Several studies have reported high rates of premarital sexual activity among Nigerian adolescents.¹ In addition, a recent survey of 17-19-year-old female adolescents in southeastern Nigeria found that 11% had trichomoniasis and 11% had a chlamydial infection, while 82% had vaginal discharge and 26% had clinical evidence of candidiasis.² Although they are usually not fatal, sexually transmitted diseases (STDs) can lead to major pregnancy complications, secondary infertility and severe discomfort. Moreover, STDs have been identified as a predisposing factor in the transmission of HIV.³ In Nigeria, where HIV seroprevalence still appears to be relatively low,⁴ increased attention to STD awareness and treatment would be likely to help slow the epidemic.

Several hypotheses have been offered to explain the high rates of sexual activity and STD infection among Nigerian adolescents, such as Nigeria's deteriorating socioeconomic situation,⁵ the erosion of traditional African values,⁶ the early onset of menarche, a widening gap between age at menarche and age at marriage,⁷ infrequent and ineffective use of barrier contraceptives⁸ and the decreased value placed on virginity.⁹ To date, however, few studies have investigated young people's perceptions of the problem.

To design appropriate interventions, it is important to know about adolescents' knowledge of and experience with STDs and about their health-seeking behavior related to STDs. For example, we need information about adolescents' knowledge of and attitudes toward using condoms for STD prevention, their use of various types of health providers for the treatment of STDs and their attitudes toward partner notification. It is widely recognized that Nigerian adolescents do not use existing reproductive health services.¹⁰ This poor utilization of public services is probably largely attributable to the fact that such services do not specifically address the needs and concerns of adolescents.

Eliciting adolescents' views on reproductive health in communities where sexuality is not openly discussed can be problematic. A quantitative research design yields limited information on this complex and sensitive topic because it is less likely to provide detailed explanations for observed patterns of behavior. Therefore, carefully conducted focus group discussions in which people discuss perceptions and behaviors of their peers may uncover behavior and knowledge related to reproductive health. In this study, we use focus groups to provide deeper insight into adolescents' perceptions, knowledge and experience regarding STD acquisition, symptoms, prevention and treatment.

Methods

Our research was carried out among adolescents attending secondary schools in Benin City, the capital of Edo State. In this study, which was part of a larger investigation of the determinants of sexual activity and treatment-seeking behavior related to STDs among adolescents in Benin City, focus group discussions were held with male and female adolescents in 12 secondary schools in the city. Before the study began, we explained it in detail to the principals and staff of the schools. In each school that agreed to take part, a teacher designated as the study coordinator described the research to students, chose the student participants and made arrangements for the focus groups. The students who were asked to participate in the group discussions were those perceived by study coordinators as likely to provide the most information.

Twenty-four focus groups were conducted in six coeducational and six single-sex schools in the city. In each of the coeducational schools, one focus group was conducted with males and one with females. The 225 focus group participants were aged 15-20, with an average age of 17.2 years for females and 17.6 years for males. The size of the groups ranged from nine to 13 students. Focus group discussions were led by trained male and female research assistants, most of whom were recent college graduates who had received training in focus group methodology. The participants did not know the facilitators.

The focus groups were conducted in English, the language used by teachers and students in the schools. In analyzing the transcripts of the discussions, we used content analysis to uncover themes and trends. The comments on each issue were then compared by sex. Results were also compared across grade levels; differences between lower and higher grades were minimal.*

The focus group discussions centered on adolescents' perceptions and beliefs regarding sexual behavior among their peers and the reasons for the patterns of behavior they observed. In addition, we elicited information on how these adolescents recognized and labeled STD symptoms, how they made choices among various methods of STD prevention and treatment, and which methods and places of treatment they preferred. Specifically, we sought information on adolescents' knowledge of and attitudes toward the use of condoms for STD prevention. Finally, the discussions addressed young people's opinions on how to increase access to various reproductive health services and on their preferred methods of acquiring reproductive health information.

Results

Sexual Behavior

Participants first discussed sexual behavior among youth in their communities. They generally agreed that sexual activity was common among their peers. Males were more likely to state that levels of sexual activity were higher among males than among females, and females felt that the reverse was true. Some students gave reasons for the high degree of sexual activity, including the perception that sex was a way to act like a grown-up: "[Sex is]...an easy way to behave like mummy and daddy." Another explained: "[Adolescent] girls have certain hormones in them which they can no longer control and at that time they want to do it with anybody they see."

