Predictors of sexual and reproductive behaviors among adolescents in a secondary school for girls in Enugu Metropolis, Nigeria

This study is a cross-sectional descriptive survey conducted among adolescent female students of Queens School, Ogui, New-layout, Enugu State, Nigeria, an allgirls government boarding and day secondary school. A sample size of 324 participants using Krejcie and Morgan’s power analysis method for a known population (2080 students) was used for the study. The participants were recruited through a simple random sampling technique from Junior Secondary (JS) 1 and 2 and Senior Secondary (SS) 1 and 2. There were a total of 83 students from JS 1, 101 from JS 2, 78 from SS 1, and 62 from SS 2.

• Adolescent students between the ages of 10 years and 19 years.

• Students enrolled in JS 1 and 2, and SS 1 and 2.

• Students who provided evidence of informed consent from both themselves and their parents or guardians.

• Students present at the time of the study.

• Students less than 10 years and above 19 years of age.

• Students in examination classes (JS 3 and SS 3). They were currently writing their examinations at the time the study was conducted.

• Students who did not provide the required consent from both themselves and their parents or guardians.

A researcher-developed questionnaire with a reliability coefficient of 0.762 was the instrument for data collection. The instrument consisted of 2 sections: Section A assessed the socio-demographic characteristics, family living characteristics and living conditions of the students, while Section B assessed their SRH behaviors.

Ethical approval was obtained from the Health Ethics and Research Committee of the Enugu State Ministry of Health (Ref: MH/MSD/REC21/441). Administrative permit was obtained from the Principal of the school before data collection. Informed consent was sought from the participants before administration distribution of the questionnaire. Two sets of consent forms were given to each student: one for the parent/guardian and one for the student. An explanation about the purpose of the study and the necessary instructions on how to fill out the questionnaire were provided. The principles of voluntary participation, anonymity, and confidentiality were upheld throughout the study. No identifiers were used in the questionnaire, eliminating the possibility of tracking the respondents’ responses back to them. Due to the sensitive nature of the study, participation was entirely voluntary, with no penalties for non-participation and withdrawal at any stage of the study. Access to the collected questionnaire was strictly restricted to the research team alone.

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 25 and Microsoft Excel (IBM Corporation, Armonk, New York, United States). Descriptive statistics (frequencies, means, and standard deviation [SD]) were used to summarize the data. Each item in Section B of the questionnaire was judged either to be safe or risky behavior. The overall SRH behavior was classified to be risky if there was early initiation of sexual activity, unprotected sex, more than one sexual partner, unsafe abortion practices, and nonuse of contraceptives; and classified safe, if otherwise, or if no sexual activity.

Chi-square and Fisher’s Exact tests were used to ascertain the factors significantly associated with SRH behavior. The Fisher Exact test was used when data failed to meet the Chi-square test assumption. These assumptions include 2 categorical variables; 2 or more categories (groups) for each variable; independence of observation (there is no relationship between the subjects in each group and the categorical variables are not paired in any way, for example, pre/post-test observation) and lastly, relatively large sample size (expected frequencies for each cell are at least 1 and expected frequencies should be at least 5 for the majority (80%) of the cells). A P-value less than 0.05 (<0.05) indicated a significant association; otherwise, no significance. Logistic regression, in the form of an odds ratio, was used to predict risky sexual and reproductive behaviors among the students.

The results given in Table 1 show that the age of the students ranged from 10 years to 18 years with a mean and SD of 13.55 ± 1.69. Almost all were Igbos (98.8%, n = 320) and Christians (99.1%, n = 321). The majority of the respondents were day students (78.4%, n = 254).

Table 2 shows that a greater proportion of the respondents were living with both parents (76.9%, 249), mostly in a nuclear family setting (94.0%, n = 234). For those not living with both parents, the majority were living with a female individual (77.3%, n = 58). In all, 104 of the respondents were living in a 3-bedroom flat (32.1%). Most of the adolescents received pocket money (84.3%, n = 273), majorly daily (46.9%, n = 128), and mostly from their parents (92.3%, n = 252).

