ABSTRACT
The general aim of this study was to assess the levels of psychological and social factors and their association with sexual risk behaviors (sexual initiation and sexual intention) among secondary school students in Rivers state. This was a cross section study design nested within a cluster randomized control trial of school aged adolescents in Okrika of Rivers state city. Employing a multistage random cluster sampling procedure six schools were randomly selected from a pool of 12 schools that are involved in a large cluster randomized intervention trial in the city. Participants from each of the 6 selected schools that met the study criteria had an equal chance to be in the study. A total of 250 participants willingly took part in this study. A total of 250 participants were included in the study, 128 (51.2) Male and 121 (48.8%) female adolescents. The mean age (SD) of the participants was 12.6 years (0.7). The proportion of adolescents with high self-esteem was found to be 35.6% (89) with almost similar proportion having low self-esteem. A little more than a third 36.5% (89) of participating adolescents had high HIV self-efficacy. While with regards to depression symptomatology score, the overall proportion of adolescents who had high depression symptomatology scores was found to be 35.2%. The proportion of adolescents who had initiated sex was 35.6%. Adolescents who had high depressive scores were 3.6 times more likely to have initiated sexual activity as compared to those with low depressive score (OR, 3.62, 95% confidence interval 2.22, 9.06; p=0.001). Adolescents with low self-esteem were two and a half times more likely to have high risky sexual intentions compared to those with high self esteem (OR, 2.62 95% confidence interval 1.00, 6.92; p=0.04). Low HIV preventive self-efficacy was associated with almost three times the odds of high risky sexual intentions compared to adolescents with high HIV perceived self-efficacy, (OR, 2.72, 95% confidence interval 1.03, 7.32; p=0.04). Current depressive symptomatology did not significantly predict responses to future sexual intentions amongst participants.
CHAPTER ONE
INTRODUCTION
1.0 BACKGROUND OF THE STUDY
Adolescents‟ sexual behavior is an area that has increasingly become a focus of research. Studies in Nigeria have shown that young adolescents engage in sexual risk behaviors including sexual initiation at an earlier age, have multiple partners and unprotected sex. A number of studies in west africa have explored psychosocial predictors of an early sexual initiation (Kaaya et al, 2002). There are no retrievable studies in the region that looked at psychological factors and sexual risk behaviors.
Globally some psychological factors have shown an association with sexual risk behaviors. However, the findings have been inconsistent. Some studies (Ethier et al, 2006; Siegel et al, 2001, Dixon et al. 2000) have shown statistically significant associations between psychological factors such as depression, self-esteem and self- efficacy and sexual risk behaviors such as condom use, sexual initiations, multiple partners and future intentions to engage in sex. However, other studies (Crosby et al 2001; McNair, 1998; Pleck et al, 1990) found insignificant relationships between psychological factors and sexual risk behaviors.
Psychological wellbeing has a strong impact on a person’s decision-making process. Adolescents with high depressive symptoms are said to have increased sexual activity and may not be able to perceive risky behaviors (Brown et al 2006). Adolescents with low self-esteem are more likely to start sex at an early age and have unprotected sex so as to conform to their peers (Pleck et al, 1990; Dixon et al, 2000; Davies et al, 2003). Adolescents, who perceive they can execute a particular behavior, are more likely to engage in that behavior and thus higher self-esteem has been reported to be associated with condom use and abstaining from sex.
Globally, about 3.4 million adolescents below 15 years are said to have HIV. This study provides more insights on how psychological factors can influence engagement in sexual initiation and future sexual intentions that put adolescents at risk for HIV transmission. Future interventions and studies can benefit from these findings.
1.1 LITERATURE REVIEW
The Human Immunodeficiency Virus (HIV) is a retrovirus that affects cells of the immune system, destroying cells making the immune system weaker with limited ability to fight off infections. Acquired Immune Deficiency Syndrome (AIDS) is the result of HIV infection and it can take 10-15 years for a person living with HIV to develop AIDS (WHO, 2001). AIDS has affected millions of individuals in the world; the spread of the disease has also affected the development of nations and the world at large (UNAIDS, 2004). For instance in Nigeria, 50% of hospital beds are occupied by people living with AIDS (TACAIDS, 2008). As already indicated more than 90% of children below age 15 years living with AIDS are reported to be from west africa. Fortunately, the numbers have been declining since 2001, with a reported 30% difference estimated between 2001 and 2010(UNAIDS, 2011).
