Youth as Navigators: A Study Protocol to Incorporate Narrative and Visual Methods Into Research on Adolescent Sexual and Gender Development Among Syrian and Jordanian Youth

Abstract

Background:

The determinants of adolescent sexual and reproductive health originate in childhood and may stem from prepubescent experiences. There has been limited research on adolescent sexual and reproductive health from a life-course perspective globally, especially in the Middle East. Youth in Jordan are exposed to rigid social expectations and gender roles, which may influence sexual and reproductive health outcomes. The ongoing conflict in Syria and refugee crisis is thought to have altered community norms thereby influencing experiences that lead toward sexual development.

Aim:

This study seeks to understand how social, cultural, environmental, and biological factors influence adolescent sexual development and reproductive health among Jordanian and Syrian youth. This study will explore how social and gender norms have influenced adolescent sexual development across the life cycle related to key transitions between childhood and adulthood.

Study Design and Methods:

Sixty-four Jordanian and Syrian males and females aged between 15 and 19 years will be recruited by convenience from community centers in four cities across Jordan. This study will integrate both visual and narrative qualitative methods. By constructing a visual time line during semistructured in-depth interviews, we seek to give youth control in the retelling of their own life stories.

Ethics and Discussion:

This study has received ethical approval from both international and local institutional review boards. The findings of this study will provide important data on emergent priorities in the field of adolescent sexual and reproductive health, such as those related to gender, sexual maturation, and social norms, that will be of national, regional, and global significance.

Keywords

ethnography methods in qualitative inquiry narrative narrative research grounded theory visual methods in-depth interviews adolescent sexual and reproductive health Jordan Syria Middle East refugees life-course

Background and Study Justification

Adolescent Sexual and Reproductive Health From a Life-Course Perspective

Adolescence is a time of profound change. While many of the physical, psychological, and behavioral changes that mark the transition to adulthood first become apparent during adolescence, their determinants often originate during childhood. Preadolescent life experiences may contribute to an adolescent’s emerging sexuality (Halpern, 2010). Gender plays an intrinsic role in sexual development, with the development of one’s gender identity occurring as a process that begins early in childhood and peaks during adolescence (Tolman, Striepe, & Harmon, 2003). Normative gender expectations have a direct influence on how individuals engage in sexual behavior. For example, aggressive male behavior may be normalized by parents or teachers during childhood, and women may be taught to be obedient, submissive, and tolerant of inappropriate sexual conduct in the years leading up to puberty (Leach, 2003). Other life experiences that are not necessarily sexual in nature may also influence an individual’s future sexual and reproductive health trajectories, such as the range of opportunities that are available to an individual based on their socioeconomic status, experiences of family hardship, or exposure to war and political instability. Approaching adolescent sexual and reproductive health from a life-course perspective examines how social, cultural, environmental, and biological factors interact throughout one’s life to influence health-related behavior and outcomes (Kuh & Hardy, 2002).

Exposure to rigid social expectations and gender norms during childhood is likely to shape an individual’s sexual identity and reproductive behavior from an early age. For example, strict cultural values, social stigmatization, and shame limit the degree to which Jordanian men participate in reproductive health-related decisions (Jordan Communication Advocacy and Policy Activity, 2016a). Gender-based violence is largely acceptable across Jordanian society (Haddad, Shotar, Younger, Alzyoud, & Bouhaidar, 2011), with patterns of abusive behavior often beginning during childhood. Female victims of gender-based violence in Jordan have described how violence is often first experienced and reproduced within families by way of family members committing discriminatory practices against women in the household families forcing their daughters into early marriage and fathers teaching their sons to use violence against women (Safadi, Swigart, Hamdan-Mansour, Banimustafa, & Constantino, 2013).

The 10 years of conflict in Syria has also profoundly changed how both Syrian and Jordanian adolescents living in Jordan experience the transition to adulthood. The pressure of more than 1.2 million refugees arriving in Jordan since the beginning of the war (Department of Statistics [Jordan], 2016) has strained the already overburdened health system and deepened existing socioeconomic deprivation and gender-based discrimination (United Nation's Children's Fund [UNICEF], 2015). The crisis has caused young girls to become increasingly vulnerable to poor sexual and reproductive health outcomes, such as early pregnancy, child marriage, gender-based violence, and sexual assault, which may be associated with changing economic pressures, community dynamics, and social norms (Jordan Communication Advocacy and Policy Activity, 2016b; United Nation's Population Fund (UNFPA) Regional Syria Response Hub, 2015; UNICEF, 2014). In particular, child marriage has increased among both Jordanians and Syrians living in communities that host large numbers of Syrian refugees and is thought to be related to a shift toward more traditional social norms in the presence of social change and upheaval, the desire to protect young girls from sexual exploitation and violence, and deepening economic turmoil (UNICEF, 2014).

