ABSTRACT
Adolescents often engage in high-risk behaviors which often have lifelong consequences. It is unclear whether an association exists between adolescents’ perception of family support and family functioning and sexual risk behavior. We conducted a cross-sectional study of 702 adolescent students (aged 15–19 years) of a university in Nigeria and assessed high-risk sexual behavior (HRSB) and their judgment of family functioning and support. We used multivariable logistic regression analyses to evaluate the relationship between HRSB and the perception of family support and functioning. We found that 114 (16.2%, 95% CI: 13.69–19.16) of the adolescents engaged in HRSB. A higher proportion of boys (22.7%, 95% CI: 17.79–28.47) than girls (12.93, 95% CI: 10.17–16.31) engaged in HRSB (P = 0.001). The prevalence of intimate partner violence in our study was 8% (95% CI: 6.19–10.29). Participants with lower perception scores were more likely to be engaged in HRSB (aOR: 0.920, 95% CI: 0.878–0.965). Likewise, the perception of family functioning was inversely related to HRSB among the participants (aOR: 0.884, 95% CI: 0.813–0.962). There is an association between adolescents’ perception of family support and functioning and HRSB. This association may provide a link in the complex interaction between the role of the family and adolescent sexuality. Programs and interventions for preventing HRSB and promoting risk-reducing autonomous decision-making among adolescents should include context- and setting-specific interventions that improve family support and functioning, and those that target in dysfunctional family settings.
SUMMARY
High-risk sexual behavior (HRSB) among adolescents may result in unwanted pregnancies, mental health issues, and sexually transmitted infections, including HIV/AIDS. These outcomes can have serious implications for the health and well-being of young people. There is evidence to suggest that adolescents’ perception of family support and how well their families function affects their sexual behavior. In this study, we interviewed 702 Nigerian adolescents aged 15–19 years about their sexual lives and other personal characteristics. We also assessed their perception of their families’ support and functioning. We then used statistical methods to identify the adolescent characteristics that were associated with (HRSB. We defined HRSB as having become sexually active at or before the age of 14 years; having sexual intercourse without using any concomitant means of preventing unwanted pregnancy, HIV, and other STIs; or having multiple concurrent sexual partners. We found that about one in every five of the adolescents was involved in sexual risk-taking and that more boys than girls engaged in HRSB. Adolescents with poor perceptions of their family support and functioning were more likely to engage in risky sexual behaviors. Also, those who had been sexually abused, especially by close relatives, were more likely to take sexual risks than the others. It is therefore important for policymakers and program experts to incorporate measures to protect adolescents from abuse, promote family support for them, and improve family functioning in policies and programs aimed at reducing sexual risk-taking among adolescents.
INTRODUCTION
Adolescence represents a period of significant physical, psychological, and mental transition that is characterized by the tendency for young people to explore and experiment in the search for self-discovery and independence.1 This exploration can however be attended by high-risk behaviors which often have lifelong consequences. Many high-risk behaviors, including HRSB, tobacco use, substance abuse, and physical inactivity, that result in premature death in adulthood have their origin in adolescence.1
High-risk sexual behaviors are those behaviors that increase the risk of unwanted pregnancy and/or sexually transmitted infections (STIs), including HIV infection. Examples of such behavior include early sexual debut (ESD) (before the age of 15 years), having unprotected sexual intercourse, having multiple sexual partners, and having sexual intercourse under the influence of alcohol or drugs.2,3 High-risk sexual behavior in adolescence is a predictor of both adverse adolescent health outcome and future HRSB in adulthood.1 High-risk sexual behavior is associated with high HIV-related morbidity and mortality among adolescents.4 Adolescent pregnancy can increase the risk of unsafe abortion, which is a leading cause of female adolescent (15–19 years) mortality. Children born to adolescents are more liable to die than those born to more mature women.5
There is a large body of research evidence from Western and high-income countries that highlights the role of family and family support on adolescents’ sexual behaviors and outcomes.6 Early sexual debut and adolescent pregnancy are associated with single-parent households.6 This relationship has been found to hold across various income strata. Adolescents raised by single parents are more likely to engage in HRSBs.6,7 The effect of family structure on adolescent sexuality is an indirect one, whereas a more direct relationship exists between low-risk adolescent sexual behavior and strong parent–adolescent interactions and communication.8–11 However, the effect of parent–adolescent communication is contextual and gender-dependent. There is an association between good parent–adolescent communication on sexuality and delayed sexual debut among female adolescents in Africa.10 However, a similar relationship exists among male adolescents in other settings.11
The limitations of previous research include the failure to consider how supportive the adolescents perceive parent–adolescent interaction and communication to be, and more specifically, the association between the perception of family support and adolescent sexual risk behavior. There is also a limited consideration for the role of family structure on the context, within which the adolescents have sexual experiences.6 Our study fills a gap in the current literature by assessing the association between perceived family support and functioning and sexual risk behaviors among a group of privileged adolescents attending a university in a low- to middle-income country. We considered the role of family structure in this relationship. The implications of our findings for policy and planning are discussed.
MATERIALS AND METHODS
Study design and procedures.
We conducted a cross-sectional study of 702 adolescent (aged 15–19 years) new students of a private university in Nigeria whom we recruited by systematic sampling from the sampling frame of new admissions after the university registration process between August and October 2018. The minimum required sample size calculation was based on a 95% confidence internal and error margin of 5% to capture enough participants to reflect a prevalence of 43.8% of sexual activity among female adolescents in Nigeria.12 We doubled the calculated sample size to improve precision. New students of private universities in Nigeria are usually adolescents from middle- or upper-class homes who are leaving home for independent existence for the first time in their lives. The new students are unexposed to the university environment which is well known to exert enormous influences on perceptions of sexuality and sexual health of individuals.13 They usually arrive at the university with experiences and attitudes toward sex that are mostly dependent on their family background, culture, religion, and personal ideals.14
We used a sampling fraction of four to select 702 participants from a list of 2,810 duly registered new students aged 15–19 years obtained from the university registry. Whenever an individual declined participation (a total of 15 students declined), we recruited the next student on the list into the study. Selected adolescents were invited through phone calls and taken through the informed consent process on arrival for their appointments. The interviewers were fresh first-year resident doctors, with minimal prior interaction with the student population. Interviews were conducted in private rooms by interviewers of the same gender with the interviewee to encourage openness.
