CONTRACEPTIVE KNOWLEDGE AND PRACTICES AMONG STUDENTS IN FEDERAL POLYTECHNIC KADUNA, NIGERIA: AN EXPLORATORY STUDY
The Population Reference Bureau (PRB) in 2011 reported a low rate of contraceptive use among Nigerian youths at 29%, despite reported high rates of sexual activity and increased awareness of the existence of contraceptive methods. This exposes the youths to the risk of contracting sexually transmitted infections and the effects associated with unwanted pregnancy. From a social constructionist standpoint, I used a mixed method research design to explore contraceptive knowledge and practices among students (18 to 25 years of age) at the Federal Polytechnic Kaduna.
I see students’ attitudes towards contraception as being historically and culturally located and dependent on the prevailing cultural arrangement at that period. I thus distance myself from the position of the Health Belief Model (HBM) by recognising that individuals’ attitudes towards contraception is not only informed by the perceived benefits of contraceptive use but also by certain external social factors which could serve as barriers to the individual’s decision to use contraceptives. I collected data from 187 students out of a sample of 200 who had been systematically selected from the Departments of Mass Communication and Architecture at the polytechnic between August and September 2013. In addition, I conducted fifteen follow-up semi-structured interviews with students and three key informant interviews; two staff at the polytechnic clinic and one private pharmacist close to the polytechnic.
Similar to other Nigerian studies among tertiary students, there is a relatively high level of sexual activity as well as high level awareness of contraceptive methods among students; however, they lack sufficient knowledge of how contraceptives function. Contraceptive use among sexually active students was also low either due to negative attitudes towards contraceptives resulting from inadequate or incomplete contraceptive information from friends or due to lack of easy access to contraceptive methods by students, partners’ influence or influences from cultural, including religious, beliefs and practices, thereby making students vulnerable to the risk associated with unprotected sex. There is therefore the need for interventions by relevant stakeholders that will seek to provide adequate information to students and develop in them positive attitudes towards contraceptive use.
Chapter 1: Introduction
Several studies show that the rate of contraceptive use among Nigerian youths has remained low over time, in spite of reported high rates of sexual activity and increased awareness of contraceptive technologies (Nwokocha, 2007; Akani, Enyindah and Babatunde, 2008; World Health Organisation (WHO), 2011; Lamina, 2013). Students in Nigerian tertiary institutions are considered a particularly high risk group in terms of reproductive health (Abiodun and Balogun, 2009). With these considerations in mind, I have used a mixed-methods research design to explore students’ contraceptive knowledge and practices in a tertiary institution in Northern Nigeria (Federal Polytechnic Kaduna) and to see whether certain social characteristics, which emerged from my review of the literature, are significant in informing their understanding and use of contraceptives in heterosexual relationships1. These characteristics are gender, religious and traditional beliefs, and sexual behaviour.
The increase in the incidence and prevalence rate of sexually transmitted infections (STIs)2 and unwanted pregnancies3 around the world, as well as the adverse consequences these developments have on the world’s population, have put the issue of contraception on the global agenda. According to the World Health Organisation (WHO), an estimated 24.4 million women globally resort to abortions annually, with youths accounting for about 50% of abortion related mortality in the African region (WHO, 2004). Unwanted pregnancies have been related to unprotected sexual intercourse as well as to contraceptive failure, also referred to as ‘contraceptive accident’ (Bankole, Oye-Adeniran, Singh, Adewole, Wulf, Sedgh and Hussain, 2006; Tayo, Akinola, Adewunmi, Osinusi, and Shittu, 2011; Osakinle, Babatunde and Alade, 2013). Unprotected sex and contraceptive accidents have been found to be responsible for an estimated 498 million cases of STIs each year among young couples (WHO, 2011).4
Over the years Nigeria has, compared to developed nations, recorded high rates of both sexually transmitted infections (STIs) and maternal deaths resulting from unsafe abortions in response to unwanted pregnancies. Unsafe abortions and the spread of STIs are still considered among the greatest challenges associated with youths’ reproductive health in Nigeria (Sedgh, Bankole, Oye- Adeniran, Adewole, Singh, and Hussain, 2006). Nigerian youths (young adults in the age bracket of 18-25 years) also form the majority of people exposed to the risk of unwanted pregnancies and
1 I have based my study on students in heterosexual relationships because of my concern with students’ vulnerability to both unwanted pregnancies and sexually transmitted diseases; it should also be noted that homosexuality is considered an illegal practice in Nigeria and is punishable by law with a jail term of 14 years.
