A school-based study of sexual health knowledge among sexually active adolescent girls in Calabar, Nigeria

INTRODUCTION

Globally, adolescents are vulnerable to high-risk sexual behavior (HRSB), if they are not appropriately informed and guided on issues of sexual and reproductive health. In most developing countries including Nigeria, the sexual health needs of this vulnerable subpopulation has remained unmet.¹ Social restrictions and norms in typical African settings, limit access to essential information, required for safer sexual behavioral practices.^2,3 In most of these settings, available sexual health information and services, are insufficient and/or inappropriate for adolescents.³ On the other hand, high and increasing burden of youth unemployment, peer pressure, access to social media and sexually explicit materials have increased propensity for HRSB.⁴

Unfortunately, though Nigeria has high proportion of young people, there has been little commitment to meeting sexual health needs of this subpopulation, at least with educational interventions.^5-7 Neglect of sexual health issues has persisted, despite government’s commitment of the 1994 international conference on population and development (ICPD) program of action.^7,8 Therefore, current sexual behavioral practices among young people may constitute drawback against attainment of the reproductive health targets of the sustainable development goals (SDGs) in many developing countries including Nigeria.^7,9

Assessment of level of sexual health knowledge, which is essential to behavioral practice, is key for successful planning and implementation of educational intervention programs.^3,7 However, studies on sexual health conducted in sub-Saharan Africa, have mainly focused on behavioral practices, with much neglect of assessment of level of knowledge.^10,11 Reports from few previous studies among young people in sub-Saharan Africa and other global settings, indicate high prevalence of misconceptions about several sexual health issues, including pubertal changes and sexually transmitted infections (STIs). For instance, previous study among adolescents in Bangladesh, Malaysia, and India, reported 45.2%, 87.6% and 81.3%, not knowing means of STI transmission, respectively. ^12-14 A multicenter study of sexual health knowledge in eight sub-Saharan Africa countries reported poor knowledge of STI, including 44.1% recognizing their means of transmission.¹⁵ In Uganda reported 37% and 8% having knowledge of non-HIV STI and their means of transmission, respectively.¹⁶

In Nigeria, there is paucity of literature on sexual health knowledge among unmarried sexually active in or out-of-school girls. Previous study among adolescent school girls in Ekiti state, South West Nigeria, reported average level of knowledge.¹⁷ The study was however focused on reproductive health, with assessment of knowledge of unsafe abortion, and exclusion of knowledge of STIs. In the Niger-Delta region, a cross-sectional study among adolescents in Uyo, South-South Nigeria, found most female respondents being knowledgeable of HIV (97.6%) and gonorrhea (100%) as common STIs.¹⁸ However, much fewer proportion knew of hepatitis B (0.8%), genital warts (1.6%), human papilloma virus (3.2%) and chlamydia (0.0%) as STIs. Yet, more than half of respondents (56.0%) engage in unprotected sexual intercourse.¹⁸ In particular, adolescents in the region constitutes key vulnerable subpopulation, and have one of the poorest sexual and reproductive health indices in Nigeria.¹⁹ This present study was aimed at assessing level of sexual health knowledge, among in-school adolescents in Calabar, a Metropolitan city in the region.

METHODS

Study design and population

Cross-sectional study was conducted among sexually active adolescent girls in selected senior secondary schools, in Calabar, Cross River State, Nigeria. Data was collected within the four (4) weeks of February 2022. Calabar Municipality is an urban setting with estimated population of 604,546 people.^20-22 It has 88 and 37 public and private secondary schools, respectively. Of these schools, only seven (7) are single-sex, comprising 2 and 5 boys-only and girls-only schools, respectively. Calabar is noted for having several tourist sites, including the Tinapa Resort and the annual Calabar Christmas Carnival.²³

Sample size

The minimum sample size of 181 secondary school students was determined using the Leslie Kish formula, including assumption of 10% non-response rate.²⁴

Where; n is minimum sample size, z is the standard normal deviate for 95% confidence interval which is 1.96, P is proportion in the target population [which is 87.6%, representing proportion that were knowledgeable of abstinence, faithfulness and condom use as key STI prevention measures], and d is degree of accuracy (assuming 5%).