Structured interviews lasting an average of 15 minutes each using standardized questionnaires were used to obtain study data from the adolescents. We excluded students with previous attendance at a higher institution from the study. The study instrument included questions that assessed personal characteristics, family structure, living arrangement, and adolescents’ perception of family support and functioning. We also assessed the adolescents’ reported involvement in HRSB. The interviews were administered in English language by physicians who previously had an 8-hour training on the objectives and procedures of the research.
MEASURES
Outcome variable.
The outcome variable was HRSB. In the current study, three HRSBs were assessed, namely, ESD, unprotected sexual intercourse, and having multiple concurrent sexual partners. Early sexual debut is having had the first sexual intercourse at or before the age of 14 years. For the analysis of ESD, we divided the adolescents into two categories: “yes” if the adolescent had sexual debut at or before the age of 14 years and “no” if the adolescent had sexual debut after 14 years or had never had sex. We coded ESD as “0” for no or “1” for yes.
We assessed unprotected sexual intercourse by asking whether the participants had engaged in unprotected sex in the previous 6 months, unprotected sex being sexual intercourse without concomitant use of any form of contraception and prophylaxis against STIs, including HIV. We then grouped the adolescents into two categories: “yes” (coded as 1) if they had engaged in unprotected sex in the previous 6 months and “no” (coded as 0) if they had not engaged in unprotected sexual intercourse in the preceding 6 months or had never had sex. Likewise, we assessed multiple concurrent sexual partnerships in the preceding 6 months, and participants were categorized as “yes” (coded as 1) if they had had more than one sexual partner in the preceding 6 months and “no” (coded as 0) if they had had only one or no sexual partner in the preceding 6 months.
We then created the composite outcome variable: “HRSB” for which we categorized the adolescents into two categories: “yes” (coded as 1) if they reported yes to any of the three HRSBs highlighted previously and “no” if they reported “no” to all of the HRSBs.
Explanatory variables.
The explanatory variables were the adolescents’ perception of family support and functioning. We assessed the perception of family support using the Perceived Social Support Scale-Family (PSS-FA).15 The PSS-FA is a 20-item questionnaire that measures the extent to which young people perceive their family as fulfilling their need for support, information, and feedback. It assesses the verbal and behavioral expression of intimacy. The questions have a scale of three options: responses indicative of social support have a score of +1, whereas responses that suggest lack of social support and “don’t know” have a score of zero. The total score ranges from 0 to 20. Higher scores indicate higher levels of social support. The scale is not affected by the participants’ moods. It has an inverse relationship with symptoms of distress and psychopathology.15 The measure has been validated in the sub-Saharan African population showing high internal consistency and evidence of convergent and divergent validity.16 We also measured the adolescents’ perception of family functioning by assessing their satisfaction with family relationships. We used the Family Adaptability, Partnership, Growth, Affection, and Resolve (APGAR) scale for this purpose.17 It is a five-parameter (adaptability, partnership, growth, affection, and resolve) family functioning scale. The three-point response scale ranges from 0 (hardly ever) to 2 (almost always). The total score ranges from 0 to 10. Higher scores are indicative of higher degrees of satisfaction with family functioning.17
Control variables.
We controlled for certain variables that are known to be related to adolescent sexual risk-taking behaviors. These included demographic characteristics, sexual/violence history, and family structure. The demographic characteristics that we assessed included age, gender, religious involvement, and paternal and maternal socioeconomic status (SES). We determined the paternal and maternal SES based on occupation and the highest level of education completed. For this purpose, we used the scales designed by Oyedeji.18 Oyedeji presented two separate five-point scales for assessing social classes of children based on education and occupation of their parents. The individuals in classes I and II are in high SES; those in class III are in the middle SES, and those in classes IV and V are in the low SES.18 We assessed the participants’ reported involvement in religious activity by determining how often they attended religious services in a month. We then grouped them into low involvement (attending services less than once in a month), moderate involvement (two to three times a month), and high involvement (once or more than once every week). We also assessed the adolescents’ reported relationship status, alcohol consumption, smoking status, and housing situations.
For sexual/violence history, we asked about sexual exposure, age at the first sexual intercourse, and the number of lifetime sexual partners. We assessed the HRSBs such as having multiple sexual partners and having unprotected sex. We also assessed the occurrence of sexual and nonsexual violence at home and intimate partner violence (IPV). We referred participants with a history of non-partnered violence or IPV to counseling services in line with the WHO’s clinical and policy guidelines on IPV and sexual violence.19
For the family structure, we assessed the number of people in the adolescents’ households, type of living arrangement, orphan status, and family type (both parents, single parent, and other guardians). We assessed parental use of verbal and physical discipline on the adolescents.
Data Analyses.
We performed quantitative data analyses using Stata/SE 15.1 (StataCorp, College Station, TX).20 Little’s test was conducted to confirm missingness completely at random, and complete case analysis was conducted. We conducted bivariate analyses (chi-square and t-tests as appropriate) to assess the relationship between HRSB and the explanatory and control variables. We ran a multivariable logistic regression model to measure the association between the perception of family support and functioning and HRSB while controlling for the control variables that had P-values < 0.25 on bivariate analyses. We excluded the sexual variables from the multivariable analysis because of their correlation with the outcome variable. In any case, the outcome variable was a composite constructed from sexual variables.
RESULTS
Descriptive analyses.