Nigeria is estimated to have 1.6 million people living with HIV/AIDS, 14% comprising adolescent aged 15-24 years old (TACAIDS, 2008). According to a global survey of HIV prevalence in 2004 by UNAIDS (2011), Nigeria is ranked 4thamongcountries of west africa with high HIV sero-prevalence. In sub- Saharan Africa, a number of studies among adolescents (Kaaya et al, 2002; Swainson, 2000; Nicholas, 1998) have looked into proximal socio-cognitive factors (age, gender, condom use self-efficacy and school performance) associated with sexual risk behaviors. There is no retrievable study in Nigeria that examines psychological factors associated with sexual risk behaviors, and sexual initiation in particular.
Sexual risk behaviors: Adolescents engage into several sexual risk behaviors (SRB). The referred SRB include early age of sex initiation, multiple partners and unprotected sex. In Nigeria, statistics show that only 49% of males and 46% of females adolescents used condom at their last high-risk sexual encounter (UNICEF, 2009). Sexual risk behaviors in the present study will be defined as sexual initiation before the age of 15, future intentions to engage in sex in the next six month, multiple partners and unprotected sex.
Early onset of sexual debut is another behavior that puts adolescents at risk of getting HIV. From a review of studies conducted in west africa, Kaaya et al (2002) argue that the mean age of sexual onset is 16 years, indicating some initiate sex prior to reaching 16 years of age. In addition, their findings show that adolescents that had ever used condoms ranged from 10% to 48%. Early sexual initiation has been linked with early pregnancy and abortion, it also influences adolescents to engage in sexual risk behaviors such as having multiple sex partners and not using condoms (Ethier et al, 2006). While sexual health knowledge alone does not reduce risk behaviors, it is an important pre- requisite for risk perception and protective actions (Crosby et al, 2001). In a survey using random cluster sampling, it was identified that less than 37% of young men aged 15-19 years knew three primary ways of avoiding HIV infection (i.e., abstinence, be faithful and consistent condom use), and 68% of girls aged 15-19 years had at least one major misconception about HIV/AIDS or had never heard of AIDS (UNICEF, Multiple Indicator Cluster Surveys, Measure DHS, 1999-2001).Matthew et al (in press) report that young school-based adolescents in Rivers state initiate sexual intercourse as early as the age of 11 years and the prevalence of sexual debut in young persons aged between 11 to 17 years old was 16.7%. In this study, intentions to engage in sex was assessed longitudinally and correlated as expected with sexual initiation. There is evidence that having multiple sexual partners increases the chances of a person acquiring HIV (Ethier et al, 2006). A study by Exavery et al (2011) examining 612 adolescents in Nigeria aged10-19 revealed that 42% reported to have multiple sex partners.
Socio-environmental factors and adolescent sexual behavior: Some studies (Boden 2006; Smith, 1997; Spencer et al, 2002; Dixon et al, 2000) have shown associations between adolescents‟ sexual behaviors and personal characteristics. Adolescents who engage in early sexual activities are more likely to engage in other problem behaviors such as abusing drugs and have poor future school performance (Smith, 1997). Socio-economic status of the family has also been identified as a factor that influences whether or not an adolescent may initiate sex at an early age or delay sex initiation. Beck (2004) argues that adolescents who are raised in less advantaged families economically are more likely to initiate sex early.
Psychological factors and sexual risk behavior: A number of studies in the United States and Europe have explored the association between sexual risk behaviors and psychological factors such as self-esteem, stress, depression, self-efficacy and anxiety. Some studies (Ethier et al, 2006; Siegel et al, 2001, Dixon et al. 2000) have shown that the named psychological factors are associated with engagement into sexual risk behaviors, while other studies (Crosby et al 2001; McNair, 1998; Pleck et al, 1990) failed to find such associations. However, most longitudinal studies manage to show that psychological factors are both predecessors and results of SRB (Butler et al, 2003; Spencer et al, 2002; Dixon et al, 2000).
