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Vol. 12(2), pp. 114-127, April - June 2020
DOI: 10.5897/JPHE2020.1219
Article Number: E17DC3863839
ISSN 2141-2316
Copyright © 2020
Author(s) retain the copyright of this article
http://www.academicjournals.org/JPHE
Journal of Public Health and Epidemiology
Full Length Research Paper
Risky sexual behaviors and substance use among
youths in post-conflict Liberia
Temitope Ogundare1*, Senait Ghebrehiwet2, Benjamin L. Harris3, Babawale Ojediran3,
Alison M. Duncan2,4, Haniya S. Syeda2, David C. Henderson2,4 and Christina P. C. Borba2,4
1School of Public Health, Boston University, Boston, USA.
2Department of Psychiatry, A. M. Dogliotti College of Medicine,University of Liberia, Monrovia, Liberia.
3A. M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia.
4Department of Psychiatry, Boston University School of Medicine, Boston, USA.
Received 10 March, 2020; Accepted 12 May, 2020
Sexually transmitted infections pose a public health crisis globally and in low and middle-income
countries, and substance use has been linked to an increased risk of engaging in risky sexual
behaviors among youths. This work aims to explore the relationship between substance use and risky
sexual behaviors among school-based youths in Liberia. An 86-question survey was developed to
collect information about substance use and sexual behaviors. The survey was validated using
qualitative data obtained from focus groups of Liberian youths. 400 students were sampled with a mean
age of 18.15 ±2.14 years. Students who use alcohol were 2.4 times more likely to have multiple sexual
partners (OR=2.38, CI= 1.06–5.32, p=0.035), 11 times more likely to engage in unwanted sexual activity
(OR=10.86, CI=1.36–86.96, p=0.025); marijuana use increased the risk of multiple unintended
pregnancies (OR=5.49, CI= 1.37–22.03, p=0.016); users of heroin had 4 times the odds of engaging in
unwanted sexual activity (OR=4.18, CI= 1.07-16.37, p=0.039). Substance use increases the risk of
engaging in risky sexual behaviors among youths in Liberia. Intervention programs that target
individual, community, and societal level determinants are needed to tackle risky sexual behaviors in
this population.
Key words: Risky sexual behaviors, substance use, Liberia, youths, adolescents, sexually transmitted
infections (STIs).
INTRODUCTION
Risky sexual behaviors, unintended pregnancy, and
sexual violence are common among youths in Sub-
Saharan Africa (Doyle et al., 2012; Kebede et al., 2005;
Tolera et al., 2019). Risky sexual behaviors, defined as
activities that put people at increased risk for Sexually
Transmitted Infections (STIs), include: having
unprotected sexual intercourse; having multiple sexual
partners over one’s lifetime; having intercourse with a
casual partner; sexual initiation at a young age; sexual
intercourse with commercial sex workers; bartering sex
*Corresponding author. E-mail: ogundare@bu.edu.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution
License 4.0 International License
for money, goods or other favors; engaging in sexual
activity under the influence of alcohol/drugs; and sexual
violence (Madise et al., 2007; Perera and Abeysena,
2018).
Adolescence is a time of developmental, physiological,
and behavioral changes, and is characterized by
increased autonomy, peer influence, risk-taking
behaviors such as initiation of sex, and alcohol/drug use
(Doyle et al., 2012; Tapert et al., 2001). Adolescents are
more likely to have multiple sexual partners, engage in
unprotected intercourse, and choose high-risk partners
compared to adults (Tapert et al., 2001). The study of
adolescent sexual behavior is important as approximately
60% of youths worldwide are currently infected with
STIs, including HIV (Da Ros and da Silva Schmitt, 2008).
STIs continue to pose a public health crisis globally and
in low and middle-income countries (LMICs) (Ritchwood
et al., 2015). Although youths make up about 25% of the
sexually active population; they comprise 50% of the
population with newly acquired STIs. In LMICs, STIs are
amongst the top ten diseases reported by both young
adult males and females, and the second most commonly
reported disease among young adult females (Da Ros
and da Silva Schmitt, 2008).
Earlier studies conducted in Liberia among in-school
youths and young adults have found high rates of risky
sexual behaviors. In one study conducted in 2008, 78%
of youths were found to be sexually active (Quiterio et al.,
2013). Of those who were sexually active, 24.9%
reported having sex for money and 20.9% had never
used a condom (Quiterio et al., 2013). Males were also
found to be more likely to have sex, have multiple sexual
partners, and initiate sex early (Quiterio et al., 2013).
Another study among youths in Liberia found 34% of their
sample had their sexual debut at less than 15 years of
age (defined as early sexual debut), and 21% of those
who were sexually active had multiple sexual partners
(Kennedy et al., 2012). Furthermore, 26% of sexually
active youths had never used a condom, 11% had got
pregnant or got someone pregnant one or more times,
and 11% reported sexual assault (Kennedy et al., 2012).
Among 1,119 young women aged 14- 25 years surveyed
in Montserrado County in Liberia, 72% reported engaging
in transactional sex. Of these women, 67% had early
sexual debut, 91% had multiple sexual partners, and 61%
had at least one pregnancy (Okigbo et al., 2014). Youths
in post-conflict Liberia face daily challenges that put them
at increased risk of risky sexual behaviors as a result of
the effects of the civil war on the country’s infrastructure,
education, and healthcare (Okigbo et al., 2014).
Substance use has been linked to an increased risk of
engaging in risky sexual behaviors among youths.
Studies report increased rates of early age of sexual
intercourse, having multiple sexual partners, and lower
rates of condom use among youths who use substances
compared to those who do not (Connell et al., 2009;
Madkour et al., 2010; Tucker et al., 2012; Vasilenko and
Lanza, 2014). Among youths in Liberia, very few studies
Ogundare et al. 115
have been conducted to explore the relationship between
risky sexual behaviors and substance use. One such
study did not find any association between alcohol use
and transactional sex (Okigbo et al., 2014) while another
study found an association between alcohol use and
engaging in sex and having multiple sexual partners - but
no other substances were explored (Quiterio et al., 2013).
