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Background: AIDS has been a scourge of universities in Africa for a long time. This study was launched at ground-level
to fight the dreaded disease by concentrating on young people and to counter the ignorance that surrounds the disease even
in numerous African universities. This study of the student community was carried out by family doctors at the University
Health Department to determine the prevalence of the determinants of young people’s reproductive health behaviour.Objectives: This study is aimed at determining young people’s sexual behaviour concerning HIV and AIDS in
the practice population of a university in Lagos, Nigeria. Method: Self-administered 63-item questionnaires were distributed amongst 2000 randomly selected students of
the University of Lagos, Lagos, Nigeria in September 2005, using a semi-structured form of the Comprehensive Youth
Survey questionnaire, developed by FOCUS (led by Pathfinder International, Futures Group International and Tulane
University School of Public Health). Results: The age distribution of the respondents was designated in the age groups of 15–19 years
(15.8%), 20–24 years (60.1%), 25–29 years (19.6%), 30–34 years (2.8%).Demographics of note were
that 88.3% of the fathers of the respondents were literate and that 94.5% of the fathers earned more than one US $ per day.
The majority of the respondents (99.1%) indicated adherence to one religious faith or the other and 58.8% believed definitely
that religion shaped their attitudes about sexual intercourse and sexuality. More than half (64.0%) denied having had sex at all
in the three months preceding the study. Furthermore, 68.8% affirmed that it was common amongst friends of their age to use condoms.
A significant number of respondents (65.5%) thought that their friends have drunken alcohol. Almost all of the respondents (94.3%)
had a positive perception of their family. Conclusion: The Programming for HIV and AIDS Reduction on university campuses
in Africa should be conducted comprehensively rather than monothematically and should,
take into consideration the five thematic areas of behaviour change communication amongst young
people concerning their reproductive health.
AIDS remains a dreaded disease1 in Africa, and every effort should be made to prevent it especially
in young people who are disproportionately affected.2,
3,4,5,6 In his
seminal report on case studies
of seven Universities in Africa on HIV and AIDS in 2001, Kelly7 concluded that a thick coat of ignorance
surrounds the disease in many African universities. This cloak is amply lined with layers of secrecy, silence, denial
and fear of stigmatization and discrimination.7 Records that name the disease available in University Health
Centres are just being upgraded.7 Even information on staff and student mortality is just being
improved.7 However, sexual activity, especially amongst the students, is rampant in all these universities,
both in Africa and all over the world.8,8,10Several studies on sexual related behaviour of students in the universities also corroborate the extent of high risk
behaviour for HIV and AIDS present in these citadels of higher learning, whether in developed or developing countries.
11,12,
13,14,15,16 Extensive research into adolescent and young people’s behaviour concerning reproductive health has
identified five thematic areas that influence these
behaviours.4,17,18,
19,20These areas comprise firstly, the individual characteristics of
young people, including their knowledge, attitudes, beliefs, values, motivations and experiences. Secondly,
their sexual partners and peers and thirdly, their families and the adults in the community play a role.
Fourthly, institutions that support the youth and provide opportunities, such as schools, workplaces and
religious organisations influence young people’s behaviour. Finally communities, through which social
expectations are transmitted about gender norms, sexual behaviour, marriage and child bearing, is an important
thematic area.17,18,19 There were no definite figures of reproductive health problems,7 but, observations
showed that these could be substantial, as the Centre was dealing with a very large student population.
Using some of the processes of Community Orientated Primary Care,21,22 a study was conceived
to investigate the problems that prevail concerning reproductive health behaviour in the population of the general or family practice. Behaviour Change Communication regarding HIV and AIDS has been ongoing in the community
surrounding the University of Lagos from the first report of HIV or AIDS in Nigeria in 1981.
In 2005, activities specifically targeted at the Lagos University students gained momentum.
