Substance use and risky sexual behaviours among sexually experienced Ghanaian youth

In most regions of the world (where information is available) the proportion of adolescents who have had sexual intercourse before marriage is high [1]. Risky sexual behaviours, including early sexual intercourse, unprotected sex, multiple sexual partners and non-contraception use can expose adolescents to sexually transmitted diseases (STDs); e.g. HIV infection and early pregnancy [2].

Apart from HIV infection, population explosion due to high birth rate in sub-Saharan Africa is a global public health concern. Because adolescents constitute the largest percentage of people in the developing countries, especially in sub-Saharan Africa [3], promotion of safe sex and encouragement of contraceptive use would contribute immensely to the reduction in sex-related morbidity and mortality caused by teenage pregnancy, abortion, HIV/AIDS etc. and at the same time reduce the population explosion. To do this however, there is the need to understand their sexual behaviours in order to design effective interventions.

Analogous to what pertains in many sub-Saharan African countries, in Ghana several cultural, economic and social factors affect adolescent reproductive health. These include limited reproductive health services, gender imbalance in sexual decision making, female genital mutilation and male favoured polygamy. In the Ghanaian cultural context, sex before marriage is forbidden. Traditionally, sex education by families is given to only girls, usually by their mothers or an elderly woman in the family during puberty rites. Furthermore, sex is regarded as sacred and sexual issues are hardly discussed in public. Consequently, although sexual health promotion including HIV/AIDS prevention in Ghana promotes abstinence, being faithful to one’s partner and the use of condoms, the former is most emphasised because of religious and cultural values. The extent to which these cultural, religious values and abstinence messages promote delay of sexual debut among young people as well as adolescent sexual behaviours in general is less known.

Health compromising behaviours such as substance use can be regarded as problem behaviour [4, 5] because they constitute a deviation from conventional behaviour. Moreover, these behaviours have been reported to co-occur [6, 7]. The association between substance use and risky sexual behaviours has often been discussed from two main theoretical perspectives. One school of thought argues that both risky sexual behaviour and substance use are examples of risk-taking behaviours and constitute deviance that share common causes [8‐10]. Thus, the relationship between substance use and risky sexual behaviour is spurious [9, 10]. Others hold the view that substance use precedes risky sexual behaviour, because, for instance, people tend to have risky sex when under influence of substance use or because they exchange sex for drugs [11]. Consequently, the latter school concludes that substance use acts as a gateway for sexual behaviour. Overall, the relationship between sexual behaviours and other problem behaviours, including substance use among adolescents have been less explored. Studies from developing countries in particular are scarce. The present study investigates the association between substance use (tobacco use, drunkenness, marijuana use and other drug uses) and risky sexual behaviours (sexual debut, condom use and number of sexual partners) among Ghanaian adolescents.

A cross-sectional survey was conducted in 2008 on health behaviours and lifestyles of school- aged adolescents in two out of the three administrative zones in Ghana. Thirty schools were randomly sampled, ten per region, from Eastern (total number of schools in the region = 2924), Greater Accra (total number of schools in the region = 1825) and Volta Regions (total number of schools in the region = 2184) in the two zones. The Ghana Education Service's School Health Programme registers of schools in the country was the source of the sampling frame. The sampling was done as follows: First, ten schools were randomly selected so that they comprised of four public Junior High Schools (total number in the three regions = 5325), two private Junior High Schools (total number in the three regions = 1395), three public Senior High Schools (total number in the three regions = 171) and one private Senior High School (total number in the three regions = 47) in each region in order to reflect the school types in Ghana. Second, in each school, all students whose names were found in the class attendance register of the randomly selected classes were eligible to participate in the survey. The eight page questionnaire was anonymous and self-administered and was tested with an initial pilot sample of 50 children in three schools. It was designed to exclude any information that will reveal the identity of the participants. One trained supervisor was assigned to each classroom during the questionnaire administration. The survey commenced simultaneously in all the participating classes in a given school to prevent contamination. Participants were asked to drop their questionnaires in an envelope placed in front of the class on completion. The present study includes all students aged 12-18-year-old (N = 1195, response rate =90% based on school attendance registers). The study protocol was approved by the ethical committee of the Ghana Health Service Research Unit in Accra, Ghana.

Of all adolescents, 25% (28% boys and 23% girls) reported having ever had sexual intercourse. About 41.3% of adolescents who were sexually experienced had sexual intercourse before age 15 years. The mean age for first sexual intercourse was 14.8 years (14.4 years for boys and 15.1 years for girls). Among those who were sexually active, 31% have multiple sexual partners (Table 1). The distributions of the SES measures are presented in Table 2. Age at first sexual intercourse was positively associated with the number of sexual partners. Half of those who ever had sexual intercourse used condoms as contraceptive but 31% did not use any contraceptives at all during the most recent sexual intercourse.

Sexual debut was relatively high among Ghanaian youth. On the contrary the use of contraception among the sexually experienced was low. Older age, male gender and rural residency increased youths’ chances of sexual debut and having one or multiple sexual partners. Substance use seems to be a gateway for risky sexual behaviours among Ghanaian youth. These evidences suggest that youth are at risk of HIV infection, other STDs as well as unwanted pregnancy with consequent health and social implications. Sexual health promotion which would emphasise not only abstinence but also the condom and the use of other contraceptives are needed to prevent the youth from becoming victims of unsafe or unplanned sex. Such interventions should take into account the likelihood of tobacco use, drunkenness, marijuana use and the use of other drugs among sexually experienced youth.

This study was financially supported by the Competitive Research Funding of the Pirkanmaa Hospital District, Juho Vainion Foundation, and the Finnish Cultural Foundation, Central Fund.