Table 1 illustrates the characteristics of the study participants disaggregated by gender. The study had more girls (66.1%) than boys (33.9%), a fair representation of the female-to-male ratio of first-year students of the institution, which is significantly skewed toward the female gender. The mean age was 17.58 ± 1.25 years. About two-thirds of the adolescents (68%) were highly involved in religious services, with more girls (72%) than boys (60.1%) being highly involved (P < 0.001). More than 90% of our study participants had mothers (92.9%) and fathers (94.2%) who belonged to high socioeconomic class. While 18.2% (95% CI: 15.43–21.23) of the adolescents reported consuming alcohol, 4.4% (95% CI: 3.09–6.23) of them were current smokers. More boys than girls reported currently consuming alcohol (P < 0.001) and smoking cigarette (P = 0.001). One hundred eighty of the adolescents (25.6%, 95% CI: 22.54–29.01) reported having ever had sexual intercourse, with a higher proportion of boys (34%, 95% CI: 28.26–40.31) than girls (21.3%, 95% CI: 17.83–25.31) (P < 0.001). The mean age at the first sexual intercourse was 15.37 ± 2.14 years, with no statistically significant difference by gender (P = 0.362). Likewise, the prevalence of ESD (10.1%, 95% CI: 8.09–12.58) was not statistically different for boys and girls (P = 0.117). The average number of lifetime sexual partners among the adolescents who had ever had sexual intercourse was 2.90 ± 1.87. This number was not different between boys and girls (P = 0.367). Higher proportions of boys than girls had ever had unprotected sex (P = 0.014) and ever had multiple sexual partners (P = 0.021). The prevalence of IPV in our study was 8% (95% CI: 6.19–10.29), with a higher proportion of boys (9.4%, 95% CI: 6.23–13.84) than girls (7.3%, 95% CI: 5.23–10.10) reporting IPV, but this difference was significant (P = 0.345). The prevalence of home violence and sexual violence at home were 15.6% (95% CI: 13.10–18.54) and 5.4% (95% CI: 3.97–7.37), respectively, with no statistically significant differences by gender (P > 0.05). The parents/guardians scolded girls more often than the boys (P < 0.001), whereas boys experienced spanking more than girls (P = 0.008). The mean Family APGAR score was 7.28 ± 2.68, with no statistical difference by gender (0.136).
Table 1.
Selected characteristics of first-year adolescents in a private university in Nigeria (2018)
| Participants’ characteristics (number of responses) | n (%) | Male (%) | Female (%) | χ2 | P-value |
|---|---|---|---|---|---|
| 238 (33.90) | 464 (66.10) | ||||
| High-risk sexual behavior (702) | 114 (16.24) | 54 (22.69) | 60 (12.93) | 11.012 | 0.001 |
| Perceived social support score (702) | 11.80 (±5.07)* | 11.11 (±5.04)* | 12.15 (±5.05)* | −2.573† | 0.010 |
| Family APGAR score (693) | 7.28 (±2.68)* | 7.07 (±2.66)* | 7.39 (±2.69)* | −1.492† | 0.136 |
| Sociodemographic characteristics | |||||
| Age, years (702) | 17.58 (±1.24)* | 17.71 (±1.24)* | 17.51 (±1.23)* | 1.979† | 0.048 |
| Religious involvement (702) | |||||
| Low involvement (never and less than once a month) | 54 (7.69) | 30 (12.61) | 24 (5.17) | – | – |
| Moderate involvement (once a month and two to three times a month) | 171 (24.36) | 65 (27.31) | 106 (22.84) | 15.864 | < 0.001 |
| High involvement (once a week or more than once a week) | 477 (67.95) | 143 (60.08) | 334 (71.98) | – | – |
| Relationship status (655) | |||||
| Not in a relationship | 358 (54.66) | 124 (56.88) | 234 (53.55) | – | – |
| Currently in a relationship | 100 (15.27) | 36 (16.51) | 64 (14.65) | 1.937 | 0.380 |
| Complicated | 197 (30.08) | 58 (26.61) | 139 (31.81) | – | – |
| Residence (685) | |||||
| Urban | 605 (88.32) | 203 (87.88) | 402 (88.55) | 0.066 | 0.797 |
| Rural | 80 (11.68) | 28 (12.12 | 52 (11.45) | – | – |
| Housing (673) | |||||
| Flat/duplex | 621 (92.27) | 201 (88.55) | 420 (94.17) | 6.674 | < 0.001 |
| Single room/self-contained apartment | 52 (7.73) | 26 (11.45) | 26 (5.83) | – | – |
| Alcohol consumption (683) | 124 (18.16) | 58 (25.22) | 66 (14.57) | 11.640 | 0.001 |
| Smoking status (681) | |||||
