Abstract
The purpose of the study was to develop a Reproductive Health Enhancement programme for in-school adolescents in Akwa Ibom State, Nigeria. To achieve the purpose thirteen research questions were posed and 13 hypotheses were postulated and tested at .05 level of significance. A modified seven steps research and development design was utilized for the study. The study population consisted of in-school adolescents (57600) and health and physical education experts (40) in University of Nigeria, Nsukka, University of Uyo and College of Education, Afaha Nsit, Akwa Ibom State. A sample of 2880 in-school adolescents was drawn from the population using a multi-stage sampling procedure. Four types of instruments were used for the study. The Reproductive Health Knowledge, Attitude and Practice Questionnaire (RHKAPQ), the Reproductive Health Focus Discussion Guide (RHFGDG), the Reproductive Health Enhancement Evaluation Guide and the Reproductive Health Enhancement Programme Questionnaire (REHEPQ). Two sets of the instrument (RHKAPQ and REHEPQ) were subjected to validation by five experts from the Department of Health Education, Science Education and Educational Foundations. The reliability indices of the RHKAPQ was .76, .74 and .61. The REHEPEC reliability index was .65. Research questions were answered using means and standard deviations. Null hypotheses were tested using ANCOVA. The findings of the baseline data revealed that in-school adolescents possessed moderate (52%) level of reproductive health (RH) knowledge, demonstrative positive ( Ì… = 2.68) attitude to RH and sometimes practised the various components of RH. On the basis of there, the Reproductive Health Enhancement Programme (REHEP) was developed. All the items of rationale ( Ì… =
3.53), philosophies ( Ì… = 3.50), goals ( Ì… = 3.59), objectives ( Ì… = 3.39), contents ( Ì… = 3.67),
methods and materials ( Ì… = 3.58), and evaluation techniques ( Ì… = 3.51) were adjudged suitable or very suitable for inclusion in REHEP. After subjecting the REHEP to trial testing, the finding showed that RH knowledge of male and female, urban and rural and those aged 11-14 and 15-19 possessed very high knowledge; they demonstrated positive attitude, and the adolescents sometimes practised the components of RH. There was significant difference in the RH knowledge, attitude and extent of practice of RH of in-school adolescents exposed to REHEP and those not exposed to REHEP No significance difference was found in the attitude of in-school adolescent exposed to REHEP according to gender, age and location. There was no significant difference in the extent of RH practice of those exposed to REHEP according to location and age while there was significant difference in the extent of RH practice according to gender. Based on the findings, it was recommended that REHEP should to adopted and implemented by relevant agencies of federal, state and local governments, non-governmental organizations and churches.
CHAPTER ONE
Introduction
Background to the Study
In this millennium, reproductive health (RH) has become an issue of common concern among various countries of the world especially during this era of HIV and AIDS. The need to care for the reproductive body organs, stay free from infections and maintain a satisfying sexual relationship without fear of infections and unwanted pregnancy is crucial to the wellbeing of everyone and should be the concern of everybody. Reproductive health according to Adesokan (2010) is an essential part of peoples’ wellbeing and is central and crucial to human growth and development. The World Health Organization – WHO (1994) has recognized the importance of reproductive system, processes and functions especially among women who have special health needs before, during and beyond the childbearing ages. The organization further reported that, reproductive health has also recognized the special needs of men as well as adolescents and enhanced peoples’ opportunities to exercise choices in all the events that surround or affect human reproduction. Despite the recognized needs for reproductive health, its associated problems account for high level of morbidity and mortality among the populace including adolescents.
Reproductive health is an essential aspect of health that ensures healthy reproductive wellbeing. The United State Agency International Developments – USAID (2009) enumerated reproductive health problems to include among others unwanted pregnancy, sexually transmitted infections (STIs), HIV and AIDs, gender base violence, early sexual debut, unsafe or risky sex, inability to negotiate sex, forced early marriage, female genital mutilation (FGM) and unsafe abortion. WHO (1995) reported that reproductive health accounts for about 30 percent of the overall burden of diseases in women and 12 per cent in men. This implies that both women and men face reproductive health problems although more in women than in men. Of greater concern has been that of teenage mothers because literature Ingwersen (2001), has shown that one in every 10 births worldwide is from teenage mothers and that pregnancy before the age 18 carries greater medical complications for mothers. The author further noted that the risk of dying from pregnancy related complications is 25 times higher for girls under 15 years and two times higher for those 15 – 19 years, while 4 million women aged 15 – 19 years have abortion every year with 40 per cent performed under unsafe conditions.
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Nigeria, being a developing country, is faced with reproductive health challenges. Available statistics show that the reproductive health situation in Nigeria is poor. For instance, United Nations Population Fund (UNPF, 2005) reported that one in 20 adolescents contracts sexually transmitted infections (STIs) each year, half of all cases of HIV infections takes place among people under age 25. . In another reports, about one in every 20 people is living with HIV and AIDs (International Development Magazine, 2002). Also, more than one third of all people living with AIDs are under the age of 23 and almost two-thirds of them are females (United Nations Children Fund-UNICEF, 2006). Studies also showed that out of 14 million people who died from reproductive health problems, about 40 per cent of those deaths occurred in Nigeria (Otiode, Oronsaye & Okonofua, 2001). In Akwa Ibom State, the impact of AIDS epidemic is devastating. Reports (Reproductive Health Survey-RHS, 2012) has shown that with the percentage prevalence rate of 6.5, the state ranked sixth to Federal Capital Territory-FCT in the league of status most ravaged by HIV and AIDs pandemic. Evidence also showed that in various hospitals and health centers, an average of three out of every 10 persons were said to have contacted the virus among which the women and adolescents in the rural communities form the highest number.
The International Conference on Population and Development ICDP (1994) which took place in Cairo focused on reproductive issues that affect women and adolescents as abuse of right and the implication of such abuse for the development of affected groups and the society. In this conference, effort was made to shift the age-old perceptions of women being viewed mainly from their reproductive abilities and responsibilities as well as adolescent right abuse to the forefront of the international and national dialogue and programmes in education, policy, legislation, health reform, provision of services, elimination of harmful cultural practices and research. In other words, there was an urgent call for government and non-governmental organizations to institute projects to promote and protect the right of women in adolescents to meet there reproductive health needs. Nigerian government in response to this call has expanded the secondary school curriculum contents in health science and social studies through the Federal and State Ministries of Education to include reproductive and sexual health issues. In health science, it is entrenched as family health and sex education. This approach was intended to improve reproductive health status (vis-Ã -vis knowledge, attitude and practice) of individuals including adolescents. The impact of this may not seem to yield much success partly because health science is optional in secondary schools and usually not taught by teachers. Moreover, whatever information in- school adolescents get regarding reproductive health matters are informal and accidental,
mostly obtained from peers and social media. The threat that confronts people from reproductive health problems is worrisome and requires research, advocacy, policy and initiatives.
