Introduction:
Many studies have reported a high frequency of unprotected sexual intercourse, multiple sexual partners, and transactional sex among young unmarried women especially university undergraduates (1-7). Sexually transmitted infections (STIs) are spread predominantly through unprotected sexual contact. Everyday, over a million people globally acquire sexually transmitted infections (STIs) (8). Beyond the risk of STI, women who engage in unprotected sex are also at risk of unplanned pregnancy and abortion (9). Studies have shown that unplanned pregnancy is high in sub-Saharan Africa (10, 11). As a result, many of these pregnancies result in induced abortion(10), many which take place in unsafe conditions due to restrictive abortion laws in this context (12, 13). It is unsurprising however that over 50% of abortion-related deaths occur among youths and adolescents only in sub-Saharan Africa(12). There is also evidence that risky sexual behaviour is associated with depression symptoms(14).
Studies have shown that knowledge of consequences of unprotected sex, especially HIV acquisition risk, is almost universal (15, 16). However, despite the increasing awareness of the consequences of risky sexual behaviour, the pattern of sexual behaviour among university undergraduates remains, surprisingly, unchanged (3). Several reasons have been put forward to explain this observed phenomenon, although there is little consensus among scholars. While others argue that the amount of freedom available in the university environment, peer influence, and alcohol consumption —all contribute to risky sexual behaviour and that sex education is critical to addressing this problem (17-22); yet, some postulate that the risky sexual behaviour is a result of complex macro-level factors such as poverty and breakdown in social and cultural norms (18, 19). For these scholars, eliminating poverty is key to addressing the risky sexual behaviour.
The link between substance use, alcohol consumption and risky sexual behaviour is well documented (21, 23-26). Alcohol and drugs appear to impair the decision-making of youths and adolescents. LaBrie, et al (25) show that young women who reported hooking up were more likely to have been drinking and subsequently feel discontent with their hook-up decisions. Snipes et al(24) also indicate that consumption of alcohol mixed with an energy drink, in particular, is linked to risky sexual behaviour, especially unprotected sex. Ritchwood et al (26) illustrate that substance use is more strongly linked to risky sexual behaviour among females compared to males.
Other scholars have considerably focused on psychosocial factors associated with risky sexual behaviours. Lansford et al(27) have established that peer rejection during childhood, affiliation with deviant peers during pre-adolescence, and delinquency in childhood and adolescence predicted risky sexual practices. In other words, youths who experienced peer rejection or who had delinquent childhood are more likely to engage in risky sexual practice. Sexting—the exchange of nude pictures through short messages with partners— is also associated with high-risk sexual behaviour(28, 29). Another study (30) has established that future expectations — “the extent to which one expects an event to actually occur”— is linked with high sexual risk behaviour. For example, expectations of drinking and being arrested are found to be associated with having multiple sexual partners and inconsistent condom use(30).
While the consequences of risky sexual behaviour and associated factors are well documented, the literature on young educated women’s perceptions of and narratives about risky sexual behaviour is scanty, and thus it is arduous to discern from available sources why such behaviour continues unabated. As argued in the Health Belief Model (31), perception is a key variable that influences health behaviour. In other words, understanding young women’s perceptions in this regard would not only contribute to the debate on the reasons for the persistence of such behaviour but also inform policy interventions needed to change young women’s risky sexual behaviour. Studies on risky sexual behaviour are either quantitative or qualitative, thus, there are methodological weaknesses associated with the use of only one method. This article addresses this weakness by utilising a mixed methods study design involving female university students from two Nigerian Universities.
Methods
Study Design
This study took place in two universities (Ekiti State University and Afe Babalola University), both in Ado-Ekiti, Nigeria in 2012. The data analysed in this study comes from a larger study that explored the sexual behaviour of students, assessed their contraceptive use, explored their knowledge and practice of emergency contraception, and examined their narratives on risky sexual behaviour and its consequences. Full details of the study area and methodology can be found elsewhere (9, 32).