2 Sexually Transmitted Infections is used in my study to refer to all infections that can be passed from one person to another through sexual activity, including HIV/AIDS
3 Unwanted pregnancy in my study is referred to not as a disease but as a situation which could lead to unsafe abortions, consequently leading to severe health hazards.
4 Young couple in my study refers to young people in a sexual relationship either within or outside marriage. As discussed earlier, I look at heterosexual couples only.
contraction of STIs (Orji, Adegbenro, and Olalekan, 2005; Fatusi and Blum, 2008: Osakinle et al, 2013). Also, due to the restrictive law against abortion in Nigeria (as discussed in the next chapter), abortions are usually done in clandestine conditions, often resulting in complications that may cause either health hazards to the individual or even death (Abiodun and Balogun, 2009). These health challenges could be significantly reduced, if not entirely avoided, by effective contraception (Omo- Aghoja, Omo-Aghoja, Aghoja, Okonofua, Aghedo, Umueri, Otayohwo, Feyi-Waboso, Onowhakpor and Inikori, 2009).
I conducted my study among students of Federal Polytechnic Kaduna (Kad Poly) in Kaduna, northern Nigeria. The polytechnic is located within Kaduna metropolis, the headquarters of Kaduna State. This location has a history of rapid urbanisation and is inhabited by people from diverse religious and cultural backgrounds from across the country, hence is often referred to by many Nigerians as a “Mini-Nigeria”. It serves as a melting pot of all ethnic nationalities in Nigeria.
In this introductory chapter, I first discuss my research problem and rationale as well as present my research questions. Following a brief statement about my research design I outline my conceptual framework, looking in particular at issues related to health-seeking behaviour, gender and sexuality (here drawing on Connell) as well as the significance of culture. (Further discussion of these issues in the Nigerian context is found in the literature review in chapter 2). Thereafter, I describe the outline of my thesis chapters.
Research problem and rationale
Although globally the level of contraceptive use is considered low compared to contraceptive awareness, certain societies have recorded higher prevalence of contraceptive use than others. The WHO in 2011 reported the general prevalence of contraceptive use to be higher in countries in Latin America, at an estimated 63%, than in countries in Africa at an estimated 20%, with the rate of non- use highest in sub-Saharan African countries. The rate of contraceptive use among the Nigerian population was reported at approximately 12% (Monjok, Smesny, Ekabua, and Essien, 2010).
Nigeria’s Population Reference Bureau (PRB) reported in 2011 that only about 29% of Nigerian youth use contraceptives; in spite of reported high rates of sexual activities and increased awareness of contraceptive technologies (Akani, et al, 2008; Fatusi and Blum, 2008: Cadmus and Owoaje, 2010: Tayo et al, 2011: Osakinle et al, 2013; Adeniji, Tijani and Owonikoko, 2013). These studies reveal that youths are generally aware of the existence of contraceptive methods and the benefits accruing from using contraceptives. However, this awareness is not reflected in the actual utilization of these methods, thereby leading to increase in the incidence of STIs and unsafe abortions resulting from unwanted pregnancies.