The vast majority agreed that in their communities, people began having sexual intercourse at an early age. The discussions reflected a general perception that females began having intercourse at a younger age than did males; the most commonly stated age of sexual debut for females was 11-13, compared with 14-15 for males. In addition, females reported an earlier age of sexual debut for both sexes than did males. Some females remarked that their peers first had sex with males in their own age-group and then became involved with older partners.

The main reason participants gave for romantic relationships (which might or might not involve sex) was attraction; material or monetary gain was the most common reason cited for sexual relationships, although peer pressure was also frequently mentioned. There was no clear consensus on whether males or females were more likely to initiate sex, although some males said that males initiated sex more frequently than did females.

The focus groups covered perceptions about sex with strangers and sex with multiple partners, including how common and how risky these behaviors are. There was a greater variety of opinion about these behaviors than about sex with a regular partner. Some participants thought that many of their peers had sex with strangers, while others disagreed; there was greater agreement that sex with multiple partners was common. Some females stated that sex with multiple partners was more common among females than among males.

Some of the reasons given for engaging in sex with strangers and multiple partners resembled those given for sexual relationships with a regular partner. Material or monetary gain was cited as the most common reason for these behaviors among both males and females. Two participants explained:

"Some will like having a sugar daddy and a boy they will keep aside. Then, they will start moving with that sugar daddy all the time. Anything they need, they will get it from that sugar daddy. But they will keep their boyfriend in one corner without asking for anything. That's why they like moving with two boys."

"...due to advice from friends, [a girl] will be persuaded to have many partners. The girl's friends can tell her that John bought shoes for her, Peter bought lipsticks, Lawrence bought earrings. They will then say if she was going out with only Lawrence, who would have bought her the shoes and lipsticks? Her friends will now persuade her to follow other men."

Other reasons cited for sex with strangers and multiple partners included sexual pleasure or satisfaction and variety. One male participant said: "Some believe in variety, saying: `It is not only okro soup you should eat.' " Another explained the appeal of having intercourse with a stranger: "I feel it is a prestige."

Many of the students felt that the high prevalence of sexual activity among their peers was problematic, attributing such behavior to the effect of poor parenting or Western attitudes conveyed through the media. Sex with strangers was viewed as more dangerous than sex with multiple partners, although there was agreement that both activities were inadvisable.

In discussing the risks of having sex with multiple partners and strangers, many participants reported feeling a sense of vulnerability to STDs and AIDS, and even took STDs for granted. One male explained his fear: "Most of these girls have sex diseases and any boy could fall a victim." In some of the groups, participants mentioned an additional concern, related to traditional beliefs, about becoming involved with a stranger: "It is wrong to have sex with a stranger because his background is unknown, whether [he is] possessed or a witch." Another echoed: "Apart from the fact that AIDS can be contracted, there is also a spiritual implication, for example, making love to a ghost."

STD Knowledge

Overall, the focus group participants had some knowledge about STDs, although there was disagreement about the medical parallels to local names and about the symptoms and causes of the STDs discussed. Gonorrhea and AIDS were identified as STDs in all of the groups, and syphilis was mentioned in many of them. A few participants described scabies, chancroid, pubic lice, candidiasis and trichomoniasis.

The students mentioned a variety of local names for STDs, including zakwa or sweety (generally referring to scabies), okrikpoto or chop garri (usually referring to syphilis), "toilet disease,"^† atori or gonococca (generally referring to gonorrhea) and ugiagbe^‡ (generally referring to AIDS). Sweety and chop garri were discussed more in the male groups, while toilet disease and atori were more frequently mentioned in the female groups. A few individuals talked about other conditions they considered STDs. For example, one said: "You can hardly cure some gonorrhea, and the very strong gonorrhea is called gono-AIDS."

Pain in the genital area and painful urination were the most frequently mentioned signs of STDs, mostly related to gonorrhea. Most groups mentioned pussy or milky discharge, swollen organs, boils, itching and rashes. Males were more likely to mention swelling, and females were more likely to mention discharge, itching and rashes. Males also discussed bloody urine, while females mentioned fever.

Some of the participants knew that STDs manifest themselves differently in males and females. Participants in half of the groups understood that STDs are often asymptomatic or slower to appear in females than in males. Not surprisingly, females were more likely than males to be aware of this difference. One explained: "For the boys, they easily know because of the symptoms, but for the females they don't show symptoms and may have it for a very long time."

