RIVERS STATE SECONDARY SCHOOL ADOLESCENTS’ SOCIAL AND PSYCHOLOGICAL VARIABLES ASSOCIATED WITH SEXUAL DEVIATIONS
ABSTRACT
The overall goal of this study was to assess the levels of psychological and social factors and their associations with sexual risk behaviors (sexual initiation and sexual intention) among Rivers State secondary school students. This was a cross-sectional study within a cluster randomized control trial of school-aged adolescents in Okrika, Rivers State.
Six schools were chosen at random from a pool of 12 schools participating in a large cluster-randomized intervention trial in the city using a multistage random cluster sampling procedure. Participants from each of the six chosen schools who met the study criteria had an equal chance of being included in the study. This study drew a total of 250 willing participants.
The study included 250 participants, 128 (51.2%) male adolescents and 121 (48.8 percent) female adolescents. The participants’ mean (standard deviation) age was 12.6 years (0.7). The proportion of adolescents with high self-esteem was 35.6 percent (89), with a nearly equal proportion having low self-esteem. A little more than a third of the participants, 36.5 percent (89), had high HIV self-efficacy.
In terms of depression symptomatology, the overall proportion of adolescents with high depression symptomatology scores was found to be 35.2 percent. The percentage of adolescents who had started having sex was 35.6 percent. Adolescents with high depressive scores were 3.6 times more likely than those with low depressive scores to have initiated sexual activity (OR, 3.62, 95 percent confidence interval 2.22, 9.06; p=0.001).
Adolescents with low self-esteem were twice as likely as those with high self-esteem to have high risky sexual intentions (OR, 2.62 95 percent confidence interval 1.00, 6.92; p=0.04). When compared to adolescents with high HIV perceived self-efficacy, low HIV preventive self-efficacy was associated with nearly three times the odds of high risky sexual intentions (OR, 2.72, 95 percent confidence interval 1.03, 7.32; p=0.04). Current depressive symptoms did not significantly predict participants’ responses to future sexual intentions.
CHAPTER ONE
INTRODUCTION
1.0 BACKGROUND OF THE STUDY
Adolescent sexual behavior is an area of study that is becoming increasingly popular. In Nigeria, studies have shown that young adolescents engage in sexual risk behaviors such as sexual initiation at a younger age, having multiple partners, and having unprotected sex. Several studies in West Africa have looked into the psychosocial predictors of early sexual initiation (Kaaya et al, 2002). In the region, there are no retrievable studies that look at psychological factors and sexual risk behaviors.
Some psychological factors have been linked to sexual risk behaviors globally. However, the results have been inconclusive. Some studies (Ethier et al., 2006; Siegel et al., 2001; Dixon et al., 2000) found statistically significant links between psychological factors like depression, self-esteem, and self-efficacy and sexual risk behaviors like condom use, sexual initiations, multiple partners, and future intentions to engage in sex. Other studies (Crosby et al 2001; McNair, 1998; Pleck et al 1990) found no relationship between psychological factors and sexual risk behaviors.
A person’s psychological well-being has a significant influence on their decision-making process. Adolescents with severe depression are said to engage in more sexual activity and may be unable to recognize risky behavior (Brown et al 2006). Adolescents with low self-esteem are more likely to begin sex at a young age and have unprotected sex to fit in with their peers (Pleck et al, 1990; Dixon et al, 2000; Davies et al, 2003). Adolescents who believe they can perform a specific behavior are more likely to engage in that behavior, and thus higher self-esteem has been linked to condom use and abstaining from sex.
Globally, an estimated 3.4 million adolescents under the age of 15 are infected with HIV. This study adds to our understanding of how psychological factors influence sexual initiation and future sexual intentions in adolescents, putting them at risk for HIV transmission. These findings can be applied to future interventions and studies.
1.1 A REVIEW OF THE LITERATURE
The Human Immunodeficiency Virus (HIV) is a retrovirus that attacks immune system cells, destroying them and weakening the immune system’s ability to fight infections. Acquired Immune Deficiency Syndrome (AIDS) is the result of HIV infection, and it can take a person living with HIV 10-15 years to develop AIDS (WHO, 2001). AIDS has affected millions of people worldwide; the disease’s spread has also had an impact on the development of nations and the world at large (UNAIDS, 2004).
