Determinants of risky sexual behaviours among adolescents in Central African Republic, Eswatini and Ghana: evidence from multi-indicator cluster surveys

Timing of sexual debut and associated sociodemographic and HIV risk factors among young people in Eswatini

Young people in sub-Saharan Africa and specifically in Eswatini (previously Swaziland), continue to be disproportionately affected by HIV despite having equitable access to antiretroviral treatment. Early sexual debut is one of the many factors linked to HIV infection that is discussed in the context of general public health. Monitoring this behavior is essential for developing preventative, evidence-based interventions. This study aims to describe the early and/or typical sexual debut among young people in Eswatini and examines sociodemographic and HIV risk factors associated with early and typical sexual debut timing. We analyzed cross-sectional secondary data from the 2016/17 Swaziland HIV Incidence Measurement Survey (SHIMS), which had a representative sample of 2,383 young people aged 18-24. Respondents were selected using a two-stage stratified probability sampling design. We applied descriptive statistics and multivariable multinomial logistic regressions to examine the data. Out of the 2,383 respondents, 71.3% had sexual experience, with 4.1% and 26.5% reporting early sexual debut (<15 years) and typical sexual debut (<18 years), respectively. Our study found that age, sex, education, marital status, wealth, sexual partners in the past 12 months, and alcohol use were significantly associated with early and/or typical sexual debut. It is crucial to consider the sociodemographic factors and HIV risk factors of young people when designing programs and interventions aimed at preventing early sexual debut or transition. This approach is necessary to promote better sexual and reproductive health in alignment with sustainable development goals.

Prevalence of risk factors for human immunodeficiency virus among sexually active women in Rwanda: a nationwide survey

BACKGROUND

The Human Immunodeficiency Virus (HIV) remains a global health burden, and despite the advancements in antiretroviral therapy and various strategies employed to curb HIV infections, the incidence of HIV remains disproportionately high among women. Therefore, this study aimed to determine the prevalence of the risk factors for the acquisition of HIV among sexually active women in Rwanda.

METHODS

Secondary data from the 2020 Rwanda Demographic Health Survey, comprising 10,684 sexually active women, was used. Multistage stratified sampling was employed to select the study participants. Multivariable logistic regression was conducted to determine the associated risk factors using the SPSS (version 25).

RESULTS

Of the 10,684 sexually active women, 28.7% (95% confidence interval (CI): 27.5-29.4) had at least one risk factor for HIV acquisition. Having no education (AOR = 3.65, 95%CI: 2.16-6.16), being unmarried (AOR = 4.50, 95%CI: 2.47-8.21), being from female-headed households (AOR = 1.75, 95%CI: 1.42-2.15), not having health insurance (AOR = 1.34, 95%CI: 1.09-1.65), no HIV test history (AOR = 1.44, 95%CI: 1.01-2.08), being from the poorest wealth quintile (AOR = 1.61, 95%CI: 1.14-2.27) and lack of exposure to mass media (AOR = 1.30, 95%CI: 1.07-1.58) were associated with higher odds of exposure to at least one HIV acquisition risk factor. In contrast, age groups of 25-34 (AOR = 0.56, 95%CI: 0.44-0.71) and 35-44 years (AOR = 0.62, 95%CI: 0.48-0.80), rural residence (AOR = 0.63, 95%CI: 0.49-0.81) and being from the western region (AOR = 0.67, 95%CI: 0.48-0.94) were associated with less odds of exposure to at least one HIV acquisition risk factor.

CONCLUSION

More than a quarter of sexually active women in Rwanda had exposure to at least one risk factor for HIV acquisition. There is a need to maximize the use of mass media in disseminating HIV prevention and behavioral change messages. Engagement of religious leaders and promotion of HIV testing, especially among the never-testers, may be vital strategies in successful HIV prevention programs.