The focus group discussions revealed more knowledge about HIV and AIDS than about other STDs, and the students did not mention the link between AIDS and other STDs. A few students gave clear descriptions of AIDS. One said: "AIDS has a very long incubation period; it stays in the human body for about two to five years or so before you start getting symptoms; the virus destroys all the resistance in the body." Another described the progress and symptoms of the syndrome: "Long incubation period, destroys the blood cells, constant fever, cold, malaria, loss of strength, frequent stooling, loss of appetite, weight loss, looking dull and fatigued." Some participants demonstrated knowledge about the causes and impact of AIDS; one gave the acronym an alternate definition—After Iniquity, Destruction Is Sure. However, only a few knew that AIDS is transmissible through blood-to-blood contact, such as sharing razor blades. Some reported that AIDS can be transmitted through sex and injections, but others incorrectly stated that infection can occur through mosquito bites and from toilets.

Treatment-Seeking Behavior

Students talked about what they and their peers do when they experience STD symptoms. For those who chose to divulge their symptoms to someone, telling friends was the most common choice; males and females were equally likely to do so. In half of the groups, however, participants stated that people with STDs usually did not tell anyone about their condition, a view expressed more often by males than by females. In more than half of the groups, someone stated that peers sometimes disclosed symptoms to a parent. Most of the females specified mothers, and a few males cited fathers; no one mentioned turning to other relatives as confidants. Only a few students reported that peers told their sexual partners about STD symptoms.

A common perception about behavior following the onset of STD symptoms was that people deliberately attempt to spread their infection. In half of the focus groups, participants said this practice was common; females were more likely than males to mention it. Some of the participants related this behavior specifically to AIDS. According to one, "They will try to get rid of it, but when they can't they will like to spread it." Another said, "The first thing that comes to the mind of the teenager is to spread the disease to other people." Still another commented, "If it is the curable one, they try to cure it, but if it is AIDS, they will conclude that they won't want to die alone, so they will start spreading it."

The focus group participants generally agreed that most adolescents with STD symptoms sought care from traditional healers, followed by patent medicine dealers, private doctors and hospitals; some mentioned use of home remedies or self-treatment with medication obtained from a chemist. No one cited public doctors, another source of treatment available in the study area.

There were few differences in treatment preferences between the male students and the female students. In approximately half of the groups, participants stated that the primary advantages of traditional healers were low cost and speed of both service delivery and cure; more males than females cited these benefits. Some participants stated that adolescents preferred traditional healers because such providers offered confidential treatment, although others attributed this preference to ignorance. High cost and slow service were the main complaints about hospitals and private doctors. A female student noted the economic advantage of self-treatment with medication from a chemist: "It is cheaper. You buy as your money can afford. Meanwhile, in hospitals, you buy as much as the doctor writes."

There were few differences in treatment preferences between males and females. Participants discussed their concerns about the lack of privacy in hospitals, which concerned females more than males. The participants thought that staff and clients gossiped about the reasons for people's visits. They also talked about how hospital staff treated young people. One male participant observed that "doctors look down on young people; they don't even have enough time for adults." Many believed that fear of being ridiculed by nurses and doctors kept adolescents from seeking treatment at hospitals. They remarked that providers in hospitals vigorously question their patients, which can be a major deterrent for young people. A female participant explained: "They fear the doctors might ask them too many questions, ridicule them, intimidate them and give them advice." One male described a fear of detention: "If you visit the hospital and the doctors find out that you have a very infectious disease, you will be isolated or put under house arrest."

STD Prevention and Treatment Methods

The participants agreed that condoms were the best method of STD prevention. Abstinence was thought to be the next most commonly used method of prevention, followed by monogamy, antibiotics and locally available preparations thought to be effective against STDs. Abstinence and monogamy were mentioned more frequently by females than by males, but males were more likely to report using local preparations for STD prevention.

Locally available preparations—herbs and roots; Krest Bitter Lemon soda; kola (a popular stimulant); and combinations of salt, potash, gin, lime and pepper fruit—were mentioned more frequently than antibiotics as ways of treating STDs. Males were more likely than females to mention the use of local preparations. Medical treatments used included tetracycline tablets, ampiclox, ampicillin, topical treatments and injections. Some students described treatments that combined folk and modern elements, such as "roots, leaves, lime [and] red and white capsules—chloramphenicol and tetracycline." Topical treatments included penicillin ointment, medical soap and creams. Another STD treatment mentioned was prayer, which, according to one student, works only "if the patient has faith."

Although focus group participants considered condoms the best way to avoid STDs, the reported prevalence of condom use varied. Students were more likely to say that condom use was low than that it was high. There was no clear consensus on whether males or females were more likely to initiate condom use.

