Survey results on sexual behaviours among secondary school students in Nigeria reveal surprising scales of sexual engagement

By Angela Iwuagwu and Benjamin Uzochukwu
 
“Researchers can be surprised at their data …” This was said by one of the authors of this blog, who due to Nigeria’s conservative cultural outlook, was surprised at how almost 50% of surveyed secondary school students affirmed sexual activeness. It was even more surprising that some of the sexually active secondary school students were involved in sexual intercourse with the same gender.
In Nigeria, the typical age for secondary school students should be between 10 and 18 years. Those within this age bracket are considered to be adolescents. It is an age of experienced puberty, marked by changes in bodily organs and hormones, early sexual urges, and exuberance.
In typical Nigerian families, parental vigilance increases as soon as children begin to mature into adolescents because they will for the first time be exposed to new feelings, inclusive of sexual feelings and manifestations of exuberance, which could go against laws and moral principles. In fact, vigilance over adolescents in a typical Nigerian setting extends beyond the home to include vigilance by adult figures in schools, neighbourhoods, markets, and worship places. Such scale of vigilance reflects the popular parlance, ‘it takes a community to train a child’.
Adolescents are expected to be steadfast in their training in school, acquire skills, and grow into becoming contributing members of society. Even in societies that support the sexualization of adolescent women, there is an increasing number of intense campaigns against such. Unfortunately, despite the many emphases of small- and large-scale vigilance over adolescents, many do not keep to the expectations of morality society has placed on them or even to the ideals of the diverse campaigns protecting adolescents from sexual engagements.
 
Sexual behaviours among adolescents in Nigeria pose a significant public health problem
For adolescents, there is just a thin line between risky and non-risky sexual behaviours. This is due to the inability of adolescents to regulate and bear the overall consequences of sexual engagements. It is for this reason, that sexual-related campaigns targeting adolescents mainly advocate abstinence. The most popular one in Nigeria for the past decade is the ‘Zip-UP!’ campaign. However, available statistics indicate that Nigerian adolescents tend not to heed such campaigns, and it is important to understand why and seek alternative approaches.
The fertility rate of 104 births per 1,000 Nigerian adolescent women is among the highest in the world. A study reported that among 428 adolescents in northern Nigeria, condomless sexual intercourse was found to be prevalent in one-third. Besides the spread of sexually transmitted infections (STIs), other concerns being witnessed as a result of this high prevalence of sexual intercourse among adolescents include unplanned pregnancies, truncated schooling, unsafe abortion, psychological worries for both adolescents and their carers, and death. The health challenges posed by sexual behaviours among adolescents extend to their carers, which is why this subject has remained of significant interest to a broad range of stakeholders.
 
Figures for adolescents’ sexual behaviours in southern-Nigeria are becoming scary
We surveyed 880 adolescents in secondary schools in the south-eastern part of Nigeria. They were between 10 and 19 years of age, drawn from rural and urban divides. We went ahead to conduct group discussions with another 80 adolescents in the region to seek more insights into the results from the survey.
Almost half (47.7%) of the surveyed adolescents confirmed participation in sexual intercourse, and some of them mentioned sexing the same gender, while others claimed to have more than one sexual partner. Substance misuse during sexual intercourse was found to be common at 93%. The misused substances in particular order are alcohol, marijuana, cigarettes, codeine, tramadol, methamphetamine, cocaine, and heroin. Of those who are sexually active, 86% never used condoms, and 75% said they had oral sex after misusing a substance. This group of adolescents also used sex as a means of exchange for drugs.
After sexual activity, less than 25% of the adolescents had confirmed pregnancies. However, adolescents in rural areas were less likely to have an abortion than those in urban areas. The study found poor parenting, exposure to uncensored videos, peer pressure, and limited knowledge of sexual and reproductive health as key factors driving up the numbers. A significant finding was that adolescents from poor homes could engage in sex for basic survival.
We discovered that primary health centres within the adolescents’ neighbourhoods were designed to provide sexual and reproductive health tips and services. Schools were also prepared to offer similar services. Disappointingly, while a good number of adolescents were unaware of such services around them, those that have ever utilised the services complained about stigmatisation and breaches of confidentiality.
 