Although undocumented scientifically, these activities included peer education, dissemination
of Information Education Communication (IEC) materials, the formation of a student’s anti-AIDS
club and the preparation of a draft policy document for HIV and AIDS for students and workers on campus.
With the award of an intervention grant by PEPFAR (United States Presidential Emergency
Programme Fund for Aids Reduction) in September 2005, a baseline study of the student
community was carried out by family doctors (family physicians and medical officers).
This study was undertaken at the health centre in collaboration with a multidisciplinary
team of sociologists, graduate nurses and public health physicians, to determine the prevalence
of the determinants of young people’s reproductive health behaviour in this practice population of the University Health Centre.
Ethical considerations was obtained from the Lagos University Teaching Hospital Research and Ethics Committee.
Written informed consent was obtained from each of the participants.
The University of Lagos Health Centre is a general practice facility run by generalist doctors
and medical officers with Master degrees in Public Health. In 2006, the facility attended to a
total of 33 857 patients comprising 5618 student patients (out of a total of 30 000 students),
8027 staff patients and 20 192 dependent patients (i.e. the spouses and children of students and staff).Self-administered 63-item questionnaires were distributed amongst 2000 randomly selected students
from the University of Lagos in Lagos, Nigeria. The university has a total student population of
30 000 (both in campus and off campus). The standard Comprehensive Youth Survey questionnaire,
developed by FOCUS (a partnership of Pathfinder International with the Futures Group International
and Tulane University School of Public Health), was used. This instrument is an internationally
validated instrument used in surveys of reproductive health behaviour in young people all over
the world. It covers the five thematic areas of youth behaviour concerning reproductive health.
These questionnaires were distributed during official school sessions. A 3-stage multistage sampling
design was used to select 200 respondents from each of the 10 faculties of the university including the
College of Medicine. In the first stage all the faculties were selected. In the second stage all the
departments in each faculty were selected and the 200 respondents from each faculty were distributed
according to the number of departments in that particular faculty. Simple random samples were then
taken by balloting to select the final number of students from each department. The minimum sample
size of 1536, (rounded up to 2000) was arrived at by using the formula: (1.96)2(p)(1-p)/d2 where p is the prevalent rate (0.5) and d is the margin of acceptable error (2.5%). Postgraduate student volunteers, trained in data collection through a one-day workshop,
distributed the questionnaires. A pilot survey was conducted using a nearby tertiary
institution to restructure the survey questionnaire to meet local needs. Data from the
questionnaires were fed into the computer and analysed using the software EPIINFO version
6.04b. All bona fide students of the university were expected to participate in the study whether they stayed on campus or off campus. A total of 1891 questionnaires were retrieved, equalling a response rate of 94.6%.
The Age Distribution (Table 1) shows that the age group of 15–24 years constituted 60.1% of the study group.
The majority (91.1%) were not married, as can be expected from their ages and 88.3% of the fathers were literate
(i.e. they have had more than 11 years of continuous education).In general, respondents had a more than average knowledge about HIV and AIDS and the prevention of
it and were aware of where to find help in a majority of cases (Table 3).
Religion
A significant percentage (58.8%) has a firm conviction that religion shapes their attitudes about
sexual intercourse and sexuality whilst 24.6% have a firm belief that it does and 5.4% accept that it does.The pertinent religious debate about AIDS and sin in relation to this study reveals that 90.5% of the
respondents do not believe that people who contracted HIV or AIDS are sinners.
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TABLE 1: The demographic profile of the respondents with reference to their
age, gender, relationship status and their home background.
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TABLE 2: The social class and income of the respondents’ fathers.
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TABLE 3: Personal HIV related knowledge and attitude.
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TABLE 4: Knowledge and attitudes that respondents revealed on how to
safeguard themselves against AIDS.
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Behavioural practices
When asked how many times they had sexual intercourse in the three months preceding the study,
64% denied having had sex at all. Of the rest, 6.4% admitted to have had sex once, and 6.7%
admitted to two to three times. Furthermore, 3.1% admitted to four to five times, 3.2% to
six to eight times and 5.4% to nine or more times, whilst 11.1% said that they could not remember.