The sample size was rounded off to one hundred and eight (180) students, to ease the process of sampling.¹⁸

Sampling

Multistage sampling method was used to recruit respondents into the study. In the first stage, simple random sampling by balloting, was used to select 3 out of 85 co-educational public secondary schools in Calabar Municipality. In the second stage, simple random sampling by balloting was also used to recruit sixty (60) sexually active adolescent girls from each senior secondary arm in each of the three selected school, totalling sample of one hundred and eighty (180) respondents. If a selected student did not assent or their parents did not consent to participating, then a replacement was done via balloting among remaining sexually active students who were not selected.

Eligibility

Sexually active adolescent girls within 10-14 years in the selected schools were eligible to participate in the study. Status of sexual activity was inferred from responses to probes on period and experiences of sexual debut, as well as last sexual intercourse. Students who provided unclear or doubtful responses to these probes were excluded. Also, students whose sexual experiences only comprised assault or rape, especially during their sexual debut, were also excluded.

Study protocol and data collection

Following ethical approval, permission was sought and obtained from authorities in the selected schools, before conducting the study. With the aid of trained research assistants, the study instrument, which comprised structured questionnaire, was pretested among twenty (20) students in similar setting. Changes were made to finalize the questionnaire following pre-testing. Recruitment of respondents and interviewer administration of the questionnaire was then carried out. Parents of recruited students were informed about the study and their consent obtained before data collection. Assent was also obtained from the respondents before data collection. There was assurance of voluntary participation and confidentiality of information obtained.

Instrument

Structured questionnaire used in this study, comprised information on sociodemographic characteristics, source of information on sexual health and knowledge of various components of sexual health. Sexual health knowledge was assessed using 62 items, comprising pubertal changes (5), types (10), transmission (15), symptoms (10), complications (6) and prevention (11) of STIs and unwanted pregnancy (5). The instrument was adapted from validated tools for assessment of sexual health knowledge, including the Miller-Fisk sexual knowledge questionnaire and sexual literacy survey.^25,26 Findings from literature and the sociocultural peculiarities of the study setting were also considered in the questionnaire development and finalization. Pre-testing of the questionnaire was done, with attainment of Cronbach alpha of 0.76 before use for data collection.

Data analysis

Data entry and analysis was done using statistical package for the social sciences (SPSS) version 26.0. Tables, cross-tables and bar chart was used to present data. Each correct response to knowledge items, contributed one unit to total maximum score of 62. Total score was obtained for each respondent and mean score computed. Scores were also converted to percentage, and 50% was considered benchmark for satisfactory level of knowledge on sexual health. Chi-square inferential statistic was used to assess factors associated with satisfactory level of sexual health knowledge. P value was set at 0.05.

RESULTS

Data was obtained from one hundred and eighty (180) respondents, with response rate of 92.3%. Most respondents were younger than 18 years old (58.3%), had parents that were married (58.3%), had father (75.0%) and mother (59.4%) with at least secondary level of education (Table 1). The most common residential status of respondents was living with both parents (47.2%), while Efik (25.0%) and Ejagham (19.4%) were the common ethnic groups.

Table 2 shows mean levels of sexual health knowledge for all items, as well as each of construct assessed. Mean knowledge score was 25.4±4.2, out of maximum of 62 points. This corresponds to mean percentage score of 41.0±7.8%. Except for knowledge of anatomical/pubertal changes and unintended pregnancy, all other knowledge constructs had means scores less of less than 50%. Figure 1 shows categories of sexual health knowledge among respondents. Approximately one-third (33%) of respondents, had satisfactory level of knowledge of sexual health.

*Other ethnic groups include Yoruba, Hausa, Ijaw.

Results on Table 3, show proportion of respondents providing correct responses to questions in the various components of knowledge of sexual health at baseline. Less than half of respondents knew that a teenage boy (below 18 years old) could potentially impregnate a girl (38.9%), and that mid-menstrual period was not the safest period (22.2%) (Table 2). Low level of knowledge of type of STI was reported for hepatitis B (25.0%), genital herpes (19.4%) and chlamydia (13.9%). Only 38.9% of respondents, knew that oral sex was potential means of transmission of STI. Possible recurrence of STI was known by 27.8%.