Reproductive health (RH) refers to a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity in all matters related to reproductive systems and to its functions and processes (WHO, 2006). This definition implies that people have the ability to remain physically, mentally and socially healthy if they maintain good reproductive health status. It also implies that people can reproduce, regulate their fertility, practise and enjoy sexual relationships and that women can safely go through pregnancy and childbirth without health hazards or complications (ICPD, 1994). Obueh, Omoriyi, and Obazuaye (2010) refers to RH as a quality of care which enhances individuals’ rights to decide freely and responsibly when to have children, the number and spacing of children as well as the right to a satisfying safer sex life. In the present study, RH refers to all matters relating to reproductive systems, functions and processes necessary in helping individuals including in- school adolescents to practise safer sex, make safe and informed reproductive choices regarding regulation of fertility, as well as understanding sexuality, and remaining free of sexually transmitted infections (STIs) in order to attain optimal reproductive health status and go through reproductive process successfully. RH has many components.
The components of RH, according to WHO (1994) and Federal Ministry of Health (2002), include family planning, safe motherhood, effective control of STIs including HIV and AIDS, prevention and management of infertility, elimination of unsafe abortion, gender equity and equality and elimination of harmful practices. Similarly, different international organizations including International Planned Parenthood Federation – IPPF (2009) and WHO (2009) have presented the components of reproductive health to include family planning, maternal and newborn health, STIs, and other reproductive tract infections (RTIs), promotion of heterosexuality, prevention and management of gender-based violence, prevention of unsafe abortion and management of post-abortive care. However, considering the components of RH outlined above by WHO and IPPF, the present study will focus on five components of reproductive health which include family planning, safe motherhood, effective control of STIs including HIV and AIDS, sexual health (heterosexual practice) and gender equity and equality. These five components were considered because they are assumed to relate more to in-school adolescents. Literature (MacCauley, Salter, Kiragu &
Senderrowitz, 1995) has shown that early initiation of sexual intercourse has far reaching effects as it results in adolescent frequently changing sexual partners and this exposed them to greater risk of STIs including HIV and AIDS. Most young people including in-school adolescents in one way or the other had encountered one or more of the reproductive health problems. Thus, adequate knowledge, positive and desirable practices and all the components of RH which are vital in enhancing their optimal reproductive health is necessary.
Family planning is essential in reducing the rate of unwanted pregnancies and also enhancing steady population growth. Oyesola (2008) defined family planning as a voluntary health measure which helps couple or partners to have the number of children they want when they are ready physically and economically for them. Family planning utilizes series of measures (abstinence, condom use, fertility awareness-based methods among others) necessary for exercising control over fertility in order to achieve a successful sexual and reproductive health, even into the future. It is also considered as a measure to prevent pregnancy and protect self against sexually transmitted infections including HIV and AIDS. Family planning in the present study is a voluntary health measure that helps individuals, whether married or not married, including the in-school adolescents to have children or enjoy sex when they are ready physically, psychologically and socio-economically in order to enjoy optimal health, good education, stable population growth and sustainable family life. Family planning is also an aspect of safe motherhood.
Safe motherhood involves saving the lives and improving the health of mothers. Safe motherhood according to Price (2002) is a measure of ensuring women’s accessibility to needed care through antenatal programme in order to facilitate their safety and optimal health throughout pregnancy and childbirth. Safe motherhood is viewed as a concept that encompasses a series of initiatives, protocols and services designed to ensure that women receive high-quality gynecological care, in order to achieve optimal health for the mother, fetus and infant during and after pregnancy, (Human Rights Policy Project, 2011). These initiatives and services are family planning, prenatal, antenatal and postpartum care. In this study, safe motherhood refers to means of creating awareness among in-school adolescents through education and services by ensuring high quality care for the mother, fetus and infant during and after pregnancy in order to adequately prepare them to handle safe motherhood skills whenever they become married and are ready to bear children. Safe motherhood also ensures the prevention of STIs including HIV and AIDS among women.
Effective control of STIs is another component of reproductive health. STIs are those
reproductive tract infections that are contracted mainly through unprotected sexual intercourse. The organisms which cause STIs may pass from person to person in blood, semen or vaginal and other body fluids during unprotected sexual intercourse (Aguilar & Gables, 2004; Lucas & Gilles, 2006; Mayo Clinic House Call – MCHC, 2010; Samuel, 2010), Most of them can also be contacted non-sexually through coming in contact with infected materials such as sharing of contaminated underwear, contaminated towels and bed linen. Available literature (Nworgu, Onyenebo, Okolo, Obadike, Ugochukwu & Mbakwe, 2009) indicated that STIs are the most implicated reproductive health problem among adolescents. The vulnerability of STIs, HIV and AIDS is increasing particularly among adolescents (15 to
25 year) in Sub-Saharan countries as a result of harmful heterosexual practices (Gilson,
2001).
Sexual health (including heterosexual practice) refers to the physical and or romantic desire to the opposite sex. Wolman (1975) refers to it as the attraction for persons of opposite sex and occurrence of sexual intercourse between members of opposite sex. Heterosexual practice is a sexual practice which exposes the individual to various reproductive health hazards ranging from unwanted pregnancy to illegal abortions, STIs including the most dreaded HIV and AIDS (Makinwa-Adebusoye, 2000). In the present study, heterosexual practice refers to all coital (penetrative) or non-coital (non- penetrative) strategies adopted by in-school adolescents to attract opposite sex, either romantically or emotionally for the purpose of satisfying sexual urge, (either mere intimacy or sexual intercourse), pleasure and other personal sexual gratifications which may or may not be harmful to their health. Heterosexual practice may be adopted desirably or undesirably. It is desirable when it is adopted safely and responsibly without harm to human health. These include practices associated with the ability to decide when to get involved in a sexual relationship; when to communicate sexual limits and negotiate condom use with partner; respect of one’s partner’s choices; protection against STIs including HIV and AIDS, unwanted pregnancy (contraception) and when to be sexually active in order to attain optimal health status. When in-school adolescents adopt the above listed practices, they can be able to enjoy sexual relationships without fear of infections, unwanted pregnancy, early or premature childbirth and associated consequences. On the other hand, undesirable heterosexual practice is associated with unprotected sexual intercourse with an unsafe partner, keeping of multiple sexual partners, buying and selling of sex and early sexual initiation.