That means that 24.8% admitted to have had sexual intercourse in the three months preceding the study.In the evaluation of the number of partners they have had sex with in the three months preceding the study,
63.1% said none, 25.2% said one, 5% said two, 2.4% said three whilst the rest had partners varying from four
to eight (2.1%). Consequently a total of 9.5% admitted to having had multiple sexual partners. The social aspect of coerced sexual intercourse revealed that 20% of the students had been forced to have
sexual intercourse, whilst 78% had not been forced (Table 5). The results also showed that 87.6% of the
students had never received anything in exchange for sex whilst 9.1% had and 26.2% are currently in a same sex relationship.
Condom use
During the study 68.8% of the respondents affirmed that amongst friends of their age,
it was common to use condoms and 47.2% of the students admitted to using condoms.In the two major areas of assessment of self-efficacy amongst these respondents, the scores were very high (Table 5).
Mass media influences
The influence of the mass media, such as radio and television, can be seen globally. In this study,
the record of the frequency with which students listen to the radio revealed that 65.8% of the students
listened to the radio every day or almost every day, 21.8% listened to it at least once per week and 3.8%
listened at least once per month. Very few did not listen to the radio regularly; 2.9% listened to it less
than once per month and a very low percentage of 2.5% of the students never listened to the radio.When asked how many times they had listened to Radio Unilag, in the preceding two weeks to the study,
only 39% said zero number of times. The rest has listened to it in varying numbers of times ranging from once to 60 times. The most significant data on peer and partner pressure (Table 6) are that 57.9% did not agree that
they should put pressure on their partner to have sex with them; unfortunately, less, but still a
significant portion, that is, 48.6% affirmed that unmarried female students in the university
community encourage other girls to have sex with male students or older men. At the same time,
49.6% affirmed that unmarried male students in the university community encourage other male
students to have sex with female students or older women. It is encouraging that 60.5%
said that there was no pressure from their friends for them to have sexual intercourse. When the respondents were asked if a peer educator has ever talked to them, 54.6%
replied in the affirmative. Of those who have talked to a peer educator, 63.7% would
like to talk to one again and 16.4% were undecided. A significant number of the respondents, 65.5% of the study group, thought that their
friends have drunk alcohol and only 19.3% of the respondents thought that none of their
friends have drunk alcohol (Table 7). It is encouraging that there was a strong perception
amongst the respondents that their friends did not use drugs, that is, 78.4% of the respondents.
Smoking seemed to be more common, as 56.9% agreed that their friends have smoked.
Family influence
Approximately half (52.2%) of the students described their family to be sweet and warm in general.
A majority of the respondents (79.8%) said that their parents supported their decisions and 61.9%
of this majority said that their parents mostly supported them whilst 17.9% said that they were fully supportive (Table 8).
A smaller percentage (10.5%) revealed that they did not know whether their parents supported their decisions.Most of the students (78.1%) had a good relationship with their brothers and sisters, and 45.3% of those students
had a good relationship with their brothers and sisters all the time, whilst 32.8% usually related to one another.
The rest of them, that is, 17.1%, sometimes related to one another (Table 8).
This study set out to explore the distribution of known determinants that influence behaviour change
amongst the youth concerning HIV and AIDS. The five thematic areas that influence behaviour change are strong
in this West African citadel of learning. These thematic areas were not explored in this particular study,
but the implications are enormous
for the control of HIV and AIDS on campuses not only in Nigeria, but across the continent.
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TABLE 5: An assessment of the self-efficacy of the respondents.
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Demographics
The socioeconomic milieu that puts people at risk of HIV and AIDS is absent in this student population.