Preference For Cervical Cancer Education: A Multisite Cross-Sectional Survey of Female Senior High School Students in Ghana

Cervical cancer incidence continues to rise in Ghana. To enhance knowledge and prevention of cervical cancer among young people in Ghana, there is a need to better understand their education preferences. The study aimed to describe female senior school students' preferences for receiving cervical cancer education. A cross-sectional survey of students from 17 schools in the Ashanti Region of Ghana assessed the strength of preference for receiving cervical cancer education from a range of sources, settings and delivery mediums. Of the 2400 participants (aged 16-24 years), the majority endorsed doctors (87%, 95%CI: 85-88%), nurses (80%, 95%CI: 78-82%) and credible health organisations (78%, 95%CI%: 76-79%) as their preferred source of education, and hospitals 83% (95%CI: 81-84%) as the preferred setting. Nearly all students (92%) endorsed at least three cervical cancer education delivery mediums, with at least three quarters endorsing television (78%, 95%CI: 77-80%), one-on-one health consultation in-person or online (77%, 95%CI: 75-79%; 75%, 95%CI: 73-77%), and health information websites (75%, 95%CI: 73-77%). Findings suggest that cervical cancer education efforts among female senior school students in Ghana should consider the use of a range of more resource-intensive individualised approaches to low-cost anonymous, generic approaches from credible sources and institutions.

Social-psychological determinants of hormonal contraceptive use intentions among adolescent girls in the Bono East Region of Ghana

Introduction

The correct and consistent use of hormonal contraceptive (HC) methods by sexually active adolescent girls can prevent pregnancy and avert the health and social consequences of unwanted pregnancy for both the mother and her child. Despite these benefits, research shows that HC use is rather low among adolescent girls globally and especially among those in low and middle-income countries. This study was carried out to assess the social-psychological determinants of HC use intentions among adolescent girls and young women.

Methods

A cross-sectional survey was conducted among 1,203 young women aged 15-24 years from 70 communities within the Kintampo North Municipality and Kintampo South District in the Bono-East Region of Ghana from April 2021 to September 2021. Multiple linear regression analysis was used to identify factors associated with the intention to use HC among the entire sample of 1,203 respondents and among two sub-samples of young women based on HC use experience.

Results

Attitude toward personal HC use (β = 0.268; p < 0.001), self-efficacy toward access and use of HC (β = 0.341; p < 0.001), and HC use experience (β = 0.647; p < 0.001) were found to be significant and unique correlates of HC use intention among the entire sample of adolescent girls. Attitude toward personal HC use and self-efficacy toward access and use of HC were also associated with HC use intention in the two sub samples significantly (p's < 0.001). In addition, among participants with no HC experience, being a Christian as opposed to participants that affiliate themselves with Islam, Traditional religion or being non-religious positively predicts future HC use (β = 0.230; p < 0.01).

Conclusion

Our results demonstrate that different groups of adolescent girls need different interventions, focusing on different determinants for the motivation to use HC. Comprehensive sexuality education, informing all adolescent girls about the personal benefits of HC use and enhancing their skills in accessing and using HCs, can support their HC use intentions to promote their reproductive health and general wellbeing.

Social Correlates of HIV-Risky Behaviours among African Canadian Adolescents Living in British Columbia, Canada: A Secondary Data Analysis

Studies have linked HIV-risky behaviours among young people to several socio-contextual factors. However, the social factors that might increase African Canadian adolescents' exposure to HIV-risky behaviours, including unprotected sex and forced or multiple-sexual partnerships, have received little or no attention in the literature. Using data from the British Columbia Adolescent Health Surveys (2003-2018) and guided by intersectionality and socio-ecological frameworks, we examined the social determinants of HIV-risky behaviours (HRB) among African Canadian adolescents in British Columbia. We observed a general decline in HRB from 2008 to 2018. However, more than half (54.5%) of the 1042 who were sexually experienced in 2018 reported having 2 or more sexual partners, and nearly half reported condom-less sex. Our results demonstrate an important need to evaluate the impacts of several social factors on health outcomes for a unique, marginalized population.

Self-reported sexually transmitted infections among adolescent girls and young women in Mali: analysis of prevalence and predictors

OBJECTIVE

To examine the prevalence and predictors of self-reported sexually transmitted infections (SR-STIs) among adolescent girls and young women in Mali.