| Never smoked | 592 (86.93) | 187 (81.30) | 405 (89.80) | – | – |
| Ex-smoker | 59 (8.66) | 29 (12.61) | 30 (6.65) | 9.733 | 0.008 |
| Current smoker | 30 (4.41) | 14 (6.09) | 16 (3.55) | – | – |
| Maternal SES (677) | |||||
| High | 629 (92.92) | 209 (91.67) | 420 (93.54) | – | – |
| Middle | 19 (2.81) | 9 (3.95) | 10 (2.23) | 1.660 | 0.436 |
| Low | 29 (4.28) | 10 (4.39) | 19 (4.23) | – | – |
| Paternal SES (673) | |||||
| High | 634 (94.21) | 214 (93.86) | 420 (94.38) | – | – |
| Middle | 22 (3.27) | 9 (3.95) | 13 (2.92) | 0.641 | 0.726 |
| Low | 17 (2.53) | 5 (2.19) | 12 (2.70) | – | – |
| Sexual and violence history | |||||
| Ever had sexual intercourse (702) | 180 (25.64) | 81 (34.03) | 99 (21.34) | 13.302 | < 0.001 |
| Age at the first sexual intercourse (178) | 15.37 (±2.14)* | 15.53 (±1.91)* | 15.24 (±2.31)* | 0.913† | 0.362 |
| Number of lifetime sexual partners (696) | 0.73 (±1.57)* | 0.94 (±1.64)* | 0.63 (±1.53)* | 2.512† | 0.012 |
| Number of lifetime sexual partners (176) | 2.90 (±1.87)* | 2.77 (±1.68)* | 3.02 (±2.02)* | −0.904† | 0.367 |
| Ever had unprotected sex (702) | 106 (15.10) | 47 (19.75) | 59 (12.72) | 6.069 | 0.014 |
| Had unprotected sex within the preceding 6 months (701) | 74 (10.56) | 32 (13.50) | 42 (9.05) | 3.291 | 0.070 |
| Ever had multiple sexual partners (702) | 69 (9.83) | 32 (13.45) | 37 (7.97) | 5.313 | 0.021 |
| Had multiple sexual partners within the preceding 6 months (702) | 60 (8.55) | 27 (11.34) | 33 (7.11) | 3.605 | 0.058 |
| Experienced home violence (691) | 108 (15.63) | 38 (16.17) | 70 (15.35) | 0.079 | 0.779 |
| Experienced sexual violence at home (701) | 38 (5.42) | 18 (7.56) | 20 (4.32) | 3.225 | 0.073 |
| Ever experienced IPV (687) | 55 (8.01) | 22 (9.36) | 33 (7.30) | 0.892 | 0.345 |
| Family structure | |||||
| Total number in household (663) | 6.36 (±2.63)* | 6.31 (±2.52)* | 6.39 (±2.68)* | −0.346† | 0.730 |
| Raised by (696) | |||||
| Two parents, biological | 593 (85.20) | 200 (85.11) | 393 (85.25) | – | – |
| Two parents, one biological | 25 (3.59) | 11 (4.68) | 14 (3.04) | 2.457 | 0.635 |
| One parent | 47 (6.75) | 15 (6.38) | 32 (6.94) | – | – |
| Other Relatives | 27 (3.88) | 7 (2.98) | 20 (4.34) | – | – |
| Nonrelatives | 4 (0.57) | 2 (0.85) | 2 (0.43) | – | – |
| Current living arrangement (693) | |||||
| With parent(s) | 654 (93.16) | 214 (89.92) | 440 (94.83) | 5.958 | 0.015 |
| With others | 48 (6.84) | 24 (10.08) | 24 (5.17) | – | – |
| Orphan status (695) | |||||
| Not an orphan | 621 (89.35) | 206 (86.92) | 415 (90.61) | – | – |
| Lost only mother | 30 (4.23) | 14 (5.91) | 16 (3.49) | 2.768 | 0.429 |
| Lost only father | 29 (4.17) | 11 (4.64) | 18 (3.93) | – | – |
| Lost both parents | 15 (2.16) | 6 (2.53) | 9 (1.97) | – | – |
| Parental discipline (verbal/scolding) (688) | |||||
| Not living with parents | 48 (6.98) | 24 (10.17) | 24 (5.31) | – | – |
| Never | 72 (10.47) | 41 (17.37) | 31 (6.86) | 26.305 | <0.001 |
| Occasionally | 380 (55.23) | 117 (49.58) | 263 (58.19) | – | – |
| Frequently | 188 (27.33) | 54 (22.88) | 134 (29.65) | – | – |
| Parental discipline (physical/spanking) (687) | |||||
| Not living with parents | 48 (6.99) | 24 (10.26) | 24 (5.30) | – | – |
| Never | 272 (39.59) | 97 (41.45) | 175 (38.63) | 11.847 | 0.008 |
| Occasionally | 297 (43.23) | 84 (35.90) | 213 (47.02) | – | – |
| Frequently | 70 (10.19) | 29 (12.39) | 41 (9.05) | – | – |
Independent test.
Mean SD.
Concerning our outcome variable, we found that 114 (16.2%, 95% CI: 13.69–19.16) of the adolescents engaged in HRSB. A higher proportion of boys (22.7%, 95% CI: 17.79–28.47) than girls (12.93, 95% CI: 10.17–16.31) engaged in HRSB (P = 0.001). The adolescents’ perception of their families’ social support was our main explanatory variable. The overall mean perception score was 11.80 ± 5.07 out of a maximum possible score of 20. The boys had a mean score of 12.15 ± 5.05 and that of the girls was 11.11 ± 5.04. The observed difference was statistically significant (P = 0.010). In Tables 2 and 3, we show the responses of the adolescents to the 20 items of the PSS-FA and the five-item Family APGAR.
Table 2.