With the majority of the students in Social Classes I and II23 as classified in Table 2, and income
brackets of N8000 per month and above, they are not in the poverty trap, nor are they in the low socioeconomic
group that is associated with high HIV and AIDS prevalence. Students in a higher educational institution have a
tremendous advantage, for, higher education students are more likely to have sexual
education25,26. Furthermore,
condom use in particular has been found to increase in student populations with higher levels of education.27
Personal HIV related knowledge and attitudes
Personal HIV related knowledge is as high in this student population as in other university
student populations in Africa26; this can also be said about most universities in Nigeria.
However, unlike most other studies where permissive attitudes prevail, attitude levels towards sexual activity
are low.20,28,30 This suggests that behaviour change communication strategies finally seem to be
working in this student community in Lagos judging from the fact that peer education, behaviour change
communication and HIV mitigating policy processes were on-going prior to the study.The perception of risk of HIV infection is low. This is the general trend amongst Nigerians of all
ages and may be attributed to the fact that Nigeria has a low prevalence rate of 4.8%.54This
low rate of perception of risk follows findings in the developed world
too.28,29 It is universally low amongst young people, who are eternal optimists.
This underscores the fact that preventive efforts concerning HIV and AIDS must become a lifestyle.
Religion
In this series, religious influence was significant in influencing attitudes to sex and
consequently preventative behaviour towards HIV and AIDS. Although not deeply explored in
this student population, high levels of religiosity are associated with low levels of sexual activity.
Few studies are available to compare with those in Nigeria. Nevertheless, religion plays a major role
in the consciousness of Nigerians. Many HIV and AIDS prevention activities are now handled successfully
by faith-based organisations, a testimony to this trend.
This trend is also found in the rest of Africa.20,27This seems to be unique to Africa and
in particular to Nigeria.25
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TABLE 7: The use of substances and the perception of the use of substances by friends of the respondents.
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TABLE 8: The influence of family relationships in the respondents’ lives.
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Behavioural practices
Rates of sexual activity amongst students in this series are consistently low at 24.8%,
although when compared to secondary school students in Malaysia, another developing country,
the rates of sexual activity in this study are higher (12.6% in Malaysia).31
Much higher rates are found in developed
countries.33,34,35 The incidence of
multiple sexual partners is low as well. The only explanation is that the five thematic areas
for young people’s preventive behaviour concerning HIV and AIDS are very strong in this student population.In a study that was carried out in Sweden amongst the general population,
sexual activity remains high amongst young people aged 16–25 years.
32 High rates of sexual activity were expected in this study,
as Lagos is perceived to be a cosmopolitan and sexually notorious city in Nigeria, even by Nigerians. It is pertinent to note that adolescent African students remain more sexually
active than their college colleagues.30
Condom use
Condom use is moderate amongst this study series (47.2%). This is quite unusual as condom use is generally
low amongst young people all over
the world.35,32,
4,38In Nigeria, however, high condom use is
more probable and driven by fear of pregnancy rather than any other reason because pregnancy in a female
student generally signals the end of her formal education.
The high level of use amongst study participants may be because of enhanced negotiation skills.36
Self-efficacy
Self-efficacy concerning the ability to engage in risky sexual behaviour was very high amongst study participants.
Although this is a self-reported activity, this is commendable. Amongst Nigerian youths,
there is a very high degree of self-confidence in almost everything they do. Whether this
confidence is real or imagined is another matter entirelyThis high level of self-efficacy pervades in the attitudes of college students on the African continent
too.26Studies consistently show that self-efficacy translates into safer
sex practices generally.40,41 However, high self-efficacy does not always
translate into safe sexual behaviour amongst college students.34
Mass media influences (radio)
One good development amongst young people is their love for music and the radio and other electronic media.
The majority of the university students in this study listen to the radio every day and especially to Radio Unilag.