Similar findings indicating low contraceptive use were found among students in Nigerian tertiary institutions, thus indicating that students are vulnerable to unwanted pregnancies and the contraction of STIs (Orji and Esimai 2005; Nwokocha, 2007; Attahir, Sufiyan, Abdulkadir, and Haruna, 2010; Wusu, 2010; Omoyeni, Akinyemi and Fatusi, 2012). Studies suggest that the high degree of social freedom in tertiary institutions in Nigeria affords students the opportunity to engage in sexual activities; in some cases this could also be triggered by the desire to acquire material gains (Nwokocha 2007; Wusu, 2010). The risk related to the high rates of sexual activity and low contraceptive usage among Nigerian students (especially unwanted pregnancy and STIs) are among the most serious health risks that young people face and can endanger not only their physical health but also their economic, emotional and social well-being (Ebuehi, Ekanem and Ebuehi, 2006).
Although there are studies on contraception among students in Nigeria, the issue of contraceptive practices among students of tertiary institutions in northern Nigeria have received little or no attention over time; as shown by my literature review which did not reveal any published work on contraceptive practices among students in this region of Nigeria. Against this background, I recognised the need to explore contraceptive knowledge and practices among tertiary-level students in northern Nigeria, in order to contribute to a greater understanding of the extent of their vulnerability to unprotected sex and its attendant problems. Based on my preliminary literature review, I was also interested in exploring the influences of social characteristics such as gender, religion, cultural backgrounds as well as students’ sexual behaviour on contraceptive use. Given the limitations of an MA research project, I designed my study to probe these possible influences without going deeply into how they work; this I recommend should be taken up in further studies.
This study was conducted among students of Federal Polytechnic Kaduna, located within Kaduna metropolis in northern Nigeria. It is hoped that the findings from this study will be useful for informing policy and practice in the polytechnic and, by extension, other institutions of higher learning in Nigeria.
My study is concerned with understanding students’ knowledge and practices of contraception. Within this context and drawing from the existing literature, my research is organised around the following questions:
· What is the level of awareness and knowledge among students in Federal Polytechnic Kaduna about different methods of contraception (both modern and traditional) and what is their primary source of contraceptive information?
· What is the extent of sexual activity among students in the Polytechnic?
· What is the extent and nature of contraceptive use among sexually active students?
· How accessible are contraceptives for sexually active students, here considering in particular availability, cost and the attitudes of Polytechnic health workers and other relevant staff towards students seeking access to contraception.
· Do social characteristics such as age, gender and cultural beliefs and practices (which were identified as important in the general literature) influence students’ understanding of and attitudes towards contraceptive use in Federal Polytechnic Kaduna?
Research design and conceptual framework
As already noted, I conducted the study using a mixed methods research design. This involves “a procedure for collecting, analysing, and mixing both quantitative and qualitative data at some stage of the research process within a single study to understand a research problem completely” (Ivankova, Creswell and Plano 2007:261). The advantage of a mixed-methods approach is that at its best it is able to offset the limitations of both quantitative and qualitative methods of research, therefore, providing a better understanding of the research problem (Fouche and Vos, 2011). In agreement with Fouche and Vos, I found that a mixed methods approach allowed me simultaneously to confirm and explore my research question (what is the level and extent of students’ knowledge and contraceptive practices?). In my third chapter, I present a more detailed discussion of the methodology I used for the study. Here I outline my approach to analysing the gap between knowledge and behaviour, in this case in relation to contraception, as well as the concepts of sexuality, gender and culture which have informed my research design.
Conceptualising the gap between knowledge and behaviour
The focus of my study is how students in Kaduna Polytechnic in heterosexual relationships relate to the issue of contraception and what social factors shape their attitudes and practices. I am motivated by studies which have revealed a gap between contraceptive awareness and contraceptive use and the negative social and health consequences of unprotected sex among young Nigerian students, including the spread of STIs and the risk associated with unsafe abortions resulting from unwanted pregnancies.
As already noted, growing concerns generated by the increasing reproductive health problems experienced by young people in developing countries of Africa, have resulted in various studies aimed at understanding why people may not use available health services despite their awareness of its existences and usefulness.