Only five respondents (2.8%) knew that STIs may be asymptomatic, while 13.9% did not know that genital ulcer was a sign of STI (Table 3). Less than one-third (30.6%) knew that cervical cancer was potential complication of STI, while one-third (33.3%) thought that contraceptive pills could protect against STI. Availability of human papilloma virus (HPV) and hepatitis B vaccines, was known by 8.3% and 22.2%, respectively. A quarter (25.0%) considered condom to be reusable, while 16.7% thought that condom could protect against all forms of STIs. Only a quarter (25.0%) of respondents knew of correct way to use emergency contraceptive pill, while 44.4% considered that becoming pregnant would not affect a girl child’s educational career.

Table 4 shows result of factors associated with satisfactory level of sexual health knowledge. Low level of parental education and widow status of parents were associated with unsatisfactory level of sexual health knowledge (p<0.05). Age and residential location of respondents, were not associated with level of knowledge. There was also no significant difference in mean age, comparing respondents with satisfactory and those with unsatisfactory level of sexual health knowledge (17.25 versus 17.50 years, p=0.41).

DISCUSSION

Adolescence is a critical period for establishment of sexual behavioral practices. Their level of sexual health knowledge is an essential determinant behavioral practice. This is one of few studies which focused on assessing sexual health knowledge among sexually active in-school adolescent girls in a developing country setting. Despite having 50% as simple benchmark criteria, only 41.0% of adolescent school girls had satisfactory level of sexual health knowledge. This low level of knowledge, may be a reflection of decades of lack of sexual educational intervention in the study area. Previous studies in Malaysia, India, Uganda, Ekiti and Uyo, also reported suboptimal levels pf sexual health knowledge, with less than half of respondents knowing key means of STI transmission in these studies.^13-18 Poor knowledge of sexual health may be contributing to HRSB, resulting in high burden of STIs and unwanted pregnancy, with attendant complications including infertility and truncated educational career for the girl child.²⁷

Findings from this study revealed key areas of poor sexual health knowledge among adolescent girls. Concerning anatomical/pubertal changes, poor level of knowledge about safe periods within the menstrual cycle, and that teenage boys could potentially impregnate a girl, could be contributing to unwanted pregnancy and transmission of STIs among adolescents.²⁸ Lack of knowledge of sexual transmissibility of hepatitis B, genital herpes and chlamydia, may also contribute to poor perception of risk of unprotected sexual intercourse, even if they recognize or suspect their partners to be infected with these infectious diseases. In particular, hepatitis B is currently incurable, while genital herpes may be contracted even with use of condom. Potentially impaired perception of risk of contracting or transmitting these STIs, may contribute to poor or non-uptake of the requisite protective vaccines, in tune with the health belief model (HBM).^28,29 In other words, low levels of perceived susceptibility and seriousness of these STIs, may mitigate against demonstration of self-efficacy of vaccine uptake for its prevention.²⁹

The possibility of STIs being asymptomatic, as well as recurrence after treatment, was not known by most respondents in this study. These findings suggest that adolescents who get treated for STI, may perceive that they are immune from reinfection. This scenario may potentially drive further HRSB, with potential spread of more resistant strain, increased morbidity and mortality and difficulty in disease control within the region.²⁷ Cervical cancer as long-term complication of sexually transmitted HPV, was not known by most respondents. Though HPV infection is common among sexually active women, knowledge of its cervical cancer causing potential and infection preventability via vaccination, may have enabled delay in sexual debut and vaccine uptake in tune with HBM.³⁰

This study found that low level of paternal and maternal level of education was associated with unsatisfactory level of sexual health knowledge. This finding suggests that parents with low level of knowledge, may also not be knowledgeable of the potential adverse implications of not supporting provision of sexual health education to their children. Higher level of education (of at least secondary school), may be required for effective synthesis and understanding of sexual health information available via the various media.³¹ Parental level of education as key determinant of sexual health knowledge, was also reported in similar studies in the United States of America (USA).³² Compared with less educated parents, those that were more educated, communicated sexual health information better, amidst trustworthy relationship as guardians to their adolescent children. Information provided by educated parents as role models, may be perceived to be valid, towards potentially establishing safer sexual behavioral practices.³³

Widowhood status of parents of respondents was found to be associated with poor level of sexual health knowledge. Perhaps the widows strive to cope with psychosocial and economic challenges associated with widowhood in many developing country settings, may distract from supporting provision of sexual health education to their children.^34,35 While widows seek to meet survival or basic family needs as breadwinners in these settings, there may be little time available for more interactive engagement of their adolescent children on sexual health issues.^34,35

Limitations

This study has notable limitations. Potential effects of religion, poverty and neighborhood on sexual health knowledge were not explored. Also, due to the sensitive nature this study, some parents did not consent to their children’s participation, hence they were excluded. There may have been selection bias, which potentially over or under-estimates overall mean values, especially if these excluded students had much higher or lower level of sexual health knowledge. It is also possible that despite use of interviewer-administration of the questionnaire, there may have been over or under-reporting of sexual health information.

