Perceptions and preferences regarding sex and contraception, amongst adolescents.

INTRODUCTION: Conceptually and by the outlook, the reproductive and sexual health needs of adolescents differ from those of adults. Adolescent girls are coerced into unwanted sex or marriage, putting them at risk of unwanted pregnancies, unsafe abortions, sexually transmitted infections (STIs) including HIV, and dangerous childbirth. A majority of young people do not have correct information on the use of contraceptives or the prevention of pregnancy and STIs, and youth-friendly reproductive health services are not readily available.
MATERIALS AND METHODS: A community-based cross-sectional study conducted among school-going 500 adolescent girls in the field practice area of Urban Health Training Centre, Tripuri, of Government Medical College, Patiala (Punjab). A survey with semi-structured, self-administered, and pretested questionnaire was conducted to collect the information on demographic characteristics, and knowledge and perceptions about safe sex.
RESULTS: Only 39.71% of girls were aware that the legal age of marriage of girls in India is 18 years. About 22% of girls said that they would prefer to have pre-marital sex and majority, out of them, belonged to nuclear families. Around 38.4% of girls knew that condom is the safest contraceptive method but a preferred choice of contraceptive method among the girls for condoms (24.40%), oral pills (20.20%), and emergency pill (19.60%).
CONCLUSION: Choice of the method with lower levels of knowledge regarding STIs and 22% preferring premarital sex may expose them to higher risks. Increasing trends of pre-marital sex with lower levels of awareness about contraception and STIs is very detrimental. Copyright:

Introduction

The reproductive and sexual health needs of adolescents differ from those of adults. Adolescent girls are often lured or deceived into sex or marriage, putting them at risk of unwanted pregnancies, unsafe abortions, sexually transmitted infections (STIs) including HIV, and dangerous childbirth.[123] A majority of young people have imprecise or incorrect information on the use of contraceptives or the prevention of pregnancy and STIs, and youth-friendly reproductive health services are far from the reach of adolescents as they target married people. Moreover, in many cultures, expressed social norms condemn premarital sex, especially for women, and there are large gender-biased differences in sexual conduct and in the ability to negotiate sexual activity and contraceptive use.[4]

The mixture of myths/stigma, concealment, lack of knowledge, social disparity, and negative media messages confuse young people, thus resulting in poor self-esteem. This not only leads to opting for ignorant choices resulting thereby unprotected sex, unplanned pregnancy, and STIs including HIV/AIDS. Research conducted by the World Health Organization suggests that much of the sexual activity that begins in adolescence is high-risk, unsafe, and often non-consensual.[5]

Adolescent health emerges as an increasingly important priority for India in the coming years, as one-fifth of India's total population constitutes the adolescents. It is pivotal to develop new strategies, monitoring, and evaluation of the existing ones and conduct operational research in this regard. The present study was done to address the issues of knowledge about contraception, STIs, and preferences regarding contraception among adolescents.

Materials and Methods

Study design

The present study was a community-based cross-sectional study conducted among school-going adolescent girls in the field practice area of Urban Health Training Centre, Tripuri, of Government Medical College, Patiala (Punjab).

Target population

All adolescent girls in the age group of 15-19 years studying in the secondary schools located in field practice area Tripuri.

The following criteria were kept in mind while selecting the participants:

Inclusion criteria

All 15-19-year-old girls studying in the secondary schools of Tripuri, irrespective of their marital status.

Those who gave their consent were interviewed.

Exclusion criteria

Girls who awithdrew their consent during the interview.

Girls who are not available at the time of data collection.

Sample size

To determine the sample size, a pilot study was conducted, and the awareness regarding contraception, STIs, and safe sex was recorded. It was found to be about 50%. This proportion is considered as the key variable in sample size determination.

Thus, the required sample size was calculated using the following formula:

N = Z2 αp (1-p)/d2

Where:

Zα = value at specified confidence level (1.96),

p = the proportion of the event in population (50% or 0.5)

d = margin of error (10% of p) = (0.1 * 0.5)

q = (1-p) = (1-0.5 = 0.5).

Applying the values in the above formula, we get

N = (1.96)2 × 0.5 × 0.5/(0.1*0.5)2

n = 0.9604/0.0025

n = 384.16 ≈ 384.

Applying a non-response rate of 15% the sample = 58 (approx.)

N = 384 + 58 = 442.

The sample is further rounded off to 500 accounting for contingencies such as non-responsiveness, consent withdrawal or recording error. Thus, this study deals with 500 adolescent girls only.

Sampling procedure

The simple random sampling design was adopted in conducting this study. The field practice area, Tripuri, of Government Medical College, Patiala was selected purposely. There are three secondary schools located in the field practice area. All of them were selected for the study. From each school, a list of 15-19 years of adolescent girls was obtained. An assent form was given to all the girls who were under 18 years of age, and a consent form was filled by girls above 18 years.

Among those who gave the consent/assent, 500 study subjects were selected by using simple random sampling with the help of random number tables.

Data collection

A cross-sectional survey with semi-structured, self-administered, and pretested questionnaire was conducted to collect the information on demographic characteristics and knowledge, and perceptions about safe sex.