I work within a social constructivist framework, starting from the premise that knowledge and reality are created interactively and embedded in specific social contexts, thereby making an individual's action a product of interchanges with their environment (White, Bondurant and Travis 2000). Thus, I recognise that students in the polytechnic will have varying attitudes towards contraception given that they come from different backgrounds with different orientations. The social constructionist approach
further suggests the examination of social processes involved in generating constructs such as the self, gender and sexuality. I thus attempt to find out if social factors, which emerged from my literature review, influences students’ contraceptive practices and how the individual in sexual relationship creates personal meanings in relation to external social realities which in turn informs his or her behaviour, in this case, in relation to the use or non-use of contraceptives. I further recognise students’ attitude towards contraceptive use as being historically and culturally located. Not only are individual attitudes specific to particular periods in history and cultures, it is also considered a product of and dependent on the prevailing arrangements in that culture at that historical period (Burr, 1995).
In my study, I thus distance myself from the position of scholars such as Rosenstock, Strecher and Becker (1988) and, more recently, Glanz, Rimer and Lewis (2002) who have attempted to explain individuals’ attitudes towards health-related issues by means of the Health Belief Model (HBM). This posits that health behaviour is informed by the perceived benefits of the particular behaviour by the individual. They assume that an individual’s behaviour on health related issues is rational; as such the individual will use contraception if he/she is convinced about its benefits. This approach fails to consider how other social factors could serve as barriers to individual’s decision to adapt certain beneficial health behaviours. Such processes could include existing patterns of gender relationships (in which one party may be coerced into sexual activity) as well as other factors such as time, cost, inconvenience, embarrassment or loss of pleasure, religion and cultural norms (Dejoy, 1996). This implies that although students are aware of the benefits accruing from the practice of contraception and may want to use it, there are other social barriers that serve to deter them which the HBM does not explain sufficiently.
Reyna and Farley (2006) reported that although adults often believe that young people view themselves as invulnerable and are therefore incapable of rationally weighing risk and benefits, this is not true, as young people do weigh risk and benefits rationally. However, they also found that even when the benefit is perceived to be greater than the risk, they sometimes go ahead to take the risk. In line with this, Thamlikitkul (2006), in his article on ‘Bridging the gap between knowledge and action for health’, is of the opinion that knowledge about health issues in itself is not enough to improve peoples’ choices towards health practices. Rather for this to be achieved, knowledge must suit the existing diverse social and political context. According to Thamlikitkul, for the ‘know-do’ gap to be bridged, institutions responsible for reproductive health in developing countries need to “invest more resources in promoting professional communicators or intermediaries to narrow the gap as well as develop a culture where decisions taken by policy-makers, health professionals and the public are based on evidence” (2006:605).
While these studies take different approaches to explaining decision-making and choice of options regarding health-related issues among young people, at the centre of them all is the common recognition of social factors impacting on the individual and influencing his/her choice of action
regardless of the rational calculation of risk and benefits. Research in Nigeria has revealed that key issues such as gender relations, cultural beliefs and practices5, as well as contraceptive accessibility all play significant roles in influencing students’ decision or choice of action with regards to the use and non-use of contraceptives (Orji and Onwudiegwu, 2002; Izugbara and Modo, 2007; Olaleye et al, 2007; Sudhinaraset, 2008). These features, function to shape and inform students’ attitudes to reproductive health issues at tertiary institutions and even at later stages in life (Izugbara and Modo, 2007; Amos, 2007; Sudhinaraset, 2008; Omo-Aghoja et al, 2009; and Avong, 2012). I have thus factored them into my research design. Below I discuss briefly how I understand them in my study.
Studies on sexuality suggest that sexual relationships are shaped by the social meanings we attach to them. For Connell (1987:111), “sexuality is socially constructed. Its bodily dimension does not exist before, or outside the social practices in which relationships between people are formed and carried on”. Literature is replete with findings on sexual behaviours of young people around the world. “Secondary sexual growth, changes in hormonal secretion, emotional, cognitive and psychological development occur around puberty, resulting in sexual curiosity and experimentation, these biological and psychological changes result in the awareness of sexuality in male and female adolescents” (Okpani and Okpani 2000:41). Research on sexuality and how it is understood and constructed in various societies should be able to assist in the development of effective and efficient sexual and reproductive health care services for youths in such societies (Izugbara and Modo, 2007). Sexuality can also only be fully understood when seen as constructed from childhood, along with gender identities (Pattman, 2005).