Use of substances other than alcohol among youths has
been found to be associated with risky sexual behaviors
including the use of marijuana (Andrade et al., 2013;
Grossman et al., 2004), cocaine (Castrucci and Martin,
2002; Tolou-Shams et al., 2010), and other drugs
including stimulants and methamphetamines (Castrucci
and Martin, 2002; Kebede et al., 2005; Tolera et al.,
2019). This study aims to explore the relationship
between the use of various substances and risky sexual
behaviors among school-based youths in Liberia and to
identify other risk factors that may be associated with
risky sexual behaviors in this population.
METHODOLOGY
Study design
An 86-question survey was developed by the research team using
several sources including the CDC 2017 State and Local Youth
Risk Behavior Survey, the 2016 Indiana College Substance Use
Survey, the WHO 2013 Global School-Based Student Health
Survey, the 2011 European School Survey Project on Alcohol and
Other Drugs, a paper on Risk Factors and Consequences of
Substance Use among Youths in Post Conflict Liberia (Lippitt,
2013), and the original 2008 pilot survey (Harris et al., 2012). The
survey was validated using qualitative data obtained from focus
group discussion conducted at two secondary schools in the capital
of Liberia, Monrovia, to identify the local terminology used by
Liberian youths to describe common substances and sexual
behaviors. The revised survey, containing the list of local
terminologies in parenthesis, was then administered in English to
students from eight secondary schools in a classroom setting.
Data collection
The sampling frame included co-educational secondary schools in
central and greater Monrovia. Recruitment letters were mailed to a
total of 55 eligible schools; of the schools that responded
expressing interest in participating in the study, ten schools were
randomly selected for inclusion. Of the ten schools included in the
study, two schools were randomly selected to participate in phase 1
of the study, while the remaining eight schools participated in phase
2. For phase 1, students participated in focus group discussions to
provide feedback on the study survey. For phase 2, 50 students
were randomly selected from each participating school, totaling 400
students across all eight schools. Study staff included a total of 10
research assistants (two research assistants per school), affiliated
with the A.M. Dogliotti Medical College at the University of Liberia,
who received training on study procedures including obtaining
consent, facilitating focus group discussions, administering surveys,
and entering data. All data collection occurred during the month of
October 2018.
Phase 1: Survey validation
In order to conduct the rapid validation of the survey, the study staff
116 J. Public Health Epidemiol.
held a focus group discussion at two secondary schools to receive
students’ feedback on the format and content of the developed
survey. Each school had 1 focus group consisting of 9-10 male and
female secondary students. Each focus group was led by two
research assistants using a semi-structured discussion guide in a
private area of the school during school hours. Before beginning
each session, research assistants provided instructions to students
that participation was voluntary, all responses shared would remain
anonymous, and there would be no repercussions for their
responses. All students provided written consent to participate in
the focus group discussions; students under the age of 18 years
provided written assent and permission signed by their parent or
guardian prior to participation in the study. Research assistants
then asked students to review the developed survey before taking
part in a focus group discussion regarding students’ thoughts on the
survey. Research assistants remained present in the classroom for
the entire session, which lasted approximately for 60 min. One
research assistant facilitated the group discussion while the other
took written notes and audio recorded the session. Upon focus
group completion, the research assistants’ notes and audio
recordings were reviewed by the study research team and used to
revise the survey prior to phase 2.
Phase 2: Survey distribution
In phase 2 of the study, the revised survey was administered by two
research assistants per school to a total of eight schools. Research
assistants provided instructions to students and reinforced that the
survey was anonymous and voluntary and that there would be no
repercussions to their responses. Surveys were then distributed to
students with both research assistants and a school representative
present in the classrooms. Once the consenting process was
complete, data were collected on demographics including age, sex,
grade, living arrangements, family SES relative to others, history of
being a child soldier, county/city of origin, ethnicity, languages
spoken, and religion. The survey also asked questions about the
lifetime and current prevalence of substance use (including alcohol,
tobacco, marijuana, heroin, cocaine, and other drugs), as well as
risk factors for substance use (including the role of peers and
sexual behaviors).Study data were entered and managed using the
REDCap electronic data capture tool hosted at Boston University
(Boston University, CTSI 1UL1TR001430).
Measures
Risky sexual behaviors were measured using 16 questions that
covered 11 risky sexual behaviors: early sexual debut; unwanted
sexual activity; number of sexual partners; sexual assault; number
of unintended pregnancies; sex for money, drugs or grades; sex
with relatives; use of birth control; and use of substances before
sex. Early sexual debut was defined as the initiation of sex at or
less than the age of 15 years. The question was, ―How old were
you when you were sexually active (did man or woman business)
for the first time? Circle one‖ with answer choices ranging from 11
to 18 years and above. Unwanted sexual activity was defined as
engaging in unwanted sexual activity as a result of the use of
alcohol and/or other drugs. A question for the use of birth control
allowed more than one option to be checked (options included the
use of condoms, pills, injectables, others and none). Questions
about peer approval about sex, being encouraged by parents to
engage in sex, social norms about the age of sexual initiation,
knowledge of safe sex, and access to condoms were also asked.
Statistical analysis
Data were analyzed using SAS version 9.4 (SAS Institute, 2012).
Age was categorized into two groups – younger than 18 years, and
18 years and older. Risky sexual behaviors were stratified by
gender and Pearson Chi-square tests were used to determine
gender differences in risky sexual behaviors. Bivariate analyses
were done using Pearson Chi-square test to test the association
between any risky sexual behavior and substance use, and using a
simple logistic regression model with risky sexual behavior as the
dependent variable and use of substances as predictor variables.
Finally, a multiple logistic regression analysis was conducted with a
model adjusting for age, sex, family socioeconomic status, and
other determinants of risky sexual behaviors (such as access to
condoms, safe sex knowledge, parental approval of sex, peer
approval of sex, and school type). For all of the tests, statistical
significance was set at alpha of 0.05. Odds ratios and 95%
confidence intervals are reported for all statistically significant
variables.
Ethical approval
Ethical approval for the study was done by the University of Liberia-
Pacific Institute for Research and Evaluation Institutional Review
Board (UL-PIRE IRB) and the Boston University Medical Campus
Institutional Review Board (BUMC IRB). Approval of the study was
also received from the Liberian Ministry of Health and Social
Welfare, and the Ministry of Education.