In Nigeria, for example, people living with AIDS occupy 50% of hospital beds (TACAIDS, 2008). As previously stated, more than 90% of children under the age of 15 living with AIDS are reported to be from West Africa. Fortunately, the figures have been declining since 2001, with a reported 30% difference between 2001 and 2010. (UNAIDS, 2011).
Nigeria is estimated to have 1.6 million people living with HIV/AIDS, with 14 percent of those being adolescents aged 15 to 24. (TACAIDS, 2008). According to a global HIV prevalence survey conducted by UNAIDS in 2004, Nigeria is ranked fourth among West African countries with high HIV sero-prevalence.
A number of studies among adolescents in Sub-Saharan Africa (Kaaya et al, 2002; Swainson, 2000; Nicholas, 1998) have investigated proximal socio-cognitive factors (age, gender, condom use self-efficacy, and school performance) associated with sexual risk behaviors. There is no retrievable study in Nigeria that investigates psychological factors associated with sexual risk behaviors, particularly sexual initiation.
Sexually risky behaviors: Adolescents engage in a variety of sexually risky behaviors (SRB). SRBs include initiation of sex at a young age, multiple partners, and unprotected sex. According to statistics in Nigeria, only 49 percent of male adolescents and 46 percent of female adolescents used a condom during their most recent high-risk sexual encounter (UNICEF, 2009). Sexual risk behaviors in the present study will be defined as sexual initiation before the age of 15, future intentions to engage in sex in the next six month, multiple partners and unprotected sex.
Another behavior that puts adolescents at risk of HIV is early sexual debut. From a review of studies conducted in west africa, Kaaya et al (2002) argue that the mean age of sexual onset is 16 years, indicating some initiate sex prior to reaching 16 years of age. Furthermore, their findings show that the proportion of adolescents who had ever used condoms ranged from 10% to 48%.
Early sexual initiation has been linked to early pregnancy and abortion; it also influences adolescent sexual risk behaviors such as having multiple sex partners and not using condoms (Ethier et al, 2006). While sexual health knowledge does not reduce risk behaviors on its own, it is a necessary prerequisite for risk perception and protective actions (Crosby et al, 2001).
In a random cluster sampling survey, it was discovered that less than 37 percent of young men aged 15-19 years knew three primary ways of avoiding HIV infection (i.e., abstinence, faithfulness, and consistent condom use), and 68 percent of young women aged 15-19 years had at least one major misconception about HIV/AIDS or had never heard of AIDS (UNICEF, Multiple Indicator Cluster Surveys, Measure DHS, 1999-2001).
According to Matthew et al (in press), young school-based adolescents in Rivers state initiate sexual intercourse as early as the age of 11 years, with the prevalence of sexual debut in young people aged 11 to 17 years being 16.7 percent. In this study, sex intentions were assessed longitudinally and correlated with sexual initiation as expected.
There is evidence that having multiple sexual partners increases a person’s chances of contracting HIV (Ethier et al, 2006). Exavery et al. (2011) discovered that 42 percent of 612 Nigerian adolescents aged 10 to 19 had multiple sex partners in a study of 612 adolescents.
Some studies (Boden 2006; Smith, 1997; Spencer et al, 2002; Dixon et al, 2000) have found associations between adolescents’ sexual behaviors and personal characteristics. Adolescents who engage in early sexual activities are more likely to engage in other problem behaviors, such as drug abuse, and to perform poorly in school in the future (Smith, 1997). The socioeconomic status of the family has also been identified as a factor that influences whether or not an adolescent initiates sex at a young age. Beck (2004) contends that adolescents raised in economically disadvantaged families are more likely to initiate sex at a young age.
Psychological factors and sexual risk behavior: A number of studies have been conducted in the United States and Europe to investigate the relationship between sexual risk behaviors and psychological factors such as self-esteem, stress, depression, self-efficacy, and anxiety.
Some studies (Ethier et al, 2006; Siegel et al, 2001, Dixon et al. 2000) found that the named psychological factors are associated with sexual risk behavior engagement, while others (Crosby et al 2001; McNair, 1998; Pleck et al 1990) did not. However, most longitudinal studies demonstrate that psychological factors are both precursors and outcomes of SRB (Butler et al, 2003; Spencer et al, 2002; Dixon et al, 2000).