Population and sampling
The quantitative aspect of the study involved 420 female university students. The appropriate sample size based on the total female student population of 6720, the confidence level of 95%, and margin of error of ±5% is 384, however, 36 was added in anticipation of missing or incomplete responses. For inclusiveness, students were clustered into the year and faculty of study. A random sample of eligible participants corresponding to the sizes of each cluster was selected. The data analysis was based on a sample size of 370, as 50 questionnaires were returned uncompleted. Participants of the qualitative study were selected purposively. The researcher identified six female university students each per level of study and recruited them to participate in the focus group discussion.
Data collection
Questionnaires were given to 420 selected students to complete and return. The questionnaires were pretested with 20 participants, who were not included in the main study. Feedback from the participants was used to improve the questionnaire. The questionnaire probed socio-demographic characteristics of participants, sexual behaviour and perceived prevalence of sexual activities on campus. Qualitatively, 20 in-depth interviews and 5 focus group discussion sessions were conducted in order to gain an understanding of the reasons for the prevalence of risky sexual behaviour among female university students. Participants of the qualitative study were selected purposively. The in-depth interview and focus group discussion questions focused on the perception of consequences of unprotected sex and reasons for sexual risk-taking among female university students.
Data analysis
Quantitative data were analysed using statistical package for social sciences (SPSS version 21, Chicago, IL, USA). Descriptive (frequency and percentages) and inferential (chi-square and cross tabulation) statistics were used to summarise the data and statistical significance were determined at a p-value less than 0.05. The in-depth interviews and focus group discussion were transcribed, and notes taken during the interviews were compared to ensure the accuracy of transcription. Computer-assisted data analysis software (Atlas.ti) was used to code the data after importing the transcription. Thematic content analysis was performed as follows: transcribed data were imported into the software; first reading and coding followed this. The codes were then grouped into main themes, and further reading followed to ensure that all relevant information was grouped and coded appropriately. A further content analysis was performed to explore subthemes and tease out unanticipated issues. Narratives of participants on sexual behaviour and consequences of unprotected sex were developed and supported with verbatim quotes. To ensure trustworthiness, results of the focus group discussions were used to validate that of the in-depth interviews. A sample of the qualitative data and analysis were given to a researcher at the faculty who is an expert in qualitative study and his suggestions were used to improve on the analysis.
Ethical consideration
The University of Ibadan Social Science and Humanities ethical committee approved the study. Verbal and written consent to participate in the study was obtained from all participants after explaining the study aim and objectives. The inclusion of participants was voluntary and the researchers respected the rights of participants to confidentiality and anonymity. Participants were informed of their right to refuse to answer questions they considered intrusive and of their right to withdraw from participation at any given time.
Results
Socio-demographic characteristics of the participants
The socio-demographic characteristics of the participants are presented in Table 1. Majority (92.0%) of the participants were 24 years and younger. Less than half of the participants (173/370) were sexually active.
Table 1: Demographic characteristics of the participants |
Characteristics |
Frequency |
Percentage |
Age (years) |
|
|
=19 |
94 |
25.4 |
20-23 |
180 |
48.6 |
=24 |
57 |
15.4 |
Year of study |
|
|
First |
68 |
18.4 |
Second |
77 |
20.8 |
Third |
98 |
26.5 |
Fourth |
99 |
26.8 |
Fifth |
28 |
7.6 |
Place of residence in school |
|
|
University residence |
108 |
29.2 |
Off-campus residence |
262 |
70.8 |
Home residence |
|
|
Rural |
112 |
30.3 |
Urban |
258 |
69.7 |
Ethnic group |
|
|
Yoruba |
321 |
86.8 |
Igbo |
|
|
Hausa/Fulani |
6 |
1.6 |
Edo/Ijaw |
9 |
2.4 |
Sexual risk-taking
As shown in Figure 1, of the 173 participants that reported being sexually active in the year preceding the survey, 105 of them reported practice of unprotected sex. A total of 46 of the 105 female students that engaged in unprotected sex reported using after-sex contraception with proven and unproven methods widely utilised and the rest did nothing.
 |
Figure -1: Overview of prevalence of sexual risk-taking among female university students |
As shown in Table 2, sexual risk taking was not significantly associated with age, place of residence, religion, and year of study.
