Sexual and reproductive health communication and awareness of contraceptive methods among secondary school female students, northern Ethiopia: a cross-sectional study

Adolescence is defined as the second decade of life, the age between 10 and 19 years [1]. It is the time of transition from childhood to adulthood during which young people experience rapid physical, social and psychological changes as a result of puberty [2].

Young people aged between 15 and 24 years make up 1.2 billion of the world’s population [3]. The health threats faced by this group are predominantly behavioral, and they can have potentially serious consequences [4]. Since young people live in a life phase of experimentation and discovery, they are exposed to health-related risks such as unwanted pregnancies [5]. Thus the group deserves due attention with a special focus on sexual and reproductive behaviors [6].

It is estimated that 11% births globally are given by adolescent girls aged 15–19, and that 95% of these births take place in low income countries. Ethiopia is one of the countries with a high adolescent birth rate [7, 8].

Each year there are about 250 million pregnancies globally; around one third of these are unintended, of which 20% end in induced abortion. Similar rates apply in low income countries, where more than one third of the 182 million pregnancies are unintended, of which 19% are subjected to abortion. However, 11% of these abortions are unsafe [9], with about 2 · 5 million (almost 14%) of all unsafe abortion in these countries occurring in women younger than 20 years. Unsafe abortion varies substantially by age across regions: 15–19 year olds account for 25% of all unsafe abortions in Africa, whereas the proportion in Asia, Latin America, and the Caribbean is much lower [10‐12].

Adolescent women who become pregnant face a greater risk of pregnancy-induced health problems and complications during childbirth than women who bear their first child at age 20 and above [13‐16]. Giving birth during adolescence is also associated with a higher than average rate of spontaneous and induced abortions [17], which can also affect the health of the mother. Not only does early child bearing have links to higher rates of maternal and child morbidity, but it can also lead to truncated educational opportunities, lower future family income, and large family size [17‐20]. These can all have devastating impacts on the social, educational and psychological life of the girls [7].

Negative outcomes of early pregnancy and Sexually Transmitted Infections (STIs), including Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), threaten the health of people in the second decade of life more than any other age group [21]. Early sexual activity has clear negative academic consequences for girls when it results in pregnancy, and it predicts lower school performance and expectations for college among girls even in the absence of pregnancy [22].

Awareness about sexual and reproductive health (SRH) matters, specifically about methods of contraception, as an important step towards gaining access to, and using a suitable contraceptive method in a timely and effective manner. A lack of awareness about methods and use of contraception exposes adolescents to the risk of unwanted pregnancy, unsafe abortion, teenage delivery, child bearing, school dropout and various complications including death [4].

A cross sectional study among sexually active high school students in South Africa indicated that 48.8% of the males and 49.1% of females had used contraception. The most common contraceptive used by males was condom (81.4%), while among females it was the injection (65.4%). Only 17.8% of the males and 22.5% of females reported always using contraception [23]. A study in Uganda also showed that condoms and coitus interruptus were the most commonly used methods used by youths [24]. Among high school students in Nigeria, only 5% of 1155 who had knowledge of contraception were using any form of contraceptive methods. In the same study, 85% of the sexually active respondents were not using any form of contraception [25].

Analysis of the 2005 Demographic and Health Survey in Ethiopia showed that three quarters of the youth aged 15–24 years knew at least one contraceptive method. Awareness was found to be lower among unmarried youth who are not sexually experienced. Men are generally more aware of contraception than women, and knowledge varies by contraceptive method. Knowledge of modern methods of contraception was substantially higher than knowledge of traditional methods among both women and men. Nearly 60% of women were aware of injectable contraceptives compared with about 50% of men [26]. Another study, conducted in north Gondar found that 75% of those surveyed had knowledge of contraception [27].

Communication about sex between parents and children is potentially an important means of transmitting sexual values, beliefs, expectations, and knowledge [28]. However, inter-generational discussions on sex-related matters are taboo in much of Africa [29], with some adults believing that informing adolescents about sex and teaching them how to protect themselves would make them sexually active [30].

This also applies in Ethiopia, where parent-youth communication on SRH issues is believed to be culturally shameful [31]. In Zeway, Ethiopia, one study indicated that only 20% of parents had ever discussed SRH issues with their children [32]. In another study, 32% of young people (32.4% of females and 32.7% of males) had ever discussed SRH issues with their parents. In the same study, youths with secondary school and above educational status (AOR = 1.70, 95% CI: 1.30-2.24), as well as those in a younger age group (AOR = 1.57, 95% CI: 1.26-1.97) were more likely to engage in discussion with their parents compared to the less educated and older respondents [33].