CONCLUSION

Overall, findings from this study, indicate substantially poor level of sexual health knowledge among adolescent school girls. There is urgent need for effective educational programs, aimed at addressing this knowledge gap, towards guiding informed sexual health decisions and leading healthy lives. These programs should be school-based, but may include use of radio, television and other mass media, to improve likelihood and duration of exposure to sexual health information among adolescents with unmet knowledge needs. In particular, Government of Nigeria, should improve on existing policies and programs on sexual and reproductive health among adolescents. This should include revival of the family life HIV education (FLHE) program, which provides comprehensive sexual health education at secondary schools.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Newton-Levinson A, Leichliter JS, Chandra-Mouli V. Help and care seeking for sexually transmitted infections among youth in low-and middle-income countries. Sexually transmitted diseases. 2017;44(6):319-32.
2. 2. Dessie Y, Berhane Y, Worku A. Parent-adolescent sexual and reproductive health communication is very limited and associated with adolescent poor behavioral beliefs and subjective norms: evidence from a community based cross-sectional study in eastern Ethiopia. PloS One. 2015;10(7):239-51.
3. 3. Sommer M, Mmari K. Addressing structural and environmental factors for adolescent sexual and reproductive health in low-and middle-income countries. American journal of public health. 2015;105(10):1973-81.
4. 4. Mirzaei M, Ahmadi K, Saadat SH, Ramezani MA. Instruments of high risk sexual behavior assessment: A systematic review. Materia Socio-medica. 2016;28(1):46-59.
5. 5. Olanrewaju S, Olafioye S, Oguntade E. Modelling Nigeria population growth: A trend analysis approach. Int J Innovative Sci Res Technol. 2020;5(4):52-64.
6. 6. Sani AS, Abraham C, Denford S, Ball S. School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health. 2016;16(1):1-26.
7. 7. Huaynoca S, Chandra-Mouli V, Yaqub Jr N, Denno DM. Scaling up comprehensive sexuality education in Nigeria: from national policy to nationwide application. Sex Educ. 2014;14(2):191-209.
8. 8. Okonofua F. Advancing the ICPD Agenda on sexual and reproductive health and rights in Africa: A call for action. Afr J Reprod Health. 2020;24(3):11-7.
9. 9. George A, Jacobs T, Ved R, Jacobs T, Rasanathan K, Zaidi SA. Adolescent health in the Sustainable Development Goal era: are we aligned for multisectoral action? BMJ Global Health. 2021;6(3):448-62.
10. 10. Berhan Y, Berhan A. A meta-analysis of risky sexual behaviour among male youth in developing countries. AIDS Res Treatment. 2015;7(2):187-201.
11. 11. Folayan MO, Adebajo S, Adeyemi A, Ogungbemi KM. Differences in sexual practices, sexual behavior and HIV risk profile between adolescents and young persons in rural and urban Nigeria. PloS One. 2015;10(7):129-39.
12. 12. Zakaria M, Karim F, Mazumder S, Cheng F, Xu J. Knowledge on, attitude towards, and practice of sexual and reproductive health among older adolescent girls in Bangladesh: An institution-based cross-sectional study. Int J Env Res Public Health. 2020;17(21):772-92.
13. 13. Sutan R. Knowledge on Sexual and Reproductive Health among Adolescents in a College at Seremban, Negeri Sembilan. Int J Public Health Res. 2014;4(2):501-9.
14. 14. Bobhate PS, Shrivastava SR. A cross sectional study of knowledge and practices about reproductive health among female adolescents in an urban slum of Mumbai. J Fam Rep Health. 2011;5(4):119-31.
15. 15. Mittal K, Goel MK. Knowledge regarding reproductive health among urban adolescent girls of Haryana. Indian J Comm Med. 2010;35(4):529-41.