| Table 2: Distribution of participants according to sexual risk-taking by demographic characteristics |
Variables |
Unprotected sex |
Condom |
P-value |
Age |
|
|
|
Less than 20 |
18 |
15 |
0.271 |
Above 20 |
87 |
53 |
|
Level |
|
|
|
First year |
8 (47.1) |
9 (52.9) |
0.427 |
Second year |
19 (52.8) |
17 (47.2) |
|
Third year |
31 (66.0) |
16 (34.0) |
|
Fourth year |
34 (61.8) |
21 (38.2) |
|
Fifth year |
13 (72.2) |
5 (27.8) |
|
Residence on campus |
|
|
|
Campus residence |
24 (58.5) |
17 (41.5) |
0.441 |
Ophidian |
81 (61.4) |
51 (38.6) |
|
Place of residence |
|
|
|
Urban |
23 (54.8) |
19 (45.2) |
0.234 |
Rural |
82 (62.6) |
49 (37.4) |
|
Religion |
|
|
|
Christianity |
88 (62.4) |
53 (37.6) |
0.220 |
Islam |
17 (53.1) |
15 (46.9) |
|
Perspectives of female students on prevalence of and underlying factors for risky sexual behaviour
A vast majority of female students (95.5%) consider sexual activity to be very high among students. Peer influence (29.2%), financial needs (16.8%), promiscuity/satisfying urge (30.2%), and lack of sex education/ peer pressure (20.8%) were the perceived reasons for high rate of premarital sex among university students. While many participants pointed out that sexual activities were rampant on campus, some emphasised that sex with multiple partners was particularly rife. Explaining why this appeared to be the case, one 23-year old year four student (in-depth interviewee) said:
Girls don’t have one boyfriend these days; one guy cannot take care of one’s needs.
Participants attributed the rampant sexual activities to factors such as freedom from parental pressure, and peer influences. Some participants reported that the need to meet financial obligations to survive on campus even pushed students to engage in transactional sex:
Most students don’t have rich parents, so, they depend on the little money they are able to make from boyfriends or “sugar daddies” to augment the little money they receive from home. I know of girls who do all manner of things on campus in order to make more money (FGD, 21-year old third-year student).
Other respondents mentioned, “lack of sex education”, “watching of pornographic movies” “promiscuity” and “emotional insecurity” as some of the factors associated with the persistent sexual activities on campus. For some respondents, marital expectancies explained the ugly phenomenon of sexual activities on campus, maintaining that sex was used to sustain and nourish relationships that have some prospect of resulting in marriage. One of the participants reported thus:
I am a final year student, I need to get married as soon as I graduate and my boyfriend has promised to marry me, so if I don’t have sex with him he will leave and seek gratification from other girls (FGD, 24-year-old, fourth-year student).
In both the FGDs and in-depth interviews, some participants described sex on campus as “indiscriminate”, with some (self-) judgmentally associating this with what they termed “lack of self-discipline”, “gaps in parental training”, and “weak religious teachings”.
Perceived consequences of unprotected sexual intercourse and reasons why the behaviour persist
The study revealed that the female students were adequately knowledgeable about the risks associated with unprotected sex. Confirming established facts about such risks, participants of different ages and in different levels made statements echoing the risks associated with unprotected sex. A 26-year old student year four student stated this during the in-depth interview:
Unprotected sex is really risky. Aside from unplanned pregnancy, what about the sexually transmitted diseases such as HIV? Unprotected sex is not good because there are so many diseases like HIV, gonorrhoea and others, which can affect the womb.
Another student (23-year-old, third-year undergraduate) judged unprotected sex and having multiple sexual partners as nothing short of a lethal combination:
When it comes to guys, they have various partners; if a guy does not have, the ex-girlfriend might have had; if she did not have, the ex-boyfriend of the ex-girlfriend might have had. The thing is just like a chain. You have to sit and think, how many girls have this man dated in the past before I met him? Unprotected sex is highly risky.
On reasons why young women engage in unprotected sex despite understanding the consequences, a fourth-year student stated thus:
It is sweet without condom, but it is risky. It is better to protect oneself than suffer the consequences. But many students want to please their boyfriends. Insisting on condom is often linked with lack of trust and it is very difficult (FGD, 21-year old, fourth-year student).
