Behavioural and environmental influences on adolescent decision making in personal relationships: a qualitative multi-stakeholder exploration in Panama.

Adolescents in Panama face multiple challenges to their sexual health, rights and well-being such as high rates of teenage pregnancy (∼30% of all pregnancies), increased HIV infections and sexual violence. In the absence of sufficient evidence-based data and an ongoing debate in Panamanian society about how to approach adolescents' health problems, the aim of this qualitative study was to explore the perceptions and attitudes of different societal actors, namely governmental employees, NGO employees, academics, members from religious groups, teachers and parents. We conducted in-depth interviews (N = 34) which focused on the behavioural and environmental factors considered to influence adolescents' decision making with regard to love, friendships and family relations. Furthermore, we explored how these stakeholders viewed the role of the education system, and the potential of including social-emotional learning (SEL) in the curriculum to provide skills and capacities, which could encourage adolescents to make better decisions and improve their well-being, in general but also in the context of sexual behaviours. Analysis revealed five central themes, i.e. perceptions towards gender roles and equality, adolescents' love (sexual) relationships, capacity needs regarding prevention of risk behaviours and the role of education, comprehensive sexuality education in schools and the potentiality of SEL in the education system. The findings of the study can enhance understanding on the views of stakeholders regarding the factors influencing adolescents' decision making, as well as regarding the possibilities of introducing SEL in the Panamanian educational curriculum. � The Author(s) 2019. Published by Oxford University Press.

Introduction

Globally, around 16 million girls between 15 and 19 years old and 2 million girls under the age of 15 years become pregnant every year [1]. Latin America and the Caribbean show the second highest teenage pregnancy rate in the world [2], only exceeded by Sub-Saharan Africa. Globally, the leading causes of death among adolescent girls between 15 and 19 years old are related to pregnancy and child bearing [3]. The consequences of becoming pregnant at an early age are mostly negative for girls. They are more likely to drop out school, and thereby increase their risk of living in poverty as adults. Moreover, stigma and rejection are common, not only for teenage mothers but also for their families and friends.

In Panama, adolescents face a variety of challenges to their sexual health and rights, most notably high rates of unwanted teenage pregnancies, sexual violence, and STI and HIV infections. Around 30% of all pregnant women in 2017 were adolescents between 10 and 19 years old [4]. A second health risk for young people in Latin America is sexual violence. Recent evidence shows that around 1.1 million adolescent girls and boys have experienced sexual violence [5]. Adolescents in Panama, and especially girls, experience such violence to a high degree. There is international agreement that the development of new knowledge, attitudes, skills and socio-economic structural networks of support should be encouraged among adolescents and young adults, in order for them to achieve healthier and safer sexual behaviours [6, 7].

However, the issues of teenage pregnancy and sexual violence, as well as general sexual health, have evoked continuous political and social struggles among different stakeholders in Panama, such as the government, conservative religious groups, parents, teachers, academics and NGOs. Moreover, the majority of these stakeholders have influenced multiple rejections by the National Assembly of legal instruments towards adolescents’ empowerment that can enhance their health and well-being (e.g. a bill to allow comprehensive sexuality education [CSE] in schools, covering physical, cognitive, social and emotional aspects of sexuality [8]). Therefore, in the absence of sufficient evidence-based data on the views of the aforementioned stakeholders, the current needs assessment study aims to explore beliefs and attitudes on the behavioural and environmental factors they considered to influence decision-making processes of adolescents in their personal and interpersonal relationships, specifically with regards to love, friendship and family relations. Furthermore, we explore stakeholders’ views on d the possibility and potential of introducing social–emotional learning (SEL) in the education system to empower adolescents through social–emotional skills development. We argue that such interpersonal skills development (e.g. decision-making, communication, negotiation, self-esteem and self-efficacy), embedded in educational programmes might allow youth to develop healthier (sexual) relationships, and as such could constitute a viable alternative in the absence of CSE, especially in conservative settings such as Panama. This needs assessment study is part of a larger project in Panama that explores alternative educational tools (e.g. SEL) to empower young people within their lives, and specifically within their interpersonal relationships.