The results in Table 3 reveal that very few of the respondents admitted to having sex before (8.6%, n = 28), of which the first sex experience was mainly before 9 years (50.0%, n = 14) of age, while the first sexual experience was coerced for more than half of the respondents (60.7%, n = 17). Nineteen (67.9%) students were currently having sex with a partner among those who have had sex before, mainly with one sex partner (68.4%, n = 13), while 7.4% (n = 24 which is 85.7% of those that once had sex) have had unprotected sex. In the past 6 months, 2.8% (n = 9 which is 32.1% of those who once had sex and 37.5% of those who once had unprotected sex) have had unprotected sex, while 1.5% (n = 5 which is 17.9% of those who once had sex) used a condom during their last sex with their partner. The majority of students who once had sex never prevented pregnancy during or after sex (57.1%, n = 16); whereas, those who prevented it mainly used condoms (32.1%, n = 9) and withdrawal methods (17.9%, n = 5). Three of the respondents, which represent 0.9% of the participants and 10.7% of those who have ever had sex, have ever been pregnant. Among the 3 that have ever been pregnant, 66.7% (n = 2) had been pregnant once, while 33.3% (n = 1) had been more than once. All (100%, n = 3) that were ever pregnant (0.9%) have once removed pregnancy. The majority (96.3%, 312) of the respondents have not once gone for voluntary HIV tests and screening. The incidence of risky SRH behavior among the study group is 7.7% (n = 25).

The findings in Table 4 show that class (P = 0.003), whom the adolescents were living with (P = 0.019), and whether they received pocket money or not (P = 0.002) were the factors significantly associated with sexual and reproductive healthcare behavior of the students. For class, students in SSS 2 were associated more with risky behavior compared with other classes [JSS1 (7.0%), JSS2 (2.9%), SSS1 (6.7%), and SSS2 (19.0%)]. Those living with both parents were associated least with risky behavior [Both parent (5.6%), single parent (18.2%) and non-parents, and foster parents (11.9%)], and those who receive pocket money were least associated with risky behavior [Receive (5.5%) and does not receive (19.6%)].

The logistic regression analysis in Table 5 shows that only non-receipt of pocket money significantly predicted risky SRH behavior, with the odds being 2.7 times higher than those that received pocket money [95% CI (1.002–7.353)]. Age (P = 0.533), class (P = 0.233), student type (P = 0.164), people living with (P = 0.229), and living arrangement (P = 0.514) were not significant predictors.

The majority of adolescents, according to the study’s findings, engage in safe SRH behavior; risky behavior was shown to be very low overall. Engaging in safe SRH behavior among adolescents helps to ensure a healthy SRH outcome; the prevalence of STIs, unintended pregnancy, and unsafe abortion practices is drastically reduced while promoting the emotional wellbeing and academic excellence of the adolescents. Thus, the finding is commendable and incongruent with that of Ajayi and Okeke,¹⁸who found that the majority of adolescents engaged in safe behaviors, including lifetime abstinence or abstinence in the past year, consistent use of condoms, and sexual fidelity. Similarly, a low prevalence of risky behavior was reported among adolescents in the study by Srahbzu and Tirfeneh.¹⁹

Most of the study participants reported having no history of sexual activity. This may be attributed to the young age of the respondents; and/or under-reporting usually associated with undesirable and sensitive questions like sexual intercourse. Sexual abstinence promotes healthy physical, social, sexual, and emotional wellbeing, as well as good academic performance, confidence, and self-respect. In collaboration with the findings, Isara and Nwaogwugwu⁸ revealed that the majority of the adolescents were sexually inactive. Eze et al.,²⁰ also reported a high prevalence of sexual inactivity among adolescents in their study.

Only a small percentage of respondents reported having had sexual experience, and this could be attributed to adolescent characteristics like interest in the opposite sex and sexual activity curiosity. This is still much of a concern as it might lead to an increased risk of multiple sexual partners and poor sexual health outcomes including, contracting STIs, unsafe abortion, unintended pregnancy, and possibly death from pregnancy and labor complications. The results are in opposition to those of Eyam et al.,²¹ who discovered a high prevalence of sexual activity among adolescents in Cross River State. The results also differ from those of Amoo et al.,²² who reported that more than half of the adolescents in their study had engaged in sexual intercourse. The geographical location of the study could be the reason for the discrepancies in the findings.