Perception of social support among first-year adolescents in a private university in Nigeria (2018)
| s/n | PSS-FA items | Yes (%) | No (%) | Do not know (%) |
|---|---|---|---|---|
| 1 | My family gives me the moral support I need | 594 (84.62) | 62 (8.83) | 46 (6.55) |
| 2 | I get good ideas about how to do things or make things from my family | 564 (92.17) | 83 (11.82) | 55 (7.83) |
| 3 | Most other people are closer to their family than I am | 201 (28.63) | 312 (44.44) | 189 (26.92) |
| 4 | When I confide to the members of my family who are closest to me, I get the idea that it makes them uncomfortable | 224 (31.91) | 333 (47.44) | 145 (20.66) |
| 5 | My family enjoys hearing about what I think | 459 (65.38) | 122 (17.38) | 121 (17.24) |
| 6 | Members of my family share many of my interests | 422 (60.11) | 144 (20.51) | 136 (19.37) |
| 7 | Certain members of my family share many of my interests | 407 (57.98) | 157 (22.36) | 138 (19.66) |
| 8 | I rely on my family for emotional support | 376 (53.56) | 241 (34.33) | 85 (12.11) |
| 9 | There is a member of my family I could go to if I were just feeling down, without feeling funny about it later | 466 (66.38) | 154 (21.94) | 82 (11.68) |
| 10 | My family and I are very open about what we think about things | 413 (58.83 | 174 (24.79) | 115 (16.38) |
| 11 | My family is sensitive to my personal needs | 465 (66.24) | 145 (20.66) | 92 (13.11) |
| 12 | Members of my family come to me for emotional support | 357 (50.85) | 246 (35.04) | 99 (14.10) |
| 13 | Members of my family are good at helping me solve problems | 468 (66.67) | 145 (20.66) | 89 (12.68) |
| 14 | I have a deep sharing relationship with a member of my family | 393 (55.98) | 218 (31.05) | 91 (12.96) |
| 15 | Members of my family get good ideas about how to do things or make things from me | 427 (60.83) | 151 (21.51) | 124 (17.66) |
| 16 | When I confide in the members of my family, it makes me uncomfortable | 250 (35.61) | 336 (47.86) | 116 (16.52) |
| 17 | Members of my family seek me out for companionship | 370 (52.71) | 198 (28.21) | 134 (19.09) |
| 18 | I think that my family feels that I am good at helping them solve problems | 393 (55.98) | 141 (20.09) | 168 (23.93) |
| 19 | I do not have a relationship with a member of my family who is as close as other people’s relationships with family members | 208 (29.63) | 314 (44.73) | 180 (25.64) |
| 20 | I wish my family were much different | 191 (27.21) | 398 (56.70) | 113 (16.10) |
PSS-FA = perceived Social Support Scale-Family.
Table 3.
Perception of family functioning (Family APGAR) among first-year adolescents in a private university in Nigeria (2018)
| Question | Domain | Responses, n (%) | ||
|---|---|---|---|---|
| Hardly ever | Some of the time | Almost always | ||
| I am satisfied that I can turn to my family for help when something is troubling me | Adaptability | 63 (9.09) | 241 (34.78) | 389 (56.13) |
| I am satisfied with the way my family talks over things with me and share problems with me | Partnership | 71 (10.25) | 269 (38.82) | 353 (50.94) |
| I am satisfied that my family accepts and supports my wishes to take on new activities or direction | Growth | 70 (10.10) | 234 (33.77) | 389 (56.13) |
| I am satisfied with the way my family expresses affection and responds to my emotions such as anger, sorrow, or love | Affection | 73 (10.53) | 250 (36.08) | 370 (53.39) |
| I am satisfied with the way my family and I share time together | Resolve | 73 (10.53) | 201 (29.00) | 419 (60.46) |
Bivariate analyses.
Table 4, on the other hand, presents the results of bivariate analyses comparing our outcome variable with the explanatory variable and other covariates. Our analysis showed that a statistically significant association exists between the adolescents’ perception of family support and HRSB (P < 0.001) and their perception of family functioning (P < 0.001). The mean PSS-FA scores for those with HRSB (9.30 ± 5.25) were significantly lower than the mean score for those without HRSB (12.28 ± 4.89). The mean Family APGAR score for adolescents with HRSB (6.28 ± 2.98) was also significantly lower (P < 0.001) than that for those without HRSB (7.48 ± 2.58). The sociodemographic characteristics that were associated with HRSB are age (P = 0.0497), gender (P < 0.001), relationship status (P < 0.001), housing situation (P = 0.024), alcohol consumption (P < 0.001), and smoking status (P < 0.001). We also identified factors related to the adolescents’ sexual history and previous experience of violence that had an association with HRSB. The factors were age at the first sexual intercourse (P < 0.001), the number of lifetime sexual partners (P < 0.001), the experience of violence at home (P = 0.008), the experience of sexual violence at home (P < 0.001), and the experience of IPV (P < 0.001). Finally, our bivariate analyses also showed an association between family structure and HRSB among adolescents. In particular, the adolescents’ living arrangement (P = 0.001) and orphan status (P = 0.016) had significant association with HRSB. Scolding (P < 0.001) and spanking (P = 0.010) were also related to HRSB.
Table 4.
Factors associated with HRSB among first-year adolescents in a private university in Nigeria
| XXX | HRSB | χ2 | P-value | |
|---|---|---|---|---|
| No (%) | Yes (% | |||
| 588 (83.76) | 114 (16.24) | |||
| Perceived social support score (702) | 12.28 (±4.89)* | 9.30 (±5.25)* | 5.892† | < 0.001 |
