In this study, we determined the prevalence of condom use, other birth control methods other than a condom and any birth control method at last sex among sexually active school-going adolescents in nine sub-Saharan African countries. Approximately two-thirds of sexually active school-going adolescents have used one form of contraception during their last sexual encounter, which is higher than a similar study conducted in Caribbean countries[14] but lower than the proportion reported in Europe, Israel, and Canada[22].
Although condom use is known to prevent pregnancy and reduces the risk of being infected with HIV/AIDS and sexually transmitted diseases, approximately half of sexually active adolescents in the nine sub-Saharan African countries used a condom during their last sexual intercourse. Our finding is in line with a community survey among adolescents conducted in seven African countries[23] among secondary school students in Tanzania and Ghana, in which 58.9% and 48% reported to have used condoms in their last sexual encounter. On the other hand, our finding is higher than the prevalence of condom use among school-going adolescents in four Caribbean countries[14] among adolescents in 10 European countries[24]. We observed that only two out of five sexually active school-going adolescents in the nine countries use birth control methods other than condoms during their last sexual encounter, which is consistent with what was recently reported among school-going adolescents in the Caribbean[14].
Consistent with previous studies[25, 26], the low uptake of other birth controls methods other than condoms may be attributed to limited access to modern contraceptive methods such as birth control pills, IUD or implant; or a shot, patch, or birth control ring among adolescents due to relatively high cost and availability. Also, low contraceptive literacy, perceived side effects, and lack of perceived risk of sexually transmitted infection(STIs) may also serve as barriers[27-29]. Discussion around contraception and sexuality within African families is still a taboo[30, 31]. At the same time, gender norms that allow boys/men to make decisions regarding sex and contraceptive use have been identified as barriers and may help explain the relatively low uptake of birth control methods in this study. Another factor is the stigma associated with using condoms among adolescents, boys and girls. Studies have reported widespread myth that girls who use a condom are promiscuous, untrustworthy, and likely to be infected with sexually transmitted infection and that real men do not use condoms [32, 33].
Interestingly, the lowest condom and other contraceptive use prevalence were observed among school-going adolescents in Tanzania. Previous Tanzania studies have reported low uptake of condoms among female sex workers and low acceptability of condom promotion and distribution among adolescents[34-37]. Reasons such as condoms promoting promiscuity and improper use of condoms are a sin against God and can cause sexually transmitted diseases have been put forward to explain the low uptake of condoms by adolescents in Tanzania[35]. Consistent with previous studies[15, 16], the highest prevalence of condom use was observed among school-going adolescents in Mozambique and Namibia. The high use of contraceptives in these countries may be attributed to increased sexual reproductive health education and promotion in response to the high prevalence of sexual risk behaviour among adolescents reported in these countries[38-40].
In line with other studies [12-14, 16, 37, 41], our multivariate analysis indicates that male and younger adolescents were likelier not to use condoms and other birth control methods. The gender disparity regarding condom use in our study may be related to gender norms regarding sexuality in most African societies. Females are often not expected to become pregnant until marriage; therefore, those who are sexually active often tend to prevent themselves from being pregnant[42]. Also, gender differences regarding the barriers to using a condom may help explain our findings. It has been reported that males experience more barriers to condom use than women, including the perception that condoms promote negative sexual experiences [43, 44]. In addition, condomless sex has been attributed to the concept of manhood and masculinity and symbol of prestige among their male peers[45].
With regard to age, older adolescents are much more aware of their sexuality, have been exposed to sexual and reproductive health education to know about the consequences of unprotected sex, and can make informed decisions regarding the use of condoms and other birth control methods compared to their younger peers. Early sexual debut was associated with no use of condoms in our study, and our finding corroborates with similar national studies conducted elsewhere[2, 46]. Early sexual debut has been linked to unintended adolescent pregnancy, STIs and high-risk behaviours in adult life[2, 46].
We also observed that those with two or more sexual partners were more likely not to use condoms compared to those with a single sexual partner. Our finding is supported by previous studies[41, 47], although in contrast with a community-based study in four districts in Tanzania[37]. Adolescents in a monogamous relationship are more likely to be aware of the perceived risk associated with indulging in unprotected sex might explain our finding. Also, adolescents with multiple sexual partners are more likely to practice other at-risk sexual behaviours, such as smoking and binge drinking[48]. Condomless sex among adolescents with multiple sexual partners is a public health risk as it promotes the spread of STIs, including HIV/AIDS. We also observed that parental support was a protective factor as it promotes the use of condoms and other birth control methods. A similar association has been reported in previous studies examining the association between parental support and young people's sexual behaviour[12, 14, 16, 49, 50]. Parental support can lead to adolescents feeling loved and, therefore, may want to live up to their parent's expectations and likely not indulge in risky sexual behaviour that would lead to pregnancy or STI. Another possible reason for our finding is that adolescents may fear being punished by their parents if their risky sexual behaviour leads to pregnancy or STI[51]. Further, parental support has been shown to enhance adolescents' social skills and help reduce peer influence on adolescents' sexual decision-making process[52].
Policy and practice implications and Future Research
Our findings suggest that adolescent reproductive health needs are largely unmet in these African countries despite recent progress that has been made over the years. The consequences of such an unmet need are increased adolescent pregnancy and STI infections, early marriage, school drop-out, and maternal and neonatal morbidity and mortality, which promote existing poverty. Our findings suggest the need for school-based sexual health education programs since they have shown to have the potential to promote contraceptive use among adolescents in Sub-Saharan Africa[53]. This includes integrating sexual and reproductive health education into existing school curricula, training teachers and peer educators, and using youth activists and celebrities as sexual and reproductive health ambassadors. However, the school-based interventions should employ a combination of faith- and culture, public health and rights-based approaches depending on the context to ensure it is acceptable and achieve the desired outcome. Also, outside the school environment, providing youth-friendly sexual and reproductive health services is another avenue to address the SRH needs of adolescents[54]. This includes training and educating stakeholders, engaging adolescents to improve SRH knowledge via media, community events and use of peer-support workers and providing support to clinicians such as recruiting peer navigators that work alongside clinicians to enhance referral and linkage to youth-friendly sexual and reproductive health services[55].
Male, younger adolescents, early sexual debut, and those with two or more sexual partners were less likely to use a condom or other birth control methods, suggesting that adolescents with such characteristics are a risk group and that school-based or youth-friendly interventions should consider them as potential targets. Also, parental support was identified as a protective factor in our study, which suggest the need to develop interventions or incorporate parents into existing adolescent sexual and reproductive program to promote adolescent-parent communication, connectedness and support. In doing so, parents need to be trained to improve their knowledge and capacity to engage in conversations regarding their child's sexual health issues and develop strategies to address socio-cultural and religious barriers that prevent effective parental engagement with their child[56].
Study strength and limitations
A key strength of our study is that it uses nationally representative samples of high school students in nine sub-Saharan countries, and the use of meta-analysis to account for heterogeneity to determine the overall prevalence of condoms and other birth control methods use strengthens the robustness of our methodology and validity of our findings. Notwithstanding, our study has some limitations that need to be considered when interpreting our findings. First, our study only targets school-going adolescents in these nine countries, and these may not be representative of the entire adolescent population in these countries. Future studies should look at out-of-school adolescents, especially vulnerable sub-population such as those living in informal settlements. Second, data collected were based on self-reported adolescents' sexual activity, which increases the tendency to over or under-report their sexual and reproductive behaviour. Third, the study employed a cross-sectional design, and causality cannot be inferred. Fourth, we excluded tobacco use as a potential explanatory variable since a large amount of data on this variable were missing in the publicly available file.