A call to action
For several people, the scale of sexual engagement and risky sexual behaviours among adolescents in a typical conservative society like Nigeria may be surprising. The consequences are too significantly destructive, hence the need to take critical actions. First, the availability of sexual and reproductive health services in primary health centres and schools should be widely communicated, and those who are responsible for these services should be trained on the vital skills needed to work in such spaces.
Five important skills would be empathy, non-judgemental attitude, acceptance, respect for confidentiality, and case management. We reckon that these skills are home to the social service disciplines like social work and psychology, and it would be appropriate to begin to take dramatic and urgent measures to strengthen the operations of the social service professionals in health centres and schools.
The relationship between substance misuse and risky sexual behaviours among adolescents has been established. A firm approach should be in place to regulate and criminalize adolescents’ exposure to such substances. This should also include community-led awareness campaigns against substance misuse in relation to risky sexual behaviors.
Finally, we recommend community-led recreational and extracurricular activities that will keep adolescents engaged, and will serve as platforms for targeted health education content. Overall, for sustainable interventions to address these scary figures, government, non-government, and community actors will have significant and concerted roles to play. Efforts should also be made to improve sexual and reproductive health rights among adolescents in Nigeria.
 
Authors Bio
Dr. Angela Chiebodi Iwuagwu is a Nigerian medical doctor with the Community Medicine department of the University of Nigeria Teaching Hospital, and Fellow of the West African College of Physicians with expertise in public health, particularly endemic and epidemic diseases. With years of experience in sub-Saharan Africa, she has worked in various roles, including senior registrar, implementing public health programmes, and providing healthcare services to mothers and children. She has also worked as a health policy researcher and participated in various health projects.
 
Prof. Benjamin Uzochukwu is a public health physician and professor at the University of Nigeria, Nsukka. He is a renowned figure in Nigeria and Africa in health policy, systems research, and analysis. He has advised various organisations on implementation research, healthcare financing, and realistic evaluation of health programs. Professor Uzochukwu is a member of several committees, including the Ministerial Expert Advisory Committee on COVID-19 Health Sector Response in Nigeria. He is a Fellow of the National Academy of Science (FAS) and the Academy of Medicine Specialists of Nigeria (FAMedS).
 
Correspondence: Dr. Angela Iwuagwu
+234 803 528 6369
angelaiwuagwu@gmail.com
 
Acknowledgment: We thank Dr Prince Agwu for expert review.

HPRG researchers @3rd Nigeria Conference on Adolescent and Youth Health and Development

The 3rd Nigeria Conference on Adolescent and Youth Health and Development organized by the Society for Adolescent and Young People’s Health in Nigeria (SAYPHIN) took place at the Zone Conference Center Gbagada, Lagos, Nigeria. The conference started on the 16th of August and concluded on the 19th of August, 2023. The theme was EKO2023 – Achieving 2023 Targets: Driving Innovation for Adolescent and Youth Health.
The Health Policy Research Group, University of Nigeria contributed to the conversation by presenting six different outputs from its over 3 years of research on adolescents and sexual and reproductive health services in Ebonyi State, Nigeria.
 