| Family APGAR score (693) | 7.48 (±2.58)* | 6.28 (±2.98)* | 4.365† | < 0.001 |
| Sociodemographic characteristics | ||||
| Age, years (702) | 17.54 (±1.24)* | 17.79 (±1.23)* | −1.966† | 0.0497 |
| Gender (702) | ||||
| Male | 180 (77.31) | 54 (22.69) | 11.012 | 0.001 |
| Female | 404 (87.07) | 60 (12.93) | – | – |
| Religious involvement (702) | ||||
| Low involvement (never and less than once a month) | 38 (70.73) | 16 (29.63) | – | – |
| Moderate involvement (once a month and two to three times a month) | 131 (76.61) | 40 (23.39) | 19.387 | < 0.001 |
| High involvement (once a week or more than once a week) | 419 (87.84) | 58 (12.26) | – | – |
| Relationship status (655) | ||||
| Not in a relationship | 326 (91.06) | 32 (8.94) | – | – |
| Currently in a relationship | 77 (77.00) | 23 (23.00) | 26.466 | < 0.001 |
| Complicated | 150 (76.14) | 47 (23.86) | – | – |
| Residence (685) | ||||
| Urban | 508 (83.97) | 97 (16.03) | 0.003 | 0.960 |
| Rural | 67 (83.94) | 13 (16.25) | – | – |
| Housing (673) | ||||
| Flat/duplex | 528 (85.02) | 93 (14.98) | 5.122 | 0.024 |
| Single room/self-contained apartment | 38 (73.08) | 14 (26.92) | – | – |
| Alcohol consumption (683) | ||||
| No | 492 (88.01) | 67 (11.99) | 36.243 | 0 < 0.001 |
| Yes | 82 (66.13) | 42 (33.87) | – | – |
| Smoking status (681) | ||||
| Never smoked | 519 (87.67) | 73 (12.33) | – | – |
| Ex-smoker | 36 (61.02) | 23 (38.98) | 49.715 | < 0.001 |
| Current smoker | 16 (53.33) | 14 (46.67) | – | – |
| Maternal SES (677) | ||||
| High | 530 (84.26) | 99 (15.74) | – | – |
| Middle | 15 (78.95) | 4 (21.05) | 0.483 | 0.769 |
| Low | 25 (86.21) | 4 (13.79) | – | – |
| Paternal SES (673) | ||||
| High | 537 (84.70) | 97 (15.30) | – | – |
| Middle | 16 (72.73) | 6 (27.27) | 2.510 | 0.308 |
| Low | 15 (88.24) | 2 (11.76) | – | – |
| Sexual and violence history | ||||
| Age at the first sexual intercourse (178) | 16.63 (±1.47)* | 14.64 (±2.13)* | 6.660† | < 0.001 |
| Number of lifetime sexual partners among all participants (696) | 0.23 (±0.87)* | 3.31 (±1.84)* | −27.635† | < 0.001 |
| Number of lifetime sexual partners among sexually active participants (176) | 2.22 (±1.70)* | 3.35(±1.82)* | −4.389† | < 0.001 |
| Experienced home violence (691) | ||||
| No | 497 (85.25) | 86 (14.75) | 6.997 | 0.008 |
| Yes | 81 (75.00) | 27 (25.00) | – | – |
| Experienced sexual violence at home (701) | ||||
| No | 580 (87.48) | 83 (12.52) | 125.871 | < 0.001 |
| Yes | 7 (18.42) | 31 (81.58) | – | – |
| Ever experienced IPV (687) | ||||
| No | 539 (85.28) | 93 (14.27) | 14.582 | < 0.001 |
| Yes | 36 (65.45) | 19 (34.55) | – | – |
| Family structure | ||||
| Total number in household (663) | 6.33 (±2.59)* | 6.55 (±2.82)* | −0.808† | 0.420 |
| Raised by (696) | ||||
| Two parents, biological | 498 (83.98) | 95 (16.02) | – | – |
| Two parents, one biological | 20 (80.00) | 5 (20.00) | – | – |
| One parent | 38 (80.85) | 9 (19.15) | 4.407 | 0.334 |
| Other relatives | 24 (88.89) | 3 (11.11) | – | – |
| Nonrelatives | 2 (50.00) | 2 (50.00) | – | – |
| Current living arrangement (702) | ||||
| With parent(s) | 556 (85.02) | 98 (14.98) | 11.068 | 0.001 |
| With others | 32 (66.67) | 16 (33.33) | – | – |
| Orphan status (695) | ||||
| Not an orphan | 524 (84.38) | 97 (15.62) | – | – |
| Lost only mother | 25 (83.33) | 5 (16.67) | 10.313 | 0.016 |
| Lost only father | 24 (82.76) | 5 (17.24) | – | – |
| Lost both parents | 8 (53.33) | 7 (46.67) | – | – |
| Parental discipline (verbal/scolding) (688) | ||||
| Not living with parents | 32 (66.67) | 16 (33.33) | – | – |
| Never | 49 (68.06) | 23 (31.94) | 28.104 | < 0.001 |
| Occasionally | 331 (87.11) | 49 (12.89) | – | – |
| Frequently | 164 (87.23) | 24 (12.77) | – | – |
| Parental discipline (physical/spanking) (687) | ||||
| Not living with parents | 32 (66.67) | 16 (33.33) | – | – |
| Never | 229 (84.19) | 43 (15.81) | 11.286 | 0.010 |
| Occasionally | 255 (85.86) | 42 (14.14) | – | – |
| Frequently | 59 (84.29) | 11 (15.71) | – | – |
IPV = Intimate partner violence; HRSB =high-risk sexual behavior; SES = socioeconomic status.
Mean (SD).
Independent t test.
Multivariable analyses.
Table 5 illustrates the “final” models after multivariable analyses: 1) between HRSB and perception of family support and 2) between HRSB and the adolescents’ judgment of family functioning. The perception of family support by the adolescent had an inverse relationship with HRSB. Participants with lower PSS-FA perception scores were more likely to engage in HRSB (aOR 0.920, 95% CI: 0.878–0.965). An important covariate in this relationship is the experience of sexual violence in the home setting. Adolescents who had experienced sexual violence at home were 17 times (aOR 17.369, 95% CI: 6.830–44.182) more likely to engage in HRSB. The other significant variables associated with engagement in HRSB were being male, cigarette smoking, lower religious involvement, and being in a relationship or having a complicated relationship status. Complicated relationship status is a term used for a variety of circumstances that include not being sure, in an on-and-off or long-distance relationship, or dating more than one person. The model had good fit to the underlying data (Hosmer–Lemeshow χ2 = 2.484, df = 8, P = 0.962) and good discrimination (area under the curve [AUC] = 0.802 [0.752–0.852], P < 0.001). We also confirmed the absence of multicollinearity (all variance inflation factors less than 3).
Table 5.