In Ethiopia, studies conducted to explore the effect of parent and peer communication about SRH issues or contraceptive methods are rare. Studies that have been conducted, in Ethiopia and elsewhere in Africa, have concentrated on awareness of contraceptive utilization and emergency contraceptives, rather than awareness about specific methods of contraception [23‐27].

The purpose of this study is, therefore, to determine the effect of parent and peers communication about SRH issues on awareness of contraceptive methods among secondary school female students in northern Ethiopia. It is hoped that the study will contribute to the design, implementation and evaluation of adolescent reproductive health programs, especially behavioral change communication programs, to enhance the reproductive health of young people. The findings will also act as baseline data for other researchers, policy makers and institutions working in this area.

The current study is one of few studies in Ethiopia to examine the effect of parent and peers communication on contraceptive awareness among secondary school students. Our study has excluded married women since the main purpose of the study was to examine the effect of parent and peers communication on contraceptive awareness among in-school unmarried youths, on the basis that awareness of married youths on contraceptive methods is very high [8].

According to this study, about 127(15.8%) of the students had ever had sexual intercourse. The figure is higher compared with a study done with high school female students in Bullen woreda (northwest Ethiopia), where 3.9% had reportedly been sexually active [34]. This might be due to the cultural inhibition both to have premarital sex and to report having had sex in northwest Ethiopia. However, the figure is much lower than a study undertaken in Zeway high school (south central Ethiopia) where 31.5% reported being sexually experienced [31]. The higher figure in this study might be due to the fact that the study subjects were males who tend to report more sexual activity in surveys than females.

On the other hand, studies among undergraduate university female students show a higher proportion of sexually active students than in our study, ranging from university-based respondents in Bahir Dar and Gondar (16.5%) [35], Addis Ababa (23.4%) [36], Kenya (47.6%) [37] and Ghana (38%) [38]. This could be because female students in these universities were away from family and were also older than the secondary school students in our study.

One-fifth (21.2%) of the students reported having had just one sexual partner in their life. This figure is much lower than a study conducted in Bahir Dar and Gondar universities (37.9%) [35], and might be due to the difference in age and place of residence, where university students are living away from their families and are therefore exposed to more partner opportunities than high school students who still live at home.

Although the unintended pregnancy rate of 15.7% in this study is comparable with a study among university students in Bahir Dar and Gondar Universities (16.5%) [35], there was a much lower rate (3.5%) [36] of unintended pregnancy among female students attending Addis Ababa University in spite of their being more sexually active. This could be due to university students possibly having better knowledge about how to protect against pregnancy as well as better awareness about contraceptive methods. In our study, we have observed a higher induced abortion rate than the national average of 2.3% [39‐41], but a lower rate (14.2%) than found in a study in Bahir Dar and Gondar universities (15.5%) [35]. Other Ethiopian studies have found the mean age of women who seek abortion to be 23 years, of whom the majority (54%) were single [39‐41]. This is broadly consistent with the findings of our study, whose subjects were unmarried young female students.

This study revealed that the majority, 88.7%, of the students have ever heard about methods of contraception, mentioning at least one contraceptive method. A further analysis of Demographic and Health Survey (DHS) of 2005 result in Ethiopia showed that a slightly lower proportion, three of every four people aged 15–24 years old, knew of at least one contraceptive method. This might be because our study population constituted an educated group, while in the DHS survey both educated and non-educated youths were included. This finding is also slightly lower than the previous studies report from Addis Ababa university female students, where 91.3% were knowledgeable about contraceptive methods [36]. This could be explained by the fact that students in tertiary education are more likely to be sexually active and to have sex and reproductive health related information than secondary school students.

The male condom was the most frequently mentioned method of contraception (66.3%) reported by our respondents. This may be due to the fact that the condom is promoted not only as a contraceptive method but also for protecting against STI including HIV/AIDS.

Awareness of the Emergency Oral Contraceptive (EOC) was much lower (39.4%) among the participants of this study than in other similar studies. For example, in a study conducted in 2012 among 368 undergraduate female students of Addis Ababa University showed that 84.2% were aware of EOC [36], while a study from university students in northwest Ethiopia reported awareness at 67.1% of the respondents [35]. This variation might be due to differences in their level of education and the greater promotion and availability of EOC in tertiary than in secondary schools.

In the current study, 82(64.6%) of those who had ever had sex reported that they used some kind of contraceptive during their last sexual intercourse. In a study among 368 sexually active adolescents in Cape Verde (West Africa), a slightly higher (69.3%) proportion reported using a contraceptive in their last sexual intercourse [42]. This could be due to lower awareness, and poorer access to contraceptive methods among our study participants.