Education remains an important avenue where children and adolescents can acquire and practice new knowledge, skills and attitudes. In Panama, there is a need for innovative educational alternatives which could offer adolescents not only factual and scientific information about sexual relationships and health, but which also allow them to develop and enhance the skills they need to make better and healthier decisions at the personal and interpersonal levels [9, 10]. SEL is a process intended for children and young people to develop and effectively apply social–emotional competences required to succeed in life, through its five core competencies: self-awareness, social awareness, responsible decision making, self-management and relationship management [11-13]. Recent evidence highlights multiple positive outcomes of SEL programmes including the reduction of interpersonal violence, bullying, drugs use prevention and disruptive behaviour [14-18]. Several educational approaches in Panama have been attempted in these areas, but with mixed results. For example, programmes such as PROBISIDA Juventud (PROBISIDA) and Youth with Options (APLAFA) have focused on HIV prevention and reproductive health [19]. However, the implementation of these programmes encountered severe limitations, such as teachers’ hesitation or refusal to address sexuality issues, lack of focus on youth empowerment, lack of inclusion of scientific knowledge and lack of quality control [19].

Although several studies in Latin America have investigated different factors associated to adolescent’s sexual risk behaviour in terms of culture, social–emotional aspects, family and social norms [6, 20], there is still a need to gain a comprehensive understanding about the individual, social and environmental determinants influencing adolescents’ decision making in personal relationships in Panama. In addition, exploring the needs and capacities of all involved stakeholders is paramount to intervention development and implementation [21], since an individual is part of a larger social environment. In particular, it is necessary to understand the perceptions and attitudes of teachers, parents, government, religious groups, ombudsman, NGOs and academics with regard to factors they consider are influencing adolescents decision making in personal and interpersonal relationships. In Panama, as well as other (conservative) countries many important decisions regarding adolescents’ health and rights (e.g. the approval of a law to include CSE in schools, the context and content of adolescents’ health services) are made by these stakeholders without consultation of adolescents’ opinions and needs. Moreover, evidence-based data regarding their perceptions and opinions about these issues is lacking, and we feel that gaining a full understanding of the cultural, social and religious perceptions of different adult stakeholders could ultimately contribute towards designing and implementing more structured, innovative and informed strategies and alternatives to CSE in conservative contexts. Especially considering the rising rates of teenage pregnancies, HIV/STIs’ infections and sexual violence in Panama, all knowledge—including the facilitating and inhibiting factors identified by stakeholders—which can inform such (educational) activities is thus valuable. Given the controversial nature of topics such as gender, gender equality, and adolescents’ love relationships in a conservative context like Panama, the adolescents’ perceptions and beliefs about these topics could only be explored in the context of their experiences with the educational programme we developed (see, e.g. A. Arauz-Ledezma, K. Massar and G. Kok, submitted for publication).

The current research utilized semi-structured in-depth interviews with a range of stakeholders in Boquete, Panama. Topics and questions were partly based on the Theory of Planned Behavior [22] and the Social Cognitive Theory [23]. These theories provide insight into the determinants of behaviour, such as attitudes, social norms and social learning, or one’s perceived ability to perform certain behaviours. Knowledge of such determinants in turn can inform behaviour change programmes.

Materials and methods

Study setting

The study was conducted in Boquete, Province of Chiriqui, Panama. Boquete is located 481 km west of Panama City, the capital of the Republic of Panama. Tourism and agriculture are the main economic activities of the region. Boquete has a level of poverty of 30.8%, and 10.4% of its population lives in extreme poverty [24]. Teenage pregnancy (pregnant girls between 10 and 19 years old) in Boquete is high, consisting of ∼30% of total pregnancies [4]. The demographics of Boquete include indigenous groups, mestizo and foreigners (mainly Americans and Europeans).

Participants and procedure

Semi-structured in-depth interviews were conducted with a range of stakeholders who were recruited using purposive sampling. Participants for this study were recruited in three ways, as this study involves multiple stakeholders. First, participants of different institutions such as government ministries, religious organizations, NGOs, the ombudsman office and academics were contacted personally. They were informed about the study’s purpose and the voluntary and confidential nature of participation. Second, following recommendations of the Ombudsman Office, a school known for its interest to participate in new programmes for adolescents’ personal development was approached, and the director was provided with a brief description of the study’s purpose and content. After consenting to participate, the school director subsequently approached the teacher responsible for different personal development programmes in the school, and authorized her to recruit other teachers who would be interested to participate in the research project. These teachers were subsequently approached by the first author to schedule an appointment for the interview. Third, parents were recruited by inviting them to attend an opening session of the research project that would be implemented at the school. All attendees received a brief overview of the study’s purpose and content. Nine individuals accepted the invitation to participate in the interviews.