Relationship between perception of family support and functioning and high-risk sexual behavior among first-year adolescents in a private university in Nigeria
| Based on perceived social support scale-family score | Adjusted odds ratio | 95% CI | P-value |
|---|---|---|---|
| Perception of family support | 0.920 | 0.878–0.965 | 0.001 |
| Gender | 0.564 | 0.339–0.938 | 0.027 |
| Smoking status | 1.937 | 1.268–2.958 | 0.002 |
| Religious involvement | 0.661 | 0.464–0.940 | 0.021 |
| Relationship status | 1.612 | 1.221–2.129 | 0.001 |
| Experience of sexual violence at home | 17.369 | 6.830–44.182 | < 0.001 |
| Based on Family APGAR score | |||
| Perception of family functioning | 0.884 | 0.813–0.962 | 0.004 |
| Gender | 0.577 | 0.355–0.940 | 0.027 |
| smoking status | 2.162 | 1.459–3.203 | < 0.001 |
| Religious involvement | 0.706 | 0.499–0.998 | 0.048 |
| Relationship status | 1.529 | 1.171–1.997 | 0.002 |
| Parental discipline (verbal/scolding) | 0.703 | 0.532–0.928 | 0.013 |
| Experience of sexual violence at home | 17.602 | 6.909–44.846 | < 0.001 |
Hosmer-Lemeshow χ2 = 2.698, df = 8, P = 0.952; Area under the curve = 0.804 (0.752–0.856), P < 0.001.
Likewise, the perception of family functioning was inversely related to HRSB among the adolescents (aOR 0.884, 95% CI: 0.813–0.962). The experience of sexual violence was also a key covariate in this relationship because adolescents who had experienced sexual assault at home were 17 times (aOR 17.602, 95% CI: 6.909–44.846) more likely to engage in HRSB. The other significant covariates were being male, cigarette smoking, lower religious involvement, and being in a relationship or having a complicated relationship status. Also, adolescents whose parents more often scolded them were less likely to engage in HRSB (aOR 0.703, 95% CI: 0.532–0.928). Also, the model had good fit to the underlying data (Hosmer–Lemeshow χ2 = 2.698, df = 8, P = 0.952) and good discrimination (AUC = 0.804 [0.752–0.856], P < 0.001). We also confirmed the absence of multicollinearity (all variance inflation factors less than 3).
Effect modification.
Table 6 shows the result of the assessment of the modification of the effect of family support and functioning on HRSB by gender and relationship status. There was no statistically significant effect modification of the relationships between perceptions of family support and functioning and adolescent HRSB by either gender or relationship status (P > 0.05).
Table 6.
Effect modification of family support and functioning on high-risk sexual behavior by gender and relationship status
| XXX | Adjusted odds ratio | 95% CI | P-value |
|---|---|---|---|
| Family support | |||
| Interaction with gender | 1.004 | 0.923–1.092 | 0.927 |
| Interaction with relationship status | 1.016 | 0.967–1.067 | 0.525 |
| Family functioning | |||
| Interaction with gender | 0.974 | 0.841–1.128 | 0.725 |
| Interaction with relationship status | 1.039 | 0.954–1.132 | 0.377 |
DISCUSSION
There is insufficient evidence in the literature regarding the association between the perception of family support and adolescent sexual risk behavior, and there is limited consideration for the role of family structure on the context, within which adolescents have sexual experiences. In this study of 702 older adolescents, we found that adolescents’ perception of family functioning and support were independently related to HRSB. Adolescents who had a better perception of their family’s support and functioning were less likely to engage in HRSB than those with poorer perception of support. A very significant covariate in these relationships was the experience of sexual violence at home. Adolescents who experienced domestic sexual violence were about 17 times more likely to engage in HRSB than those who did not. The other significant covariates were gender, smoking status, relationship status, and religious involvement. We also found that parental discipline (verbal/scolding) was a significant covariate in the relationship between perception of family functioning and HRSB.
About one-third of male and one in five female adolescents reported ever having sex. The average age at the first intercourse was 15.37 years. One in 10 of the participants had their first sexual intercourse at the age of 14 years or earlier. Some other HRSBs like unprotected sex and multiple sex partners were also prevalent. According to the 2018 Nigeria Demographic and Health Survey (NDHS), 19% female and 3% of male adolescents aged 15–19 years had the first sexual intercourse before the age of 15 years.21 Also, 43.8% of girls and 15.5% of boys aged between 15 and 19 years are sexually active.12 Our study suggests that more boys and fewer girls compared with the national average are having ESD and are sexually active. However, according to the 2018 NDHS, adolescent girls are more likely to have early coitarche and to be sexually active than boys.21 Trend analyses of adolescent sexual behavior in successive birth cohorts show that increasing proportions of adolescents are having sex and that adolescents are increasingly adopting high-risk sexual lifestyles.22 In addition to adolescent morbidity and mortality, sexual risk-taking has implications in adulthood, for example, for fertility and other aspects of sexual and reproductive health.1,5 Our finding supports the current WHO recommendation on adolescent comprehensive sexuality education.23 For optimal benefit, sexuality education should commence before sexual debut and should target both male and female adolescents. According to our study, the median age of sexual debut is 15 years, suggesting that comprehensive sexual education should commence much earlier than the age of 15 years.
Our findings also showed that adolescents (8%) experienced IPV. There is evidence to suggest that the burden of IPV among adolescents is significant. The lifetime prevalence of IPV among ever-partnered women aged 15–19 years based on data from 81 countries is estimated to be 29.4%.24 The relatively low prevalence we found may be because none of our participants is married or presently cohabiting with a partner. Adolescent IPV usually occurs in the context of marriage or cohabitation.25 Also, the absence of an effect of gender on IPV contradicts previous documentation of higher rates among female adolescents.25–27 Although this finding could also be viewed in the background of non-partnership among the study participants, there is a need to subject it to a more detailed investigation. Nevertheless, the burden of IPV among non-partnered adolescents seems significant. Hence, there is a need for well-designed and properly evaluated interventions that target non-partnered adolescents. Also, the absence of boy–girl differences in the experience of sexual violence within the family setting contradicts the literature, which suggests that girl child is at a higher risk of home sexual violence.28 Our finding is likely the consequence of the narrow demographic of our study participants, with more than 90% being from high-income families.