Gender describes the socially constructed roles, activities and responsibilities
assigned to women and men in a given culture, location or time (WHO, 2009). Gender role is everything a person says and does to indicate to others or to self the degree that one is either a male or a female or ambivalent (Samuel, 2010). Gender role is a public expression of gender identity while gender identity is the private expression of gender role. Gender roles often dictate who is supposed to be passive or aggressive in sexual relationships and what the proper motivations are for seeking sexual activity (WHO, 2009). For instance, girls often report the need for intimacy, love and affection while boys often report curiosity, pleasure and status among their peers. In order to ensure optimal reproductive health status, people including in-school adolescents in the present study require adequate information on the various RH components in order to improve upon their level of reproductive knowledge, demonstrate positive attitude and adopt desirable sexual practices. There is need for the in- school adolescents to have very high or adequate knowledge of all the components of reproductive health.
Ideally, adolescents typically range from eleven to nineteen years. Although there may be ranges beyond this age bracket. WHO (2003) described individuals between the ages of 11 to 19 years as adolescents. Based on chronological and developmental order, Melgosa (2002) classified adolescents as early adolescents (11-15 years); middle adolescents (16-18 years) and late adolescents (19-22 years). In this study, people found within the age range of
11-19 years who are still in secondary schools (in-school) are considered as adolescents. They consist of Junior Secondary one to three (JSS 1-3) and Senior Secondary one to three (SSI-3) students. Adolescents are full of youthful exuberance and are under peer group influence. Thus, they experiment with a lot of things including sex. Yet due to social, cultural and religious restrictions young people may have less or no access to reproductive health information to guide them in wise decision-making. They may show negative attitude towards reproductive health matters or may adopt risky sexual practices which expose them to RH problems. Determining the reproductive health knowledge, attitude and practice of in- school adolescents was then inevitable. This was done by conducting a base line data/pilot study to determine the knowledge, attitude and practice of reproductive health of in-school adolescents in order to finding out the status of RH status of in-schools with a view to development a reproductive health enhancing programme (RE – ). The pilot study revealed that in-school adolescent had moderate level of knowledge of all tested components of reproductive health, positive attitude and sometimes practised undesirable reproductive health. Whereas in-school adolescents are supposed to have very high level of reproductive
health and positive attitude to enable them adopt desirable reproductive health practice that can ensure a healthy and successfully reproductive health life. Since the result of the pilot study is showing otherwise, something was done to remedy this situation. This culminated to the need to develop a reproductive health enhancement programme (REHEP) for in-school adolescents in Akwa Ibom State which was implemented to enhance RH KAP of in-school adolescents.
Development refers to a process of producing new or innovative package, project or programme. Bukenya, Ngatia and Kibua (2011) opined that development is a multifaceted process involving the mobilization and use of physical, financial and human resources to improve standard of living in all aspects of social, mental, emotional, economic, cultural and environmental dimension of human existence. Development in the context of this study is the process of identifying and planning acceptable teaching and learning experiences or activities (contents) using appropriate methods and materials, evaluation techniques with the view of improving reproductive health knowledge, attitude and practices of in-school adolescents. Development of REHEP was very indispensible for the mere fact that the in-school adolescents’ level of RH knowledge, attitude and practice was found to be inadequate.
A programme is produced to achieve a desired goal by the people or for the people concerned. Saroji (1992) explained that a programme is a plan of action which aim at accomplishing clear or specific goals or objectives with details on what work to be done, by whom, when, and how and what resources that should be used to accomplish the objectives. The programme in this study refers to a set of ideas, related activities and strategies carefully and logically put together to enhance, improve or increase cognition (knowledge), attitude, and practice, indicating what activities to be undertaken, those to perform them, how and when they should be done. It also include how those activities should be evaluated to determined whether the objectives have been achieved. Specifically, the purpose of the programme is to enhance the acquisition of reproductive health vis-a-vis of improving reproductive health knowledge, attitude and desirable RH practice among in-school adolescents. This programme was developed using different steps.
Studies have shown that a programme is a step by step process (UNESCO, 1981; Rama, 2007 & Safari, 2009). For instance, Gall and Borg (2007) suggested ten steps to develop a valid and reliable programme. These include: identifying the instructional goal or goals; conducting instructional analysis, analyzing learners and context; developing and selecting instructional materials; designing and conducting formative evaluation of
instruction. However, the authors maintained that there could be a modification in the ten steps to suit the conditions of any study undertaken as a thesis. The present study modified the ten steps to six steps (since it is a thesis) which include: Step 1. determining the baseline findings; Step 2. determining the rationale, philosophy, goals, objectives, contents and instructional methods; 3. validating the drafted programme by experts; 4. identifying the programme components, Step 5. trial-testing the programme to determine its effectiveness; Step 6 and the last which is the final development of REHEP. The components of proposed REHEP included all the reproductive health components as they relate to adolescents: family planning, safe motherhood, STIs including HIV and AIDS, heterosexual practice and gender roles. The contents of the proposed programme was arrived at after situation analysis by the baseline findings. In other words, from the baseline findings, there was evidence of low or moderate reproductive health knowledge, negative attitude to RH matters. In addition in- school adolescents sometimes adopted undesirable RH practices. These findings necessitated the development of REHAP which is shown in (Appendix A). This was followed by reviewing literature to determine what the components of the programme should consist of in order to bring about enhancement.
Enhancement means improving the quality of something or process that has been in existence. An enhancement programme according to Rehor (2010) refers to an innovative strategy which aims at reinforcement of work in a particular setting. In this study, enhancement programme refers to measures or strategies and techniques which are harnessed and if adopted help to improve the quality, value or status of reproductive health of in-school adolescents. Such measures include carefully articulating activities for the provision of scientific information capable of directing the in-school adolescents to cultivate positive desirable reproductive attitudes practices. When an enhancement programme is concerned with reproductive health, it is referred to as reproductive health enhancement programme (REHEP). Reproductive health enhancement programme is therefore an innovative and carefully structured activities, ideas and actions which seek to improve on the quality or status of reproductive health knowledge of in-school adolescents. Such REHEP should have the following components: namely rationale, philosophy, goals, objectives, contents, methods and materials, and evaluation techniques.