The final sample included 34 participants: Government Ministries employees (n = 3; 2 male, 1 female), teachers (n = 14; 1 male, 13 female), members of religious groups (n = 2; male); academics (n = 2; female), health promotion specialists (n = 2; 1 male, 1 female), an NGO employee (n = 1; female), Ombudsman Office employee (n = 1; female) and parents (n = 9; 3 male, 6 female). The Ministry of Education of Panama, through the regional office in David, Chiriqu�, as well as the Ethical Research Committee of Psychology and Neuroscience of Maastricht University provided ethical approval for the content and procedures used in this study, and all participants provided verbal and written informed consent before the interview started.

After consenting to participate, respondents were scheduled for an interview. Since we were investigating sensitive topics, we put extra effort into thoroughly informing our participants about the nature, aim, and content of the interviews before commencing with the questions. We assured participants’ anonymity by not documenting any identifiable details of participants, and by not making any video or audio recordings. The interviews were conducted in Spanish. The interviews were recorded in hand-written notes, and were translated into English for data analysis purposes. The participants selected the locations of the interviews, except for the teachers who were interviewed at the school location. The interviews were conducted by the first author, who has the Panamanian nationality and who was conscious of the social and economic vulnerabilities of teachers and government employees voicing their opinions regarding the topics at hand. Participants were informed that they could stop the interview if they wanted, without any explanation at any given moment; moreover, at any sign of distress the interviewer terminated the interview.

Research instrument and data analysis

A semi-structured interview guide was used. The questions were based on theoretical concepts, and a literature review on the topics of equality between women and men, the topics covered in CSE and SEL. Furthermore, the interview protocol was based on the Theory of Planned Behavior [22] and the Social Cognitive Theory [23]. Specifically, knowledge, attitudes, beliefs and social norms were explored with regard to the following topics: gender, gender roles, love relationships of adolescents, teenage pregnancy, equality of opportunities and rights for women and men, the role of the educational system, providing adolescents with information and skills about these issues, CSE and SEL. Participants were asked questions such as ‘How do you define gender?’, ‘What is gender equality?’ and ‘How do you perceive the role of education in the promotion of gender equality?’. The first five questions of the protocol were similar for all stakeholders, however, depending on their roles (e.g. government, parents, teachers and religious groups), the questions differed in content and coverage. For an overview of the interview guide, with specific questions for each stakeholder, see Supplementary data.

All 34 transcripts of the in-depth interviews were translated from Spanish into English and saved in MS Word. The researchers read them repeatedly and thoroughly to validate transcripts. They were analysed line by line and coded thematically. Since the interviews were semi-structured, the coding scheme was similar to the topics in the interview protocol. Data were analysed using directed content analysis approach [25]. This approach allowed for a categorization based on data derived from theory and relevant previous findings. An iterative coding process was used [26], ensuring that preliminary and inductively arrived coding categories, were a reliable and accurate representation of the data content.

Results

After a detailed examination, the data revealed themes could be grouped under two main areas which is presented in the next sections: behavioural factors and environmental factors. Subthemes within the category of behavioural factors were: perceptions towards gender roles and equality, adolescents love (sexual relations), capacity needs regarding prevention of risk behaviours and the role of education; and within the category environmental determinants, the subthemes were: CSE, and the potential of SEL in the education system.

Main area I: Behavioural factors

Theme 1: Perceptions towards gender roles and equality

There was a general belief among most interviewees that the roles of women and men, boys and girls with regard to the responsibilities and tasks assigned to them [….], including they way they act, value themselves and behave, whether in personal, interpersonal relationships or other areas of life, are a logical consequence of the sex they are born with. They also stated that these roles are generally accepted in Panamanian society, as well as the fact that women do not enjoy the same opportunities as men. A clear distinction between biological sex on the one hand, and gender roles or culturally developed and assigned roles and responsibilities of women and men on the other was not present among the respondents:

I think it [the word gender] is used to divide the sexes, women or men. I think because I am born as a man, I have a different way to be and do things than a woman, let’s say our rights are different (Father, 35–45)

Some respondents expressed that prevalent perceptions on sex, gender, gender inequalities and each sex’ roles and responsibilities in society, were in most cases sustained by the patriarchal and machismo culture in Panama. They mentioned that from a very young age, boys are exposed to ideas about their tasks as protectors, providers, and to be head of the household. Some of the respondents also mentioned that these inequalities are reinforced in Panama in a structural manner, e.g. in church and in schools, and they perceived patriarchal hierarchies in all levels of society.