Self-esteem and Sexual Risk Behavior: When it comes to self-esteem, Boden (2006) contends that youth with low self-esteem feel less valuable and have a negative self-image. Self-image has been shown in studies to influence people’s views on sex and sexuality (Baumeister, 1999; Tesser, 2001). This suggests that youths with low self-esteem are more likely to engage in risky behaviors.
This assertion can logically be attributed to a weaker internal locus of control in adolescents with low self-esteem (Tesser, 2001), which impairs their ability to evaluate their options and the consequences of their behaviors. The main point made here is that youth with low self-esteem are more likely than those with high self-esteem to engage in SRB behaviors such as having multiple sexual partners, sexual initiation at a young age, and using condoms inconsistently and/or incorrectly.
A study conducted in the United States that investigated the relationship between the number of sexual partners and low self-esteem among adolescents (Boden, 2006) discovered significant associations between the ages of 15 and 18 years and insignificant associations between older ages (21-25 years). The author observes that the mechanisms for this association may be indirect, working through other factors such as childhood and family experiences. Peers can easily persuade youths with low self-esteem to participate in SRB because they want to please others (Harrill, 2003).
Spencer et al. (2002) followed 188 young adolescents aged 12 to 14 years old in a longitudinal study to determine temporality in associations between self-esteem and sexual initiation by gender. The findings revealed
that 40 percent of boys and 31 percent of girls initiated sex at the end of two-year follow up period. Boys with high self-esteem were 2.4 times more likely to initiate sexual intercourse than boys with low self-esteem, while girls with low self-esteem were 3 times more likely to initiate sexual intercourse than girls with high self-esteem.
When examining psychological factors and SRB in155 adolescent females, Ethier et al (2006) showed that low self-esteem is associated with only some SRBs including having had a risky partner. Having multiple partners, on the other hand, was not significantly associated with self-esteem, though it was associated with greater psychological distress.
The findings suggest that the mechanisms of the association between low self-esteem and SRB in female adolescent may work through the influence of self-esteem on sexual partner choices or the ability to negotiate for safer sexual practices. Other studies have discovered links between self-esteem and SRB. According to Davies et al. (2003), low self-esteem predicts inconsistent condom use among female African American adolescents.
However, the findings of associations between self-esteem and SRB are inconsistent. In a sample of older adolescents/young adults who were university young adolescents, Kalina et al (2009) discovered an insignificant association between self-esteem and inconsistent condom use. Other studies (McNair, 1998; Pleck et al, 1990) found no significant relationships between self-esteem and inconsistent condom use, which supported these findings.
SRB has been reported to be reduced by interventions that increase self-esteem. Dixon et al. (2000) used a group intervention to improve self-esteem in pregnant African American adolescents and found that SRB decreased after the intervention.
Self-efficacy and sexual risk behavior: Perceived self-efficacy is a person’s belief that he or she is capable of performing a specific behavior if he or she is confident in performing the specific behavior (Bandura, 1989). In other words, a person’s perception of his or her ability to carry out a behavior is an important predictor of the likelihood of the behavior being carried out.
Another psychological factor that has been linked to SRB among adolescents is self-efficacy. The central idea is that when an adolescent doubts their ability to engage in safe sexual practices, they are more likely to engage in them.
Participate in SRB. Adolescents who lack self-efficacy for correct and consistent condom use, for example, are more likely not to use condoms when having sex. Adolescents who believe they have a high level of self-efficacy in their ability to avoid risky sexual behaviors can understand risk situations and are intrinsically motivated to avoid SRB such as multiple partners and unprotected sex (Holschneider and Alexander, 2003).
Sexual initiation at a young age increases the risk of HIV infection; the ability of a young person to believe that they are capable of preventing HIV increases the likelihood that they will engage in safer sexual behaviors such as abstinence (Tenkorang & Maticka-Tyndale, 2008).
Kanekar and Sharma (2009) assessed 150 African American college young adolescents using self-report scales containing some socio-cognitive theory constructs, including self-efficacy, to determine predictors of safer sexual behaviors. According to the findings of their study, self-efficacy is directly related to safer sex behaviors (delay sex and condom use). This suggests that youth may try to engage in safer sex behaviors if they believe they have the ability to do so.