DESIGN

We performed a cross-sectional analysis of data from the Demographic and Health Survey of Mali, which was conducted in 2018. A weighted sample of 2105 adolescent girls and young women aged 15-24 was included. Percentages were used to summarise the results of the prevalence of SR-STIs. We used a multilevel binary logistic regression analysis to examine the predictors of SR-STIs. The results were presented using an adjusted odds ratio (aOR) with 95% confidence interval (CI). Statistical significance was set at p<0.05.

SETTING

Mali.

PARTICIPANTS

Adolescent girls (15-19 years) and young women (20-24 years).

OUTCOME MEASURE

SR-STIs.

RESULTS

The prevalence of SR-STIs among the adolescent girls and young women was 14.1% (95% CI=12.3 to 16.2). Adolescent girls and young women who had ever tested for HIV, those with one parity, those with multiparity, those with two or more sexual partners, those residing in urban areas, and those exposed to mass media were more likely to self-report STIs. However, those residing in Sikasso and Kidal regions were less likely to report STIs.

CONCLUSION

Our study has shown that SR-STIs are prevalent among adolescent girls and young women in Mali. Health authorities in Mali and other stakeholders should formulate and implement policies and programmes that increase health education among adolescent girls and young women and encourage free and easy access to STI prevention and treatment services.

Prevalence and correlates of modifiable risk factors for cervical cancer and HPV infection among senior high school students in Ghana: a latent class analysis

BACKGROUND

While health risk behaviours are likely to co-occur, there is dearth of studies exploring the clustering of cervical cancer and HPV infection risk factors among adolescents. This study aimed to determine: 1) the prevalence of modifiable risk factors for cervical cancer and HPV infection, 2) the clustering of modifiable risk factors for cervical cancer and HPV infection, and 3) factors associated with the identified clusters.

METHODS

Female students (aged 16-24 years, N = 2400) recruited from 17 randomly selected senior high schools in the Ashanti Region, Ghana completed a questionnaire assessing modifiable risk factors for cervical cancer and HPV infection including sexual experience, early sexual intercourse (< 18 years), unprotected sex, smoking, sexually transmitted infections (STIs); multiple sexual partners (MSP) and smoking. Latent class analysis explored separate classes of students according to their risk factor profiles for cervical cancer and HPV infection. Latent class regression analysis explored factors associated with latent class memberships.

RESULTS

Approximately one in three students (34%, 95%CI: 32%-36%) reported exposure to at least one risk factor. Two separate classes emerged: high-risk and low-risk (cervical cancer: 24% and 76% of students, respectively; HPV infection: 26% and 74% of students, respectively). Compared to participants in the low-risk classes i) the cervical cancer high-risk class were more likely to report exposure to oral contraceptives; early sexual intercourse (< 18 years); STIs; MSP and smoking; and ii) the HPV infection high risk class were more likely to report exposure to sexual intercourse; unprotected sex and MSP. Participants with higher risk factor knowledge had significantly higher odds of belonging to cervical cancer and HPV infection high-risk classes. Participants with greater perceived susceptibility to cervical cancer and HPV infection were more likely to belong to the high-risk HPV infection class. Sociodemographic characteristics and greater perceived seriousness about cervical cancer and HPV infection had significantly lower odds of belonging to both high-risk classes.

CONCLUSIONS

The co-occurrence of cervical cancer and HPV infection risk factors suggests that a single school-based multi-component risk reduction intervention could concurrently target multiple risk behaviours. However, students in the high risk class may benefit from more complex risk reduction interventions.

"Our parents kiss in front of us": Reasons for early sexual debut among in-school youth in the Manzini Region in Eswatini

BACKGROUND

Early sexual debut (i.e., sex before the age of 15 years), especially if it is unprotected, may increase the risk of acquiring HIV, sexually transmitted infections, and unwanted pregnancies. We investigated the reasons for early sexual debut among in-school youth in Eswatini, a setting with high HIV incidence among youth.