The structural patriarchal system transcends the family sphere, influencing other structures such as political, economic, cultural, social, religious, among others. (Ombudsman Office employee, woman, 30–35)

On the other hand, respondents also referred to adjustments in the perceptions about the roles and responsibility of women and men in society which seem to be emerging, in particular due to the increase in single mothers. In Panama 31% of all Panamanian children are living only with their mothers and most of the interviewees acknowledged that the ‘traditional’ hierarchical structure of a man at the head of the family is subject to change, especially when women become single parents or join extended families. However, some respondents also mentioned that often another male takes on the role of ‘head of the household’ in such extended families:

When my first husband left me, I felt totally alone, but I am grateful my father could provide an example to my children and in many ways be the head of the family. Eventually I married again and things changed, my new husband could protect us. (Mother, 35–45)

Most respondents indicated the importance for women to obtain an education to be able to live an independent life and make their own choices. They highlighted that avoiding early pregnancies could provide better opportunities to young women to achieve a higher level of education, and to enjoy a general better quality of life. Some respondents (e.g. a father) also pointed out that it should not be solely the school’s responsibility to teach about equal rights and opportunities, but that family at home plays an important role as well:

I believe that we as parents need to be also present in the life of our kids and work together with the school. The school can do one part only. Much of the practice needs to be at home as well. (Father, 30–40)

There were mixed opinions among respondents whether women and men enjoy the same rights and opportunities in Panama. In terms of education, about two third of respondents considered the access of girls to school highly important, since this might increase their opportunities of finding paid jobs, and thereby breaking the cycle of poverty. However, other respondents mentioned that education alone does not ensure direct changes in unequal norms and values, and the behaviours that follow from these:

I believe there is equality among sexes as they both have the same rights of overcoming obstacles through education for example. Opportunities are there for all, but some women do not profit from it. I see so many girls looking for a husband, who becomes responsible economically of them than to work hard to achieve economic independence. (Teacher, woman, 30–40)

Some respondents mentioned that especially conservative religious beliefs appear to have a strong influence on the way equality of rights and opportunities for women and men are approached, and laws are implemented in society. They expressed that the perpetuation of such conservative beliefs could be one factor undermining the equality of these rights and opportunities for the sexes. Within churches, ‘family values’ appears to be the dominant narrative, and these values are supported not only by religious groups members but also by some teachers:

In our culture, religion is our base to set values and norms. Family values are completely lost in our society. Young people are barely exposed to positive role models who use their religious beliefs to moderate their behaviour and to be a good example for others (Teacher, woman, 40–50)

According to most participants poverty (and lack of knowledge or education) was an additional important factor influencing the rights and opportunities of men and women. Some respondents also mentioned that teenage pregnancies may be the result from these factors, since some girls seek financial support from older men as a means to escape poverty.

Theme 2: Perceptions on adolescents’ love (sexual) relationships

Love (and sexual) relationships among young people seemed to be a concern for respondents, in particular regarding the equality of rights, responsibilities and opportunities for boys and girls in such relationships. Some respondents expressed concern that in cultures like Panama, which they considered inherently patriarchal, girls are expected to remain submissive and to accept that someone else makes decisions for them. However, more than half of the respondents stressed that reality is contrasted with these perceptions, since a high percentage of girls are taking on roles as adolescent mothers, which in most cases diminished their (career) opportunities.