Another female student explains:
We, ladies, make the mistake of wanting to satisfy our boyfriends at all costs. We should think twice and never condone unprotected sex. They should think twice and avoid unprotected sex because of HIV, diseases and unwanted pregnancy. In fact, ladies should avoid sex for now. They should wait till marriage (IDI, 17-year old, year one student)
On how to prevent the risky sexual behaviour and its consequences, some students emphasised “behavioural change”, particularly abstinence. Sex education focusing on safe sexual practices was also recommended as a tool for achieving behavioural change as illustrated by the following remarks:
Unprotected sex is a sure way to contract HIV and other STDs. It’s also an open invitation to unwanted pregnancy. That is why lectures and talks should be given at primary school, secondary school, and tertiary institutions (IDI, 27-year old, fourth-year student).
Discussion
This study sought to estimate the prevalence of unprotected sex among female university students and also to explain reasons for risky sexual behaviour. Taken together, the foregoing results indicate that sexual risk-taking is rife among female university students despite having knowledge of its consequences. The prevalence of unprotected sex was very high (60.7%) among female undergraduate students. The rate of unprotected sex found in this study is higher than that reported in a South African study (3) but similar to those of a previous study in Nigeria (33). The high prevalence of unprotected sexual practice reported by our study suggests that the risk of transmission of sexually transmitted diseases may be equally high among university students. Our findings show that the prevalence of unprotected sex is high, irrespective of participants’ background characteristics.
With regards to respondents’ narratives about personal and societal factors associated with risky sexual behaviour among university students, the findings appear consistent with the extant literature on this subject (2, 34). Personal factors like new-found “freedom” (associated with university life) and the need to meet a “normal” physiological need combine with macro-level factors such as a lack of adequate sexual education, poverty and socio-cultural expectations about marriage to create an environment where risky sexual behaviour not only thrive but appear to be justified by some respondents. This underscores the imperative of ensuring that interventions aimed at behavioural change must be holistic and robust. Previous studies have highlighted many of these factors (1, 2, 34-38).
While students have accurate knowledge of the consequences of unprotected sex, this knowledge appears to be applied in ways that are disempowering, where it is applied at all. Interestingly, the findings pertaining to knowledge about consequences of unprotected sex is in sharp contrast to studies that have attributed unprotected sex to lack of knowledge about its consequences (2). In the case of the present study, unprotected sex occurs in spite of the accurate knowledge of its consequences among university students. The foregoing scenarios are intriguing paradoxes.
Previous study already established a link between sexual risk-taking, and alcohol and drug use (39). Use of alcohol and drug may explain the paradox of good knowledge of consequences of unprotected sex and sexual risk-taking in the context of this present study. However, this is speculative as our study did not explore these associations, hence, future studies could explore the link between alcohol consumption and risky sexual behaviour among female university students in Nigeria.
Nonetheless, inferring from our findings, the perception that condom does reduce the fun of sex could explain why some students would rather engage in unprotected sex despite the knowledge of its consequences. Also, it appears that many female students could not negotiate for safer sex irrespective of their knowledge of its potential consequences. Another explanation for the paradox of unprotected sex occurs in spite of the accurate knowledge of its consequences is the issue of trust in relationships. Female students appear to allow an unprotected sex because they trust their partner to be STI-free. In other words, insisting on use of condoms suggests lack of trust and permitting an unprotected sex is considered to be evidence of trust. Also, participants’ narrative consistently shows that female students do go the extra mile to satisfy their partners because of a promise of marriage in the future even when that could potentially endanger their health.
This study examined the prevalence of unprotected sex and further explores female students’ narrative about sexual risk-taking. We did not explore behavioural correlates of risky sexual behaviour, which is also an important aspect of the discourse. Nonetheless, our study contributes to extant literature by explaining why risky sexual behaviour remains persistent despite knowledge of its consequences. Our study shows that despite adequate knowledge of consequences of unprotected sex, female university students engage in it due to lack of safe negotiating skills, perception that condom reduces fun, unprotected sex as evidence of faithfulness in relationship and need to satisfy a potential future husband. Future studies could explore the behavioural correlates of risky sexual behaviour in our study settings.