Self-esteem and Sexual Risk Behavior: Looking at self-esteem, Boden (2006) argues that youth with low self-esteem tend to feel they have less worth and have a poor self-image. Studies have shown that individual’s views of sex and sexuality are influenced by self-image (Baumeister, 1999; Tesser, 2001). Counter intuitively, this suggests youths with low self-esteem, are more likely to be involved in risky behaviors. This assertion can logically be a result of weaker internal locus of control in youths with lower self esteem (Tesser, 2001), which impedes abilities to evaluate their options and the consequences of their behaviors. The main assertion underlined here, is that youth who have low self-esteem compared to those with higher self- esteem may be more likely to engage themselves into SRB such as having multiple sexual partners, sexual initiation at an early age, using condoms inconsistently and/or incorrectly. A study in United States that explored associations between the number of sexual partners and low self-esteem among adolescents (Boden, 2006) found significant associations for the age interval 15-18 years and insignificant association for older ages (21-25 years). The author notes that mechanisms for this association may not be a direct association, but an indirect one working through other factors such as childhood and family experiences. Youths with low self-esteem can be more easily persuaded by peers to engage in SRB due to the desire to please others (Harrill, 2003).
In a longitudinal study, Spencer et al (2002) followed 188 young adolescents age between 12 to 14 years old in a study that aimed to determine temporality in associations between self-esteem and sexual initiation by gender. Findings showed
that 40% of boys and 31% of girls initiated sex at the end of two-year follow up period. Boys with high compared to low self-esteem were 2.4 times more likely to initiate sexual intercourse; while girls with low compared to high self-esteem were 3 times more likely to initiate sexual intercourse compared to sexual delay.
When examining psychological factors and SRB in155 adolescent females, Ethier et al (2006) showed that low self-esteem is associated with only some SRBs including having had a risky partner. However, having multiple partners was not significantly associated with self-esteem, although it was associated with more psychological distress. The findings suggest that the mechanisms of the association between low self-esteem and SRB in female adolescent may operate through the influence of self- esteem on choices made about types of sexual partners or ability to negotiate for safer sexual practices. Other studies have found associations between self-esteem and SRB. Davies et al (2003) reports low self-esteem foresees inconsistent condom use among female African American adolescents. Findings of associations between self-esteem and SRB are however not consistent. Kalina et al (2009) found insignificant association between self-esteem and inconsistent condom use in a sample of older adolescents/young adults who were university young adolescents. These findings supported those from other studies (McNair, 1998; Pleck et al, 1990) that were also unable to find significant relationships between self-esteem and inconsistent condom use.
Interventions that improve self-esteem have been reported to decrease SRB. Dixon et al. (2000) used a group intervention to improve self-esteem in pregnant African American adolescents and documented reductions in SRB post-intervening.
Self-efficacy and sexual risk behavior: Perceived self-efficacy is the belief of a person that he/she is able to achieve a particular behavior, if he/she is confident of undertaking the particular behavior (Bandura, 1989). In other words, perception of a person’s ability to execute a behavior is an essential indicator of the likelihood of the behavior being carried out.
Self-efficacy is another psychological factor that has shown significant relationships with SRB among adolescent. The main notion is that when an adolescent believes less of their capability to engage in safe sexual practices, they are more likely to
engage in SRB. For example, when adolescent have low self-efficacy for correct and consistent condom use, they are more likely not to use condom when they engage in sex. Adolescents with high self-efficacy of their ability to avoid risky sexual behaviors are capable of understanding risk situations and are intrinsically motivated to avoid SRB such as multiple partners and unprotected sex (Holschneider and Alexander, 2003). Sexual initiation at an early age contributes to HIV infection risks; the ability of a young person to perceive that they are capable of preventing themselves from HIV increases the possibility that they will engage in safer sexual behaviors such as abstinence (Tenkorang & Maticka-Tyndale, 2008). In determining predictors of safer sexual behaviors, Kanekar and Sharma (2009) assessed 150 African American college young adolescents using self-report scales containing some socio-cognitive theory constructs including self-efficacy. Results of their study showed that self-efficacy is directly associated with safer sex behaviors (delay sex and condom use). This suggests that youth may attempt to engage in safer sex behaviors if they feel that they have the ability to practice such behaviors.