Rationale describes the scientific justification for a particular action and beliefs. National Policy on Adolescent Health (1995) explained that rationale for reproductive health is to assist in the provision of correct and adequate information, guidance and services for the
promotion of reproductive health status and prevention of numerous reproductive health problems. Reproductive health morbidities including STIs, HIV and AIDS, consequences of illegal abortion including vesico-vaginal fistula and mortality resulting from undesirable sexual practices are serious health challenges among adolescents including pregnant adolescents females. Early sexual initiation is another reproductive health issue common among in-school adolescents as they lack adequate information and skill need to delay onset of intercourse. The Nigeria Demographic Health Survey (NDHS, 2003) reported that approximately a quarter of the males (10 – 19 years) and half of females in the same age group had initiated sexual intercourse. There is need to provide appropriate structures for enhancing and improving the right and welfare of adolescents in the society to ensure effective function and self actualization including reproductive health. The need has also in advanced for strengthening national health system to create effective, efficient, accessible and affordable services that can help to better the heath status of Nigerians including in-school adolescent in Akwa Ibom State through accelerated achievement of related Millennium Development Goals (MDGs).
Philosophy is a systematic study of concepts such as truth, reality, reason and logic, ethics and morality, justice, beauty and Good. It may mean a set of beliefs or attitude to life that guides people’s behaviours or actions. Dhaven (2005) opined that philosophy means a search for a general understanding of values and reality which signifies a natural and necessary urge in human beings to know them and the world in which they live and function. Allah (2005) explained that philosophy provides a framework for broad issues and tasks such as determining the goals and objectives, contents and the learning materials and teaching activities regarding reproductive health. Philosophy in this study refers to guiding principles as adolescents search for RH knowledge, attitude and practice.
Goal or aim simply refers to a target, something one hopes to achieve. Keleher and Amstrong (2005) referred to programme goals as statements about long term outcomes and should articulate what changes are required by implementing a programme. Goals are broad statements that relate to improving the general health of people and particularly that of reproductive health of adolescents. The ultimate goal of reproductive health is desirable health practice or behaviour. This can be achieved through scientific health information, altering undesirable (harmful) reproductive health practices such as unsafe sex, abortion, enlightening in-school adolescents on the use of reproductive health services and dissuading adolescents from adopting unwholesome reproductive health practices. Goals are usually
broken down into objectives.
Objective refers to the intended outcome of something. These are specific tasks that show what a programme is supposed to be achieved. Wilburn and Wilburn (2010) regard objectives as specific and concise statements that state who will make what change, by who, how much, where and when. Objective is a brief, clear measurable statement that describes the desired learning outcomes of instruction, that is, the specific knowledge, attitude, practices and values learners should exhibit. Objectives of reproductive health enhancement programme are concerned with learning outcome of adolescents in this case adequate knowledge, positive reproductive health attitude and desirable reproductive practices and behaviours. These can be achieved through appropriate reproductive health contents.
Content refers to topics, subject matter areas involved or contained in a programme. Content areas in health including reproductive health are concerned with three domains of knowledge attitude and practice (KAP), and sometimes values are added. Contents of reproductive health enhancement programme included family planning, STIs, HIV and AIDS, heterosexual practice and gender roles and were determined the baseline findings. Proper delivery of these content areas of reproductive health enhancement programme will depend on proper selection and use of appropriate instructional methods and materials.
Instructional methods and techniques are formal ways a teacher uses to deliver lesson (knowledge, attitude, practices) or skills and values to learners (Barnstein, 2006). O’Bannon and Pucket (2007) referred to instructional methods as ways that information, skills and practices are presented to the students or learners. Methods are organized processes used by teachers to enable learners learn what they desire them to learn from those experiences they may require based on their exposure to learning experiences facilitated by the teacher. Such methods adopted in the programme included discussion, demonstration, story-telling, dramatization, question and answer, project, excursion, illustration methods, buzz session, and interactive learning approach. The methods and techniques could also be used to evaluate the programme.
Evaluation is an important and essential component of any learning and teaching programme, such as that of reproductive health enhancement programme. Ekpo (1991) submitted that instructional process calls for evaluation to determine the extent to which students have attained the intended objectives. Evaluation is a process of finding out how the learning experiences, as developed and organized are actually producing desired results (Tyler, 1975). Brown et al. (1982) defined evaluation as a process used to obtain information
from direct observation of behaviours, knowledge from tests and other devices to assess a students’ overall progress towards some predetermined goals or objectives. Evaluation of reproductive health enhancement programme refers to the assessment of the knowledge, attitudes and practices regarding reproductive health of in-school adolescents. The outcome of evaluation may be influenced by some factors. From the forgoing, RH enhancement programme consisted of the rationale, philosophy, goal, objectives, content, methods and materials and evaluation enhancement. The programme after development was trial-tested on in-school adolescents in relation to its effects on certain demographic factors.
Knowledge of the aforementioned RH components is essential for everyone including in-school adolescents. Knowledge is the sum of our perceptions, views and propositions that have been established and tested as correct reflections as far as they are objective realities (Comforth, 1986). The author stressed that the beginning of all knowledge lies in the sense perception, the reality of which is proved beyond mere acquisition of facts to establish testing and its consequent use in human endeavours. This definition implies that knowledge can be perceived or recalled. This definition refers more to the acquisition of facts or information and does not indicate the process of acquisition. WHO (1996) opined that knowledge is a prerequisite to any health practice. The report maintained that many of the ailments suffered are to a large extent inflicted by anti-health practices because many people are not well informed. Okafor (1997) pointed out that knowledge is a precursor to behavior though not all knowledge is translated into behavior.
When in-school adolescents learn about reproductive health and its various components including practices or skills, it is referred to as reproductive health knowledge (RHK). RHK in the present study refers to the acquisition of scientific information, facts, or ideas, regarding family planning, safe motherhood, STIs including HIV and AIDS, heterosexual practices and gender roles by in-school adolescents to enable them develop positive attitudes and demonstrate desirable RH practices to attain optimal health status. Acquisition of adequate and correct RHK by in-school adolescents has many benefits. Such knowledge will help them make safe and informed reproductive health decisions choices and choices to attain optimal health. Gebhard (1997) maintained that, the provision of adequate RHK will prevent high rates of teenage pregnancy, illegitimate birth, unsafe abortion, STIs, HIV and AIDS. On the other hand, lack of adequate knowledge of reproductive health can encourage teenage pregnancy illegitimate and unsafe abortion and STIs. Another common concern among in-school adolescents is their attitude towards reproductive health matters.