Life-Course Research With Adolescents: The Use of Narrative and Visual Approaches

Life-course research focuses on understanding how social relations, individual identity and agency, biology, history, and culture interact with time, period, and cohort effects to influence an individual’s life trajectory (Giele & Elder, 1998). To understand the influence of certain events, life-course research often focuses on transitions, defined as changes in status or identity that provide an opportunity for behavior change, and turning points, which represent dramatic shifts in the direction of one’s life (Elder, Johnson, & Crosnoe, 2003). Integrating a life-course perspective into research on sexual development represents an important opportunity to reframe existing research in this domain as a dynamic process that may be influenced by the sequencing of live events (Halpern, 2010). To date, there has been limited research into the development of sexuality during childhood and adolescence as part of a natural process of sexual development (Ehrhardt, 1996; Mmari et al., 2017).

Methodological approaches that enable participants to construct their own life stories are one way to support data collection from a longitudinal perspective that also values context (Verd & Andreu, 2011). Stories are central to the child and adolescent experience and are one way in which youth can effectively link a daunting history into discrete, meaningful episodes (World Health Organization, 1992). Capturing the adolescent experience through story enables participants to construct their lives through dialogue in a nonlinear manner that allows the participant to infuse life events with meaning and enables the researcher to facilitate an exploration of the relationships between experiences across the life course (World Health Organization, 1992). The use of story also incorporates an interactionist approach of how biological, social, cultural, and historical factors blur over time to jointly influence an individual’s developing sexual identity (Tolman & Diamond, 2001). Narrative and visual aids have previously been used alongside life-story approaches to foster rich discussion within the context of in-depth interviews with adolescents about how their experiences from childhood through adolescence have shaped their reproductive health and evolving sexual identities (Adams, Salazar, & Lundgren, 2013; Bayer, Tsui, & Hindin, 2010; Mmari et al., 2017; Shah, Zambezi, & Simasiku, 1999).

Narrative approaches enable a participant to engage in a conversation with an interviewer in which the participants are prompted to explore their lives in an open-ended manner, so that they have the power to direct and focus on the discussion on the situations, contexts, and experiences that they consider to be influential to their lives (Bayer, Gilman, Tsui, & Hindin, 2010; Berends, 2011). The elicitation of life stories is a narrative approach that empowers participants to control the way their life story is organized in that it focuses on the way that the participant understands the events in their life to have unfolded and embraces the subjective way in which participants remember, perceive, and interpret events throughout their life; this approach is distinct from other life-history approaches that seek to uncover an objective accounting of sequenced events (Habermas & Bluck, 2000). Life stories and narrative are thought to be especially effective when used with adolescents as they provide the participant with more agency to control the topics discussed (Mmari et al., 2017).

Time lines are a visual representation of a life story that are often displayed in a chronological sequence whereby significance and meaning is attached to specific events (Bagnoli, 2009; Berends, 2011). Used alone, time lines may oversimplify a series of events (Patterson, Markey, & Somers, 2012); however, when used in conjunction with narrative interviews, the use of time lines may enhance the participant’s and researcher’s ability to explore the complexity of the data and enhance its accuracy and completeness (Goldenberg, Finneran, Andes, & Stephenson, 2016; Harper, 2000). In this sense, the purpose of incorporating time lines into research, especially among children and adolescents, is to serve as both a means to produce data but also as a way to engage participants and stimulate a deeper level of recall and discussion (Kesby, 2000; Morrow, 2001).

While emerging as an important methodology in public health research (Kolar, Ahmad, Chan, & Erickson, 2015; Patterson et al., 2012; Thomas et al., 2015), the use of visual time lines in conjunction with in-depth interviews is thought to be particularly well suited in the study of sensitive topics with marginalized populations, or those that have experienced trauma, by serving as both a memory aid and a means to embed experience within the broader context of life events (Blackbeard & Lindegger, 2015; Guenette & Marshall, 2009; Kesby, 2000; Kolar et al., 2015). Additionally, a time line can serve as a shared point of reference that can be iteratively referenced by the participant and the interviewer throughout the course of the interview (Kolar et al., 2015). To this point, referencing the visual time line that is produced by the participants themselves may help to improve the participant’s comfort by building rapport (Dickson-Swift, James, Kippen, & Liamputtong, 2007; Goldenberg et al., 2016) and reducing the power differential between the interviewer and participant (Mmari et al., 2017). The combination of narrative and visual methods may help participants, especially adolescents who may not be fully capable of expressing themselves verbally in certain domains, to access and describe experiences that may not be easily represented by the use of verbal language alone (Mmari et al., 2017; Sheridan, Chamberlain, & Dupuis, 2011).

