CHAPTER ONE
Introduction
Background to the Study `
Sexual and reproductive health diseases account for high levels of mortality among adolescents in developed and developing countries despite worldwide efforts to improve their overall health. Each year in the developing countries of Africa, 14 million adolescents die from sexual and reproductive health diseases. About 40 per cent of these deaths occur in Nigeria (Otoide, Oronsaye & Okonofua, 2001). Sexual and reproductive health (SRH) problems confronting adolescents in Nigeria has become a focus of research, advocacy, policy and legal initiatives. Otoide et. al. identified the sexual and reproductive health (SRH) problems of adolescents to include early sexual debut, early and forced marriages, female genital mutilation (FGM), unprotected sexual activities, sexually transmitted infections (STIs). Also implicated are HIV and AIDS, low contraceptive use, sexual and gender based violence, inability to negotiate safe sex, unwanted pregnancies, clandestine abortion and other pregnancy related complications. These SRH problems are preventable if adolescents have access to and utilize SRH services. Casey (2001), Doherty (2005) and United States Agency for International Development-USAID (2012) asserted that for adolescents to attain optimal SRH, they need SRH services that are age appropriate, factual, youth friendly and cost effective.
Sexual health though an integral part of reproductive health goes beyond reproductive health. Girard (1999) defined sexual health as that part of reproductive health which is concerned with healthy sexual development, equitable and responsible relationship and sexual fulfillment, freedom from illnesses, disease, disability, violence and other harmful practices related to sex and sexuality. Department for International Development- DFID (2004) described sexual health as the enhancement of life and personal relations and not merely counselling, education and care related to reproduction and STIs. World Health Organization-WHO (2003) defined reproductive health as a state of complete physical, mental and social well being and not merely the absence of disease or infirmly in all matters relating to the reproductive system, its functions and processes. Sexual and reproductive health according to Kamau (2006) is the ability of individuals to attain optimal sexual development, prevent diseases, disabilities and death from sexuality and reproduction. This implies that people are able to have satisfying and safe sex life and that they have the capacity to have children and the freedom to decide if, when and how often to do so. In this study, SRH shall be described as a state in which adolescents are free from diseases and illnesses of the reproductive system and are free to engage in responsible relationships without coercion. For adolescents to achieve this, they need SRH services that are age appropriate.
Studies (Population Report (1985), Kuunibe, Nkegbe and Mumin (2012) posited that some factors such as age, gender, school type, religious affiliation and location (urban-rural) have been identified to correlate with SRH services utilization. For example Advocates for Youths (2005) observed that age has a great influence on utilization of health services. According to them, young persons are usually brought to health facilities by either their parents or wards to seek health care. Tilahum, Simkhada and Regimi (2008) reported that in some health facilities, young people who come to seek SRH services are driven away by health care providers, the reason being that young people who seek such services are either spoilt or wayward and not good for marriage.
Gender differentials in health services utilization have received consistent attention among researchers. UNFPA (2000) discovered that there are gender variations in the utilization of SRH services among adolescents. Females have been consistently shown to have higher health conscious attitudes and concerns than men but men have more economic empowerment and have more freedom to move about freely. The common reason advanced for gender differences is the different socialization patterns between boys and girls. Malarchar (2010) reported that girls face social and psychological barriers to accessing SRH services as against their male counterparts due to gender stereotypes.
School type is a factor that could influence utilization of sexual and reproductive health services. Tilahum, Simkhada and Regimi (2008) reported that school type play a major role in SRH services utilization. According to them, adolescents who attend mixed schools feel more confident to access SRH services than those who attend boys’ only or girls’ only schools.
Olunloyo (2009) asserted that religion to a large extent greatly influences what people believe value and practice as a people. Parents, community and religious leaders are however divided on issues pertaining to the discussion and provision of SRH services for adolescents. According to them, adolescents should conform to religious principles of pre marital chastity.
Stone and Ingham (2002) reported that adolescents who live in rural communities where the provision of adolescent sexual and reproductive health (ASRH) services are frowned at may be socially excluded from utilizing existing SRH services. Pate (2001) described the relationship between health services utilization and location noting that the use of health services is higher among urban dwellers than rural dwellers. The National Demographic and Health Survey (2009) reported differences in utilization of health services among rural and urban adolescents attending hospital for services related to SRH.