RESULTS
Demographic characteristics
A total of 400 students were sampled with age ranging
between 12 and 23 years, and a mean of 18.15 ±2.14
years. Of these students, 209 (54.9%) were males, 254
(66.2%) were aged 18 years and above, and 299 (74.8%)
were from private high schools. Demographic
characteristics of the study sample are presented in
Table 1.
Risky sexual behaviors
Of the 400 students in the sample, 58% (n=222) were
sexually active, and of these, 64.4% were males. Of
those who were sexually active: 34.1% (n=74) initiated
sex at age 15 years and below, 38.6% (n=83) had 2 – 5
sexual partners, 22.8% (n=49) had 6 or more sexual
partners, 28.8% (n=64) reported using no form of birth
control, 24% (n=49) had at least one unintended
pregnancy, and 25.1% (n=53) reported experiencing
sexual assault, 19.6% (n=42) reported using substances
before sex, 16.6% (n=35) engaged in unwanted sexual
activity as a result of using substances, 14.8% (n=31)
had had sex for money, 8.2% (n=17) had sex in
exchange for drugs, 6.8% (n=14) had exchanged sex for
grades, and 18.6% (n=39) had sex with an older relative
or adult (Table 2).
Compared to females, males were more likely to: have
multiple sexual partners (χ2=18.25, df=2, p=0.0001), use
substances before sex (χ2=4.26, df=1, p=0.039), engage
in sexual activities for drugs (χ2=4.42, df=1, p=0.035),
Ogundare et al. 117
Table 1. Demographic characteristics of secondary school students in
Monrovia, Liberia.
Variable
Total N (%)
Age (years) a
400 (100)
<18 years
130 (33.9)
≥18 years
254 (66.1)
Mean (SD) 18.15 (2.14)
Sex b
Female
172 (45.1)
Male
209 (54.9)
Grade c
7th and 8th
35 (9.4)
9th and 10th
138 (36.9)
11th and 12th
201 (53.7)
Living arrangements d
Both parents
69 (17.8)
One parent
188 (48.6)
Siblings or other relatives
93 (24.0)
Friends or non-relatives
21 (5.4)
Other
16 (4.1)
Family SES relative to peers e
Relatively better
230 (66.5)
Relatively the same
30 (8.7)
Relatively worse
86 (24.9)
Religion f
Christian
264 (85.7)
Muslim
34 (11.0)
Other
5 (1.6)
Missing: (a) 16; (b) 19; (c) 26; (d) 13; (e) 54; (f) 92.
initiate sexual activity at a younger age (χ2=13.51, df=2,
p=0.0012), and use condoms (χ2=13.45, df=1,
p=0.0002). There was a non-linear association observed
between gender and unintended pregnancies (χ2=7.09,
df=2, p=0.029) with more females (57.6%) reporting one
unintended pregnancy compared to males (42.4%).
However, more males reported two or more unintended
pregnancies (62.5%) compared to females (37.5%). The
only association found between age and risky sexual
behaviors was related to having multiple sexual partners.
Students 18 years and older were more likely to have
multiple sexual partners compared to those younger than
18 years (χ2=11.12, df=2, p=0.004).
Substance use and risky sexual behaviors
Among those students who were sexually active, risky
sexual behaviors were associated with the use of any
substances in the past 30 days in the bivariate analysis -
except for age of sexual debut, unintended pregnancy
and use of birth control (Table 3). When each substance
was examined (Table 4), use of alcohol, tobacco,
marijuana, cocaine, heroin alcohol use was associated
with: having multiple sexual partners, using substances
before sex, engaging in unwanted sexual activity, and
sex with relatives. Use of tobacco was associated with
having 6 or more sexual partners, having 2 unintended
pregnancies, use of substances before sex, having
unwanted sexual activity, having sex for money, having
sex in exchange for drugs, having sex in exchange for
grades, experiencing sexual assault, and having sex with
relatives. Marijuana use was associated with: having 6 or
more sexual partners, having one or more unintended
pregnancies, use of substances before sex, having
unwanted sexual activity, having sex for money, having
118 J. Public Health Epidemiol.
Table 2. Risky sexual behaviors among youths in post-conflict Liberia.
Variable
N (%)
Male N (%)
Female N (%)
χ2
df
p-value
Sexually active
222 (58.0)
143 (64.4)
79 (35.6)
18.45
1
<0.0001
Age at first sex (n =217)
≤ 15 years
74 (34.1)
60 (81.1)
14 (18.9)
16 - 17 years
78 (35.9)
48 (55.1)
39 (44.9)
13.51
2
0.0012
≥ 18 years
65 (30.0)
52 (56.9)
38 (43.1)
Number of sexual partners (n= 215)
1
83 (38.6)
41 (49.4)
42 (50.6)
2 - 5
83 (38.6)
56 (67.5)
27 (32.5)
18.25
2
0.0001
≥ 6
49 (22.8)
42 (85.7)
7 (14.3)
Use of birth control
None
64 (28.8)
37 (57.8)
27 (42.2)
1.71
1
0.191
Condoms
129 (58.1)
96 (74.4)
33 (25.6)
13.45
1
0.0002
Pills
12 (5.41)
5 (41.7)
7 (58.3)
2.86
1
0.091
Injectables
12 (5.41)
5 (41.7)
7 (58.3)
2.86
1
0.091
Others
5 (2.3)
1 (20.0)
4 (80.0)
4.4
1
0.055
Number of times pregnant (n=204)
0
155 (76.0)
104 (67.1)
51 (32.9)
1
33 (16.2)
14 (42.4)
19 (57.6)
7.09
2
0.029
2
16 (7.8)
10 (62.5)
6 (37.5)
Use of substance before sex (n= 214)
42 (19.6)
33 (78.6)
9 (21.4)
4.26
1
0.039
Unwanted sexual activity** (n=211)
35 (16.6)
25 (71.4)
10 (28.6)
0.78
1
0.378
Sex for money or gifts (n=209)
31 (14.8)
21 (67.7)
10 (32.3)
0.21
1
0.648
Sex for alcohol or drugs (n=208)
17 (8.2)
15 (88.2)
2 (11.8)
4.42
1
0.035
Sex for grades (n=206)
14 (6.8)
11 (78.6)
3 (21.4)
1.37
1
0.242
Sexual assault (n= 211)
53 (25.1)
33 (62.3)
20 (37.7)
0.09
1
0.764
Sex from relatives (n=210)
39 (18.6)
28 (71.8)
11 (28.2)
1.32
1
0.25
*Fisher’s exact test used in cases where >25% of cells have expected count <5. **Defined as engaging in unwanted sexual activity as a result of
using alcohol and/or drugs.