Interventions to reduce SRB have increasingly emphasized strategies to boost HIV transmission prevention self-efficacy. For example, Siegel et al (2001) discovered that an increase in self-efficacy resulted in fewer sexual behaviors (multiple partners, condom use, and sexual initiation) in intervention group participants after a 10-month follow-up period compared to control group participants.
Butler et al. (2003) found that higher self-efficacy significantly increased safer sexual behaviors in an intervention for HIV-positive adolescents with hemophilia (consistent condom use, outer-course, or abstinence). Higher self-efficacy for some safe sexual behavior, on the other hand, has not been consistently reported.
Crosby et al. (2001) discovered no significant relationship between self-efficacy for correct condom use and condom application skills in African American females. According to the authors, perceived ability to use condoms may not be related to actual skills.
Depression and Sexual Risk Behavior: Depression can be a mood state or, when combined with a number of core symptoms, it can represent a syndrome of mood disorders (including major depression, dysthymic disorder, and depressive disorder not otherwise specified).
The current study will look at depressive symptoms expressed by children, such as fatigue, worthlessness, guilt, and poor concentration, to name a few (APA, 2000). A number of risky behaviors, including drug abuse, suicide, and sexual intercourse, have been linked to depressive symptoms (Hallfors et al, 2005; Spriggs et al, 2008).
In a study on depression and romantic relationships, Welsh et al (2003) discovered strong associations between psychological factors and early sexual intercourse among young adolescents in America. Adolescents who reported early sexual intercourse had higher levels of depressive symptoms. The finding suggests that psychological distress in adolescents may influence early sexual initiation.
Martin et al. (2005) examined SRB in young urban adolescent girls in a similar study. Findings of this study showed that young sexually active girls compared to those not sexually active had a greater number of depressive symptoms. These findings are consistent with other studies’ findings (Hallfors et al, 2005; Spriggs et al, 2008). Spriggs et al. (2008), on the other hand, only found associations between depression and SRB in females, while there was no association between sexual initiation and depression symptoms in males.
Caminis et al. (2007) investigated 1,368 adolescents’ sexual behavior and its associations with psychological factors. While males initiated sexual intercourse at a younger age than females, they found no significant associations between depression and sexual initiation or other SRB. Some of the inconsistent findings may be explained by age differences in the study samples of adolescents.
Longmore (2004) discovered that female adolescents aged 13 years were more likely to have an association between depressive symptoms and sexual initiation than those aged 15 and 17 years in a study that assessed associations between depressive symptomatology and sex initiation in older and younger adolescents.
1.2 DESCRIPTION OF THE PROBLEM
HIV/AIDS is a chronic, life-threatening disease that has afflicted millions of people worldwide. According to the most recent data, 3.4 million children under the age of 15 were reported to be living with HIV globally in 2010. (UNAIDS, 2011). West Africa is home to more than 90% of HIV-positive adolescents. The pandemic continues to disproportionately affect people in West Africa, which accounts for 68 percent of the disease burden despite having only 12 percent of the world’s population.
Nigeria has a population of 40 million people, with 1.8 million suffering from AIDS (TACAIDS, 2008). In Nigeria, heterosexual transmission is the most common mode of HIV transmission, new infections continue to occur, and the epidemic is most prevalent among young people aged 15 to 24. (Shisana, 2005).
Because of the ongoing impact of HIV/AIDS in Nigeria, there is a clear need for more research on sexual risk factors, particularly psychological risk factors (proximal determinants of SRB), in order to better understand the disease’s impact and inform policy and control programs.
According to research, the most dramatic developmental events in an adolescent’s life are psychological and cognitive changes, including an increase in sexual desire, which is accompanied by new and mysterious feelings and thoughts associated with these sexual desires (Greathead, Devenish, & Funnell, 1998). Adolescents’ decisions to pursue or not pursue these desires are influenced by a variety of risk factors that must be understood in order to be appropriately addressed.
Studies on adolescent sexual risk-taking behavior have shed some light on the factors that put adolescents’ reproductive health at risk. For example, depression has been shown to influence adolescents to engage in sexual risk behaviors such as early sexual initiation and multiple partners (Welsh et al, 2003); self-esteem has been linked to the initiation of sexual acts (Spencer et al, 2002), risky partner selection, and unprotected sex (Ethier et al 2006); and finally, self-efficacy has been linked to safer sexual practices (Kanekar and Sharma, 2009).