Conclusion
We found a high prevalence of risky sexual behaviour among the female university students in the setting of the study. Constellation of factors such as poverty, peer influence, hormonal drive and nourishment of marital expectations underlie the paradox of persistence of risky sexual behaviour despite the awareness of its health risks. Change in sexual behaviour of this cohort will require multi-faceted strategies targeting socio-cultural norms and empowerment of women to develop skills in negotiating safe sex.
Declarations
Conflict of interests: The authors declare that they have no competing interests.
Author’s contributions: AIA and EEN conceptualised, designed the protocol and collected data, while OVA, DTG and WA provided intellectual inputs into the design of the protocol and drafted the manuscript. All authors read and approved the final manuscript for publication.
Funding: AIA received master’s scholarship award from the Ekiti State scholarship board. The scholarship board had no role in the design of the study.
References
- Choudhry V, Östergren P-O, Ambresin A-E, Kyagaba E, Agardh A. Giving or receiving something for sex: a cross-sectional study of transactional sex among Ugandan university students. 2014.
- Sujay R. Premarital sexual behaviour among unmarried college students of Gujarat India. 2009.
- Hoque ME. Reported risky sexual practices amongst female undergraduate students in KwaZulu-Natal, South Africa. African Journal of Primary Health Care & Family Medicine. 2011;3(1):281.
- Imaledo JA, Peter-Kio OB, Asuquo EO. Pattern of risky sexual behavior and associated factors among undergraduate students of the University of Port Harcourt, Rivers State, Nigeria. Pan African Medical Journal. 2012;12(1):97.
- Alabi BO. Rampant Sexual Intercourse among Female Undergraduates in Nigeria and Induced-Abortion Related Morbidity. Journal of Studies in Social Sciences. 2014;8(1):61-80.
- Oluwatoyin F, Oyetunde M. Risky sexual behavior among secondary school adolescents in Ibadan North Local Government Area, Nigeria. JNHS. 2014;3:34-44.
- Noubiap JJN, Nansseu JRN, Ndoula ST, Wang B, Jingi AM, Bigna JJR, et al. Prevalence and correlates of HIV-risky sexual behaviors among students attending the Medical and Social Welfare Center of the University of Maroua, Cameroon. BMC research notes. 2015;8(1):635.
- WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Geneva: World Health Organization; 2013.
- Ajayi AI, Nwokocha EE, Adeniyi OV, Ter Goon D, Akpan W. Unplanned pregnancy-risks and use of emergency contraception: a survey of two Nigerian Universities. BMC Health Services Research. 2017;17(1):382.
- Sedgh G, Singh S, Shah IH, Åhman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. The Lancet. 2012;379(9816):625-32.
- Sedgh G, Singh S, Hussain R. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plan. 2014;45.
- Shah IH, Åhman E. Unsafe abortion differentials in 2008 by age and developing country region: high burden among young women. Reprod Health Matters. 2012;20.
- World Health Organization. Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008. WHO; 2013 2011.
- Othieno CJ, Okoth R, Peltzer K, Pengpid S, Malla LO. Risky HIV sexual behaviour and depression among University of Nairobi students. Annals of General Psychiatry. 2015;14(1):16.
- Taffa N. Sexual activity of out-of-school youth, and their knowledge and attitude about STDs and HIV/AIDS in Southern Ethiopia. The Ethiopian Journal of Health Development (EJHD). 1998;12(1):17-22.
- Nwatu C, Young E, Ezeala-Adikaibe B, Okafor C, Onwuekwe I. HIV and Sexually Transmitted Infections knowledge and practices: a survey of female secondary school students in Enugu, South East Nigeria. JMR. 2017;3(2):66-70.
- Maharaj P, Munthree C. Coerced first sexual intercourse and selected reproductive health outcomes among young women in KwaZulu-Natal, South Africa. Journal of Biosocial Science. 2007;39(02):231-44.
- Madise N, Zulu E, Ciera J. Is poverty a driver for risky sexual behaviour? Evidence from national surveys of adolescents in four African countries: original research article. African Journal of Reproductive Health. 2007;11(3):83-98.