Young people in Nigeria are fanatical football fans and the radio is the cheapest and fastest means of gathering
news about their favourite teams, whether in Nigeria or in Europe. Exposure to mass media-related HIV and
AIDS programming has been linked to attitudinal and behavioural changes both in Nigeria and in the rest
of the world.42 In a study conducted in China, exposure to multiple sources of HIV information
(where at least one source was the mass media) was significantly related to HIV knowledge and a less
stigmatizing attitude towards People Living With HIV and AIDS (PLWHA).42 Mass media
in China has been a major source of HIV information to the public.42
Enhancing the content and penetration of HIV and AIDS campaigns within various channels of the
media can be an important strategy in disseminating HIV knowledge and reducing HIV-related
discrimination 42 The possibility of reaching millions of young people through
global networks with minimal marginal costs after production creates a new paradigm for
reaching an important segment of young people.43,44
Substance use and the perception of substance use
Crack cocaine smoking has been identified as a risk factor for HIV and
AIDS;45,46,5 however, as
little as 20.8% of the students in the study group are suspected of taking hard drugs (Table 7) The substance
most commonly abused by young people is tobacco, either as cigarettes or as snuff.49 This was also
the case in this study, with rates being as high as 60%. The risk, however, of contracting HIV and AIDS is
more readily associated with hard drug use than with cigarette smoking.46,
47,49 The other substance
referred to in this study was alcohol. Increased sexual activity coupled with alcohol abuse increases the
risk of contracting HIV and AIDS.50 Quite a high proportion of students in this study drank
alcohol (approximately 64%, Table 7).
Further studies are needed to identify the drugs used by the 20.8% who were classified as hard drug users.
Peer and partner pressure
On average, the pressure exerted by these students on each other to perform adverse sexual acts was not high.
There is no obvious explanation for this. This was in contrast to other studies on the continent where peer pressure
amongst university students to have sex is high.20,51,
50The question is whether this lower peer pressure
was a result of the high religiosity of these students. There is no doubt that previous HIV and AIDS
programming in this student community has influenced the trend towards the high prevalence of these positive determinants.
Family influence
Family influences amongst the respondents of this study are very strong even for nonreproductive issues.
Family ties in Nigeria remain very
strong which may have influenced HIV and AIDS behaviour in this student population, although it was not explored in this study.
Programming for HIV and AIDS reduction on university campuses in Africa should be comprehensive
rather than vertical single intervention based. In doing so, the five thematic areas of behaviour
change communication amongst young people concerning
reproductive health, backed by a health centre run by generalist doctors practicing Community
Oriented Primary Care, are a sine qua non.
Research significance
Most programming and evaluation of interventions in sexual behavior amongst young people has
been monothematic and population based. We present a multithematic
programming that emanates from a family practice facility; an example of a partial process of Community Oriented Primary Care (COPC).
Limitations of the study
The usual reservation about the absolute reliability of self-reported observations in a research study is made.
However the sheer number of respondents puts this reservation at the most minimum level.
We acknowledge the leadership support and kind gesture given to us to carry out this study
by the then Vice-Chancellor of the University of Lagos, Prof Ibidapo-Obe who launched
us on our journey into HIV and AIDS programming on campus by establishing the University
of Lagos AIDS, Tuberculosis and Malaria (ATM) Committee. We also acknowledge the financial
support given to us by the United States Embassy in Nigeria via the US President’s
Emergency Plan for AIDS Relief (PEPFAR) funds.
Authors’ contributions
O.A. was the principal investigator and author of the study. He conceptualised the research work,
conducted an extensive literature review, cleaned and analysed the initial data, wrote the first
draft of the article and was responsible for the production of the final version. K.O. supervised
data gathering, participated in the writing of the first draft of the article, participated in the
critical review of the first draft of the article. A.M.O. coordinated field worker logistics in
data gathering, collated questionnaire results, and participated in a critical review of the first
draft of the article. VO participated in a critical review of the first draft of the article. AA participated in a
critical review of the whole article. AA participated in a critical review of the whole article.
KOA provided health center demographic data.
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