However, these studies were conducted in high-income Western cultural contexts where the psychological constructs may have a different meaning, and it is unclear whether the findings will translate to a low-income country with a different socio-cultural context, such as Nigeria. Similar studies in other West African contexts are uncommon and could not be found in the literature.
Wide variations in self-reported SRBs among West African adolescents have been observed, with the possibility of culturally driven under-reporting in females and over-reporting in males (Kaaya et al, 2002). A recent study found that intentions to engage in SRBs are closely related to initiated acts when assessed prospectively (Mathews et al, in press), potentially providing a more accurate measure when collecting self-reported data from young adolescents.
In West Africa, studies have found links between sexual risky behavior and proximal psychosocial influencing factors in adolescents, such as normative values and individual attitudes toward sexual risk and protective behaviors (Kaaya et al, 2002; Swainson, 2000; Nicholas, 1998). Few studies, however, have looked at the effects of psychological factors like self-esteem and depression on sexual risk behavior like early sexual initiation in adolescent populations in West Africa.
There is a need for studies that provide a better understanding of the relationships between SRBs and more complex psychological risk factors in order to inform the development of more targeted and comprehensive HIV infection control interventions. Understanding the relationships between SRBs and self-efficacy, depression, and self-esteem has an added benefit because intervening early may have a longer lasting effect on how a person behaves in the future.
This is due to the fact that intervening can occur prior to full personality integration and thus have a positive influence in shaping personality in a direction that fosters safer sexual practices. The proposed study’s goal is to better understand the impact of these psychological factors on sex intentions and sexual behavior initiation.
1.3 RATIONALIZATION
Most HIV prevention studies and interventions have focused on socio-cognitive and psychosocial factors that influence sexual transmission risks, but few have systematically identified core psychological factors associated with SRBs. The current study adds to our understanding of how psychological factors can influence sexual initiation and future sexual intentions in adolescents, putting them at risk of HIV transmission.
The current study’s findings will provide data on psychological factors (depression, self-efficacy, and self-esteem) in young adolescents in a low-income country. There will also be information on whether these psychological factors influence adolescents’ intentions to engage in sex and engage in sexual risk behaviors.
The findings will help to shape more comprehensive HIV transmission risk reduction interventions for adolescent populations. In Nigeria, focusing on reducing psychological risk factors will supplement existing strategies to raise awareness of sexual risk behaviors and knowledge of HIV/AIDS.
THEORY FRAMEWORK 1.4
To answer the research questions, Bandura’s social cognitive theory (1971) and its underlying constructs will be used. The primary goal of constructs such as motivation and self-efficacy is to investigate behavior and predict it.
Theory of Social Cognitive Behavior
The social cognitive theory was developed by theorists such as Bandura (1971) in order to explain behavior. In determining behavior, this theory “… suggests that behavior, the environment, and personal factors all influence each other” (Eggen & Kauchak, 1999). This theory relies on several underlying constructs.
Motivation
Motivation, according to cognitive theory, is a process that directs an individual’s behavior toward the completion of a goal. It motivates people to seek a better understanding of their life experiences and fosters a long-term expectation of successful goal achievement. This motivational process is aided by positive incentives in the form of positive reinforcement (Bandura, 1971).
Furthermore, unless a person perceives a successful outcome, they are less likely to act. Finally, motivation can be influenced either intrinsically or extrinsically (Bandura, 1971). Depression and motivation have been linked in studies (Musty & Kaback, 1995) As a result, the proposed study hypothesizes that adolescents with severe depressive symptoms may be unmotivated to engage in safer sexual behaviors.
Self-efficacy
The concept of self-efficacy is a significant construct that expanded on Bandura’s theory. “Perceived self-efficacy refers to beliefs in one’s ability to plan and carry out the actions necessary to manage potential situations.” People’s efficacy beliefs affect how they think, feel, motivate themselves, and act” (Bandura, 1995). “Self-efficacy beliefs are based on people’s expectations that they have certain knowledge and skills, as well as the ability to take the actions needed to overcome problems and succeed under life’s stresses and pressures” (Sutton & Fall, 1995).