Male condom and withdrawal methods were the most commonly used type of methods among sexually active students in the current study, the Cape Verde study [42], as well as in another study conducted in Uganda [24]. On the other hand, a study among reproductive health service users in Haiti showed that fewer adolescents (42%) used a contraceptive during their last sexual intercourse [43]. This could have been because their first sexual partner was older, which can lead to power differentials between the partners [43], which in turn can affect the decision making process to use contraceptives.

In the current study and other previous studies, the main source of information about contraceptive methods was the media, in the form of TV and radio. In our study, more than half (57.6%) received their information from media, as compared to a study in Addis Ababa university, where the proportion was 75.5% [36]. This difference might have arisen because the media can be accessed by more students in the university compared to high school students, regardless of their parental socioeconomic status.

However, in contrast to our study where media (TV/radio) were the main source of information for SRH issues, a study among high school students in northwest Ethiopia showed that the most frequently mentioned source of information was school (83.3%) [34]. This difference could be because of low access to TV and radio by students in this more remote area, and further, even for those who had access, the media material may not include tailored and targeted SRH programs for that region. A study among undergraduate students indicated that the main source of information for contraceptive was the media, which can be accessed by most students in urban areas [36].

In the previous six months, fewer than half (43.5%) of the participants had discussed SRH matters with their parent/s. Other studies in this issue have indicated that a smaller proportion, 32.4% [33] and 28.9% [34], of students had discussion with their parents on SRH issues. There are no previous studies which reported on associations between parent and peer communications and awareness of contraceptive methods, but we found that 94.9% of the students who discussed SRH issues with their parents in this study were aware of contraception methods, which was significantly more than those who had not discussed SRH issues with their parents. Similarly, 493(61.1%) of the participants reported having had discussion on SRH matters with their peer/s in the past six months, a finding which is comparable with other study in eastern Wollega Zone, west Ethiopia (59.5%)[33]. Additionally, study participants who have discussed on SRH issues with their peers (93.9%) were more likely to have awareness on contraceptive methods than their counter parts (84%). These findings are supported by a South African study, which pointed to the potential importance of parent and peer communication as a means of creating awareness about SRH issues [30].

About three quarters (74.9%) of the study participants reported to have discussed sexually transmitted infections including HIV/AIDS with their parent/s, which is similar to studies conducted in other part of Ethiopia, 67.8% [33] and 78.6% [34]. Similarly, about two thirds (63.7%) of the students had discussed the topic with their peer/s. Another study conducted in Benishangul Gumuz region, northwest Ethiopia, reported that almost three quarters (73.1%) of the participants had discussed the topic with their peers [34]. These relatively high proportions may be the result of concern and worry about HIV and AIDS caused by the topic being commonly discussed in the media. By contrast, just 25.6%, of the students had discussed methods of contraception with their parent/s, although this was higher than in another study in west Ethiopia, where only 10% had done so [33].

Students who were enrolled in higher (senior secondary schools) educational level (93.4%) were more likely to have awareness on contraceptive methods compared to those who were in junior schools (85.2%). This could be due to youths in higher educational level being more likely to engage in discussion with their parents about SRH issues compared to their counter parts [33], and these groups are more likely to have better awareness on contraceptive methods, which is also indicated as main finding in our study.

In this study, school attendance (public or private), students’ stream of study (natural or social), origin of residence (urban or rural) and parental educational level, and perceived economic status were not significantly associated with female secondary students’ awareness of contraceptive methods in northern Ethiopia. This could be due to most of the students’ sources of information about contraceptive methods being national/local audio-visual media, which have considerable amounts of programming related to contraceptive methods tailored for young people. In addition to this, media could be easily accessed in urban areas such as our study setting.

Three limitations of the study should be mentioned. First, despite the efforts made to ensure data validity, it is not possible to guarantee that students provided honest answers to all the questions, especially those concerned with sensitive issues such as sex. Second, the study was conducted in six selected urban-based secondary school female students in the northern part of Ethiopia, and thus the findings cannot be generalized for all secondary school female students in Ethiopia. Third, male students were not included in the study.

This study showed that many of our female student respondents had a history of sexual intercourse, though significant numbers of students had no awareness about how to prevent pregnancy. Six months prior to the study, fewer than half of the participants reported to have discussed SRH matters with their parent/s, but almost two-thirds of the students had discussed SRH matters with their peer/s. Although audio-visual media such as television and radio were participants’ main and preferred source of information about contraceptive methods, we found that discussing SRH issues with parents and peers positively affected students’ awareness about contraceptive methods. Therefore, strategies to enhance and improve open communication on sexual and reproductive health between parents and students, as well as peer-to-peer education in schools, should be developed and strengthened as a means of increasing awareness about contraceptive methods. In a community where some young people feel shame when talking about SRH issues with families and even with their peers, such programmes could play an important role in helping teenage girls and young women to prevent unwanted pregnancy and its consequences.