Interventions to reduce SRB have increasingly focused on strategies to improve HIV transmission prevention self-efficacy. For instance, Siegel et al (2001) found an increase in self-efficacy resulted in less sexual behaviors (multiple partners, condom use and sexual initiation) in intervention compared to control group participants after a 10 month follow-up period. Butler et al. (2003), in an intervention for HIV-positive adolescents with hemophilia showed higher self-efficacy significantly increased safer sexual behaviors (consistent condom use, outer-course, or abstinence). However, higher self-efficacy for some safe sexual behavior has not been consistently reported. A study by Crosby et al (2001) among African American females showed no significant relationship between self-efficacy for correct use of condoms and condom application skills. The authors argue that perceived ability to use condom may not relate with the actual skills.
Depression and Sexual risk Behavior: Depression may be either a mood state or when clustered with a number of core symptoms depict syndromes of mood disorders (including major depression, dysthymic disorder, and depressive disorder not otherwise specified). The present study will examine depressive symptoms expressed by children, including loss of energy, feeling worthlessness, guilt, and poor concentration to name a few (APA, 2000). A number of risky behaviors such as drug abuse, suicide and sexual intercourse have been associated with depressive symptomatology (Hallfors et al, 2005; Spriggs et al, 2008).
Welsh et al (2003) found strong associations between psychological factors and early sexual intercourse among young adolescents in America, in a study exploring depression and romantic relationships. Adolescents who reported early sexual intercourse scored higher on depressive symptomatology. The finding suggests that early sexual initiation may be influenced by psychological distress in adolescents. In a similar study, Martin et al (2005) assessed SRB among young urban adolescent girls. Findings of this study showed that young sexually active girls compared to those not sexually active had a greater number of depressive symptoms. These findings are consistent with findings of other studies (Hallfors et al, 2005; Spriggs et al, 2008). However Spriggs et al (2008) only found associations between depression and SRB among females while in males, there was no association between sexual initiation and symptoms of depression. Similarly, Caminis et al (2007) examined 1,368 adolescents on their sexual behavior and associations with psychological factors. While findings showed males initiated sexual intercourse at an earlier age compared to females, they reported insignificant associations between depression and sexual initiation or other SRB. Age differences in study samples of adolescents may explain some of the inconsistent findings. Findings of a study by Long more (2004) that assessed associations between depressive symptomatology and sex initiation in older and younger adolescents showed female adolescents aged 13 years were more likely to have an association between depressive symptoms and sexual initiation than those aged 15 and 17 years.
1.2 STATEMENT OF THE PROBLEM
HIV/AIDS is a chronic life threatening disease that has rapidly affected millions of people in the world. The most recent data shows, a total of 3.4 million children below 15 years old in 2010 were reported to be living with HIV globally (UNAIDS, 2011). More than 90% of adolescents living with HIV reside in west africa. The pandemic continues to disproportionally affect the people of west africa, accounting for 68% of the disease burden, albeit only accounting for 12% of the world’s population. Nigeria has a population of 40 million; of whom 1.8 million are living with AIDS (TACAIDS, 2008). In Nigeria, heterosexual transmission is the major mode of HIV transmission, new infections continue to occur, and the highest incidence of the epidemic is reported among young people between the ages of 15-24 years (Shisana, 2005). Due to the continuing impact of HIV/AIDS in Nigeria, there is a clear need for more studies to focus on sexual risk factors, particularly psychological risk factors (proximal determinants of SRB), in order to understand the impact of the disease and inform policy and control programs.
Research has shown that the most dramatic of all the developmental events in the life of the adolescent are psychological and cognitive changes, including the increase in sexual desire, highlighted by new and mysterious feelings and thoughts associated with these sexual desires (Greathead, Devenish, & Funnell, 1998). Adolescents‟ decisions to pursue these desire or not, are influenced by various risk factors which need to be understood in order to be appropriately addressed. Studies on adolescent sexual risk taking behavior have shed some light on influences that put adolescents at risk for their reproductive health. For instance depression been has seen to play a role in influencing adolescents to engage into sexual risk behaviors such as early sexual initiation and multiple partners (Welsh et al, 2003); self-esteem has been implicated in the initiation of sexual acts (Spencer et al, 2002), and risky partner selection and unprotected sex (Ethier et al 2006); and lastly self-efficacy has been shown to influence safer sexual practices (Kanekar and Sharma, 2009). These studies have however, been conducted in high income Western cultural contexts where the psychological constructs may have a different meaning, and it is unclear if findings will translate to a low-income country with a different socio-cultural context such as Nigeria. Similar studies in other west africa contexts are rare could not be retrieved from the literature.