Foundational Work

In preparation for this research, the study team has conducted a series of stakeholder consultations over the last 2 years in preparation for this research activity, including with local policy makers (such as government officials and representatives from relevant government ministries), stakeholders (such as representatives from donor organizations, nongovernmental organizations, and health service delivery organizations active in Jordan), and members of the study population (Jordanian and Syrian youth aged 15–19 years). During the consultations, we used stakeholder input to guide and refine our research objectives, questions, and methodological approaches in order to ensure that our research is contextually relevant, appropriate, and that it meets local priorities. In these consultations, we also sought stakeholder input on ethical concerns such as those surrounding how to best engage minors in the study, aspects surrounding parental permission, and how to ensure comfort of the participants in discussing sensitive topics. In addition to consultations, an exhaustive literature and document review was conducted on adolescent sexual and reproductive health in Jordan prior to designing this protocol. Taken together, these activities highlighted the questions above as important research gaps that will facilitate the design of interventions to address the proximate and upstream causes of poor sexual and reproductive health outcomes among youth.

Research Objectives

Using a combination of narrative, in-depth interviews and visual time lines, we seek to understand how social, cultural, environmental, and biological factors across the life-course influence adolescent sexual development and reproductive health among Jordanian and Syrian youth between the ages of 15 and 19 years, especially those related to social norms surrounding sexual behavior and gender roles. Specially, we will examine the following:

What do youth describe as key transitions and turning points between childhood and adolescence?

How do youth describe the social and gender norms present in their community, and how does the community respond to those who do not comply?

How are gender norms first established during childhood, and how do norms and expectations change as participants advance through the life cycle? How do such norms influence youth’s sexual and care-seeking behavior?

How has the experience of being a refugee or accepting refugees changed norms surrounding gender expectations, sexual behavior, and access to care?

Our study will make an important contribution to the literature on adolescent sexual and reproductive health in Jordan and in other humanitarian settings by focusing on the shifting population dynamics given the influx of Syrian refugees, while offering a comparative perspective between the sexual and reproductive health needs of Jordanian and Syrian youth. This study focuses on emergent priorities in the field of adolescent sexual and reproductive health, such as those related to gender, sexual maturation, and social norms, that will be of national, regional, and global significance (Evans & Forte, 2013). Given the qualitative nature of the research, youth participants will be provided a platform in which to offer in-depth information about their current sexual and reproductive health needs that have not previously been assessed in existing research.

Method

Methodological Appraoch

To accomplish the objectives of this study, we will use narrative, in-depth interviews that incorporate the creation of a visual time line. The interviews will focus on collecting the participants’ life stories to understand how their life trajectories, including those related to sexuality, social pressure, gender norms, migration, and changes in community composition, have shaped their sexual identity and reproductive health-related behavior and beliefs from childhood to adolescence.

As the construction narrative life stories is based in flexible dialogue between the participant and the interviewer, the role, social position, and identity of the interviewer has an important role in shaping the data production process (Shacklock & Thorp, 2005). We will draw upon the peer ethnographic method in selecting the interviewers in the study, so that they will be known and trusted members of the participants’ community (Price & Hawkins, 2002). In our case, the interviewers will be individuals of the same sex as the participants who regularly work with youth at the local community development centers from which participants will be recrutied. Using this approach has been effective in conducting qualitative research on sensitive topics with youth in that it does not require the same amount of time dedicated to building rapport and trust between the participant and interviewer as in traditional anthropological methods (Price & Hawkins, 2002).

Interviewers will begin the interview telling the participant that they are interested in hearing their life story. Participants will be given a pen and a piece of blank paper to write down a time line depicting their life story in any way that they would like. As a prompt, the interviewer will instruct the participant to think about their life story as a series of chapters that they should depict on the time line along with a brief summary of the plot and characters involved in each chapter. The participant can include whatever details they think are important. Once the time line is complete, the participant will be asked to verbally describe the content of the time line to the interviewer.