Presentation 1
Unequal power relations between healthcare providers and young clients: barriers to accessing Sexual and Reproductive Health services in Ebony State, southeast Nigeria
Presented by Chibuike Agu
This was a cross-sectional study using qualitative data collection methods. Power dynamics between providers and young clients occurs on the basis of different social stratifiers. The provision of youth-friendly health services in the state is adversely influenced by the power imbalance between providers and young clients. Findings showed the various forms of expression of power by service providers towards young people seeking sexual and reproductive health care. Healthcare providers do not respect the SRH rights of young people. Thus, they often dictate the type of services young people should have. Sometimes, healthcare providers deny certain forms of SRH services. They also verbally abuse young people and report them to their parents or school authorities as punishment for accessing SRH care. The effect of the power imbalance is that young people feel humiliated, ashamed, or scared to visit health facilities for SRH services.
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How to cite: Agu C, Agu I, Mbachu C, Onwujekwe O (2023).  Unequal power relations between healthcare providers and young clients: barriers to accessing Sexual and Reproductive Health services in Ebony State, southeast Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 2
Effects of a School Health Intervention on Adolescents’ Knowledge of Sexual and Reproductive Health Issues in Ebonyi State, Southeast Nigeria
Presented by Chibuike Agu
This study evaluated the impact of a school-based health intervention on the knowledge of SRH among adolescents in six local government areas of Ebonyi State, Nigeria. The study applied the matching method of impact evaluation using ‘synthetic’ controls. Data were collected from 503 adolescent boys and girls aged 13–18, using a pretested structured, interviewer-administered questionnaire. Participants were selected through simple random sampling technique. A significantly higher proportion of respondents who participated in the intervention (94.16%) had good knowledge of SRH compared to those who did not participate in the intervention (85.77%), p = 0.002. Female adolescents were 3.2 times less likely to have good knowledge compared to male adolescents. Other predictors of good knowledge about SRH include living in rural areas and participating in the intervention. The school-based intervention improved the knowledge of SRH issues among adolescents. The adoption and scale-up of such interventions should ensure that there is equal participation of girls, junior students, working adolescents, and those who reside in urban areas.
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How to cite: Agu C, Mbachu C, Agu I, Ebigbiremolen G, Iloabachie U, Agu O, Onwujekwe O (2023). Effects of a School Health Intervention on Adolescents’ Knowledge of Sexual and Reproductive Health Issues in Ebonyi State, Southeast Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 3
Determinants of health service providers’ attitude towards equitability in sexual relationships in south-east Nigeria.
Presented by Ozioma Agu
Understanding the beliefs and attitudes of health service providers toward gender equitability in sexual relationships is significant in designing interventions for the effective delivery of gender-equitable youth-friendly sexual and reproductive health (SRH) services. This study examines health service providers’ attitudes toward young girls’ and young boys’ expectations in sexual relationships. This was a cross-sectional study carried out in six local government areas in Ebonyi State, Southeast Nigeria. The findings show that a good number of respondents 104(40.78%) agreed that young men and women should have sex before they become engaged to see whether they are suited for each other. Further analysis showed that health service providers whose health facilities are located in urban areas were more likely to have negative attitudes towards male expectations (t-value= -2.04) in sexual relationships by 18%. Health service providers’ attitudes toward equitability in sexual relationships underline the need to prioritize interventions that take into account the predictors of gender and societal norms regarding sexual relationships for the effective delivery of gender-equitable youth-friendly SRH services among young people.
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How to cite: Agu O, Mbachu C, Onwujekwe O (2023). Determinants of health service providers’ attitude towards equitability in sexual relationships in south-east Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 4
Attitude of healthcare providers towards providing youth-friendly health services to young people in Nigeria
Presented by Aloysius Odii
Healthcare providers of Youth Friendly Health Services (YFHS) are expected to have respect for young people and ensure privacy and confidentiality during contact with them. However, there are reports of poor treatment of young people who access sexual and reproductive health services. We have asked policymakers, young people, and health workers to describe the contexts and attitudes of providers toward adolescents seeking YFHS. The study was conducted in Ebonyi State because it has a high rate of teenage pregnancies and an unmet need for contraceptives among young people. A total of 20 In-depth Interviews (IDIs) and 10 focus Group Discussions (FGDs) were held with healthcare providers, policymakers and young people aged 15-24 years. Findings indicate that healthcare providers express both negative and positive attitudes when providing YFHS to young people. The attitude expressed is context-specific – depends on the disposition of the healthcare provider, the type of services sought, the age, marital status and gender. Healthcare providers’ attitude when dealing with young people is inconsistent and subject to change, depending on the context, which has implications for policy.
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How to cite: Odii A, Mbachu C, Onwujekwe O (2023). Attitude of healthcare providers towards providing youth-friendly health services to young people in Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 5
Multi-level predictors of young people’s attitude towards gender biases concerning rape, sexual and domestic violence in an intimate relationship among young people, Ebonyi State, Nigeria
Presented by Ifunanya Agu
Many victims of sexual violence, rape, stalking, and intimate partner violence were first victimized at an early age. To cultivate healthy relationships among young people, there is a need to address adverse gender norms and inequalities that facilitate rape and violence in intimate relationships. This study assessed multi-level factors that shape young people’s attitudes towards gender biases about rape, sexual violence, and violence in intimate relationships. Data were collected from 1,020 young people using an interviewer-administered questionnaire. Findings revealed that most (64%) young people agree that when a girl doesn’t physically fight back, you cannot really say it was rape. Many agreed that a girl who is raped is promiscuous or has a bad reputation (50%) and usually did something careless to put herself in that situation (45%). A good number 360(35%) of young people also agree that violence against a wife or girlfriend is a private matter and the girl/young woman 323(32%) should tolerate violence to keep her relationship or family together. Young girls showed a more positive attitude about sexual violence (b=0.10, CI=0.04-0.16), rape (b=0.13, CI=0.07-0.18) and domestic violence (b=0.09, CI= -0.03-0.15), in intimate relationships than young boys.
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How to cite: Agu I, Eze I, Agu C, Mbachu C, Onwujekwe O (2023). Multi-level predictors of young people’s attitude towards gender biases concerning rape, sexual and domestic violence in an intimate relationship among young people, Ebonyi State, Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 6
How well did an intervention to improve adolescents’ attitudes towards contraception, abortion, and sexual violence work in southeast Nigeria?
Presented by Ifunanya Agu
This study identified the factors that explain the attitudes of adolescents to the use of condoms, contraception, abortion, and sexual violence in urban and rural communities, following the implementation of an intervention in Nigeria. The intervention led to an increased number of adolescents who discuss sex-related matters with someone (b=0.076; cl=-0.02-0.1). Age was a significant predictor of improved attitude to issue on SRH and with every year’s increase in age among adolescents, there was a 5% and 3% increase in a positive attitude towards condom use(b=0.047) and contraception(b=0.025). The FGDs showed that with participation in school- and community-based interventions, adolescents became bolder in their decision to use condoms when engaging in casual sexual intercourse and were more confident and assertive to say no to sexual harassment and forced sex. Adolescents reported that the attitudinal change in condom use decreased the occurrence of parents arresting male sexual partners for getting adolescent females pregnant in the communities. There is a need to sustain and scale up the intervention to cover the entire state and all parts of Nigeria with similar contexts for the universal promotion of positive attitudes towards contraceptive use, abortion, and sexual violence among diverse adolescents.
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How to cite: Agu I, Agu C, Eze I, Agu O, Okeke C, Eigbiremolen G, Mbachu C, Onwujekwe O (2023). How well did an intervention to improve adolescents’ attitudes towards contraception, abortion, and sexual violence work in southeast Nigeria? Presented at EKO 2023 Conference from 16th to 19th August.
 