sex in exchange for drugs, and having sex in exchange
for grades. Cocaine use was associated with: use of
substances before sex, having unwanted sexual activity,
having sex for money, having sex in exchange for drugs,
having sex in exchange for grades, and having sex with
relatives. Use of heroin was associated with: having 2 or
more unintended pregnancies, use of substances before
sex, having unwanted sexual activity, having sex for
money, having sex in exchange for drugs, and having sex
in exchange for grades. The use of other drugs
wasassociated with: having 6 or more sexual partners,
use of substances before sex, having unwanted sexual
activity, having sex in exchange for drugs, experiencing
sexual assault, and having sex from relatives.
Independent predictors of risky sexual behaviors
In the final multivariable logistic regression model (Table
5), students who use alcohol were 2.4 times more likely
to have 2-5 sexual partners (OR=2.38, CI= 1.06–5.32,
p=0.035), 3.7 times more likely to have 6 or more sexual
partners (OR=3.67, CI= 1.33–10.09, p=0.012), and 11
times more likely to engage in unwanted sexual activity
(OR=10.86, CI= 1.36–86.96, p=0.025) compared to those
who do not drink alcohol. Marijuana use increased the
risk of multiple unintended pregnancies (OR=5.49, CI=
1.37-22.03, p=0.016). Those who use heroin have 4
times the odds of engaging in unwanted sexual activity
(OR=4.18, CI= 1.07-16.37, p=0.039), 3 times the odds of
having sex for money (OR=3.46, CI= 1.07-11.26,
p=0.039), and 6 times the odds of having sex for drugs
(OR=6.14, CI= 1.32-28.65, p=0.021). Those who were
using other drugs were more likely to use substances
before sex (OR=7.79, CI= 2.60-23.38, p=0.0002), engage
in unwanted sexual activity (OR=3.38, CI= 1.05-10.93,
p=0.042), exchange sex for grades (OR=9.23, CI= 2.39-
Ogundare et al. 119
Table 3. Any substance use in the past 30-days and risky sexual behaviors among sexually active youths in post-conflict Liberia.
Variable
Yes
No
χ2
df
p-value
N (%)
N (%)
Sex
Male
110 (76.9)
33 (23.1)
4.7
1
0.03
Female
50 (63.3)
29 (36.7)
Age category
< 18 years
30 (71.4)
12 (28.6)
0.03
1
0.86
≥ 18 years
131 (72.8)
49 (27.2)
Age at first sex
≤ 15 years
60 (78.9)
16 (21.1)
2.61
1
0.271
16 - 17 years
57 (71.3)
23 (28.7)
≥ 18 years
45 (67.2)
22 (32.8)
Number of sexual partners
1
51 (60.7)
33 (39.3)
10.76
2
0.005
2 - 5
67 (77.9)
19 (22.1)
≥ 6
43 (84.3)
8 (15.7)
Use of birth control
none
42 (64.6)
23 (35.4)
2.43
1
0.119
condoms
101 (75.9)
32 (24.1)
2.42
1
0.12
others*
19 (76.0)
6 (24.0)
0.22
1
0.636
Number of times pregnant
0
111 (70.3)
47 (29.7)
1.23
2
0.541
1
26 (74.3)
9 (25.7)
≥2
14 (82.3)
3 (17.7)
Use of substance before sex
38 (88.4)
5 (11.6)
6.59
1
0.01
Unwanted sexual activity**
36 (97.3)
1 (2.7)
13.99
1
0.0002
Sex for money
30 (88.2)
4 (11.8)
4.99
1
0.026
Sex for drugs
17 (94.4)
1 (5.6)
4.77
1
0.028
Sex for grades
15 (100.0)
0 (0.0)
6.08
1
0.013
Sexual assault
47 (83.9)
9 (16.1)
5.52
1
0.019
Sex from relatives
37 (88.1)
5 (11.9)
9.65
1
0.008
* Defined as pills, injectables and other methods of birth control; ** Defined as engaging in unwanted sexual activity as a result of using
alcohol and/or drugs; Fisher’s exact test used in cases where >25% of cells have expected count <5.
35.60, p=0.001), experience sexual assault (OR=4.14,
CI=1.62-10.59, p=0.003), and engage in sexual activities
with relatives (OR=3.97, CI= 1.30-12.19, p=0.016).Being
male, having knowledge of safe sex, and having access
to condoms were also independent predictors of
engaging in risky sexual behaviors. Males were 12 times
more likely to have 6 or more sexual partners compared
to females (OR=11.56, CI= 3.52-37.96, p<0.0001) and
were 60% less likely to be victims of sexual assault
(OR=0.43, CI= 0.19-0.96, p=0.039). Having access to
condoms increased the odds of using a condom
(OR=5.06, CI= 2.06–12.41, p=0.0004) and decreased the
odds of not using any form of birth control (OR=0.24, CI=
0.10–0.55, p=0.0008). Having knowledge of safe sex
increased the risk of using substances before sex
(OR=3.11, CI= 1.03–9.40, p=0.045), having sex with
relatives (OR=3.97, CI= 1.30–12.19, p=0.016), and
having experienced sexual assault (OR=3.65, CI= 1.51–
8.81, p=0.004).
DISCUSSION
This study examined the relationship between substance
120 J. Public Health Epidemiol.
Table 4. Past 30-days substance use and risky sexual behaviors among sexually active youths in post-conflict Liberia.