The visual time line will serve as an anchor point throughout the subsequent dialogic portion of the interview. Interview questions will build successively on each other, and questions will focus on specific stories that the participants remember about key events, transitions, and turning points that the participant identifies in their life. Interviewers will also ask participants specific questions about key events related to their developing sexual and gender identity and how these changes impacted their relationships with family and friends. Some illustrative questions from participant interviews are as follows:

At what point on your time line did you realize you were no longer considered to be a child? What happened? Did this change your relationship with your parents and friends? If so, how? Did it change anything about your daily life or what you could or couldn’t do? If so, please describe.

Can you draw a star on your time line to mark the first time you started to like someone in a romantic way? Can you tell me the story of what happened?

Are boys and girls expected to behave in a certain way in your community? Can you please describe? Have the expectations changed at certain points in your life? If so, can you point those time periods out on your time line?

When are boys and girls expected to get married in your community? If you have been married, or if any of your friends have been married, can you point out when on your time line that has occurred? Can you tell me the story of what happened? How did it make you feel at the time? How does it make you feel now? Have you noticed any changes in when children are expected to get married in your community during the different chapters in your life? If so, why do you think this happened?

Given the particular circumstances surrounding Syrian refugees, Syrian youth will be asked additional questions pertaining to how they experienced gender expectations before and after their migration to Jordan. As all of the communities in the study include large populations of Syrian refugees, to better understand changes in social norms as they relate to community dynamics, Jordanian participants will be asked about whether they have noticed any changes in norms within their communities since Syrians began arriving in their community. Throughout the interview, the interviewer will engage in active listening and focus on asking simple, open-ended questions that enable the participant to guide the telling of their life story.

It is expected that each interview will take approximately 1.5–2 hr to complete. All interviews will take place at community development centers in a private room. Only the data collector will be present in the room at the time of the interview.

Sampling and Recruitment

Participants will be recruited from four communities in Jordan that each has a large number of Syrian refugees: Amman, Irbid, Mafraq, and Zarqa. Participants will be recruited by convenience from local community development centers present in each community. If an individual is aged between 15 and 19 years and is of either Jordanian or Syrian in national origin, they will be eligible to particpate in the study. We intend to enroll 4 Jordanian males, 4 Jordanian females, 4 Syrian males, and 4 Syrian females from each community, for a total sample size of 64 individuals. We believe that this is a robust sample size that will be sufficient for analytic comparisons by gender and national origin. As we will use the concept of saturation described by Corbin and Strauss (1990) as a guiding principle for determining our sample size, our final sample size may change as a result of when we reach a point of redundancy at which no new insights or themes can be identified during analysis.

Data Handling and Analysis

All interviews will be audio recorded and transcribed. Transcriptions will be linked with each participants’ visual time line. All personally identifiable information will be removed from both the transcripts and the visual time lines. Audio files will be destroyed after transcription is complete and the quality is verified. All data will be entered into the qualitative software analysis program Atlas.ti, version 8.3 (Muhr, 2004).

Given the limited existing research within our topical domain, we will use an iterative and inductive analytic approach based on grounded theory. A grounded theory approach will enable us to generate new concepts for anlaysis through an ongoing interaction with the data rather than identifying ways in which our data affirm preceived notions or ideas (Charmaz, 2006). We will use the constant comparitive method whereby data are sequentially and continually compared with previously collected data in order to refine categories and concepts (Glaser, 1965). This process will begin once the first interviews are completed, so that we can continue to refine and inform subsequent data collection, as necessary, should additional questions arise. We will begin by analyzing the transcripts using line-by-line coding in order to remain open to the data and its nuance (Charmaz, 2006). We will then continue with focused coding to sort, organize, and reassemble data around emergent themes (Charmaz & Belgrave, 2012; Creswell, 1998).

Given the large amount of data that will be generated by this study, data anlysis will be carried out by a team of four individuals with direct involvement in developing the study design and instruments. The team will collaboratively develop and finalize a codebook based on an iterative process. The team will begin by coding the first five interviews conducted. After the coding is complete, the team will meet to discuss emergent themes and to develop an initial codebook that will include specific definitions for each code. The coders will then recode the initial five interviews with the new codebook. Interrater reliability will be assessed to determine the exent to which the coders agree on the use of the codes. The coders will then code another five interviews using the codebook. Once complete, the coders will meet again to discuss any additional emergent codes to be added to the codebook. The four coders will then divide up the remaining interviews and code them independently if interrater reliability is found to be sufficent between coders. The coders will meet periodically to discuss emergent themes that should be added to the codebook. Once no new codes are identified, previously coded interviews will be revisisted.

Ethics

This study has been approved by the institutional review boards at the Harvard T.H. Chan School of Public Health and the University of Jordan School of Nursing.