Half of the respondents who reported being sexually active in this study had had their first sexual intercourse before 9 years of age. The moderate prevalence of the early sexual debut found in the study could be explained by the fact that the majority of the respondents’ first sexual experiences were coerced (i.e., sexual violence and assault). This is quite disturbing and raises an alarm because early sexual initiation can increase the likelihood of many sexual partners, the prevalence of unprotected sex, the risk of STIs, unintended adolescent pregnancy, and unsafe abortions, all of which harm adolescent SRH. Sexual violence has a profound psychological and social effect on the victim, which causes emotions of powerlessness and weakness that can deplete the victim’s self-esteem and increase vulnerability to further sexual violence. The victims might struggle with physical, social, mental, emotional, and sexual issues; not to mention that academic struggles could result too. In correspondence with this result, Isara and Nwaogwugwu⁸ disclosed that many adolescents who had their first sexual experience before the age of 15 years were forced and unplanned.⁸

The study’s findings also showed that the majority of the sexually active respondents were currently sexually active with only one sexual partner. This may be attributed to the young age of the respondents and probably the fear of the consequences associated with having multiple sexual partners such as contracting STIs. Similarly, Owoeye and Nwaogwugwu²³ revealed that a high proportion of sexually active students had single sexual partners in their study.

More than half of the sexually active adolescents have had unprotected sex. They did not use any form of contraception, like condoms, pills, etc., during the sexual activity. This might be because the majority of the sexual intercourse found among these adolescents was before 9 years of age, coerced, and unplanned. This result is unsettling because of the adverse effect on the physical, social, mental, and sexual health of adolescents. The direct results of unprotected sex include unintended pregnancy, unsafe abortion, and contraction of STIs, and these are met with stigma and shame in Nigeria. Due to the possibility of them dropping out of school, the academic success of adolescents may be impacted, which could have long-term effects. This result is in line with the findings of Eyeberu et al.,²⁴ who reported that the majority of the sexually active participants used condoms inconsistently. More so, Olorunsola et al.,⁵ indicated that female adolescents accounted for more inconsistent use of condoms during sexual intercourse.

Condom and withdrawal methods were the 2 main ways of preventing unintended pregnancy as reported by the respondents in this study. This might be due to the perceived side effects of other methods of contraception. Condoms when used consistently and correctly are highly effective (99%) in preventing pregnancy and STIs. They are a reliable form of contraception and do not have any significant side effects. The withdrawal method does not have any significant side effects and can be combined with other contraception methods to increase effectiveness. However, it does not prevent contraction of STIs and is not as effective as a condom in preventing pregnancy, though, it is about 78% to 80% effective when done correctly. This result resonates with the results of Thepthien and Celyn,²⁶ where adolescents reported that condoms were the most common method of birth control, followed by emergency contraception and withdrawal methods.

All the respondents in this study who had a history of unintended pregnancy had terminated pregnancies at least once that were either carried out in the hospital, chemist shop, or at home. The inability of the students to handle the shame and stigma that come with teenage pregnancy as well as the limiting effect it might have on their academics and future, might have spurred this action. Criminal abortion in Nigeria is illegal and carries a heavy jail sentence of up to 14 years imprisonment. The only form of abortion that is legal in Nigeria is therapeutic abortion, that is, when the life of the pregnant woman is at risk. As a result, pregnant adolescents resort to unsafe abortion methods, leading to abortion-related complications such as septicemia, severe vaginal bleeding, infertility, and increasing mortality and morbidity rates in the country. In tandem with these findings, Isara and Nwaogwugwu8 discovered that the majority of the respondents who had a history of unintended pregnancy had aborted pregnancies at least once in a patent medicine store.