These socio-demographic variables according to various reports are believed to correlate with SRH services utilization among adolescents.
Correlation is the extent of relationship or relatedness between two or more variables. Phillips (2005) described correlation as a complementary, parallel or reciprocal relationship between two comparable entities; which the extent is usually expressed as a coefficient called correlation coefficient. Correlation in this study is the relationship between utilization of SRH services and some socio-demographic variables among adolescents.
The International Conference on Population and Development-(ICPD) (1994) noted that adolescent SRH services are basic human rights and emphasized the importance of the provision of SRH services to adolescents in order to address their reproductive health challenges across the life span. Tilahun, Mengistie, Egata and Reda (2012) reported that sometimes adolescents lack access to and are less comfortable utilizing SRH services. One reason cited for this was that parents, health care providers and educators are sometimes unwilling to provide age-appropriate SRH services to them. The discomfort lies in their belief that providing adolescents with SRH services will encourage sexual promiscuity. Also, several factors ranging from social, demographic, cultural, economic and gender-related factors also influence the utilization of SRH services by adolescents. Allan Guttmarcher Institute-AGI (2006) reported that approximately 14 million adolescents in both developed and developing countries die from diseases and complications related to SRH. Iyaniwura, Daniel and Adelowo (2007) observed that this could be attributed to the fact that globally adolescents’ utilization of SRH services remains unsatisfactory accounting for high levels of morbidity and mortality. Nigerian adolescents like their counterparts all over the world are also exposed to several sexual and reproductive health-related risks.
WHO (2003) observed that adolescents are highly vulnerable to diseases and social changes in the environment which predispose them to sexual risk-taking behaviours including early sexual activities with evidence of increased SRH problems. DFID (2004) reported that despite the inclusion of SRH in the Millennium Development Goals and the recognized need for SRH service provision for adolescents, they are still neglected in the implementation of health services especially SRH services. Akinyele and Onifade (2006) asserted that the neglect is as a result of the notion that adolescents are believed to be less vulnerable to diseases than children and the aged. The age of sexual debut has increased for adolescents in Nigeria. Nwaorgu, Onyeneho, Onyegebgu, Okolo, Obadike, Ugochukwu and Mbaekwe (2009) revealed that over sixteen per cent of teenage females in Nigeria reported first sexual intercourse by age 15. Among young women aged 20 to 24, nearly half (49.4%) reported first sex by age 18. Among teenage males, 8.3 per cent reported first sex by age 15. Among those aged 20 to 24, 36.3 per cent reported first sexual intercourse by age 18. Similarly, USAID/NIGERIA (2012) reported that the median age of first intercourse for women is 17.7 and for men 20.6 and that there is a likelihood that they will engage in unprotected multiple sexual relationships which may result in sexually transmitted infections (STIs) including HIV, unwanted pregnancies and abortions. STIs have been identified as a predisposing factor in the transmission of HIV infection. According to Ingwersen (2001) about 500, 000 young people are infected with STI daily. She noted that most STIs are not fatal, but can lead to major complications such as infertility and general ill health. UNICEF (2006) reported that more than a third of all people living with HIV & AIDS are under the age of 23 and almost two-thirds of them are females. Otive-Igbuzor (2003) opined that in Sub-Saharan Africa, among young aged 15 to 24, two girls are infected for every boy and for adolescents aged 15 to 19 years, five or six girls are infected.
One in every ten births worldwide is to teenage mothers. Ingwerson observed that early pregnancy impacts on a girl’s education, economic wellbeing and health. He noted that pregnancy before the age of 18 years carries greater medical risks for mothers. The risk of dying from pregnancy-related complications is 25 times higher for girls under 15 and two times higher for those aged 15-19 than for women in their mid-twenties. Similarly, four million women aged 15-19 years have abortions every year, 40 per cent of which are performed under unsafe conditions. In two separate community-based studies on abortion prevalence among Nigerian women by Otoide, Oronsaye and Okonofua (2001), and Nwaorgu et.al (2009) it was reported that one-third of those who obtained abortions were adolescent girls. Nwaorgu, et al (2009) also indicated that up to 80 per cent of Nigerian patients with abortion-related complications were adolescent girls.