We found that the reported experience of parental discipline in the form of scolding (verbal) and spanking (physical) is common among adolescents. Whereas the boys tended to have experienced spanking more than the girls, the reverse was the case concerning scolding. In traditional Nigerian societies, children and young people had strict upbringing, which encourages parental discipline.29 Most parents consider scolding and, when necessary, spanking to be the best way to instill discipline in young people.30 Adolescents whose parents scolded were less likely to report HRSB. This finding corroborates the finding of a longitudinal study among Kenyan adolescents which found that fewer adolescents who were slapped or scolded reported sexual debut.3 The anticipation of parental discipline is thought to deter adolescents from risky sexual behavior,31–33 especially in contexts such as Nigeria, where corporal punishment is acceptable.32 Decades of research show that spanking has significant mental health consequences including developmental maladaptation and behavioral and cognitive problems.34,35 However, there is reasonable evidence to believe that the association between parental discipline and mental health outcomes is dependent on ethnicity.36,37 Spanking is protective among African-Americans,38 and there is often a vibrant pro- and anti-parental child discipline rights arguments in many contemporary settings. There is a need to investigate the relationship between parental discipline and mental health in African settings where the practice persists.
The current study found that the perceptions of family support and functioning are inversely related to engagement in HRSB among adolescents. Adolescents who perceive their families as being supportive or functional are less likely to be engaged in HRSB. Parents/guardians are an important source of sexual and reproductive health information for adolescents.6 Available evidence shows that family contexts influence ESD and adolescent HRSB. Adolescents with high-quality parenting tend to delay sexual debut and abstain from high sexual-risk behaviors.3,6 However, the different aspects of parenting do not follow a straightforward pattern. Although good parent–adolescent communication is thought to be protective against HRSB, high level of parental monitoring produces contradictory results.3,31,39 Studies in African settings did not find any association between parental monitoring and sexual risk-taking.3,10 By contrast, studies from Western countries show that close parenting tends to reduce HRSB among adolescents.39–43 A meta-analysis of studies published between 1984 and 2014 showed that close monitoring by parents increased contraceptive use among adolescents.44
In essence, the relationship between parenting and adolescent sexual risk-taking is complex. The association might depend on culture, setting, and context.3,6 Perception of parenting is also context- and setting-specific. The adolescents’ overall perception of parenting may be key to understanding the complex interaction between parenting and sexual behavior among adolescents. The relationship between parenting, adolescent perception of parenting, and sexual behavior should be the subject of further research. We recommend the use of qualitative methods to explore these relationships to provide a better understanding. Programs and interventions for preventing and controlling adolescent HRSB should include context- and setting-specific interventions that improve family support and functioning. Such programs should also include interventions to enhance functionality and support of the family.
We found that the experience of sexual violence at home is a significant covariate in adolescent sexuality. Sexual abuse in home settings has been found to lead to increased sexual risk-taking in adolescence, including ESD, prostitution, and sexual victimization.3,41,45,46 Hence, early domestic sexual abuse is a potent determinant of risky sexual behavior in adolescence. Some demographic factors (being male, low religious involvement, and being in a complicated relationship) were also related to sexual risk-taking. High levels of religious preoccupation are likely to enhance morality which in turn might deter adolescents from having sex.
Overall, the evidence from our study suggests that the home setting is critical to adolescent sexual behavior. Specifically, pertinent factors such as family functioning and support, the experience of sexual violence, parental discipline, and religious involvement within the family influence the sexual behaviors of adolescents. Therefore, policymaking and strategy formulation around adolescent sexuality must recognize these issues and include evidence-based efforts to promote optimal family functioning and support and mitigate sexual violence at home. Also, context-specific innovations to moderate parental discipline and religious involvement, as necessary, are needed.
Limitations of the study.
There are some limitations to broader interpretation of our findings. First, the study population is first-year students of a private university. More than 90% of them belong to the high socioeconomic class with many of them being from elitist backgrounds. They are a relatively narrow demographic group and not representative of the general Nigeria population in which only 5% belong to the high socioeconomic group.47 But then, this study represents a rare unique group of adolescents and exposes the need for an inquiry into disadvantaged socioeconomic groups, who may not have the same level of family support and functioning. Second, the use of self-report to obtain data on highly sensitive issues predisposes our findings to some bias. However, we exerted all legitimate efforts to ensure confidentiality and encourage accurate reporting as much as possible. There is marked predominance of female participants which reflect the institution’s admission rates but may not be indicative of general admission rate in all universities in Nigeria.
CONCLUSION
Despite the inherent limitations, our study fills a gap in knowledge regarding the mechanism of HRSBs among adolescents in Nigeria and sub-Saharan Africa. It enriches the argument for the role of family in adolescent sexuality. Our primary aim was to assess the link between adolescents’ perception of their families’ support and functioning and sexual risk-taking. We found a significant relationship even after controlling for demographic characteristics, sexual/violence history, and family structure. The perception of family function/support may provide a link in the complex interaction between the role of family and adolescent sexuality. Our finding supports the current recommendation for adolescent comprehensive sex education and suggests that comprehensive sex education should commence much earlier than the age of 15 years. The relationship between parenting, adolescent perception of parenting, and sexual behavior should be the subject of further research, especially in broader contexts, in sub-Saharan Africa. Programs and interventions for preventing and controlling adolescent HRSB should include context- and setting-specific interventions that would improve adolescents’ perception of family support and functioning. Also, there is a critical need for targeted interventions for adolescents in dysfunctional family settings, where support is lacking to mitigate engagement in HRSB.
We also found a huge burden of IPV among non-partnered adolescents. There is a need for well-designed and properly evaluated interventions that target non-partnered adolescents. The practice of parental discipline persists in our study population and shields adolescents from HRSB.
ACKNOWLEDGMENTS
We would like to thank all the staff of the departments of community medicine and family medicine of the Benjamin Carson School of Medicine, Babcock University, and Ilishan for the kind support in the course of the research. We also thank the participants for their kind contributions. The American Society of Tropical Medicine and Hygiene (ASTMH) assisted with publication expenses.
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