- Gillespie S, Kadiyala S, Greener R. Is poverty or wealth driving HIV transmission? Aids. 2007;21:S5-S16.
- Dunkle KL, Jewkes R, Nduna M, Jama N, Levin J, Sikweyiya Y, et al. Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: prevalence, predictors, and associations with gender-based violence. Social Science & Medicine. 2007;65(6):1235-48.
- Brown JL, Vanable PA. Alcohol use, partner type, and risky sexual behavior among college students: Findings from an event-level study. Addictive Behaviors. 2007;32(12):2940-52.
- Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. The Lancet. 2007;369(9568):1220-31.
- Seth P, Wingood GM, DiClemente RJ, Robinson LS. Alcohol use as a marker for risky sexual behaviors and biologically confirmed sexually transmitted infections among young adult African-American women. Women's Health Issues. 2011;21(2):130-5.
- Snipes DJ, Benotsch EG. High-risk cocktails and high-risk sex: examining the relation between alcohol mixed with energy drink consumption, sexual behavior, and drug use in college students. Addictive Behaviors. 2013;38(1):1418-23.
- LaBrie JW, Hummer JF, Ghaidarov TM, Lac A, Kenney SR. Hooking up in the college context: The event-level effects of alcohol use and partner familiarity on hookup behaviors and contentment. Journal of Sex Research. 2014;51(1):62-73.
- Ritchwood TD, Ford H, DeCoster J, Sutton M, Lochman JE. Risky sexual behavior and substance use among adolescents: A meta-analysis. Children and Youth Services Review. 2015;52:74-88.
- 27. Lansford JE, Dodge KA, Fontaine RG, Bates JE, Pettit GS. Peer rejection, affiliation with deviant peers, delinquency, and risky sexual behavior. Journal of youth and adolescence. 2014;43(10):1742-51.
- Benotsch EG, Snipes DJ, Martin AM, Bull SS. Sexting, substance use, and sexual risk behavior in young adults. Journal of Adolescent Health. 2013;52(3):307-13.
- Houck CD, Barker D, Rizzo C, Hancock E, Norton A, Brown LK. Sexting and sexual behavior in at-risk adolescents. Pediatrics. 2014;133(2):e276-e82.
- Sipsma HL, Ickovics JR, Lin H, Kershaw TS. The impact of future expectations on adolescent sexual risk behavior. Journal of Youth and Adolescence. 2015;44(1):170-83.
- Strecher VJ, Rosenstock IM. The health belief model. Cambridge handbook of psychology, health and medicine. 1997:113-7.
- Ajayi AI, Nwokocha EE, Akpan W, Adeniyi OV. Use of non-emergency contraceptive pills and concoctions as emergency contraception among Nigerian University students: results of a qualitative study. BMC Public Health. 2016;16(1):1046.
- Oyedokun AO. Determinants of contraceptive usage: lessons from women in Osun State, Nigeria. Journal of Humanities and Social Science. 2007;1(2):1-14.
- Nwokocha E. Transactional Sex in Nigerian Universities: Social and Demographic Implications. UNILAG Sociological Review. 2007;8:57-82.
- Cadmus E, Owoaje E. Patterns of contraceptive use among female undergraduates in the University of Ibadan, Nigeria. Int J Health. 2010;10(2).
- Wusu O, Isiugo-Abanihe U. Interconnections of Changing Gender Roles, Socialisation and Youth Sexual Behaviour: Youth’s View. LASU Journal of Social Sciences. 2007;6(1):244-62.
- Ndifon W, Ogaji D, Etuk S. Sexuality, Contraception And Unintended Pregnancy Among Female Student Nurses In Calabar, Nigeria. Benin Journal of Postgraduate Medicine. 2006;8(1):12
- Elliott L, Johnson C. Sex on campus: The naked truth about the real sex lives of college students: Random House; 1997.
- Anderson JE, Mueller TE. Trends in Sexual Risk Behavior and Unprotected Sex Among High School Students, 1991-2005: The Role of Substance Use. Journal of School Health. 2008;78(11):575-80.
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