Key Social Norms Take-aways Social norms at interpersonal, community, and macro-social levels significantly shape adolescent girls’ sexual and reproductive health (SRH) behaviors in Ghana. Norms that stigmatize adolescent sexuality—rooted in religious and cultural expectations of abstinence and female modesty—limit young women’s access to family planning (FP) services, contribute to secrecy, coercion, and judgment, and ultimately hinder informed decision-making. These normative environments can reinforce gendered power imbalances and diminish adolescents’ reproductive autonomy.

Objectives To explore the multilevel social influences—interpersonal, community, and macro-social—on adolescent girls’ SRH decision-making and behaviors in urban Ghana, particularly regarding contraception, pregnancy, and use of FP services.

Methods This qualitative study used in-depth, semi-structured interviews with 63 young women aged 15–24 in Accra and Kumasi, Ghana. Participants were recruited from high schools and public health facilities. Grounded theory informed the thematic analysis, which employed both inductive and deductive coding to identify key themes across multiple ecological levels. Data were analyzed collaboratively by U.S. and Ghanaian researchers using Dedoose software.

Social Norms Measures and Methods The study did not use quantitative measures of social norms but instead elicited qualitative data on perceived and enacted norms through open-ended questions. Norms were identified through participants’ narratives about peer, parental, partner, and community expectations and judgments. The analysis was guided by a social ecological framework that conceptualizes norms as operating at interpersonal (e.g., peers, partners), community (e.g., gossip, labeling), and macro-social (e.g., religious doctrine, school curricula, health provider attitudes) levels.

Results Interpersonal relationships, particularly with partners and peers, often exerted pressure or coercion around sexual debut and contraceptive use. Community norms largely discouraged premarital sex and framed sexually active girls as “bad girls,” creating stigma and secrecy. At the macro-social level, religious teachings and judgmental health care environments further deterred young women from seeking SRH services. Education on SRH was often limited, biased, or moralistic. These influences interacted to shape girls’ SRH choices, often without adequate information or support.

Conclusions Multilevel social influences reinforce stigma and undermine adolescent girls’ ability to make informed reproductive decisions. Effective SRH interventions in similar settings must engage with and transform harmful norms at all ecological levels—from families and peers to community leaders and institutions—to create supportive environments for adolescent reproductive autonomy and well-being.