In our society there is much contrast. Girls and women learn since young age about their inferiority and that they have to be submissive. But then they are sent to school and are expected to make the best decisions. There are too many messages and less skills. (Academic, woman 55–65)

Teachers and academics also remarked that young girls receive the message sometimes at school and from modern mass media that they should make their own decisions, also in their love relationships. Nevertheless, this message is in sharp contrast to the gender roles they have been raised to follow, and may cause confusion, since they might not have the knowledge and capacities to navigate such independence:

Young people have the rights to set out goals for life and learn about their responsibilities and opportunities. However, mass media and the internet influence in great measure the way young people see how love relationships should work, and the importance of becoming mature to make better decision concerning their sexuality. (Teacher, woman, 35–45)

Importantly, half of respondents noted that boys also receive contradictory messages about what is expected from them: on the one hand they are raised to feel superior to women, and in charge of the household; on the other hand however, these boys are also part of a culture where absence from the family scene, having multiple girlfriends, and not supporting their girlfriends when they get pregnant is not condemned:

In our society for ages men and boys are aware that they can play in a few love relationships at the same time. It is socially accepted. The consequences of these acts are in most cases in detriment of women and girls rights and opportunities. (NGO employee, woman, 25–35)

Interestingly, according to the majority of respondents, these boys are also not stimulated—either by their family or by the adolescent mother—to assume their role as, e.g. an adolescent father, and to provide for their child:

When my son impregnated his girlfriend, he was 16 years old and we encouraged him to keep in school, as a way to be better prepared for life. I was also very young when I got him. We did not support his girlfriend economically. (Father, 45–55)

Theme 3: Perceptions on capacity needs regarding prevention of risk behaviours and the role of education

Most participants considered formal education to play a crucial role in prevention efforts regarding adolescent risk behaviours, such as early unprotected sexual activities leading to teenage pregnancy and HIV infections; as well as the use of violence to solve problems. Nevertheless, participants showed divided opinions regarding to what extent and how education could enhance the capacities of young people to make better decisions on personal relationship issues, and to avoid these risk behaviours that could endanger their health and limit their opportunities in life. A majority of respondents mentioned that there should be more opportunities in the regular school curriculum to include lessons on the development of (inter) personal skills and relationship negotiation:

In the past, when I was at school we had civic education that included the values a citizen should develop as to be considered a decent person and do good to society. Nowadays children are more busy to follow curriculum: mathematics, science, geography. This is not bad, but they could receive extra information about how to treat each other, how can they solve problems without violence for example. (Mother, 35–45)

One important barrier mentioned by the teachers was the lack of time at school to include lessons on personal skills development in the regular curriculum. Furthermore, they were concerned they themselves lacked the skills and confidence to provide such lessons to adolescents:

Honestly I am not sure if we are completely prepared as teachers to give lessons on such specific topics as life skills. We required a lot of capacity building first, to then be able to fully transfer this kind of knowledge. (Teacher, woman, 55–65)

Moreover, although there are national laws regarding the necessity of covering the topic of the personal development of new generations as ‘integral beings’ in the school curriculum, there is a lack of financial resources to implement these policies.

Financial resources are lacking to cover all young population’s needs in terms of prevention against teenage pregnancies, HIV infections or other diseases. Even more, to equipping them with life skills. Also isolated efforts from different actors in society, are not being effective to reduce adolescents risk behaviors. (Health Regional Office employee, man, 35–45)

Lastly, almost half of the respondents, and members of religious groups in particular, also identified a clear role for religion in preventing risky behaviours. They considered that schools need to be more in line with the church’s guidance on how young people learn about handling feelings, emotions, and becoming a person prepared for an adult life.

Main area II: Environmental and institutional factors

Theme 4: CSE in schools

At the time of the interviews, there was a national debate on passing a bill which would allow schools to deliver CSE in Panama. As a result and mirroring this debate, there were proponents and opponents among the interviewees, and their opinions were divided in terms of their perceptions on the necessity of CSE in the national educational curriculum, the content, the capacities of teachers on the subject matter, and the level of institutional support. Some respondents—particularly the members of religious groups—showed strong opposition to the introduction of sexuality education as part of the school curriculum, as they felt it might encourage early sexual behaviour of adolescents or homosexuality. These proponents felt abstinence and family values were key to preventing disease and pregnancies, and that these issues should be the ones communicated in church, at school, and at home.