Attitude is a hypothetical construct that represents an individual’s degree of like or dislike for a person, object, place or thing. Answer Com (2011) defined attitude as a state of mind or feeling, disposition about a given phenomenon. WHO (2011) defined attitude as a person’s views and belief about a thing, process or person that often lead to positive or negative behavior. Attitude as used in this study refers to the way an in-school adolescents feel, think and express their likes or dislikes, favour or disfavour toward certain issues that can positively or negatively affect his or her reproductive health (Jayson, 2008). The author further maintained that most attitudes are the result of either direct experience or observational learning from the environment that may provoke thoughts or feeling about RH.
Practice refers to the act or process of doing something. Brown (1993) defined practice as performing an act habitually or constantly. Practice according to Core (1993) is the actual performance or application of knowledge. Practice is defined as any customary action or proceeding regarded as an individual’s habit (Funks & Wagnalls, 2003). As used in the present study, practice refers to what and manners in-school adolescents do with respect to certain reproductive issues. A practice of sexual or reproductive health matter is termed reproductive health practice (RHP). In this study, RHP refers to the action or habitual performance or behaviour of health promoting or enhancing (e.g. abstinence, maintaining one faithful partner condom use and delayed sexual, initiation) and non-health promoting or compromising aspects of RFI issues. These practices may be desirable or undesirable. For instance, the in-school adolescent who abstains from sexual intercourse is adopting a desirable practice because: he or she may likely not contact STIs or HIV and AIDS. On the contrary, the in-school adolescent who keeps many sexual partners is adopting undesirable heterosexual practice because of the risk of STIs, HIV and AIDS. These practices may be common among in-school adolescents including those in the present study. There is, therefore, the need to find out the reproductive health practice of in-school adolescents. Lack of knowledge of RH among in-school adolescents may exert negative influence on their reproductive attitude and practice thereby ushering in RH problems such as HIV, STIs, unwanted pregnancy, unsafe abortion, early birth and early parenting. On the other hand, adequate and correct RH knowledge can impact on in-school adolescents’ RH attitude and practice, thus reducing RH problems among them.
Demographic factors such as age, gender, level of education, school type and location have been identified by Fadiora, Oboro, Akinwusi, Adeotu, Bello and Egbewale, (2002) and Slaymaker, Walker, Zaba, and Collumbien, (2005) as capable of impinging on adolescents’
RH knowledge, attitude and practices. However, the variables of age, gender and school location were considered in the present study. Several studies have shown that adolescents initiate heterosexual intercourse at relatively early period. For instance, studies on the attitude indicated that adolescents began sexual activity in their early teens and even pre-teenage years (Eggleston, Jackson, & Flardee, 1999). Similarly, another study indicated that, 25 per cent or more girls ages 15-19 years were initiated into heterosexual vaginal intercourse before age 15 in Niger, Guinea Central African Republic, Mozambique and Bangladesh (Macro International Demographic Health Surveys, 2000). The situation may not be too different in Nigeria, the present study area.
Gender has also been identified as a strong factor associated with health knowledge and attitude. Moukhyer, Van Eijk, Bosmah and De Vries (2006) found out that boys had more knowledge of some components of reproductive health than girls. Adeokun, Rickets, Ajuwon and Ladipo (2009) in their reports found that, more boys than girls had knowledge of pregnancy prevention. On school location as its relates reproductive health practice, Orubuloye, Caldwell and Caldwell (1991) showed that rural dwellers keep more sexual partners than their counterparts in the urban setting. This situation may be similar to what obtains in Akwa Ibom State. Residential location is also implicated on health knowledge, attitude and practice. Ezedum, Onyedika and Eze (2003) found that rural students’ knowledge of RH was low, while that of urban students was high. The findings further showed that irrespective of their school location, the students possessed moderate knowledge of all aspects of reproductive health. The present study will examine whether the demographic characteristics of age, gender and school location in determining whether reproductive, health enhancement programme has influence on the knowledge, attitude and practice of in-school adolescents.
The study anchored on five theories which include cognitive dissonance theory (CDT), social learning theory (SLT), theory of reasoned action (TRA) and health belief model (HBM) and wheeler’s and Taba’s curriculum models. The CDT explained the health educator’s attempt to improve the individual’s understanding of or change in belief about a health issue (example HIV cannot be contacted through unsafe sex) may be through questioning and instruction. The social learning theory provided the basis upon which the adolescents’ environment can precipitate change in undesirable sexual practices. The social learning theory helped to provide the basis upon which the adolescents’ environment will precipitate change in undesirable sexual practices. The TRA considered the individual’s
behavior as determined by his or her attitude towards the outcome of that behavior while the HBM helped to explained adolescents’ health beliefs that shaped their attitude and influence their sexual practices. Another model of outmost consideration was Taba’s curriculum model.
Taba (1980) proposed a seven – step curriculum model. She believes that the phases should be specific to avoid any confusion. Her model has a starting and an end point. The phases include situation analysis, selection of objectives, selection of learning experiences, selection of content, organization of learning experiences, organization of content, and evaluation. The model was relevant to this study since of REHEP was developed using seven steps similar to Taba’s model.
Akwa Ibom State is one of the thirty-six states in Nigeria with thirty-one local government areas. It has a total of four hundred and sixty-nine government and privately owned secondary schools (State Ministry of Education 2011/2012 academic session). These secondary schools have adolescents within the age range of 1l and 19 years who are still under the care of their parents or guardians. The major occupations of the parents is mostly farming, trading, fishing, weaving while few are in civil service. The occupations of the parents and guardians occupy much of their time with little or no chance left for them to give attention to their children by observing and listening to their questions especially as it relates to reproductive health issues. Most parents and guardians, because of cultural and societal norms avoid giving children including adolescents correct answers to questions bordering on sex and sexuality. Adegboyega and Olanipekun (2011) lamented that in Nigeria, Akwa State inclusive, sex and sexuality issues are associated with many taboos and prohibitions and are discussed in secrecy. Most parents believe that RH issues should not be discussed or if as all it should be done in secrecy to avoid exposing the young ones to promiscuity. Hiding information related to reproductive health from adolescents as noted by Mathew (2004) has impacted negatively on their reproductive health knowledge attitude and practice. Besides, Health Science, a senior secondary school subject, with topics bordering on family health and sex education is an optional subject. Hence, some schools do not teach it at all.