Variable
Yes
No
OR
95% CI
p-value
N (%)
N (%)
Alcohol
Number of sexual partners
1
48 (57.1)
36 (42.9)
Reference
2 – 5
62 (72.1)
24 (27.9)
1.94
1.02, 3.67
0.043
≥ 6
38 (77.5)
11 (22.5)
2.59
1.17, 5.75
0.019
Use of substance before sex
36 (87.8)
5 (12.2)
4.28
1.60, 11.45
0.004
Unwanted sexual activity#
33 (91.7)
3 (8.3)
6.64
1.96, 22.49
0.002
Sex from relatives
33 (80.5)
8 (19.5)
2.44
1.06, 5.62
0.035
Tobacco
Number of sexual partners
1
12 (14.8)
69 (85.2)
Reference
2 – 5
12 (14.6)
70 (85.4)
0.99
0.41, 2.35
0.974
≥ 6
15 (31.3)
33 (68.7)
2.61
1.10, 6.21
0.03
Number of times pregnant
0
14 (9.0)
141 (91.0)
Reference
≥2
7 (41.2)
10 (58.8)
3.01
1.01, 8.95
0.047
Use of substance before sex
16 (43.2)
21 (56.8)
4.97
2.27, 10.89
<0.0001
Unwanted sexual activity#
13 (38.2)
21 (61.8)
3.67
1.63, 8.25
0.002
Sex for money
13 (40.6)
19 (59.4)
3.87
1.71, 8.78
0.001
Sex for drugs
8 (47.1)
9 (52.9)
4.68
1.67, 13.10
0.003
Sex for grades
8 (57.1)
6 (42.9)
6.8
2.20, 20.96
0.001
Sexual assault
16 (29.6)
38 (70.4)
2.49
1.19, 5.21
0.016
Sex from relatives
12 (32.4)
25 (67.6)
2.62
1.17, 5.87
0.019
Marijuana
Number of sexual partners
1
8 (9.8)
74 (90.2)
Reference
2 – 5
10 (12.1)
73 (87.9)
1.27
0.47, 3.39
0.637
≥ 6
13 (26.0)
37 (74.0)
3.25
1.24, 8.53
0.017
Number of times pregnant
0
14 (9.0)
141 (91.0)
Reference
1
7 (21.9)
25 (78.1)
2.82
1.04, 7.68
0.043
≥2
7 (41.2)
10 (58.8)
7.05
2.32, 21.42
0.001
Use of substance before sex
12 (30.0)
28 (70.0)
3.5
1.53, 7.99
0.003
Unwanted sexual activity#
10 (27.8)
26 (72.2)
3.16
1.32, 7.55
0.01
Sex for money
10 (30.3)
23 (69.7)
3.21
1.34, 7.67
0.009
Sex for drugs
7 (38.9)
11 (61.1)
4.65
1.64, 13.19
0.004
Sex for grades
6 (40.0)
9 (60.0)
4.45
1.46, 13.58
0.009
Cocaine
Use of substance before sex
8 (20.0)
32 (80.0)
5
1.75, 14.30
0.003
Unwanted sexual activity#
8 (22.9)
27 (77.1)
6.9
2.31, 20.58
0.001
Sex for money
6 (18.8)
26 (81.3)
3.74
1.25, 11.16
0.018
Sex for drugs
6 (37.5)
10 (62.5)
11.93
3.55, 40.16
<0.0001
Sex for grades
5 (35.7)
9 (64.3)
8.94
2.56, 31.25
0.001
Sex from relatives
6 (15.8)
32 (84.2)
3.25
1.08, 9.77
0.036
Ogundare et al. 121
Table 4. Cont’d.
Heroin
Number of times pregnant
0
13 (8.5)
140 (91.5)
Reference
1
7 (21.2)
26 (78.8)
2.9
1.06, 7.96
0.039
≥2
4 (23.5)
13 (76.5)
3.31
0.94, 11.64
0.062
Use of substance before sex
9 (24.3)
28 (75.7)
3.43
1.37, 8.59
0.009
Unwanted sexual activity#
12 (34.3)
23 (65.7)
7.09
2.85, 17.63
<0.0001
Sex for money
10 (32.3)
21 (67.7)
5.97
2.33, 15.31
0.0002
Sex for drugs
7 (41.2)
10 (58.8)
7.66
2.57, 22.84
0.0003
Sex for grades
6 (42.9)
8 (57.1)
7.25
2.26, 23.23
0.001
Other drugs
Number of sexual partners
1
9 (11.1)
72 (88.9)
Reference
2 - 5
9 (11.1)
72 (88.9)
1
0.38, 2.67
1
≥ 6
15 (30.0)
35 (70.0)
3.43
1.37, 8.61
0.009
Use of birth control
condoms
25 (19.5)
103 (80.5)
2.55
1.09, 5.94
0.03
Use of substance before sex
15 (38.5)
24 (61.5)
5.35
2.38, 12.01
<0.0001
Unwanted sexual activity#
14 (40.0)
21 (60.0)
5.44
2.38, 12.44
<0.0001
Sex for drugs
6 (35.3)
11 (64.7)
3.58
1.22, 10.54
0.021
Sexual assault
16 (28.6)
40 (71.4)
3.63
1.65, 7.97
0.001
Sex from relative
11 (28.2)
28 (71.8)
2.73
1.19, 6.29
0.018
# Defined as engaging in unwanted sexual activity as a result of using alcohol and/or drugs.
Table 5. Multiple logistic regression analysis of the predictors of risky sexual behaviors among youths in post-conflict Liberia.
Variable
Beta
SE
Wald
AOR
CI (lower, upper)
p-value
Number of sexual partners (ref = 1)
Male (ref = females)
2 – 5
0.38
0.2
3.65
2.15
(0.98, 4.72)
0.056
≥ 6
1.22
0.3
16.26
11.56
(3.52, 37.96)
<0.0001
< 18 years (ref = 18+ years)
2 – 5
-0.13
0.23
0.33
0.77
(0.31, 1.90)
0.564
≥ 6
-1.19
0.43
7.73
0.09
(0.02, 0.50)
0.005
Alcohol use (ref = no)
2 – 5
0.43
0.21
4.43
2.38
(1.06, 5.32)
0.035
≥ 6
0.65
0.26
6.34
3.67
(1.33, 10.09)
0.012
Use of birth control
None
Access to condoms (ref = no)
-0.72
0.22
11.15
0.24
(0.10, 0.55)
0.0008
Condoms
Access to condoms (ref = no)
0.81
0.23
12.53
5.06
(2.06, 12.41)
0.0004
Number of times pregnant (ref = 0)
Marijuana use (ref =no)
1
0.33
0.31
1.11
1.94
(0.57, 6.64)
0.293
≥2
0.85
0.35
5.76
5.49
(1.37, 22.03)
