized and built structures in the post-apartheid era, this created shifts in interpersonal dynamics that affected this loss of social cohesion. This decline in mutual care is also both influenced by and influences violence and gang activity in the neighborhood (Brown-Luthango, 2016). This lack of community support, in particular for AGYW experiencing GBV or pregnancy, is a significant contributor to women remaining in precarious situations, whether due to fear of judgment or fear of non-responsiveness. It is clear that to address SRH outcomes, cultural shifts around support of AGYW are necessary.

Limited communication around SRH was also identified as a key component of SRH by participants. Guidance on SRH from those with similar lived experience has a positive impact on SRH outcomes (Duby et al., 2021). However, a culture of silence is pervasive within the community. Many in Freedom Park do not publicly discuss SRH outcomes, including instances of abuse or adolescent pregnancy. This contributes to the culture of “putting on a brave face,” so that community support for experiences of abuse is perceived as nonexistent by AGYW. Participants identified these issues of communication and social support as a critical component of addressing their priority SRH issues.

Impact of history

The complexity of Coloured culture, heritage, and Indigeneity has a significant impact on the SRH needs of AGYW in Freedom Park. The community is “Coloured,” with many of the older generation identifying Indigenous Khoisan roots. The apartheid government used racial classification systems to not only define where people could live and work and what resources they could access, but also erase identity, ethnicity, and culture (Cloete, 2023). Further, the integration of informal communities into formal settlements in the post-apartheid era disrupted many of the social patterns and supports that had been created during that time period, and created further inequalities in social power structures (Brown-Luthango, 2016). This erasure of culture, tradition, and identity had a lasting impact on the well-being and cohesiveness of Freedom Park.

The end of the apartheid era is within living memory for much of the Freedom Park community, and its ramifications continue to impact the younger, “born free” generation. An extended history of social marginalization through pass laws, limited access to resources and services, such as health and sanitation, control of gender and sexuality, and authoritative government regulation are a significant cause of the socio-economic inequality, high unemployment rates, violence, and gangsterism within the community. These directly influence the lack of hospitals, clinics, and educational facilities, as well as the geographic distance of the neighborhood from the city center where most employment opportunities can be found. As a result of this, participants have limited access to available resources and are forced into the precarious situations identified throughout the research. Syndemic theory, or the theory that socio-cultural factors cluster and combine to exacerbate negative health outcomes (in this instance SRH outcomes), further emphasizes the significant impact that these intersecting socio-economic, cultural, and historical components have on the vulnerability and well-being of AGYW in Freedom Park (Choi et al., 2019; Duby et al., 2021). The lasting historical influences of systemic oppression must be addressed, alongside the cultural and socio-economic issues that stem from them, to address AGYW’s priority SRH needs.

Addressing the identified SRH needs must go beyond the symptom, and instead prioritize addressing the interconnected nature of SRH with context and environment. The burden of addressing these needs lies not with women accessing resources to address the SRH outcomes, but on the broader community and programmatic approaches to effectively address root causes.

Acceptance of body mapping

Decolonized research approaches prioritize the self-determination of participants, and redress historical and ongoing harms by examining, acknowledging, and addressing the social and historical context (Andermahr, 2016). The use of decolonizing methodologies in this research supported community empowerment and equality in the research process (Omodan, 2025). Not only did this create a greater sense of ownership of the findings (Gingell et al., 2024), but also led to the development of a novel data collection method.

The body mapping method was adapted by community members to align with AGYW’s specific concerns and needs and provide a range of opportunity for in-depth expression. The CAC identified clear criteria as critical to increase acceptance by the community and deliver the necessary data. The application of this adapted data collection method was met with approval from the CAC, as by meeting the criteria they had established it provided a culturally appropriate and effective method of discussing sexual health. This method provided participants with an opportunity to illustrate how these socio-cultural and historical processes play out in an acute manner in everyday life.

An unintended outcome of this research was that centering this population’s voices created a sense of ownership and agency that seemed to spread to their everyday lives, building confidence and engagement with other community members. Feedback on the efficacy and usability of this data collection method and participatory model was communicated both during the workshops, and informally to researchers and the CAC. Participants noted that the process provided them with greater freedom and more methods of communication than just spoken word. Despite the intensity of the subject matter, researchers observed that participants laughed, chatted, and told stories more freely while drawing body maps.

The use of body mapping as a tool for interpretation and expression, but also for art and play, helped create a space for AGYW to share personal experiences without fear of judgment, and confidence in being listened to. Body mapping activities have been used in SRH research as a valuable tool for self-expression. The process helps participants feel comfortable, and to speak openly about sensitive, personal, traumatic, and emotional topics, and provides (Naidoo et al., 2021).

Limitations

SRH research is prone to eliciting concerns about privacy and personal safety. The researchers built safeguards, such as group body mapping, and discussions of confidentiality within the workshops into the process. A potential limitation is that some participants may not have shared some personal experiences out of fear of gossip; however, the shared body maps were an effective strategy to mitigate this. Another limitation is that some women in the community may not have wanted to participate in the research at all, as they may not have been aware of the mitigation strategies in place. Nonetheless, almost twice the number of the identified sample size participated.

Other limitations of this study were logistical, such as finding alternate and appropriate locations when security concerns arose on short notice. This was addressed by adjusting start times and having Neighborhood Watch members accompany RAs to bring participants to different locations. Finally, while all participants spoke English and Afrikaans, there were linguistic limitations when participants switched to Afrikaans for certain conversations, as the researcher is not fluent. However, RAs were prepared to translate, and this was an infrequent occurrence.

Conclusion

The experiences shared by the participants emphasized the importance of systemic, sociological, economic, and historical causes of AGYW’s SRH experiences. By demonstrating the nuance and interconnectedness of these issues, this study provides a starting point for future research to further explore the root causes of negative SRH outcomes, and how to improve the well-being of AGYW in Freedom Park. The decolonized approach to this research reveals the importance of understanding and addressing the intersection of historical trauma and socio-economic impacts on SRH outcomes, and listening to the needs of AGYW in their own communities.

Even while discussing shared experiences of violence, women portrayed resilience through their survival, active participation, and particularly amongst the younger adolescents, their desire for change. We believe that body mapping, in particular this novel format, presented a unique strategy for sharing stories, experiences, and defining priorities.

The identification of contextual components of SRH, and the SRH priorities of GBV and adolescent pregnancy as topics requiring intervention and solution provide the next step for such action research projects. Researchers are continuing to work with participants in exploring root causes, and how AGYW believe they should or could be addressed, to improve their SRH. Further studies will provide details on this subsequent community engagement, as researchers work with the community to design an appropriate response to these needs.

Exploration of SRH with AGYW requires empowering approaches that provide ample opportunity for self-expression, while simultaneously addressing colonial histories and their intersecting influence on present realities. By taking this approach, our research identified potential areas for intervention that show promise to address intersecting realities. Interventions to address SRH should start with understanding the issue to be addressed from the perspective of people experiencing it.

This work was conducted as a component of the primary author’s doctoral research.

Funding Statement

This project is supported by a grant from The Ontario HIV Treatment Network (OHTN).

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.