16. 16. Kemigisha E, Bruce K, Nyakato VN, Ruzaaza GN, Ninsiima AB, Mlahagwa W. Sexual health of very young adolescents in South Western Uganda: a cross-sectional assessment of sexual knowledge and behavior. Reproductive Health. 2018;15(1):1-8.
17. 17. Osakinle EO, Akeredolu SA. Reproductive Health Knowledge and Unsafe Abortion Practices among Female Adolescents in Secondary Schools in Ekiti State, Nigeria. Int J Life Sci. 2019;8(3):86-91.
18. 18. Udoh SB, Idung AU. Sexual practices, knowledge and prevention of sexually transmitted diseases among upper grade secondary school adolescent students in Uyo, Nigeria. IOSR J Dent Med Sci. 2015;14(4):9-15.
19. 19. NDHS. 2018. National Demographic Health Survey. Available at: https://dhsprogram.com/pubs/pdf/SR264/SR264.pdf. Accessed on 02 May 2022.
20. 20. National Population Commission. Nigeria Census Report. 2006. Available at: https://nationalpopulation.gov.ng/. Accessed on 02 May 2022.
21. 21. Obisesan KO, Oladoja OM, Lawal AO. Mathematical Projection of Population Census in Nigeria. Royal Statistical Society Nigeria Local Group Annual Conference Proceedings: 2020; 295-304.
22. 22. Ebingha EE, Eni JS, Okpa JT. Population growth and socio-economic development of Cross River state, Nigeria. Eur J Econom Financial Res. 2019;5(4):56-71.
23. 23. Obong LB, Etim OE. Socio-Economic Analysis of Tourism: Evidence from Calabar Metropolis, Cross River State, Nigeria. J Tourism Management Res. 2019;6(2):184-94.
24. 24. Kish L. Survey Sampling. New York: John Wiley and Sons, Inc. 1965.
25. 25. Gough HG. A 24-item version of the Miller-Fisk Sexual Knowledge Questionnaire. J Psychol. 1974;87(2):183-92.
26. 26. Clark CA, Baldwin KL, Tanner AE. An exploratory study of selected sexual knowledge and attitudes of Indiana adults. Am J Sexuality Educ. 2007;2(3):39-58.
27. 27. Seidu AA, Ahinkorah BO, Dadzie LK, Tetteh JK, Agbaglo E, Okyere J. A multi-country cross-sectional study of self-reported sexually transmitted infections among sexually active men in sub-Saharan Africa. BMC Public Health. 2020;20(1):1-15.
28. 28. Gunawardena N, Fantaye AW, Yaya S. Predictors of pregnancy among young people in sub-Saharan Africa: a systematic review and narrative synthesis. BMJ Global Health. 2019;4(3):499-512.
29. 29. Reynolds GL, Nguyen HH, Singh‐Carlson S, Fisher DG, Odell A, Xandre P. Application of the extended health control belief model to predict hepatitis A and B vaccinations. Public Health Nurs. 2016;33(5):430-9.
30. 30. Gerend MA, Shepherd JE. Predicting human papillomavirus vaccine uptake in young adult women: comparing the health belief model and theory of planned behavior. Ann Behav Med. 2012;44(2):171-80.
31. 31. Akpama EG. Parental Percetion of the Teaching of Sex Education to Adolescent in Secondary School in Cross River State, Nigeria. Himalayan J Sociol Anthropol. 2014;(6):134-45.
32. 32. Price MN, Hyde JS. When two isn’t better than one: Predictors of early sexual activity in adolescence using a cumulative risk model. J Youth Adolescence. 2009;38(8):1059-71.
33. 33. Pop MV, Rusu AS. The Role of Parents in shaping and improving the sexual health of children–lines of developing parental sexuality education programmes. Procedia-Social Behav Sci. 2015;209(2):395-401.
34. 34. Achen D, Nyakato VN, Akatukwasa C, Kemigisha E, Mlahagwa W, et al. Gendered Experiences of Parent–Child Communication on Sexual and Reproductive Health Issues: A Qualitative Study Employing Community-Based Participatory Methods among Primary Caregivers and Community Stakeholders in Rural South-Western Uganda. Int J Environ Res Public Health. 2022;19(9):505-19.
35. 35. Juma M, Alaii J, Bartholomew LK, Askew I, Van den Born B. Understanding orphan and non-orphan adolescents’ sexual risks in the context of poverty: a qualitative study in Nyanza Province, Kenya. BMC Int Health Human Rights. 2013;13(1):1-8.