Wide variations have been noted in self-reported SRBs amongst West African adolescents, and the possibility of culturally driven under-reporting in females and over-reporting in male adolescents (Kaaya et al, 2002). A recent study shows that intentions to engage in SRBs is closely correlated to initiated acts when assessed prospectively (Mathews et al, in press), providing a measure perhaps of greater accuracy when collecting self-reported information from young adolescents.
Studies in west africa have shown associations between sexual risky behaviors and proximal psychosocial influencing factors in adolescents, such as normative values and individual attitudes towards sexual risk and protective behaviors (Kaaya et al, 2002; Swainson, 2000; Nicholas, 1998). However, few studies have explored relationships between psychological factors such as self- esteem and depression on sexual risk behavior like early sexual initiation in adolescent populations of west Africa.
There is a need for studies that provide a better understanding of the associations between SRBs and more complex psychological risk factors, in order to inform the development of more targeted and comprehensive interventions aimed at controlling the spread of HIV infection. There is an added advantage in understanding associations between SRBs and self-efficacy, depression and self-esteem, as intervening early may have longer lasting influence on how a person behaves in the future. This is because intervening can happen prior to full integration of personality and hence have a positive influence in shaping personality in a direction that fosters safer sexual practices. The focus of the proposed study is to better understand the influence of these psychological factors on intentions to engage in sex and initiation of sexual behavior.
1.3 RATIONALE
Most studies and interventions on HIV prevention have examined socio-cognitive and psychosocial factors influencing sexual transmission risks and less have systematically determined core psychological factors associated with SRBs. The current study provides more insight on how psychological factors can influence engagement in sexual initiation and future sexual intentions that put adolescents at risk of HIV transmission.
Findings of the current study will provide information on psychological factors (depression, self-efficacy and self-esteem) among young adolescents in a low- income country. Information will also be provided on whether these psychological factors may influence adolescents‟ intentions to engage in sex and practice of sexual risk behaviors.
The findings will inform a more comprehensive interventions for HIV transmission risk reduction in adolescent populations. Focusing on decreasing psychological risk factors in Nigeria will augment existing strategies to increase awareness of sexual risk behaviors as well as increasing knowledge of HIV/AIDS.
1.4 THEORETICAL FRAMEWORK
Bandura‟s social cognitive theory (1971) and its underlying constructs will be integrated to answer the research questions. Constructs such as motivation and self- efficacy, have the primary goal of examining behavior and its prediction.
Social Cognitive Theory
In an effort to explain behavior, theorists, like Bandura (1971) developed the social cognitive theory. This theory, “… suggests that behavior, the environment and personal factors all influence each other” in determining behavior (Eggen & Kauchak, 1999). Several underlying constructs are important within this theory.
Motivation
From a cognitive theory perspective, motivation is a process that directs an individual’s behavior towards completion of a goal. It propels an individual to seek a better understanding of life experiences and fosters a sustained expectation of successful goal achievement. Positive incentives in the form of positive reinforcement support this motivational process (Bandura, 1971). Also, unless an individual perceives a successful outcome, they are less likely to take action. Ultimately, motivation can be intrinsically or extrinsically influenced (Bandura, 1971). Studies have shown a link between depression and motivation (Musty & Kaback, 1995) Therefore the proposed study conceptualize that adolescent with high depressive symptoms may not be motivated to practice safer sexual behaviors.