Conversely, other respondents, including some parents, stated they were very much in favour of introducing CSE in schools in Panama. They argued that the current rates of teenage pregnancies and STD’s infections, as well as the use of violence among young people highlight the need to find strategies to approach and possibly solve these issues. Some however uttered concerns about the manner in which such a programme should be implemented:

If we as parents are ensured that our children, through an educational program will develop capacities to avoid bad situations, including about their own sexual behaviour or against violence, I am sure that a lot of parents, even if they are opposed to sexuality education, will be open to dialogue and see possibilities. The problem is that this issue is always approached in an imposing way, so nobody will accept it like this. (Father, 35–45)

In addition to concerns about the content of a possible CSE programme, parents (but also religious groups members and academics) raised concerns about the capacities of teachers to carry out such programmes at schools. A narrative of taboos, lack of knowledge, and a lack of personal capacities emerged, which influenced evaluations about the potential performance of teachers to provide CSE:

Most teachers are not prepared to impart CSE. It is important to include them and parents in capacity development strategies, and to unite efforts increasing their social–emotional capacities as well. (Academic, woman, 55–65)

On the other hand, academics and an NGO representative expressed that given the expected strong resistance to the acceptance of CSE in the school curriculum, assessing and developing the capacities of teachers on the subject matter was crucial, and especially given the fact that some parents indicated they did not feel capable to address issues like sexuality with their children at home:

I do not feel comfortable to talk about sexuality with my children. For me is better if they receive it at school. We grew up with so much taboos and lack of information, and I am sure must be other ways to talk about this properly with children. (Father, 30–40)

Respondents agreed that school-based interventions which combine social–emotional education and promotion of equal relations and opportunities for women and men (gender equality) were most suitable to tackle adolescents’ capacities development with the aim to enhance equal relationships and respect. Some mentioned that such interventions could even be used as nuanced ways to enhance safe and healthy sexual and reproductive behaviours of adolescents in the absence of a CSE curriculum:

Our office has recommended the government to put more efforts on educational curriculum to elaborate programs on awareness raising, which can modify stereotyped attitudes and cultural norms about the responsibilities and roles of women and men in the family, at work, politics and society; including the adoption of measures to target boys and men (Ombudsman Office employee, woman, 35–45)

Theme 5: The potential of SEL in the education system

Participants were asked about which specific personal capacities, behaviours, or skills they considered young people should enhance to navigate their lives, whether at school or at home. Most of the respondents mentioned they felt that adolescents needed to learn persistence to establish and achieve certain goals, as well as the skills to learn how to make better decisions which would benefit their lives:

With all the debates going on how education could play a transformative role in the life of young people, capacities as better decision making, teamwork with respect, persistence, better communication and solving problems should be basic to ensure citizens are more aware of safe ways to achieve goals and contribute to society. (Regional Education Office employee, male, 45–55)

I try always to encourage my children to think carefully anytime they decide to do something. Any step will have consequences. Schools are also a great place where young people could practice how to treat each other with respect. (Mother, 35–45)

Interestingly, more than the half of parents recognized that developing social emotional capacities of adolescents is a task not only of schools but that requires a continue repetitive approach at home, highlight the importance of parents involvement in sort educational path towards a more holistic development of young people.

I am interested that my children learn about how to make better decisions, to be respectful and to persist to achieve their dreams. However, I believe that we as parents need to be also present in the life of our kids and work together with the school. The school can do one part only. Much of the practice need to be at home as well. (Father, 25–35)

On the question if stakeholders will support the inclusion of social–emotional learning programmes at school level, with the aim to provide adolescents with social–emotional capacities, which not only could help adolescents to make better decisions in their personal and interpersonal relationships, but that also promotes healthier behaviours towards the increase of self-value, respect for themselves and others and promote the eradication of the use of violence of all kinds, the responses were unanimously positive, highlighting the potential benefits for young people on the long term.

Discussion

Although sexual health education is considered a basic human right, which is seen as crucial to adolescent development and the achievement of gender equality, as well as the prevention of STIs and teenage pregnancies [1], in many countries it is a contested and sensitive issue, creating debate and resistance at multiple levels in societies. In Panama, governmental and societal debate concerning the sexual and reproductive health of adolescents is still ongoing, with strong opponents and proponents of the need for CSE. In the current study, different society stakeholders were therefore interviewed to investigate their perceptions regarding the psychosocial and contextual determinants influencing adolescents’ decision making in personal and sexual relationships. Moreover, since the stakeholders—in particular, the parents and teachers—are crucial to successful intervention development and implementation, their needs and capacities were also explored.