Pleasure and expression of love were reported as the main reasons for engaging in consensual sexual activity by adolescents in this study. This might be attributed to the increased interest in the opposite sex and sexual curiosity associated with the adolescent period. Similarly, Owoeye and Nwaogwugwu²³ reported that expression of love, pleasure, peer pressure, and incentives were reported as the reasons for consensual sex among adolescents.

In this study, the factors that were significantly associated with the sexual and reproductive healthcare behavior of adolescents were receiving pocket money and the living arrangements of the adolescents. Those living with both parents and receiving pocket money were found to be least associated with risky sexual behavior. The love, care, peace, connection, and social bond experienced by adolescents living with their parents might prevent them from engaging in risky sexual behavior. Tekletsadik et al.,²⁷ reported a similar finding where students who did not live with their families were more than 9 times likely to be engaged in risky sexual behaviors as opposed to those students who did. Additionally, Ajayi and Okeke¹⁸ found, in line with the study’s results, that individuals who lived with both parents were reported to have a higher likelihood of practising sexual abstinence.

Adolescent students in SS 2 class were found to be more associated with risky sexual behavior. Students in higher classes see themselves as adults, independent, and capable of making decisions for themselves. This might be the reason for these findings. Quite comparably, Eyam et al.,²¹ reported that class, age, place of residence, residing with parents, and parental monitoring were the determinants of adolescent SRH behavior.

Only non-receipts of pocket money significantly predicted risky SRH behavior with the odds being 2.7 times higher than those that receive pocket money. Access to pocket money by the adolescent helps to cater to their basic needs, wherein finance must be attended to for buying pads, cosmetics, wear, snacks/foods, and general upkeep. When adolescents are in want, they might tend to seek inappropriate ways to meet their needs, thereby increasing their vulnerability and making themselves as sexual prey. However, the findings of Sendekie and Worku, and Mekonnem^28,29 were in opposition to this. Students with more pocket money were more likely to have risky sexual behavior than those with less, indicating that financial freedom might encourage students to experiment with risky sexual practice. This contradicting view might be due to the geographical location of the research participants.

The high rate of safe sexual behavior among teenagers points to the effectiveness of providing comprehensive sex education. Nurses play a critical role in developing and delivering comprehensive SRH education tailored to adolescents. They can also educate the community on the dangers of sexual coercion and sexual exploitation of adolescents. Regarding the association between family living arrangements and SRH behaviors, nurses can collaborate with parents to promote open communication with adolescents and supportive family environments. Nurses can advocate for policies that support adolescent SRH, including school-based health services and economic interventions such as stipends to reduce financial vulnerabilities that may predispose adolescents to risky sexual behaviors. Knowledge of adolescent SRH behaviors and their predictors enables the nurse to collaborate with other healthcare professionals, educators, and parents/guardians to ensure a holistic approach to adolescent SRH. With these, better public health outcomes are promoted, STI transmission is decreased, and unintended pregnancies are decreased.

The study utilized a well-structured and validated questionnaire with a good reliability coefficient of 0.762, ensuring consistency and reliability of the instrument. The on-the-spot collection of data ensured a 100% return rate of the questionnaires. The sample size was adequately calculated ensuring a robust representation of the adolescent population in the school and effective representation of adolescents in each class to ensure generalizability.

One of the major limitations of the study was the issue of social desirability. Adolescents may have under-reported risky behaviors or over-reported safe sexual behaviors to align with societal expectations, particularly due to the sensitivity of the questions regarding their sexual activity and reproductive health. However, this was mitigated by upholding the principle of confidentiality, ensuring that respondents’ responses cannot be traced back to them as there are no identifiers in the questionnaire, and also allowing respondents to independently and privately fill out the questionnaire without interference. Access to the collected data was strictly restricted to the research team. Another limitation was recall bias, as participants may not accurately remember or report past SRH behaviors, especially events that occurred at a younger age. Students in examination classes (JS 3 and SS 2) were excluded, which may have a limiting effect on the generalizability of the study findings. Lastly, the study was conducted in a single secondary school in Enugu metropolis, limiting the generalizability of the results to other regions, schools, or broader populations of adolescents with different cultural, social, and economic contexts.