METHODS

This was a qualitative, exploratory-descriptive study whereby data were collected from 81 sexually active in-school youth through seven focus group discussions (FGDs) in four purposively selected public high schools (two urban and two rural) in the Manzini region, Eswatini. In each school, except one, two FGDs (one for boys and one for girls) were conducted. Qualitative data were coded and analyzed thematically in Dedoose version 8.2.14.

RESULTS

Nearly 40% of the participants reported having initiated sexual activity before 18 years. Six major themes emerged from the data: i) Intrapersonal factors (feeling mature, religiosity, nutritional or dietary patterns); ii) Parenting and household factors (living arrangement, lack of sexuality education, working parents, negative role-modeling from adults); iii) Peer and partner pressure (pressure from friends, threats from sexual partners, intergenerational sexual partnerships and transactional sex, testing sexual prowess, desire to fit in); iv) Contextual factors (neighborhood, location); v) Mass media (cell phone ownership, social media, and television shows or movies); and vi) Cultural factors (attending traditional ceremonies, loss of cultural norms, values, and traditions, and dress code).

CONCLUSION AND RECOMMENDATIONS

The poor monitoring and negative role-modeling by elders highlight the importance of involving parents or guardians as key stakeholders when designing interventions targeting risky sexual behavior among youth. The multifaceted nature of the cited reasons for early sexual debut calls for interventions aimed at curbing risky sexual behavior to be culturally sensitive and responsive to the themes identified in this study.

Prevalence and Factors Associated with Risky Sexual Behaviors Among Sexually Active Female Adolescents in Zambia

Despite decades long commitment to women's reproductive health rights, sexually transmitted diseases and unintended pregnancies continue to be major public health concerns in sub-Saharan Africa. In order to provide an evidence base for future policy and services, this study aims to explore the prevalence and factors associated with risky sexual behaviors (RSB) among sexually active Zambian female adolescents using a nationally representative sample. Data on females, aged 15-19 (n = 3000), were obtained from the 2018 Zambia Demographic and Health Survey, an interviewer-administered, nationally representative survey that used multistage sampling. The study conducted multiple logistic regression to explore the correlates of RSB. Of the 3000 respondents, 49.7% (1490) reported ever having sexual intercourse of which 71.1% reported engaging in RSB. Among sexually active female adolescents, the following RSB percentage were reported: intercourse before age 16 (50.6%), nonuse of condoms at last intercourse (37.8%), engaging in transactional sex (6.2%), alcohol use at last intercourse (4.6%), and multiple sexual partners (1.9%). Educational attainment and household wealth showed strong inverse trends with RSB risk and there were notably large geographic differences in RSB within Zambia (22.1% in Lusaka region vs. 62.4% in Western province). The multiple logistic regression results revealed that those who were younger, unmarried, with less than secondary education, without access to Internet, and residents of Western Zambia were significantly more likely to have engaged in RSB (AOR: 1.74-7.69, p < 0.05). Given the negative health outcomes associated with RSB, Zambian adolescent health care programs may strategically target limited resources to the identified risk groups.

Multiple sexual partnership among adolescent boys and young men in Ghana: analysis of the 2003-2014 Ghana Demographic and Health Survey

BACKGROUND

Multiple sexual partnership (MSP) is a major cause of HIV/AIDS epidemic and unplanned pregnancies in sub-Saharan Africa. We investigate how individual, household, interpersonal, community and structural factors correlate with multiple sexual partnership of adolescent boys and young men in Ghana.

METHODS

We pooled secondary data from the 2003, 2008 and 2014 Ghana Demographic and Health Surveys (GDHS). Analytic sample of 1422 males aged 15-24 years who are sexually active and never married were used for the study. The outcome variable for the study was two or more sexual partners in the last 12 months preceding the survey. Five models were fitted using multilevel mixed effects logistic regression to identify predictors of multiple sexual partners. Results were presented using adjusted odds ratios (ORadj) with its corresponding 95% confidence interval.