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Unfavorable working conditions in primary health centers are hindering access to sexual and reproductive health services for young people in Nigeria

Some facts about the sexual and reproductive health of young people
Adolescents in low- and middle-income countries (LMICs) contribute an estimated 21 million pregnancies yearly. Half of these pregnancies are unplanned, and half of them end in unsafe abortions.
One in every five girls in Nigeria between ages 15 and 19 has commenced childbearing. Early childbearing has negative consequences on the physical and mental health of girls. Up to 50% of dropout among adolescent girls is caused by teenage pregnancy.
The risk of acquiring a sexually transmitted infection (STI) is highest among young people aged 15–24. The most recent National HIV & AIDS and Reproductive Health Survey (NARHS) reported that about 9.8% of young people in Nigeria experienced symptoms of STI in the year preceding the survey.
 
Primary health centres are not meeting the SRH needs of young people
One way to ensure that young people have access to lifesaving SRH information and services is through viable social services like counselling and youth-friendly centres. Unfortunately, such centres are scarce in Nigeria, creating the need for replacements through primary health centres (PHCs). PHCs are well-positioned to address the SRH needs of young people due to the availability of trained health workers, and the possibility of finding social service professionals like social workers and psychologists to work in primary healthcare facilities.
“Think about the 17-year-old pregnant Sophia who resides in a remote village in Nigeria where the only skilled health worker is in the PHC, or the 21-year-old Jimoh who has an STI and his only access to proper treatment is the PHC.”
The reality here is that the PHC should be the rallying point for young people who need SRH services such as counselling, contraceptives, treatment of STIs, maternity care and post-abortion care. However, PHCs in their current state do not appeal to young people. They (young people) prefer to go elsewhere when they need SRH services, and their reasons are linked to the attitudes of health workers.
The big question here, is – “How do health workers repel young people from PHCs, and why?”
 
Findings from a stakeholder consultation workshop
Researchers from the Health Policy Research Group, University, University of Nigeria, held a two-day stakeholder consultation workshop at Abakaliki, Ebonyi State on the 3rd and 4th of May, 2023 with stakeholders in adolescent sexual and reproductive health. In attendance, were: relevant officials from the State Ministries of Health, Women Affairs, Youth, Sports, and Social Development, as well as officials from the Ebonyi State Primary Healthcare Development Agency, implementing partners, facility health managers and representatives of adolescents.
 