It was administered under the supervision of the investigator to prevent the participants from sharing responses. The semi-structured questionnaire included topics relating to knowledge regarding safe sex. Each question was explained to the subject in both English and vernacular languages. Collected data were entered, cleaned, and analysed using EPI-Info software. Descriptive statistics was used for socio-demographic variables. Chi-square test was applied to find an association between variables, and P value of <0.05 was considered significant.

Ethical considerations

Due clearance was obtained from the institutional ethics committee. Written consent was obtained from the participants after explaining the objectives of the study. In the case of respondents below 18 years of age, assent form was used, and for respondents aged 18 years and above, informed consent was taken from the respondents. Only those who gave the consent/assent were interviewed. Care was taken to ensure privacy and confidentiality. The participants were made comfortable by maintaining anonymity in the questionnaire administered to them.

Permission to conduct the study was also taken from the school authorities. Since the study was conducted during school timings, it was made sure that study timings were not affected. The anonymity of the school was maintained during data compilation and analysis.

Results

Majority of adolescents were in the age range of 15-17 years, and only about one-fourth of them were from 17 to 19 years range. Among the adolescents in study group, 62.2% were from nuclear family while 37.80% belonged to joint family.

Out of 481 subjects, only 191 (38.2%) were aware that the legal age of marriage for girls is 18 years. Among the rest either didn’t answer or replied wrong, 150 (30%) replied that it is 25 years and 140 (28%) said that 21 years. Regarding their preference for premarital sex, 22% replied in affirmation [Table 1 and Figure 1].

Table 1

Association of preference of study subjects having sex before marriage with their type of family

Type of Family (n=500)	Prefer to Have Sex Before marriage
	Yes		No
	Number	Percentage	Number	Percentage
Joint	30	27.27	159	40.77
Nuclear	80	72.73	231	59.23
Total	110	100.00	390	100.00

Chi-square: 6.65; P value<0.05

Figure 1

Distribution of subjects according to their preference for having premarital sex

A significant association between the nuclear status of a family and preference for pre-marital sex (P < 0.05) was observed amongst participants as shown in Table 1.

Majority of the subjects, i.e., 442 (88.40%) were aware that unprotected sex can transmit disease, while 40 (8.00%) subjects said that it cannot transmit any disease.

Awareness regarding HIV being a sexually transmitted disease was much more in comparison to other diseases [Table 2].

Table 2

Distribution of subjects according to their awareness regarding STIs

Diseases	No. of subjects	Percentage
HIV/AIDS	443	88.60
Hepatitis B/C	67	13.40
Syphilis	60	12.00
Gonorrhoea	69	13.80

*One girl answered more than one option

Table 3 shows that 192 (38.40%) subjects said that condom is the safest method to prevent STIs. An overwhelming proportion of 62.6% replied wrong or didn’t reply. But when asked about their preferred choice of contraceptive, the choice for a condom as a preferred method was of only 24.4% and another important finding was more than one-third did not answer [Figure 2].

Table 3

Distribution of subjects according to their awareness regarding the safest method to prevent STIs, and the preferred choice of contraceptive

Responses for contraceptives	Awareness regarding the safest method to prevent STIs (No. of Subjects)	Preferred choice of contraceptive (No. of Subjects)
Condom	192 (38.40%)	122 (24.40%)
Oral pills	63 (12.60%)	101 (20.20%)
Emergency pills	141 (28.20%)	98 (19.60%)
No Response	104 (20.80%)	179 (35.80%)
Total	500 (100.00%)	500 (100.00%)

Figure 2

Distribution of subjects according to their choice of contraceptives

Talking about awareness regarding the occurrence of contraceptive failure, near half of the subjects, i.e., 268 (53.60%) knew it can occur and one-third, i.e., 148 (29.60%) subjects replied that contraceptive methods cannot fail.

It has been concluded from Table 4 that out of 268 subjects who said that contraceptive failure can occur, about three-fourth of them, i.e., 202 (75.37%) said that a doctor was their preferred choice of consultation in case of a contraceptive failure while 52 (19.40%) subjects said that they would consult their mothers and 32 (11.94%) would approach their friends.

Table 4

Distribution of subjects regarding the choice of consultation after contraceptive failure (n=268)

Consultation after failure*	No. of Subjects (n=268)	Percentage
Doctor	202	75.37
Mother	52	19.40
Friends	32	11.94
Some Other	14	5.22