Moreover, the state is located in the South-South zone of Nigeria. Some of the local Government Areas (L.G.As) share boundaries with International and other African communities and are therefore commercial areas which attract strangers who come into the State for the purpose of one business and the other. These border towns include Ibaka-Seaport (Atlantic Ocean), Ibeno-Ghana border town (Exon Mobil). Young people including adolescents take undue advantage of this and engage in hawking and prostitution. The
hawking activities which involve walking about, advertizing and selling the goods expose them to sex menace. These adolescents who are into this promiscuous lifestyle are exposed to unprotected sex which may predispose them to STIs including HIV and AIDS unwanted pregnancy, unsafe abortion and early childbirth and its attendant consequences and sometimes premature deaths, while some even drop out of school. Moreover, in some part of Akwa Ibom State, some cultures still permit harmful practices such as sexual violence against women including adolescents and forced marriage. The researcher also observed that there is a high rate of reproductive health problems among adolescents in the State. The scenarios regarding Akwa Ibom State justify efforts at increasing the level of reproductive health knowledge of adolescents.
Knowledge of RH issues may positively affect the attitude of an individual thereby paving a way for desirable practice (Gyepi-Harbrah, 1985; Oloko & Omoloye, 1993). For instance, literature reported that adolescent have high level of knowledge, positive attitude and desirable RH practice (WHO, 2011) in developed countries such as United States. This may likely be the case because adolescents in USA are allowed access to reproductive and sexual health information and services (Gallant & Maticka-Tyndale, 2004). Whereas, the WFIO biennial report 1992-1993 showed low level of knowledge of reproductive and sexual health in United Republic of Tanzania. This resulted in teenagers practicing unprotected sex and keeping of older men as sexual partners (WHO, 1994)). A similar study in Mexico among women under twenty years of age reported low knowledge of contraception even when a reasonable percentage never wanted to get pregnant (WHO, 1994). This apparent trends among adolescents in developing nations provide a platform for an assumption that the above may not be too different from that of Akwa Ibom State.
Several studies (Fadiora, Oboro, Akinwusi, Adeotu, Bello & Egbewale, 2002; Slaymaker, Walker, Zaba & Collumbien 2005; WHO 2007) have suggested that focusing on reproductive health of adolescents is both a challenge and an opportunity for health care workers, parents, teachers, health educators, health planners and religious groups to share responsibility to identify and prevent undesirable sexual practices among adolescents including those in schools. Efforts to reduce or prevent unwanted pregnancy, unsafe abortion, STIs, HIV and AIDS, early marriage, early parenthood, infertility, dropout from school and death associated with RH problems call for a study such as the present one. Incidentally, to the best knowledge of the researcher, there is neither evaluative study nor basic survey on reproductive health knowledge, attitude and practice of in-school adolescents cover Akwa
Ibom State. This situation posed a serious concern to the researcher and therefore prompted her to undertake the present study which was to develop a reproductive health enhancement programme for in-school adolescents in Akwa Ibom State, Nigeria.
Young people including in-school adolescents frequently indulge in sexual practices which may expose them to certain reproductive health problems (Eggleston, Jackson, & Hardee, 1999). Like other health problems, reproductive health problems such as unwanted pregnancy, STIs, HIV and AIDS, unsafe abortion, dropping out of school and premature death can mar the reproductive life of adolescents. It was, therefore, necessary to develop an enhancement programme tailored to improving upon adolescents’ RH knowledge, attitude and practice.
Statement of the Problem
The importance of sexual and reproductive health (SRH) cannot be overemphasized. This is because Adesokan (2010) maintained that it is an essential part of people’s well being and is central and crucial to human development and survival. Reproductive health has been recognized as the special needs of women and men as well as adolescents as it enhances people’s opportunities to exercise choice in all the matters that surround or affect human reproduction. The need to care for the reproductive body parts, stay free from infections and maintain a satisfying sexual relationship without fear of infections and unwanted pregnancy is crucial to the well-being of everyone and should therefore be the concerned of every one too. The bedrock in achieving this maximum of reproductive health requires very high or adequate level of knowledge of reproductive health, positive attitude towards reproductive health matters and desirable reproductive health practices, especially during childhood and adolescent years. Adequate knowledge of, positive attitude and desirable RH practice are the bases for achieving the overall aim of reproductive health and achieving these is capable of reducing the incidence and prevalence of unwanted pregnancy, acquisition of STIs, abortions and maternal mortality in Nigeria at large and Akwa Ibom State in particular. Programmes in family health and sex education are designed and structured to equip adolescents with both adequate knowledge and skills regarding RH to enable them develop positive attitude that will help them adopt desirable sexual practices.
Despite these efforts, evidence abound indicating the preponderance of unwanted pregnancy, harmful sexual practices, STIs especially among adolescents. Experience has also shown that in-school adolescent indulge in harmful sexual practices including unprotected sex, multiple sexual partnership and early sexual initiation. Incidence or prevalence of this
situation may be a factor of lack of or inadequate knowledge of RH which is usually a precursor to negative attitude and undesirable sexual practices. The reproductive health problems of adolescents may be as a result of not deliberately teaching reproductive health as a subject in schools and needs investigation
Evidence seems to indicate that low or moderate level of knowledge, negative attitude and adoption of undesirable health practices in general and reproductive health can be improved in diverse ways including development of a programme. The study therefore sought to develop a programme that can be implemented in schools and other settings to bring about enhancement of knowledge, development of positive attitude and adoption desirable reproductive health practices for in-school adolescents in Akwa Ibom State.