Self-efficacy
The concept of self-efficacy is an important construct that extended Bandura‟s theory. “Perceived self-efficacy refers to beliefs in one‟s capabilities to organize and execute the courses of action required to manage prospective situations. Efficacy beliefs influence how people think, feel, motivate themselves and act” (Bandura, 1995). “Self-efficacy beliefs are based on individuals‟ expectations that one possesses certain knowledge and skills, as well as the capability to take actions required to overcome problems and to succeed under the stresses and pressures of life (Sutton & Fall, 1995). In other words, a person’s perceived self-efficacy is strongly influenced by ones perceived behavioral control (Ajzen, 1991). According to Bandura‟s theory (Sinclair & O‟Boyle, 1999), judgments regarding one‟s own competence and not just confidence that the behavior can be done successfully are a critical efficacy factor necessary to produce a behavior change.
1.5 Operational definitions
Adolescence: Adolescence is defined as a period of transition from child to adulthood. It includes teenagers (aged 13 to 19 years) and may overlap with youth (aged 15 to 24 years). Literature defines adolescence as the period of time from early adolescence to late adolescence, between the approximate ages of 10 years to 21 years of age (Neinstein et al., 1996); others have defined it as a period between 10 to 19 years (Kiangi 1995) and from 12 or 13 to 19 years of age (Jarvis, 1996). For this study, young adolescence is defined as the period between 12 to 14 years of age.
Self Esteem: One‟s attitude towards oneself or ones opinion or evaluation of oneself, which may be positive (favorable or high), neutral, or negative (unfavorable or low). Also called self-evaluation.
Depressive symptomatology: State of sadness, gloom, and pessimistic ideation, with loss of interest or pleasure in normally enjoyable activities, accompanied in severe cases by anorexia and consequent weight loss, insomnia (especially middle and terminal insomnia)or hypersomnia, asthenia, feelings of worthlessness or guilt, diminished ability to think or concentrate, or recurrent thoughts of death or suicide. It appears as a symptom of many mental disorders
AIDS: Acquired immune deficiency syndrome, a disorder believed to be caused by HIV retrovirus and transmitted by infectious blood entering the body.
HIV: Human immunodeficiency virus, a retrovirus that is transmitted through sexual contact, infected blood or blood products, and from mother to child via placenta, and breaks down the body’s immune system
Preventive HIV/AIDS self-efficacy: Ability to achieve desired results in preventing oneself against HIV/AIDS disease. Perceived self-efficacy includes beliefs about one’s ability or competence to bring about intended results with regards to HIV/AIDS prevention.
Personal Factors: Modifying variables that describe specific demographic data (Larouche, 1998). In this study, it includes age, gender, grade (standard), parent‟s level of education, and religion.
1.6 RESEARCH QUESTIONS
The broad research question of the proposed study is:
- “Do psychological factors (self-esteem, depression and HIV preventive self- efficacy) influence sexual initiation and sexual intentions in school-based young adolescents?”
Specifically:
- “What is the level of self-esteem in school based young adolescents?”
- “What is the prevalence of depressive symptomatology among school based young adolescents?”
- What is the proportion of school based young adolescents with high HIV preventive self-efficacy?
- “Is there an association between self-esteem and sexual initiation and sexual intentions in school-based young adolescents?”
- “Is depressive symptomatology associated with sexual initiation and sexual intentions in school-based young adolescents?” and
- “Is HIV preventive self-efficacy associated with sexual initiation and sexual intentions in school-based young adolescents?”
1.7 STUDY OBJECTIVES
1.7.1 Broad Objective
To assess the social and psychological factors associated with sexual deviations among secondary school adolescents in Rivers state
1.72 Specific Objectives
- To determine levels of self esteem amongst school-based young adolescents aged 12-14 years in Okrika, Rivers state
- To determine the prevalence of depressive symptomatology among school- based young adolescents aged 12-14 years in Okrika, Rivers state
- To assess the level of HIV preventive self-efficacy among school-based young adolescents aged 12-14 years in Okrika, Rivers state
- To determine associations between self-esteem and SRB (sexual initiation and future sexual intentions) in school-based young adolescents aged 12-14 years in Okrika, Rivers state
- To determine associations between depression symptomatology and SRB (sexual initiation and future sexual intentions) in school-based young adolescents aged 12-14 years in Okrika, Rivers state
- To determine if HIV preventive self-efficacy is associated with SRB (sexual initiation and future sexual intentions) among school-based young adolescents aged 12-14 years in Okrika, Rivers state
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