*One girl answered more than one option

Discussion

Adolescents are more prone to experimentation when it comes to being involved in sexual activity probably out of curiosity or peer pressure. This was further contemplated through the present study that 22% of subjects preferred to have sex before marriage. Out of these majority of them belonged to nuclear families. Feeling of isolation experienced by the adolescents in nuclear families, greater exposure to media, and peer pressure can be few of probable reasons. The figures for affirmation to premarital sex wavered from one-fifth to one-third of adolescents in various studies. Concordant results were shown by Kumar and Tiwari[6] in a study conducted among youth living in two city-slums of Delhi and Lucknow on knowledge, attitude, and behaviour towards pre-marital sexuality and revealed that 19% youth agreed with the approval of premarital sex. Another study was conducted in Dhankuta district of Nepal which revealed that 16% of adolescents preferred premarital sex.[7] A similar study conducted in Pokhara Valley of Nepal showed that 41% of the students (which included both boys and girls) did not mind having premarital sex.[8] It has been reported in a study conducted by Jain et al.[9] that 22.7% of the participants felt that it was ok to have sex with different people and 39.72% felt premarital sex gives popularity. However, in another study, it was a meagre 6.6% who were in favour of premarital sex with staggering 85.8% were against premarital sex.[10]

At Ghana, it was found that 32.88% were in favour and 58.56% were against premarital sex.[11] Gupta et al.[12] conducted a community based cross-sectional study among adolescent girls from a rural area of Varanasi District and found that 12.5% adolescent girls were having a premarital romantic relationship and around 2.75% admitted to having pre-marital sexual relation.

The findings from the current study also indicate that knowledge about STIs, other than HIV/AIDS, was very poor among adolescent girls. Diseases like Hepatitis B/C and Syphilis were known only to 13.4% and 12% of adolescent girls, respectively, as STIs. According to NFHS-4 data around 49.3% of women have comprehensive knowledge of HIV/AIDS.[13] In a previous study, it was reported that among unmarried rural adolescents of New Delhi, less than one-fifth of participants were aware of STIs other than HIV.[14] Similar results were found in a different study which revealed that only 34.28% of school-going adolescent girls had knowledge about HIV and STDs.[15] The findings of the study conducted by McManus and Dhar[16] indicated that knowledge about STIs other than HIV/AIDS was poor among adolescent girls as a majority (71%) had not heard about Genital Herpes, and around 44% had not heard about Gonorrhoea or Syphilis. Some other studies have shown that young women have awareness of STIs. It has been observed in a study conducted at Vadodara district that about 47% of young women had heard about HIV.[17] It was found in another study that 73.9% knew about HIV, while 11.5% had knowledge about Syphilis and only 5% about gonorrhoea.[9] Similar findings have been observed about awareness of HIV with 93.8%[18] and 80%[19] while it was 11% for other STIs.[18]

Regarding the awareness about the safest method to prevent STIs, only 38.4% of study subjects in the present study answered condoms as the safest method. A cross-sectional study conducted in various schools of Faridkot city of Punjab by Grover et al.[20] showed that about 62.25% of the girls knew about condoms for safe sex. Another study conducted by Renjhen et al.[21] showed that around 85% of subjects knew about condoms but only 40% had knowledge about contraceptive pills. At Chandigarh, about 83.4% knew about condom, 67.1% about oral pills, and 65.3% about emergency contraceptives.[18]

A study conducted by Patanwar et al.[22] also reported low levels (8.9%) of knowledge regarding the use of condoms as a safe contraceptive method. Similar results have also been observed in another study which reported that 11.3% of the girls knew correctly knew about safe sexual intercourse, i.e., using an effective barrier method like a condom during sexual intercourse.[23] Verma et al.[24] conducted a study among adolescent girls of Bhavnagar (Gujarat), and observed that only 10.8% of girls knew about one or the other contraceptive method. The most well-known method among them was oral pills, followed by condom, IUDs and permanent methods. In a previous study conducted at Wardha, 58% had a positive attitude towards condom use[9] in contrast to the present study which was only 24.4%.

The need of Adolescent friendly health services is on high demand in relation to various health issues faced by adolescents. These clinics provide routine check-ups at primary, secondary, and tertiary levels on fixed days, and time to adolescents, married, and unmarried, girls, and boys during the sessions. ARSH clinics, under NHM, acts as a key strategy of RMNCH + A, provides information, and gives counselling on adolescent sexual and reproductive health. Stigma and unfriendly attitude of providers is hindering girls to approach.

In the present study, it was found that the majority of the subjects, i.e., 53.60% were aware that contraceptive failure can occur. And out of these girls, three-fourth (75.37%) of them preferred consulting a doctor in such a case. A study conducted by Joshi et al.[25] showed that only 43% of adolescent girls willingly reported to adolescent-friendly clinics to seek help for reproductive health issues. In another study by Chauhan SL, et al. it was found that baseline service utilization was as low as 20%-23% at some places.[26]

Conclusion

It has been concluded from the current study that adolescents had better knowledge regarding HIV as compared to other STIs. Near half (53.6%) of them knew that contraceptive failure can occur, and the majority (75%) preferred to consult a doctor in case of eventuality. A good proportion (38.4%) had knowledge about the protective effect of a condom. In spite of this knowledge, preference for a condom as a contraceptive method was only 24.4%; hinting that besides the knowledge certain other factors will decide which contraceptive method will be chosen. Choice of the method with lower levels of knowledge regarding STIs and 22% preferring premarital sex may expose them to higher risks.

Limitations

Adolescents, who are not attending schools, are not included in the study, so not represented. This sample is from a limited geographical area, hence not able to generalize.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.