Muller (2010) revealed that condom use among adolescents varies widely by gender with more boys having access to condoms than females. He equally noted that on the average thirty eight per cent of adolescent males (16-18) years of age used a condom at last sexual intercourse with only eighteen per cent of girls who had multiple sex partners using a condom. According to him, boys tend to have more sex exploration than girls and they believe that engaging in multiple sexual relationships is a way of asserting their masculinity.
In order to address issues relating to the SRH of adolescents the Government of Nigeria in 1999 convened a National Conference on adolescent SRH. According to Action Health Incorporated- AHI (2002) the conference among other achievements adopted a framework for the provision of adolescent SRH services in Nigeria. However, this laudable development received strong resistance from various quarters. Many had associated the provision of SRH services and the open discourse of SRH issues with promiscuity on the part of young people and permissiveness on the part of the larger society. The report however asserted that adolescents need to be provided with SRH services that are affordable, accessible, confidential, non-judgmental and friendly since addressing the SRH needs of adolescents is crucial to Nigeria’s economic and social well being.
Service is the action of helping or doing work for someone. Services according to Hornby (2006) means to give offer or provide. Kamau (2006) described services as the means of providing or offering something to individuals or groups. According to Ngomi (2008) SRH services are services that promote a state of complete physical, mental and emotional well being and not merely the absence of disease or infirmity in all aspects of sex, sexuality and the reproductive system. Such services according to her include counseling, sexuality education, and reinforcement for abstinence, contraception/family planning services, prevention, screening and treatment for STIs. Also included are HIV testing and counseling, condoms distribution and prevention of unwanted pregnancies and clandestine abortion. Some of these services are provided by some health facilities and youth friendly centres in the State but the extent to which adolescents utilize them is not clear. The present study will be concerned with counseling, health education, prevention, treatment, family planning and referral services as it relates to condom use, STI prevention and treatment, HIV testing and counseling, and prevention of unwanted pregnancies and clandestine abortion among male and female in school adolescents. Available literature (Ngomi, 2008, Nwaorgu et.al, 2009 and Malarcher, 2010) indicated that these are the most implicated SRH problems among adolescents. Also the rate at which adolescent boys and girls contract STIs which predispose them to HIV/AIDS, and the rate at which female teenagers become pregnant is worrisome and needs to be addressed. These SRH problems according to Ngomi can be prevented if adolescents utilize SRH services.
The need for utilization of health services is paramount to optimum health. Dickson-Tetteh (2001) stated that the utilization of health services play important roles in both health promotion and prevention. USAID/NIGERIA (2012) observed with dismay that SRH services utilization among adolescents in Nigeria still remains low despite efforts by government and non-governmental organizations. They attributed the situation to the fact that some of the services are inaccessible, inappropriate or unaffordable to young people. Dickson-Tetteh noted that SRH services are either physically inaccessible or have opening times that prevent easy access for youths. Similarly, staff attitude ranging from being judgmental, to treating adolescents’ requests for services with hostility, and denying those services also impact negatively on adolescents’ utilization of SRH services.
Utilization is the process of using something for a practical purpose. Buttler (2004) described utilization as putting to use, especially to find a profitable or practical use for something. Doherty (2005) described utilization as a means of using services and goods in ways that the users derive benefits from such services. In this study, utilization will be taken to mean the extent to which in-school adolescents make use of SRH services available to them. Malarcher (2010) and Kuunibe, Nkegbe and Mumin (2012) reported that globally, there is under-utilization of SRH services by adolescents. According to Malarcher utilization of SRH services by adolescents in some countries has remained low while in some countries only a fair attempt is made to use these services despite recent investments by government in adolescent health. He disclosed that economic and social factors, gender roles and religious conservatism could be responsible for the low rate of utilization of SRH services. Doherty (2005) highlighted some factors which could affect SRH services utilization by adolescents to include lack of clear adolescent health policies, lack of guidelines for provisions of SRH services to adolescents, lack of information about existing services as well as the focus on provision of services in the urban areas to the neglect of those adolescents in the rural areas. She equally noted that the type of school an adolescent attends may to a large extent influence his or her utilization of SRH services. Studies Tilahum, Simkhada and Regimi (2008) and Addai 2000 have shown that adolescents who attend mixed schools are more disposed to utilizing SRH services than those who attend boys only or girls’ only schools.