0.016
122 J. Public Health Epidemiol.
Table 5. Cont’d
Use of substance before sex
Safe sex awareness (reference=no)
0.57
0.28
4.02
3.11
(1.03, 9.40)
0.045
Other drugs use (reference = no)
1.03
0.28
13.42
7.79
(2.60, 23.38)
0.0002
Unwanted sexual activity#
Alcohol use (ref = no)
1.19
0.53
5.05
10.86
(1.36, 86.96)
0.025
Heroin use (ref = no)
0.72
0.35
4.23
4.18
(1.07, 16.37)
0.039
Other drugs use (ref = no)
0.61
0.3
4.14
3.38
(1.05, 10.93)
0.042
Sex for money
Heroin use (ref = no)
0.62
0.3
4.27
3.46
(1.07, 11.26)
0.039
Sex for drugs
Heroin use (ref = no)
0.91
0.39
5.33
6.14
(1.32, 28.65)
0.021
Sex for grades
Other drugs use (ref = no)
1.11
0.34
10.4
9.23
(2.39, 35.60)
0.001
Sexual assault
Male (reference = female)
-0.43
0.21
4.26
0.43
(0.19, 0.96)
0.039
Safe sex awareness (reference = no)
0.65
0.23
8.26
3.65
(1.51, 8.81)
0.004
Other drug use (reference = no)
0.71
0.24
8.81
4.14
(1.62, 10.59)
0.003
Sex from relatives
Safe sex awareness (reference = No)
0.83
0.31
7.23
5.25
(1.57, 17.56)
0.007
Other drugs use (reference = no)
0.69
0.29
5.82
3.97
(1.30, 12.19)
0.016
#Defined as engaging in unwanted sexual activity as a result of using alcohol and/or drugs. Model adjusted for age, sex, family SES, peer
approval of sex, social norms about sex, knowledge of safe sex, access to condoms, parental encouragement of sex.
use and risky sexual behaviors among youth in Liberia.
The findings from this study show that most school-based
Liberian youths are sexually active (58% with a higher
prevalence of sexually active male students than female)
and those risky sexual behaviors are prevalent among
Liberian youths. In the study sample, 1 in 4 youths
reported sexual assault, about 3 in 10 youth had sex at
15 years or younger. In addition, 1 in 5 reported
substance use before sex, 1 in 6 had unwanted sex as a
result of substance use, and between 6.8 and 18.6% had
transactional sex for money, grades or drugs.
In an earlier study among youths in Liberia, the
proportion of youths who were sexually active was higher
than that reported in the current study (78 vs. 58%)
(Quiterio et al., 2013). This difference may be due to the
higher average age of study participants in the 2008
study compared to those in the current study. In Sub-
Saharan Africa, a trend towards less risky sexual
behaviors has been reported (Doyle et al., 2012).
Changes in technology, increasing use of social media by
youths, and an increase in education about STIs and HIV
in schools have led to a decline in the prevalence of
sexual activity among youths (Ethier et al., 2018). Although
the civil war in Liberia damaged the education and
healthcare systems, there have been attempts to
revitalize school-based social services and formulate
adolescent sexual health policies (Kennedy et al., 2012).
The reduced prevalence of sexually active youths in
this study may be the result of such interventions.
Similar to this study, another study conducted among
802 adolescents in Liberia found the proportion of those
who initiated sex at ages 15 years and younger was 34%
(Kennedy et al., 2012). While the prevalence of sexual
activity appears to be reducing, the prevalence of early
initiation of sex appears static. Substance use, lack of
parental supervision, encouragement by parents to
engage in transactional sex, and socioeconomic
difficulties have all been cited as reasons for the
persistence of early initiation of sexual activity (Gizaw et
al., 2014; Kassa et al., 2015; Mazengia and Worku, 2009;
Rudatsikira et al., 2007). Early sexual debut is associated
with increased risk of STIs including HIV (Shrestha et al.,
2016; Stöckl et al., 2013), having multiple sexual partners
(Shrestha et al., 2016; Son et al., 2016; Yaya and
Bishwajit, 2018) and engaging in other risky sexual
behaviors (Baumgartner et al., 2009; Okigbo et al., 2014;
Shrestha et al., 2016).
In a sample of young females in Liberia, 70% of those
who were sexually active had traded sex for material
benefits (Okigbo et al., 2014). In this study, the
prevalence among females was much lower (14.8%)
which may be due to the sampling methods that were
restricted to in-school youths. This may have impacted
the prevalence of risky sexual behaviors reported in this
study because out-of-school youths have a higher
prevalence of risky sexual behaviors compared to in-
school youths (Ndyanabangi et al., 2004). However, the
prevalence of sexual activity among females was higher
than those previously reported by Atwood et al. in a
sample of in-school youths in Liberia (Atwood et al.,
2012). Transactional sex increases the risk of STIs and
HIV because it often involves age and power differentials,
a reduction in the capacity of youth (usually female) to
negotiate condom use, and often involves substance use
(Atwood et al., 2012). Transactional sex also increases
the likelihood of sexual assault and violence (Atwood et
al., 2011; Okigbo et al., 2014). In the current study, there
were no gender differences found in engagement in
transactional sex similar to an earlier study by Quiterio et
al. (Quiterio et al., 2013) among youths in Liberia. Other
studies found that females are usually more likely to
engage in transactional sex and, in some instances, are
encouraged to engage in transactional sex by their
parents in order to contribute to the family’s income
(Atwood et al., 2011; Okigbo et al., 2014; Tolera et al.,
2019). A significant proportion of adolescent boys have
also been found to engage in transactional sex (Adjei and
Saewyc, 2017; Moore and Biddlecom, 2007).
In the current study, 1 in 4 youths had experienced
sexual violence, which is similar to prevalence rates
reported among youths in Ethiopia (Tolera et al., 2019).
However, this rate is higher than those reported in two
studies conducted among 8th graders (ages 12 – 23
years) in public schools in South Africa where the
prevalence of sexual violence was 9.5 and 3.9%
respectively (De Vries et al., 2014; Pöllänen et al., 2018).