One of the main findings of this study is a general assumption among the respondents that one’s biological sex determines one’s gender roles, rights and opportunities in life. For example, several respondents gave evidence of the perception that girls, due to the sex they are born with, are the ones who are supposed to take care of the family and be submissive to men. This is in line with findings in other Latin American countries, such as Ecuador, Costa Rica, Colombia, Brazil and Peru, where religious beliefs and social norms regarding the stereotypical roles of women and men are still prevalent, and guide individuals’ behaviours [27]. The respondents indicated that these societal norms might have been caused—and sustained—due to the fact that Panama has a patriarchal and machismo culture. However, respondents also indicated they felt that these societal perceptions about men, women, and their roles should change towards equality. This finding is in line with a trend during the past years showing that multiple attempts to include CSE as part of the school curriculum have failed, in part due to existing conservative beliefs regarding sexual and reproductive health education at schools and gender equality agenda [27]. Moreover, interestingly, and in line developments in other Central American countries, in Panama women more often take on the role of (financial) head of their households, especially in the absence of men in the family, or to join extended families where the male figure is represented by another man. Thus, even though women and girls are expected to conform to traditional gender roles, they are often confronted with a different reality, which reflect global influences (e.g. mass media, telenovelas, internet, advertising, social media) of modern romance discourses that are re-defining gender roles perceptions, models, relations and aspirations of young people [28, 29]. In contrast to the messages women and girls receive, the norms surrounding boys’ behaviour are very different. Half of the respondents mentioned that boys are raised with the beliefs that being absent from the family scene and not being responsible in case of a pregnancy are not condemned; and that there often are no consequences when a boy impregnates his girlfriend and then leaves her. This finding highlights current masculinity paradigm in society and its prevalence through boy’s behaviour, as well as the need to a broader focus on gender roles transformations. Recent evidence shows that a gender role perspective could add to prevention programme effectiveness aimed at Latino adolescents [30].

Indeed, our respondents recognize that the capacities of women to act and make their own choices in this new reality seem to be linked to getting educated and generate income, since the majority of respondents indicated there is a need to encourage girls to finish their education, as a way to acquire economic independence. This finding is in line with different studies in Latin America that show associations between low levels of educational achievement on the one hand, and unplanned teenage pregnancies, inter-generational poverty and multiple (health) risk behaviours on the other [31-33]. However, some respondents also recognized that although education has a potential to transform inequalities [34] more comprehensive and structural changes in the country would be needed to really change social norms about gender inequality, and with that, adolescents’ health issues. These respondents also pointed out that religious beliefs and religious leaders form socio-cultural barriers to considerations of different constructions of equal gender rights and opportunities, as well as to the inclusion of CSE in the school curriculum. Indeed, most of our respondents considered ‘family and moral values’ as fundamental in the relationships between women and men in Panamanian society, and stated that these values are communicated by religious beliefs and in the school setting.

The respondents were aware of the current reality of many girls taken on mothers’ roles, and making life changing decisions such as abandoning school. Indeed, the link between adolescents’ sexual and reproductive health, rights and opportunities, and how they manage these within their love relationships seemed to be a main worry of respondents of this study. Importantly, more than half of the respondents stated that they felt adolescence must be a period to get educated and be under parental supervision, also with respect to sexual activities. Previous research in other countries in Latin America has shown that family, friends and the social environment during adolescence are both positively and negatively associated with adolescents’ pregnancies [20, 35–38]. Almost all respondents further indicated that poverty affects adolescents to a large extent, and especially girls. It was mentioned that young girls often start love relationships with older men as a way to gain financial stability and protection in their lives. The influence of poverty on early pregnancy, school dropouts, and risk behaviour of adolescents in Latin America has been established in previous studies as well [39, 40]. Combined with adolescent girls’ reduced chances of obtaining a higher level of education in Panama due to early pregnancies, this finding thus stresses the need for youth development programmes for girls and boys, which focus on enhancing their skills and capacities to obtaining educational and economic opportunities, as well as the inclusion of comprehensive(sexual) health education [41]. The role of education to promote the acquisition of interpersonal skills (social and emotional) as a way to prevent risky sexual behaviour and improve decision making regarding relationships and sexuality, was considered essential by respondents. More than the half of participants were in favour of including such ‘empowerment’ skills training in the regular educational curriculum as a way to prevent risk behaviours and negotiate their personal relationships. This result is in line with studies highlighting that increasing certain social–emotional skills and capacities can improve the way they value themselves (self-esteem), increase their persistence and confidence to achieve goals, and create awareness of the need for more self-respect and respect to others [33, 39, 42–46]. When asked which skills they deemed most suitable for school-based programmes, respondents mentioned capacities to make better decision, teamwork, better communication, respect for themselves and others, and solving problems without violence were the skills mentioned most often by the respondents as useful and necessary.

