Young Women in Ghana Co-Design New Paths to HIV Testing and Prevention

In the sprawling urban neighborhoods of Greater Accra and the semi-rural communities of Ghana’s Eastern Region, adolescent girls and young women face a paradox that has frustrated public health officials for years. The tools to prevent HIV exist, they are endorsed by national policy, and they are increasingly available, yet the young women who stand to benefit most from HIV self-testing kits and pre-exposure prophylaxis, known as PrEP, rarely use them. A new study published in BMC Health Services Research argues that the gap is not a failure of awareness or motivation alone, but the product of intersecting cultural, interpersonal, and structural forces that no single intervention can dismantle. The research, conducted under the banner of the WISE WOMAN study, took an unusually direct approach to the problem: it asked young women themselves to identify the barriers in their lives and then to design the solutions, working alongside community interest-holders in a structured co-creation process.

The research team, led by Gloria Aidoo-Frimpong of the University at Buffalo in collaboration with Ghanaian colleagues from institutions including Ensign Global University and hospitals in Osiem and Offinso, brought together ten adolescent girls and young women and five community interest-holders for an intensive co-creation workshop. The methodological architecture of the study reflected a deliberate commitment to participatory design. Rather than extracting survey responses and departing, the investigators audio-recorded group discussions, captured facilitator field notes, and employed the Nominal Group Technique, a structured consensus method in which participants independently generate and rank ideas before the group deliberates. This ranking procedure allowed the researchers to quantify which barriers participants considered most pressing, while the open discussions and intervention prototypes revealed the texture and reasoning behind those priorities. Transcripts were then subjected to thematic analysis with iterative coding and consensus refinement, a process in which coders repeatedly revisited the data until the interpretive categories stabilized.

What emerged from the analysis was a four-tier map of obstacles operating at distinct but interlocking levels. The first and arguably most pervasive domain involved cultural and religious norms that moralized female sexuality. Participants described how conversations about HIV prevention were frequently framed as evidence of inappropriate behavior, so that a young woman seeking an HIV test or requesting PrEP risked being read as sexually active, and therefore as transgressing expectations of feminine propriety. This moral framing transformed a straightforward health behavior into a social gamble. The second domain concerned knowledge that was real but not actionable. Many participants had heard of HIV self-testing and PrEP, yet they lacked procedural clarity about how the tests worked, how PrEP should be taken, and what to do with a result, leaving them uncertain at precisely the moments when confidence mattered most.

The third barrier domain was emotional and relational. Fear and stigma did not operate only through overt discrimination; they worked through anticipatory distress, the dread of what might happen if a test were discovered, and through relational scrutiny, the sense that partners, family members, or neighbors were constantly evaluating a young woman’s choices. Confidentiality concerns compounded this anxiety, because participants worried that clinic staff or visible service points could expose their prevention activities to their communities. The fourth domain was structural: inconsistent availability of services meant that even motivated women could not count on finding supplies, financial barriers put testing kits and clinic visits out of reach for some, geographic inequities concentrated resources in places easier for urban than rural women to access, and health system practices themselves sometimes deterred rather than welcomed young clients.

The analytical insight of the study lies in how these domains interact. A young woman might possess accurate knowledge about PrEP, for example, but cultural norms that moralize female sexuality could make it socially costly to visit a clinic, while financial constraints and unreliable stock could render the trip futile even if she overcame her hesitation. Conversely, a well-stocked facility in her neighborhood would not help if she feared being seen entering it. The researchers mapped each barrier to the level at which it manifested, individual, interpersonal, socio-cultural, or structural, and then aligned the co-created strategies to those manifestations. This multilevel mapping matters for implementation science because interventions that address only one layer tend to be overwhelmed by the others. A peer education program, however well designed, will struggle if the nearest clinic has no PrEP in stock or if faith leaders publicly condemn its use.

The strategies that participants designed were strikingly concrete and culturally embedded. Storytelling emerged as a central vehicle: narratives grounded in local experience could carry prevention information in forms that felt legitimate rather than clinical, allowing sensitive topics to be discussed without triggering the moral judgments that direct messaging provoked. Participants also proposed deliberate engagement with faith leaders, recognizing that religious authorities shape the very norms that moralize female sexuality, and that their endorsement could either unlock or foreclose community acceptance of HIV prevention services. Rather than treating religion as an obstacle to be circumvented, the young women positioned faith communities as potential allies whose involvement could reframe prevention as responsible and respectable behavior.

Digital tools featured prominently in the co-designed package, but with an attention to developmental nuance that top-down programs often miss. Participants envisioned peer-led education delivered through WhatsApp, the messaging platform that dominates social communication in Ghana, with content tailored to different stages of adolescence and young adulthood. The rationale was that a fourteen-year-old girl navigating school and family supervision has different prevention needs, relationship contexts, and communication preferences than a twenty-two-year-old woman in a partnership or running her own household. A single undifferentiated message, the participants argued, would speak to neither. Alongside the peer-led channels, they proposed anonymous digital support mechanisms that would allow young women to ask questions and seek reassurance without revealing their identities, directly targeting the confidentiality fears that the analysis had identified as a core barrier.

The final strand of the co-designed strategy addressed the structural layer through decentralized, community-based service delivery. By moving HIV self-testing kits and PrEP access out of centralized facilities and into community settings, the participants aimed to reduce the geographic and financial costs of prevention while shrinking the visibility that made clinic visits socially risky. The emphasis on decentralization reflects a broader recognition in health services research that access is not merely a matter of distance but of the total burden, in time, money, and social exposure, that a service imposes on its user. For young women whose mobility and spending money may be controlled by others, a service that requires a long, conspicuous journey is effectively unavailable regardless of its official existence.

The WISE WOMAN findings now set the stage for a pilot phase intended to evaluate the feasibility and acceptability of the co-created strategies and to refine them for broader scale-up. The study’s authors emphasize that grounding intervention design in lived experience and structural reality offers contextually specific guidance that imported models cannot supply, and the ethical architecture of the work, approved by the University at Buffalo’s Institutional Review Board and Ensign Global College’s ethics committee and conducted in accordance with the Declaration of Helsinki and Ghana’s Data Protection Act, underscores the care taken with a vulnerable population. The research was funded through the University at Buffalo’s global research seed funding program, with the funders having no role in the design or interpretation. Whether storytelling circles, faith-leader partnerships, WhatsApp peer networks, and community distribution points can measurably raise testing and PrEP uptake remains to be demonstrated, but the study makes a compelling methodological claim: the young women closest to the problem are also the most precise diagnosticians of it, and interventions that begin with their analysis stand a far better chance of surviving contact with the communities they aim to serve.

Subject of Research: Women-centered co-design of HIV self-testing and PrEP implementation strategies for adolescent girls and young women in Ghana

Article Title: Co-developing women-centered strategies to improve HIV self-testing and PrEP uptake among adolescent girls and young women in Ghana: Findings from the WISE WOMAN study

Article References: Aidoo-Frimpong, G., Mensah, W. K., Anyidoho, D. S., Obeng, Y. A., Abubakar, A. T., & Oduro, M. A. (2026). Co-developing women-centered strategies to improve HIV self-testing and PrEP uptake among adolescent girls and young women in Ghana: Findings from the WISE WOMAN study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15750-1

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15750-1

Keywords: HIV self-testing, PrEP, adolescent girls and young women, Ghana, participatory research, implementation science, human-centered design, nominal group technique, HIV stigma, women's health, community-based services, sub-Saharan Africa