RESULTS

The pooled data prevalence of multiple sexual partnership was 28.1%, with 18.7%, 30.0% and 33.3% of adolescent boys and young men involved in multiple sexual partnerships in 2003, 2008 and 2014, respectively. Results of the study showed that young men aged 20-24 years [ORadj = 1.39, 95% CI = 1.01-1.91], being from household with richest wealth index [ORadj = 1.76, 95% CI = 1.01-3.06] and those with secondary/higher education [ORadj = 2.94, 95% CI = 1.44-6.06] were more likely to have multiple sexual partners. On the other hand, those who delayed their first sex [ORadj = 0.45, 95% CI = 0.29-0.70] and those currently using modern contraceptive methods [ORadj = 0.37, 95% CI = 0.28-0.50] were less likely to have multiple sexual partners.

CONCLUSION

The findings provide support for the social ecological argument that sexual health behaviours are influenced by individual, interpersonal, community and contextual characteristics. Future policies and interventions seeking to address the increasing prevalence of multiple sexual partnerships among adolescent boys and young men should take into consideration family planning programmes and sexual education in affluent communities, secondary and higher institutions.

Conflicting HIV/AIDS Sex Education Policies and Mixed Messaging among Educators and Students in the Lower Manya Krobo Municipality, Ghana

While school-based comprehensive sex education (CSE) is effective in HIV prevention among young people ages 10-24 years, Ghana's national sexual and reproductive health education policy promotes abstinence. Meanwhile, the Ministry of Health's HIV prevention programs provide more comprehensive school-based education. This qualitative study evaluated the HIV/AIDS education program in the Lower Manya Krobo Municipality to assess the perspectives of students and educators in 10 schools on school-based sexual and reproductive health programs, including HIV/AIDS education and conflicting HIV/AIDS sex education policies. HIV prevalence in the Lower Manya Krobo Municipality of Ghana was more than twice the national average at 5.64% in 2018, and prevalence among youth in the municipality aged 15-24 was the highest in the nation at 0.8%. Educators have mixed feelings regarding abstinence-based and CSE approaches. However, students generally endorse abstinence and describe the limitations of condom use. Ambiguity in overarching policies is identified as a factor that could influence the orientation of school-based health educators, create disharmony in sex education interventions, introduce confusing sex education messages to young people, and create a potentially narrow curriculum that limits the gamut of HIV/AIDS sex education to exclude young people's risky sexual behaviours and diverse teaching and implementation strategies. Policies and the scope of sex education should be realigned to ensure the transparent implementation of HIV/AIDS sex education programs in Ghana.

Self-reported sexually transmitted infections among sexually active men in Ghana

Background

In sub-Saharan Africa, sexually transmitted infections (STIs) other than HIV are major public health problems. This study, therefore, sought to assess the prevalence and factors associated with self-reported STIsamong sexually active men in Ghana.

Methods

Data from the 2014 Ghana demographic and health survey wereused to conduct the study. This research included a total of 3051 sexually active men aged 15–59 years. Self-reported STI was the outcome variable. The data were analyzed using both descriptive (frequencies and percentages) and inferential (binary logistic regression) analysis.

Results

The prevalence of self-reported STIs in the past 12 months preceding the survey was 6.0% (CI:4.7–6.8). Compared to men aged 45-59 years, those aged 25–34 (aOR = 2.96, CI: 1.64–5.35), 15–24 (aOR = 2.19, CI: 1.13–4.26), and 35–44 (aOR = 2.29, CI: 1.23–4.24) were more likely to report an STI. Men who had 2 or more sexual partners apart from their spouse were more likely to report an STI compared to those with no other partner apart from spouse (aOR = 4.24, CI: 2.52–7.14). However, those who had their first sex when they were 20 years and above (AOR = 0.66, CI: 0.47–0.93) and men who read newspaper/magazine had lower odds (aOR = 0.53, CI: 0.37–0.77) of reporting STIs compared to those who had sex below 20 and those who did not read newspaper/magazine respectively.

Conclusion

The study has revealed a relatively low prevalence of self-reported STI among sexually active men in Ghana. Sexually active men aged 25–34 years, those whose age at first sex is below 20 years and those with two or more sexual partners apart from their spouse had higher odds of reporting STIs. However, reading a newspaper was found to be positive in reducing the odds of reporting STIs. To reduce STIs among sexually active men in Ghana, it is important for health systems and stakeholders to consider these factors and put in place measures to mitigate those that put men at risk of STIs and encourage the adoption of the protective factors. Mass media can be used as a useful avenue for encouraging men to report STIs in order to avoid transmitting them to their partners. 