As the study population includes vulnerable groups, special ethical considerations need to be addressed during study conduct to safeguard participant rights. As individuals above and below the age of majority (18 years) in Jordan will be recruited for this study, the study will adopt different recruitment, consent, and permission procedures dependent on participant age. Minors will undergo informed assent procedures and will be required to provide signed parental permission slips which must be returned to the study staff in person by parents/legal guardians. Individuals over the age of 18 will undergo informed consent at the time of recruitment. Additionally, refugees will be included in this study. Refugees constitute a large percentage of the population in all the study communities. Given their large number, as well as the fact that many governmental and nongovernmental organizations in the study communities work with refugees, their participation in this study is not expected to cause any additional risk.

Confidentiality will be maintained throughout the study by following several procedures. At no time will we collect direct, personal identifiers. There will be no documents that link an individual to any direct, personally identifiable information. Study staff will be instructed not to collect any personally identifiable information in any of the data collection materials. Additionally, interviews will occur in a private space located inside community development centers run by a local nongovernmental organization. Both adolescents and parents regularly participate in events at these community development centers, which will help to protect participants’ anonymity.

Rigor

We will adopt several of the strategies proposed by Morse (2015) to ensure rigor in our research approach, with a particular focus on those surrounding the constructs of validity (the accuracy of data) and reliability (the dependability of data). To ensure our data are valid, we will attempt to collect thick, rich data. Establishing trust and rapport between the participant and the interviewer is vital to obtaining rich data, which we believe will be supported by our use of the peer ethnographic method. Additionally, we will tend to issues of sample size and appropriateness by using the principle of saturation to guide the number of interviews conducted, as well as recruiting from several geographic areas to ensure variation within our sample. Finally, we will examine our data for negative cases in order to challenge our prevailing assumptions about the data. To address reliability, we will focus on ensuring our results are both stable and dependable. During the coding phase, we will develop a codebook and assess interrater reliability at key points in the analytic process to ensure that the research results are consistent and reproducible (Armstrong, Gosling, Weinman, & Marteau, 1997). Additionally, as we reach the point of saturation, we expect that narratives will begin to overlap providing and offer internal consistency and verification.

Discussion

Implications for Future Research and Dissemination

This study uses a novel approach to explore a sensitive and understudied topical domain with youth, especially among youth in the Middle East. Using a life-course perspective will contribute to emerging research priorities in the domain of adolescent sexual and reproductive health (Patton et al., 2016). The results of this study will be relevant for improving youth-oriented research, programs, and policy across the region, while also providing documentation to support the replication of this type of research elsewhere. Results will be published in peer-reviewed journals to reach a global academic audience. Local dissemination will occur through the development of research briefs and reports to share with local government bodies and relevant stakeholders in Jordan.

Limitations

While we attempt to minimize the limitations of our study, there remain several worth discussing. All interviewers will undergo a rigorous training process in which they are provided with both didactic and interactive training. Interviewers will also have the opportunity to practice the interview techniques during the pretesting phase; however, the interviewers may still lack experience using visual aids during in-depth interviews in comparison with verbal techniques. Some interviewers may be skeptical about the ability of the participants to use visual methods and as a result, they may downplay the development of time line during the interview process, they may not refer back to the time line as a basis for questions, or they may feel more comfortable staying in the verbal mode of interview (Shah et al., 1999). We will carefully monitor and assess interview quality throughout the data collection process and provide feedback to interviewers as needed if there are ways that they can strengthen their use of the visual time line within their interviews.

Another potential limitation is that while interviewers are from the same peer group as the participants who will be selected, there may be some inherent conflict or distrust related to power dynamics between the participant and the interviewer. For example, Syrian refugees may feel marginalized in their communities and, as a result, may not be willing to share the same depth of personal information with the interviewers. We will address this issue as part of the training and emphasize the importance of establishing rapport and trust with participants from the beginning of the interview through the use of introductions and small talk. Additionally, we have structured the interview guides, so that the interviews begin with general life questions that the participant will feel more comfortable discussing before advancing to questions that are more sensitive in nature.

Footnotes

Authors’ Note

All authors were involved in conceptualization of the study design and development of study methods, instruments, and protocol. Jewel Gausman wrote the first draft. Areej Othman, Maysoon Otoom, Abeer Shaheen, and Ana Langer provided critical input and revisions. All authors approved of the final draft.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is part of the Sexual and Reproductive Health Research Programme with project number W 08.560.012, which is financed by the WOTRO Science for Global Development of the Netherlands Organisation for Scientific Research (NWO).

ORCID iD

Jewel Gausman

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