Purpose of the Study
The purpose of the study is to develop a reproductive health enhancement programme (REHEP) for in-school adolescents in Akwa Ibom State, Nigeria. Specifically, the study determined:
1. in-school adolescents’ level of reproductive health knowledge;
2. in-school adolescents’ attitude toward reproductive health;
3. in-school adolescents’ extent of reproductive health practice;
4. acceptable rationale;
5. acceptable philosophy;
6. acceptable goals;
7. acceptable objectives;
8. acceptable contents;
9. acceptable method and material;
10. acceptable evaluation techniques;
11. acceptable reproductive health enhancement programme (REHEP) for in-school adolescents;
12. differences in level of RH knowledge of in-school adolescents exposed and not exposed to REHEP;
13. differences in RH attitude of in-school adolescents exposed and not exposed to
REHEP;
14. differences in in-school adolescents extent of RH practice exposed not exposed to
REHEP;
15. effects of REHEP on in-school adolescents’ level of RH knowledge according to
location;
16. effects of REHEP on in-school adolescents’ level of RH knowledge according to
gender;
17. effect of REHEP on in-school adolescents’ level of RH knowledge according to age;
18. effect of REHEP on in-school adolescents’ RH attitude according to location;
19. Effect of REHEP on in-school adolescents’ RH attitude according to gender ;
20. Effect of REHEP on in-school adolescents’ RH attitude according to age;
21. Effect of REHEP on in-school adolescents’ RH practice according to location;
22. Effect of REHEP on in-school adolescents’ RH practice according to gender and
23. Effect of REHEP on in-school adolescents’ RH practice according to age.
Research Questions
The following research questions were posed to guide the study:
1. What is the level of reproductive health knowledge of in-school adolescents?
2. What is the attitude of in-school adolescents toward reproductive health?
3. What is the in-school adolescents’ extent of RH practice?
4. What are the acceptable rationale for REHEP?
5. What are the acceptable philosophies for REHEP?
6. What are the acceptable goals for REHEP?
7. What are the acceptable objectives for REHEP?
8. What are the acceptable contents for REHEP?
9. What are the acceptable methods and materials for REHEP?
10. What are the acceptable evaluation techniques for REHEP?
11. What is the acceptable REHEP for in-school adolescents?
12. What is the difference in the level of knowledge of in-schools adolescents exposed and not exposed to REHEP?
13. What is the difference in the attitude of in-school adolescents exposed and not exposed to REHEP?
14. What is the difference in the extent of RH practice of in-school adolescent exposed and not exposed to REHEP?
15. What is the effect of REHEP on the RH knowledge, of in-school adolescents according to gender?
16. What is the effect REHEP on the RH attitude of in-school adolescents according to gender?
17. What is the extent of RH practice of in-school adolescents according gender?
18. What is the effect of REHEP on in-school adolescents’ level of RH knowledge according to location?
19. What is the effect of REHEP on RH attitude of in-school adolescents according to location?
20. What is the effect of REHEP on RH practice of in-school adolescents according to location?
21. What is the effect of REHEP on RH knowledge of in-school adolescents according to age?
22. What is the effect of REHEP on RH attitude of in-school adolescents according to age?
23. What is the effect of REHEP on RH practice of in-school adolescents according age?
Hypotheses
The following null hypotheses were postulated and tested as .05 level of significance:
1. There is no significant difference in the level of RH knowledge of in-school adolescents exposed and not exposed to REHEP.
2. There is no significant difference in the RH mean attitude of in-school adolescents exposed and not exposed to REHEP.
3. There is no significant difference in the extent of RH practice of in-school adolescents exposed and not exposed to REHEP.
4. There is no significant difference in the level of RH knowledge of in-school adolescents exposed to REHEP according to location.
5. There is no significant difference in the level of RH knowledge of in-school adolescents exposed to REHEP according to gender.
6. There is no significant difference in the level of RH knowledge of in-school adolescents exposed to REHEP according to age.
7. There is no significant difference in mean RH attitude of in-school adolescents exposed to REHEP according to location.
8. This is no significant difference in the mean RH attitude of in-school adolescents exposed to REHEP according gender.
9. There is no significant difference in the mean RH attitude of in-school adolescents exposed to REHEP according to age.
10. There is no significant difference in the extent of RH practice of in-school adolescents exposed to REHEP according to location.
11. There is no significant difference in the extent of RH practice of in-school adolescents exposed to REHEP according to gender.
12. There is no significant difference in the extent of RH practice of in-school adolescents exposed to REHEP according to age.
Significance of the Study
The findings from the study will be of immense value to the in-school adolescents’, health educators, guidance counselors, parents, Ministries of Health and Education, other health professionals, non-governmental organizations (NGOs). Specifically, the study provided data on in-school adolescents’ level of knowledge of family planning, safe motherhood, STIs including HIV/AIDS, heterosexual practice and gender roles which were moderate. The findings will be beneficial to in-school adolescents’ who will be adequately informed of their status of RH knowledge. Such information may likely help them to seek means of increasing their knowledge on RH. The findings will be useful to health educators and also parents who will be abreast of in-school adolescents’, moderate level of knowledge of RH, thus working towards increasing their knowledge towards consequences of undesirable sexual practices which can in turn promote sexual abstinence among in-school adolescents’.
The finding on attitude of in-school adolescents toward reproductive health components was positive. The health educators use this reports as a guide to encourage more positive attitude towards reproductive health among in-school adolescents’ in order to reduce reproductive health problems among them. The findings will also be of benefit the in-school adolescents’ who will use the report to work towards maintaining the positive attitude to parent themselves from RH problems. The findings will be useful to school health nurses and guidance counselors who are interested in the promotion of these RH components among adolescents. For instance, positive attitude toward heterosexual practices can help encourage safer sex among in-school adolescents’.
Data generated from the baseline data on the level of RH knowledge possessed by in- school adolescents, attitude demonstrated by them and extent of practice of RH helped the researcher to determine the contents of the reproductive health enhancement programme. The programme could assist in increasing RH knowledge, reinforcing positive RH attitude and enhancing desirable RH practices.
Data on acceptable rationale for reproductive health enhancement programme were generated which revealed that all the rationale for reproductive health enhancement programme as they concern adolescents’ were acceptable. The findings will be useful to health professionals and health educators as it will serve as a guide in the implementation of the programme on in-school adolescents. The findings will serve as a guide to school counselors who are interested in improving their counseling services among in-school adolescents.
Data were also generated on the acceptable philosophies of reproductive health enhancement programme for in-school adolescents which revealed that the philosophy of reproductive health enhancement programme was acceptable. The finding will be beneficial to the Ministry of Education who will use the report to improve upon the time allotment for health education subjects to enable the contents to be covered. The in-school adolescents’ will benefit as the report will help them work towards increasing their level of RH knowledge as well as effectively utilizing RH services to improve their RH status.