Gender relations in heterosexual relationships
Here I find Connells’s concept of ‘cathexis’ (desire) and the role it plays in gender relations pertinent. Cathexis refers to the construction of emotionally charged social relationships with other people in the real world. In patterns of desire within socially hegemonic gender relations, Cathexis sees male and female partners in heterosexual relationships as not just different but unequal. I thus situated my study around heterosexual relationships among students which may be ambivalent.6
The nature of interaction and communication among partners in relationships through the expressions of gender identities and roles has been found to influence decision making regarding reproductive health issues (Iwuagwu et al, 2000; Adaramaja, Adenubi and Nnbueze, 2010; Gibbs, 2012). In a patrilineal society such as Nigeria, there is reportedly a pronounced domination of men in terms of decision making in intimate relationships both within and outside marriage. This male dominance in
5 I use cultural belief here as a general belief system of a people including both religious and other traditional forms of belief.
6 both affectionate and hostile relationships
decision making also extends to issues around contraception, where according to Duze and Mohammed (2006), a man often feels it is his responsibility to decide whether or not his female partner uses contraceptives. This perception is widely shared among people of different ethnic groups, making it a prevailing gender norm that males are superior partners, while females are subservient partners who are expected to concede to the views and decisions of the male in sexual relationships (Adamu, 2008).
Gender inequality in relationships as this, has informed agitations by civil organisations towards the establishment of more tolerant structures in the society that will rather ensure equality in all aspects between males and females. This has led to the fight for the emancipation of women in terms of rights of control over their own bodies as regard issues of reproductive health (Smith, 2000).
Cultural beliefs and practices
Cultural beliefs and practices (including religion) are been passed on to young people and continue to shape their perceptions and attitudes towards issues around them (Manjok et al, 2010). In their study, Monjok et al argued that the interplay of culturally held values and norms continue to influence the prevalence of contraceptive use among young people. Beliefs that have been identified include: that women must bear children to please their husbands, that only promiscuous women use contraceptives, that modern contraception is a means to control the African population thereby reducing its capacity to resist external domination, and that all sexual acts must be open to the possibility of procreation (Duze and Mohammed, 2006; Avong, 2012). These beliefs and practices vary from one society to the other.
Studies of cultural change in Nigeria indicate a transition from ‘traditional’ to ‘modern’ (western) values among Nigerian students, thereby, exposing them to challenges in defining their rights and responsibilities in terms of gender expectations and sexuality (Oloruntoba-Oju, 2007; Amoran et al, 2005). While some students tend to follow this trend of cultural transition, others remain cut up within the traditional cultural and religious values which govern their lives. However, these students interact with one another on a daily basis and through the process of interaction they influence one another by creating conflicting ideas around health issues, including contraception and this interaction is also part of the context influencing decision-making around contraceptive use among Nigerian students (Oloruntoba-Oju, 2007; Abah, 2009; Lawal, 2010).
The study is organised into five chapters, including this introductory chapter. The next chapter focuses on my literature review. This review helped me develop my conceptual framework for the study as well as give an indication of the gaps the research needs to fill. Chapter three discusses the methodology and the rationale for adopting each method used in the study. It includes: the scope of
study, the study population, sampling methods and sample size as well as data collection procedures and the methods used to analyse the data collected. It also presents the ethical considerations for the research as well as reflections from my research process. Chapter four carries the presentation of findings, interpretation and discussions as to how my results were reached. The final chapter discusses these findings within a broadly social constructionist paradigm and compares it with previous works in the same aspect. As the last chapter, it also presents my conclusion as well as recommendations for future research..