In other words, a person’s perceived behavioral control has a strong influence on their perceived self-efficacy (Ajzen, 1991). According to Bandura’s theory (Sinclair & O’Boyle, 1999), a critical efficacy factor required to produce a behavior change is judgments about one’s own competence, not just confidence that the behavior can be done successfully.
1.5 DEFINITIONS OF OPERATING SYSTEMS
Adolescence: Adolescence is defined as the period between childhood and adulthood. It includes adolescents (aged 13 to 19) and may overlap with youth (aged 15 to 24 years). Adolescence is defined in the literature as the period of time from early adolescence to late adolescence, between the ages of 10 and 21 (Neinstein et al., 1996); others have defined it as a period between 10 and 19 years (Kiangi 1995) and from 12 or 13 to 19 years of age (Jarvis, 1996). For the purposes of this study, young adolescence is defined as the age range of 12 to 14 years.
Self Esteem: A person’s attitude toward themselves or their opinion or evaluation of themselves, which can be positive (favorable or high), neutral, or negative (unfavorable or low). Also known as self-evaluation.
Depressive symptomatology: A state of sadness, gloom, and pessimistic ideation, with loss of interest or pleasure in normally enjoyable activities, accompanied in severe cases by anorexia and subsequent weight loss, insomnia (especially middle and terminal insomnia), asthenia, feelings of worthlessness or guilt, diminished ability to think or concentrate, or recurring thoughts of death or suicide. It is a symptom of a variety of mental disorders.
AIDS: Acquired immune deficiency syndrome, a condition thought to be caused by the HIV retrovirus and spread by infectious blood entering the body.
HIV: Human immunodeficiency virus, a retrovirus that spreads through sexual contact, infected blood or blood products, and from mother to child via the placenta and weakens the immune system.
Preventive HIV/AIDS self-efficacy: The ability to achieve desired outcomes in the prevention of HIV/AIDS disease. Perceived self-efficacy refers to beliefs about one’s ability or competence to achieve the desired results in HIV/AIDS prevention.
Personal Factors: Variables that are modified to describe specific demographic data (Larouche, 1998). It includes age, gender, grade (standard), parent’s level of education, and religion in this study.
1.6 QUESTIONS FOR FURTHER RESEARCH
The proposed study’s broad research question is:
“Do psychological factors (such as self-esteem, depression, and HIV prevention self-efficacy) influence sexual initiation and sexual intentions in school-aged young adolescents?”
Specifically:
“How do young adolescents in school feel about themselves?”
“How common is depressive symptomatology among school-aged young adolescents?”
What percentage of school-aged young adolescents have high HIV prevention self-efficacy?
“Does self-esteem have a relationship with sexual initiation and sexual intentions in school-aged young adolescents?”
“Is there a link between depressive symptoms and sexual initiation and intentions in school-aged young adolescents?” as well as “Is HIV preventive self-efficacy related to sexual initiation and sexual intentions in school-aged young adolescents?”
1.7 OBJECTIVES FOR STUDY
1.7.1 OVERALL OBJECTIVE
To assess the social and psychological factors associated with sexual deviations among Rivers State secondary school adolescents.
1.72 PARTICULAR OBJECTIVES
To assess self-esteem levels among school-aged young adolescents aged 12-14 years in Okrika, Rivers state.
To ascertain the prevalence of depressive symptoms among young adolescents aged 12-14 years in Okrika, Rivers state.
The purpose of this study was to determine the level of HIV preventive self-efficacy among school-aged young adolescents aged 12-14 years in Okrika, Rivers state.
To investigate the relationships between self-esteem and SRB (sexual initiation and future sexual intentions) in school-aged young adolescents aged 12-14 in Okrika, Rivers state.
The purpose of this study was to look for links between depression symptoms and SRB (sexual initiation and future sexual intentions) in school-aged young adolescents aged 12-14 in Okrika, Rivers state.
To see if HIV preventive self-efficacy is related to SRB (sexual initiation and future sexual intentions) among 12-14-year-old school-aged young adolescents in Okrika, Rivers state.
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RIVERS STATE SECONDARY SCHOOL ADOLESCENTS’ SOCIAL AND PSYCHOLOGICAL VARIABLES ASSOCIATED WITH SEXUAL DEVIATIONS