However, CSE was not seen as a part of such integral education. Most respondents, especially religious groups members, parents and some teachers, expressed an explicit concern that sexuality education would promote early sexual activity among adolescents; they would prefer the school-based health education to emphasize abstinence.

Interestingly, although the respondents saw a clear role for the school as educators in the area of enhancing interpersonal skills, they also considered the school’s influence to be supplementary. They indicated that the task of teaching family values and moral norms, including sexuality, should be the responsibility of parents, with the guidance of the church. One reason they felt this way was their perception of teachers’ lack of time and lack of capacities to include interpersonal skills development as a subject in the regular school curriculum. This finding resonates with past research highlighting the implications of adding additional curricular activities to the already heavy work load of teachers [47-49]. Nevertheless, it is essential that educational programmes oriented to adolescents health promotion including personal and interpersonal capacity development, focus on a holistic approach where teachers and parents play a central role increasing first their own personal capacities and working in unison, as to ensure rise of future interventions’ effectiveness.

The findings of this study highlight some similarities and differences among stakeholders. For example, the perceptions on current gender norms, roles and responsibilities were not only similar but generally accepted by almost all stakeholders. Nevertheless, it seemed that for academics, NGO, Ombudsman, some teachers and parents, the constant changes on gender discourses as a result of the influences of modern media and re-shaped family structures may change gender relations in the long term and influence the perpetuity of such current gender discourses. Furthermore, while the majority of stakeholders expressed negativity towards CSE, notably about the way it is presented in the national debate and consequences in terms of family values erosion and promotion of adolescents early sexual activity, interestingly, all stakeholders, especially teachers, parents, government and religious groups members expressed their support towards innovative educational alternatives (e.g. SEL/personal-interpersonal development skills), which could reinforce modern forms of gender relations and in such way promote adolescent healthy decision and relations which in turn can improve their health and well-being. Differences arouse in terms of how such learning strategies will be implemented, emphasizing lack of time in current educational curriculum and personal/institutional capacities of stakeholders (teachers, government structures, parents) as potential limitations. Further research is necessary to enhance understanding on these issues.

Limitations

Some limitations should be acknowledged about the current research. First, since this study reports the results of qualitative interviews of multiple stakeholders in Panamanian society, the findings cannot be generalized to other Latin American countries. Likewise, because the study covers a small sample of interviews, the results may not be generalized to all stakeholders in the country. Second, given the contested notion of the concepts discussed during this study and the ongoing debate in Panama regarding the inclusion of CSE in the school curriculum, the responses of participants may have been affected by a desire to be socially acceptable—as a way to protect their work relationships and income, and this may be especially relevant for the respondents working at the governmental level. However, we tried to prevent such influences by guaranteeing full confidentiality and anonymity during the interviews. Third, adolescents perspectives were not addressed in this article, as the paper deepens understanding on the opinions of other important stakeholders in the Panamanian society. Furthermore, the possible influence of media on adolescents gender perspectives, behaviours and decision-making processes constitute issues requiring further research.

This study has pointed out the complexities of discussing and increasing adolescents’ health needs, including sexuality, in current Panamanian society. The historical and socio-cultural influences on perceptions about men and women, gender roles, opportunities, and responsibilities seem to a great extent to guide stakeholders opinions. Nevertheless, the study highlights that there are avenues to explore alternative ways of increasing adolescents’ knowledge, attitudes, and skills in the context of decision making in personal and sexual relationships.

Conclusion

The findings of this study suggest that interpersonal skills development (e.g. decision making, communication, negotiation, self-esteem, self-efficacy) embedded in educational programmes, seem to be a viable alternative in the absence of CSE, especially in conservative settings such as Panama. This approach seems to comply with major obstacles mentioned by stakeholders, such as local cultural norms and religious beliefs regarding interpersonal relations between women and men and their influences on behaviour, rights and opportunities. By supplementing the regular educational curriculum with such ‘empowerment’ programmes, healthier (sexual) relationships between boys and girls could be achieved, and rates of teenage pregnancies could ultimately be reduced.

Conflict of interest statement

None declared.

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