Similar to other studies (Atwood et al., 2012; Tolera et al.,
2019), our study found that females were more likely to
experience sexual violence compared to males.
However, in two studies among youth in South-Africa, the
prevalence of sexual violence was found to be higher in
males compared to females (De Vries et al., 2014;
Pöllänen et al., 2018). This suggests that it is possible
that sexual violence is common in males but due to the
lack of focus on sexual violence in males, it has largely
gone underreported. Similar to transactional sex, it may
be that males are suffering in silence, especially given
the culture of masculinity in many African countries where
men are not allowed to complain or show any signs of
weakness (Adjei and Saewyc, 2017).
The study found that 58% of sexually active youths
reported condom use, while 28.8% reported no form of
contraception use. The rate of condom use in this study
Ogundare et al. 123
is higher than earlier studies conducted in Liberia
(Kennedy et al., 2012; Okigbo et al., 2014; Quiterio et al.,
2013), Ethiopia (Kebede et al., 2005; Tolera et al., 2019),
Ghana, Uganda, Malawi, and Burkina-Faso (Madise et
al., 2007). In a review of risky sexual behaviors of
countries in Sub-Saharan Africa, the average rate of
condom use was found to be below 50% (Doyle et al.,
2012). Though encouraging, this result should be
interpreted with caution as this study was carried out in
the capital city of Monrovia, and it has been shown that
condom use is lower in rural areas (Doyle et al., 2012;
Madise et al., 2007). Youths who reported having access
to condoms in this study were more likely to use a
condom. Making condoms accessible is an effective
strategy in increasing condom use and promoting positive
sexual behaviors among youths (Wang et al., 2018).
However, other studies have noted that condom access
is not the only factor that predicts condom use among in-
school adolescents; lack of accurate information about
condoms and misinformation can also contribute to low
condom use among youths (Atwood et al., 2011; Tolera
et al., 2019), as well as negative attitudes towards
condom use (Ndyanabangi et al., 2004). As reported in
other studies (Kennedy et al., 2012), males were more
likely to use condoms in our study and were more likely
to demonstrate self-efficacy in the purchase and correct
usage of condoms (Meekers and Klein, 2002). Females
are usually disadvantaged in negotiating condom use,
especially considering potential age and power
differentials involved (Atwood et al., 2011; Moore and
Biddlecom, 2007; Okigbo et al., 2014).
Risky sexual behaviors were found to be associated
with substance use in this study. The use of alcohol,
marijuana, heroin, and other drugs increased the risk of
engaging in risky sexual behaviors. Although cocaine and
tobacco use were associated with risky sexual behaviors
in the bivariate analysis, they were no longer statistically
significant in the multivariable analysis. Alcohol use in
youths has been found to be associated with having
multiple sexual partners (Doku, 2012; Oppong et al.,
2014; Quiterio et al., 2013), engaging in transactional sex
(Okigbo et al., 2014; Oppong et al., 2014), and having
unprotected sex (Kebede et al., 2005; Oppong et al.,
2014). In contrast, other studies have reported no
association between alcohol use in youths and risky
sexual behaviors (Espinoza et al., 2019; Tolera et al.,
2019). Alcohol consumption decreases inhibitions, affects
rational thinking and decision making, and increases risk-
taking behaviors. These effects may be amplified in
youths (Kebede et al., 2005; Ritchwood et al., 2015).
Similarly, marijuana use in youths has been reported to
increase the risk of unintended pregnancies (Cavazos-
Rehg et al., 2011; Jonas et al., 2016), multiple sexual
partners (Doku, 2012; Oppong Asante et al., 2014) and
transactional sex (Oppong et al., 2014). Like alcohol,
marijuana use also decreases inhibitions and increases
risk-taking behaviors (Espinoza et al., 2019). In a study
124 J. Public Health Epidemiol.
among eighth-graders in South Africa, Palen et al. (2006)
found that marijuana use increases the risk of casual sex;
however, there was no association with condom use. The
authors concluded that in designing interventions, the
message should be framed to reflect the link between
substance use and casual sex, and how that may
increase the risk of STIs and unintended pregnancies.
This message may increase consistent condom usage
among youths (Palen et al., 2006).
Similar to previous studies among youths in Ghana and
the United States (Doku, 2012; Espinoza et al., 2019;
Tapert et al., 2001), youths who reported heroin use had
an increased risk of engaging in unwanted sexual activity
and transactional sex compared to youths who did not
use heroin. Those who use other drugs (including drugs
such as tramadol, diazepam, amphetamines, and other
stimulants) were also more likely to engage in risky
sexual behaviors, including having unwanted sexual
activity and transactional sex. Studies among youths in
Ghana and Ethiopia have reported associations between
risky sexual behaviors and the use of stimulants (such as
khat), diazepam, and hallucinogens (Doku, 2012; Kebede
et al., 2005; Tolera et al., 2019).
The risk of engaging in risky sexual behaviors is said to
be higher in youths who use alcohol alone or in
combination with other substances. Among high-risk
youths, those who used marijuana but not alcohol had
less risk of engaging in risky sexual behaviors than
youths who used alcohol alone or in combination with
other substances (Gillman et al., 2018). Therefore,
interventions to reduce substance use in the context of
risky sexual behaviors may be more effective when
alcohol consumption is targeted either alone or in
combination with other substances (Gillman et al., 2018).
This is important because, among youths who use
substances, alcohol is the most common substance
consumed (Quiterio et al., 2013; Tolera et al., 2019).
Although in the final regression analysis, tobacco and
cocaine use were not associated with risky sexual
behaviors in this study, associations between tobacco
use and risky sexual behaviors have been reported
among youth in Ghana (Doku, 2012; Oppong et al.,
2014), Scotland (Jackson et al., 2012), and the United
States (Espinoza et al., 2019).