"Knowledge I seek because culture doesn't work anymore … It doesn't work, death comes": the experiences of third-generation female caregivers (gogos) in South Africa discussing sex, sexuality and HIV and AIDS with children in their care

Background

Sexual reproductive health communication between parents and children has been shown to promote safer sexual choices. In many South African households, third-generation female caregivers, often grandmothers or other older females, locally known as gogos, are primary caregivers of children due to parents being deceased or absent. Subsequently, the responsibility of talking about sex and related issues has shifted to these gogos. This study explored the experiences of gogos living in Alexandra, Johannesburg on talking about sex, sexuality and HIV and AIDS with children aged 10–18 years that are in their care.

Methods

Ten primary caregivers were purposively selected. Data were collected through in-depth individual interviews. Thematic analysis was performed and inductive codes and themes identified.

Results

All gogos selected found it difficult to discuss sex, sexuality and HIV and AIDS due to culture and traditional values impacting on personal experiences as well as generation and gender barriers. Perceived low self-efficacy due to low levels of knowledge and limited skills in speaking about sex, sexuality and HIV and AIDS also contributed to low levels of sexual reproductive health communication.

Conclusions

This study highlights the need for interventions that focus on improving gogos’ knowledge about sexual reproductive health in addition to providing them with the skills to talk about sex, sexuality and HIV and AIDS with children in their care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10494-5.

A multi-country cross-sectional study of self-reported sexually transmitted infections among sexually active men in sub-Saharan Africa

Background

Despite the importance of self-reporting health in sexually transmitted infections (STIs) control, studies on self-reported sexually transmitted infections (SR-STIs) are scanty, especially in sub-Saharan Africa (SSA). This study assessed the prevalence and factors associated with SR-STIs among sexually active men (SAM) in SSA.

Methods

Analysis was done based on the current Demographic and Health Survey of 27 countries in SSA conducted between 2010 and 2018. A total of 130,916 SAM were included in the analysis. The outcome variable was SR-STI. Descriptive and inferential statistics were performed with a statistical significance set at p < 0.05.

Results

On the average, the prevalence of STIs among SAM in SSA was 3.8%, which ranged from 13.5% in Liberia to 0.4% in Niger. Sexually-active men aged 25–34 (AOR = 1.77, CI:1.6–1.95) were more likely to report STIs, compared to those aged 45 or more years. Respondents who were working (AOR = 1.24, CI: 1.12–1.38) and those who had their first sex at ages below 20 (AOR = 1.20, CI:1.11–1.29) were more likely to report STIs, compared to those who were not working and those who had their first sex when they were 20 years and above. Also, SAM who were not using condom had higher odds of STIs (AOR = 1.35, CI: 1.25–1.46), compared to those who were using condom. Further, SAM with no comprehensive HIV and AIDS knowledge had higher odds (AOR = 1.43, CI: 1.08–1.22) of STIs, compared to those who reported to have HIV/AIDS knowledge. Conversely, the odds of reporting STIs was lower among residents of rural areas (AOR = 0.93, CI: 0.88–0.99) compared to their counterparts in urban areas, respondents who had no other sexual partner (AOR = 0.32, CI: 0.29–0.35) compared to those who had 2 or more sexual partners excluding their spouses, those who reported not paying for sex (AOR = 0.55, CI: 0.51–0.59) compared to those who paid for sex, and those who did not read newspapers (AOR = 0.93, CI: 0.86–0.99) compared to those who read.

Conclusion

STIs prevalence across the selected countries in SSA showed distinct cross-country variations. Current findings suggest that STIs intervention priorities must be given across countries with high prevalence. Several socio-demographic factors predicted SR-STIs. To reduce the prevalence of STIs among SAM in SSA, it is prudent to take these factors (e.g., age, condom use, employment status, HIV/AIDS knowledge) into consideration when planning health education and STIs prevention strategies among SAM.