Stakeholders lamented that inefficiencies in the Primary Health Care system make it difficult for primary healthcare workers to provide sexual and reproductive health services to young people
 
 
In the table below, we highlight how these inefficiencies are making PHCs less appealing to young people, that is the ‘whys’ and the ‘hows’ respectively.
The ‘hows’ The ‘whys’
PHCs are not open in the late afternoons or evenings (that is after school or work hours) when young people are able to access services PHCs do not have the number of health workers that are required to provide 24-hour services
The skilled health workers are not available in the PHCs in the evenings. There is no provision for accommodation for skilled health workers. Or the available accommodation is poorly maintained and not livable. Absence of security in the facilities to provide cover at night for health workers and epileptic power supply with little or no provision of an alternative means of power supply  
PHC workers do not have the skills or training to provide the services that young people need Many PHCs are manned by unskilled health workers such as community health extension workers. The State government has not employed skilled health workers to replace the retired workforce and there are no qualified social service professionals like social workers and psychologists. 
The design of the PHC may not be appealing to young people and may discourage them from seeking care Many PHCs do not have separate entrances and exits for young people. There is no provision for secluded spaces for young people to receive care
Poorly motivated PHC health workers may affect their attitude toward providing friendly care Many of the health workers at the PHCs are either unpaid volunteers or underpaid workers
Non-provision of certain SRH services to young people who come to seek care Religious beliefs and personal values of health workers conflict with their provision of contraceptive services to young people. Health workers are constrained by the restrictive abortion laws in the country
 
What is the way forward?
  • The stakeholders agreed that there is a need for continuous advocacy to the State government to employ more health workers and social service professionals in the facilities.
  • There is a need to integrate the volunteer health workers formally into the health workforce so that they receive payment for their services. This will improve the motivation of these health workers who are a major contributor to the staff strength of the PHCs.
  • The State government should channel funding to improve the working conditions and environment in the PHCs. The Basic Health Provision Fund (BHCF) can be leveraged in funding things that are allowed by the tenet of the funding.
  • PHC-model which is young people-friendly and welcoming to young people was proposed to enable the PHCs to be the first port of call for young people.
  • The research team will go further to implement co-designed intervention strategies at the PHC level to make SRH services more appealing to young people.
 
Acknowledgement of contributors
Chinazom Ekwueme (MBBS, MWACP) Prince Agwu (PhD)
Ifunanya Agu (MSc) Chinyere Mbachu (MBBS, FWACP)
Irene Eze (MBBS, FWACP) Obinna Onwujekwe (MBBS, PhD)
 
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Call for Expressions of Interest (Updated): Implementation research to strengthen data systems for immunization coverage and equity (IR Accelerator) Initiative

This is a call for expression of interest (EOI) from implementer-led research teams who wish to undertake implementation research that will contribute to strengthening data and information systems for immunization coverage and equity in Nigeria.

We are seeking to fund up to eight (8) implementation research projects that will contribute to improving our understanding of the challenges and solutions for improving immunization data and information systems in Nigeria. Hence, the research projects will provide evidence on the real world factors that impact/influence the quality of immunization data, and potential strategies for addressing implementation bottlenecks and accelerating immunization coverage and equity.

Background

Nigeria has the highest number of unimmunized children in the world, estimated at 4.3 million in 2018. The coverage of DPT3/Penta 3 fell from 52% in 2014 (SMART) to 33% in 2016 (MICS/NICS). Hence, millions of infants are vulnerable to serious health and nutrition threats because they miss out on basic vaccines. In order to better understand how to reach these children and their families, locally relevant evidence is needed.

Implementation research (IR) can help us generate locally relevant evidence and useful information to better understand and address key challenges faced by the National Programme on Immunization (NPI) in Nigeria1.

The Implementation Research (IR) Accelerator Initiative is part of a collaboration between the Alliance for Health Policy and Systems Research (the Alliance), UNICEF and Gavi (the Vaccine Alliance) which has a twofold objective to promote: i) the generation of high quality, relevant and usable implementation research on data and information systems for immunization; and ii) the application and use of the evidence to address implementation bottlenecks and accelerate impact on coverage and equity.

The Health Policy Research Group (HPRG), College of Medicine, University of Nigeria Nsukka (Enugu-Campus), is the Technical Support Centre (Mentor Institution) for the Alliance in stewarding the Implementation research initiative that was informed by research priorities proposed by a broad range of Nigerian stakeholders.

Read the full call here – Updated Call for EOIs on Implementation Research in Immunization Data Systems _ Nov 26