Our study identified an association between substance
use and risky sexual behaviors among youths in Liberia,
a country recovering from decades of conflict. Although
this relationship is not causal, the co-occurrence of
substance use and risky sexual behaviors in youths can
produce a synergistic effect to cause adverse health
consequences (Jackson et al., 2012). It is, therefore,
necessary to develop effective intervention programs to
address substance use and risky sexual behaviors
among this population. Effective intervention will address
the determinants of these behaviors at multiple levels –
individual, community, and societal/policy. Interventions
targeted at the individual level may be delivered in a
school setting and should consist of educational
programs targeted at both substance use and risky
sexual behaviors with context regarding their interactive
effects. Additionally, interventions should aim to increase
self-efficacy in condom acquisition and correct use.
Ideally, these educational components should be
targeted before the initiation of sexual activity (before the
age of 15 years). However, it should be noted that
knowledge of safe sex is not enough to prevent youths
from engaging in risky sexual behaviors. In our study,
those with knowledge about safe sex were more likely to
engage in risky sexual behaviors, including transactional
sex and non-use of condoms. Therefore, educational
programs must be paired with other interventions to
formulate a comprehensive intervention to tackle risky
sexual behaviors in youths. School-based interventions
have been shown to be effective in reducing risky sexual
behaviors among adolescents. In South Africa, Jemmott
et al. (2010) conducted a school-based intervention
program among 1,057 sixth grade students, consisting of
one-hour sessions that included interactive exercises,
games, brainstorming, role-playing, and group
discussions. They reported a reduction in unprotected
vaginal intercourse, vaginal intercourse and multiple
sexual partners among students who received the
intervention compared to controls (Jemmott et al., 2010).
Future interventions should also include community-
based programs that address the location and
affordability of condoms to make condoms more
accessible. School clinics are ideal locations for making
condoms available and can be paired with safe sex
education. Previous research has found that parental
support for condoms has been declining and that
perceived parental approval for condom use is
associated with increased condom use (Doyle et al.,
2012). Therefore, interventions to address risky sexual
behaviors among youths must also target the parents. In
addition, studies reveal that parents sometimes
encourage and pressure female children to engage
intransactional sex, which should also be a target for
intervention in reducing risky sexual behaviors (Atwood et
al., 2011; Okigbo et al., 2014).
On the society/policy level, the fundamental needs of
the population must be addressed, such as poverty,
unemployment, and trauma. Interventions to address
risky sexual behaviors among youths, especially
transactional sex, have often failed because the drivers of
these behaviors are economic (Atwood et al., 2012;
Okigbo et al., 2014). School policies should be enacted
and enforced to prevent the exploitation of students by
teachers for grades. Though not highlighted in this study,
students in high school have reported being coerced by
teachers to have sex in exchange for better grades
(Atwood et al., 2011; Tolera et al., 2019). To stop male
teachers from sexually harassing female students in
South Africa, the National Department of Education
introduced an amendment to the Employment of Educators
Act that requires provincial departments of education to
dismiss any educator found guilty of having a sexual
relationship with a learner of the school where he or she
is employed. The South African Council for Educators
(SACE) Act also makes provision for the removal from
the register of any educator found guilty of a breach of
the code of professional ethics (Prinsloo, 2006).
According to Prinsloo, the following recommendations
may be put in place to prevent exploitation of students by
teachers: 1) developing a school culture in which values
and human rights are protected, promoted and fulfilled; 2)
equipping the learners with the necessary skills to be
able to assert themselves in cases of emotional and
sexual harassment, victimization, intimidation, hate
speech and all forms of sexism; 3) creating an awareness
of the definition and different forms of sexual harassment;
4) developing a standard of conduct among gender
groups; 5) creating a climate of trust in which
stereotyping is avoided; 6) encouraging female learners
to talk to educators who are trusted about any incident of
sexual harassment or sexual abuse; and 7) creating a
safe school environment conducive to effective teaching
and learning (Prinsloo, 2006). In addition to policies,
school personnel training has also been shown to be an
effective intervention program to reduce the exploitation
of students by teachers. (Schwandt and Underwood,
2016)
This study has several limitations that must be
considered in interpreting the findings. First, it was
conducted among selected schools in Monrovia, which is
an urban area. Our findings may not be generalizable to
youths in rural areas and to out-of-school youth. Indeed,
studies have found that compared to in-school youths,
out-of-school youths have a much higher prevalence of
risky sexual behaviors and less opportunity for safe sex
education (Ndyanabangi et al., 2004; Oppong Asante et
al., 2014). Second, the study utilized a self-report survey
that may be subject to social desirability bias. Also,
several of the variables contained missing data which
may affect the overall effect of the associations detected
in this study. Third, this study did not take into account
psychiatric morbidity in assessing both the prevalence of
substance use and the increased risk of engaging in risky
sexual behaviors. Among youths, it has been shown that
among risky sexual behaviors, substance use and
psychological distress are interconnected (Caminis et al.,
2007; Page and hall,2009).
Conclusion
This study found that risky sexual behaviors are quite
common among youths in Liberia and that substance use
among youth increases the risk of engaging in risky
sexual behaviors. These behaviors put them at increased
risk of STIs including HIV, unintended pregnancies and
sexual violence. Intervention programs that target
individual, community, and societal level determinants
Ogundare et al. 125
are needed to tackle risky sexual behaviors in this
population. Educational programs for youths should start
early (before the initiation of sexual activity and
consequent school drop-out), provide accurate
information about the risk associated with risky sexual
behaviors, discuss the link between substance use and
risky sexual behaviors, provide accurate information
about condom use, and promote self-efficacy to obtain
and use condoms. Community-based interventions
should promote parental support for condom use, and
parental disapproval of transactional sex and other risky
sexual behaviors. Policy interventions should focus on
tackling poverty and unemployment, and enacting and
enforcing policies to prevent sexual exploitation of
youths.
CONFLICT OF INTERESTS
The authors have not declared any conflict of interests.
ACKNOWLEDGEMENTS
The authors are grateful for the following local research
assistants from the A.M. Dogliotti College of Medicine at
the University of Liberia who carried out data collection
for the study: Wilbur TS Harris, Emmanuel D Lah, Clarice
Dixon, Terry Juty Socro, Emmanuel Flomo, Matthew
Kolleh, Theophilus Sieka, James T Helb Jr, Harriet N
Yangian, and Kodjo N Tehoungue and also appreciate
the support of the Liberia Ministry of Health and the
Liberia Ministry of Education. This work was supported by
the National Institute of Mental Health under Grant
Number K01MH100428.
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