Data on acceptable goals of reproductive health enhancement programme revealed that all the goals were acceptable for inclusion in REHEP. The data will be useful to the State Government through the Ministry of Education who will consider adequate employment of qualified professional teachers to handle the subject in order to ensure effective teaching of the subject in schools to achieve the stated goals. The finding will provide awareness to most parents who still perceive sexuality education as secret issues to appreciate and understand sexual information as a means of helping adolescents achieve healthy and successful sexual maturation.
Data generated on acceptable objectives of reproductive health enhancement programme revealed that all the objectives were acceptable. The findings will be beneficial to health educators and other programme implementers. These personal will be guided in the selective of appropriate materials and methods for proper implementation of the programme. The in-school adolescents will be informed of what are expected of them after each lesson. This will help to boost their interest in paying more attention during the lesson to ensure proper assimilation of the reproductive health topics.
Data were generated on acceptable contents of reproductive health enhancement programme of in-school adolescents’ which showed that all the components of RH as it affects adolescents’ are covered. The findings will assist the health educators and other health professionals in the step- by- step presentation of the topics during presentation. This will go
a long way to ease proper understanding of the lesson by the in-school adolescents. The findings will be useful to in-school adolescents’ who will be equipped with all the reproductive health components that can help to enhance their knowledge. The Ministry of Education and Curriculum developers who are interested in reviewing the existing secondary school health education curriculum will also find the report useful. The health – based professionals who may desire to develop reproductive health enhancement programme for other groups of adolescents will find the findings or report as a guide to improve upon the level of knowledge of the targeted population. The finding on contents such as gender actualization and roles will equip the in-school adolescents with skills, attitude and beliefs about sex roles, sexual identity and behaviours that can replace ignorance, guilt, fear and secrecy with understanding rationality and openness, thus taking the right steps toward taking decisions regarding reproductive health issues.
Data on acceptable methods and materials necessary for proper implementation of REHEP was also revealed in the study. All the selected methods and materials were acceptable .The findings will be beneficial to the health educators and other health professionals. These personnel will find the implementation intensity and easy for the purpose of achieving the stated objectives. The findings will also help the implementers to indentify the weaknesses of the learners and device means to improve upon their efforts. The findings will be beneficial to in-school adolescents’ who will be exposed to the varied methods and materials. The adolescents’ will find the teaching-learning situations exciting and interesting which will in turn encourage proper comprehension of the RH topics. The variations in the methods and materials will reduce boredom among the students during lesson presentation.
The study provided data on the acceptable evaluative techniques for the reproductive health enhancement programme. The findings will be beneficial to in-school adolescents’ who will find the class or lesson period engaging and competitive which will motivate them to be attentive and will reduce boredom. The findings will be of immense value to the health educators and other health professionals who will identify the areas of emphasis with ease in order to achieve the stated objectives. The varied evaluative techniques in the report will create room for effective assessment of individual participant which will in turn ensure effective learning among the participants.
The acceptable reproductive health enhancement programme (REHEP) that was developed will serve as a guide to health educators, other programme implementers,
Ministries and other organizations who will adopt the programme. The programme will also be very useful to the in-school adolescents’ whom it is meant for by equipping them with adequate reproductive health information that will help to increase their RH knowledge to reduce RH problems and lead a meaningful and healthy reproductive life. The parents will benefit from the programme as the adolescents’ will share the ideas in the programme as the adolescents’ will share the ideas in the programme with them and siblings when at home.
Data were generated on the effect of reproductive health enhancement programme on the level of knowledge, attitude and practice of in-school adolescents’ regarding gender. The findings may reveal differences in the level of knowledge, attitude and practice of male and female in-school adolescents’. These findings will be useful to health professionals, Ministries of Health and Education and health educators in designing reproductive health programme and services that will suit both genders. The findings will be beneficial to school counselors who will use the reports to identify areas of emphasis that will satisfy the needs of the two sexes. The finding will expose female in-school adolescents to their reproductive rights and identify skills to protect the rights.
Data provided on the effect of reproductive health enhancement programme on the knowledge, attitude and practice of in-school location revealed positive effect. The findings will be useful to Ministry of Education on Curriculum development. The findings will serve as a guide to the Ministry of Education and Curriculum developers in reviewing the curriculum.
Data generated on the effect of reproduction health enhancement programme on the knowledge, attitude and practice according to age of in-school adolescents’ revealed positive effect. The findings will serve as a guide to Federal Ministry of Education and curriculum developers in developing age appropriate curriculum for students in secondary schools. The finding will also serve as an eye-opener to parents who will see the need to select and discuss sexual issues with their wards early enough rather than shying away and leaving the discussion for teachers in schools. The in-school adolescents will appreciate sexuality education appropriate to their ages and as a result develop positive attitude toward adopting desirable RH practice to accomplish successful adulthood. The finding will serve as a pointer to other researchers to focus their attention on adolescents’ reproductive health knowledge, attitude and practice.
Within the field of reproductive health in general and its effects on knowledge, attitude and practice of in-school adolescents in particular, better generated would add to the
pool of existing data and serve as reference materials for health educators when they are planning workshops or seminars for their clients. It would also have to improved the education system because teaching learning among in-school adolescents would be enhanced by using the programme in future. Furthermore, the findings of this study would be supportive of Wheeler’s, Kerr’s, Nicholls and Nicholls and Taba’s curriculum models upon which this work is based. These models were all found to be relevant to reproductive health enhancement programme and with the recommended for reproductive health enhancement programme aimed at increasing knowledge, improving attitude and encouraging adoption reproductive health practices.
Scope of the Study
The study covered in- school adolescents in all the secondary schools in Akwa Ibom State. The components of RH included family planning, safe motherhood, STIs including HIV and AIDS, heterosexual practice and gender roles. The independent variables examined in the study included age, gender, and school location. Each of these variables was investigated in relation to the level of knowledge, attitude and practice of reproductive health. The study also covered the programme components which included rationale, philosophy, goals, objectives, contents, methods and materials as well as evaluation for teaching reproductive health enhancement programme for in-school adolescents in Akwa Ibom State. The study anchored on four theories and one model.
This material content is developed to serve as a GUIDE for students to conduct academic research
DEVELOPMENT OF REPRODUCTIVE HEALTH ENHANCEMENT PROGRAMME FOR IN-SCHOOL ADOLESCENTS IN AKWA IBOM STATE NIGERIA>
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