In many of the focus groups, students discussed why people dislike using condoms. Many thought they decrease the enjoyment of sex, a view expressed more frequently by females than by males. Others cited such barriers as ignorance about the advantages of condoms, fear that they can burst and cause injury, and concern that they waste time. Some students expressed fears about the quality of condoms available in their communities. One stated: "Condoms are of different grades. Those available in Third World countries are of low quality. Sperm can penetrate through them."

The common perception that condom use communicates mistrust was reflected in the groups: "The girls believe that it is lack of trust that makes their boyfriends want to use condoms on them, so they don't allow it." One boy explained that his peers do not use condoms "unless they don't like the girl. Maybe they want her for fun. That's when they use condoms. For their own girlfriends, they don't because they usually trust them."

Sources of Information

The focus group discussions provided valuable information on how to educate and treat young people with STDs and on the most effective sources of STD information. Overall, females knew more about sources of STD information than males did. Generally, participants described newspapers, magazines, and posters as the most common sources of STD information for young people, followed closely by radio, television and film. Some participants reported that young people also learned about STDs from family members and from school-related events. Males said that friends or peers were the most common sources of information.

The students viewed public education campaigns using electronic media (radio, television and film) as the most effective way to transmit information on STDs to young people. Health education campaigns at markets and public places were also perceived as effective, particularly by females, as were print media, schools and health seminars. Students had similar ideas about condom promotion: They thought electronic media were the best way to communicate with young people about the advantages of condom use, followed by schools, health seminars and print media.

Many students discussed the roles that parents play in young people's reproductive health. However, participants often noted that parents did not know any more than their children about reproductive health, and no one stated that parents (or friends and peers) were an ideal source of information on STDs. Some raised concerns about the effectiveness of peer educators, a common element of educational campaigns for youth. These were concerns about limited reach; one student suggested that if you are a peer educator, "You will only tell your [friends], but you won't tell others. So [peer education] won't be that effective."

Discussion

The focus group discussions provided important insights into young people's knowledge and attitudes toward STDs and their treatment and prevention. Results from the analysis suggest possible ways of decreasing STD prevalence by promoting responsible prevention and treatment-seeking behavior. Strengthening reproductive health programs can help achieve these goals by addressing adolescents' perceptions of risk, emphasizing the links between HIV and STDs, decreasing barriers to service provision for youth, involving parents and youth in programs, and considering gender differences in program planning and implementation.

Addressing the risk associated with a range of sexual activities, including sex with a regular partner, is a step toward encouraging responsible behavior. Students in the focus groups were aware that some of the sexual activity that was commonplace among their peers could have adverse health consequences. They noted that having multiple partners and engaging in sex with unknown partners were high-risk behaviors, but they did not acknowledge the potential health risks of intercourse with a regular, known partner. This result suggests that familiarity with a sexual partner is accompanied by a perception of decreased risk.

The focus groups also revealed that a perception of risk does not necessarily translate into safe behavior, indicating that educational programs cannot simply focus on the negative consequences of behavior. Regardless of their knowledge about risk, students described attitudes that discouraged safe behavior. Students reported that people intentionally spread STDs, especially HIV. Many students think that getting an STD is inevitable, a perception that can discourage them from taking preventive measures.

STD control should be an important component of AIDS prevention campaigns.¹¹ Our results reveal that AIDS campaigns in this area have failed to make the link between AIDS and STDs. Many of the focus group participants were aware of the consequences of AIDS, but not the role STDs play in HIV transmission. Emphasizing that STDs increase the likelihood of HIV transmission may increase young people's concern about STDs and lead to less risky behavior. Pointing out that the behaviors that put one at risk for STDs are the same as those that put one at risk for HIV infection is another way to capitalize on knowledge about HIV to promote STD prevention efforts.

A key component of STD control strategies is improvement of STD diagnosis and treatment, which is done most effectively through formal health services. In the focus groups, the central issues underlying adolescents' treatment decisions were cost, time, providers' lack of interpersonal skills, and confidentiality. Improving the quality of formal health care by targeting some of these concerns would increase the likelihood that young people will seek advice and treatment for STDs. Training providers in sensitivity, confidentiality and other special needs of young people might increase attendance of youths at hospitals and clinics.

Establishing youth-friendly services, which are emerging in various countries in Africa, is a way to increase access.¹² Although approaches vary, such services usually emphasize low-cost or free treatment and staff trained to treat young people sensitively. In Nigeria, a few nongovernmental organizations have filled a gap by serving youth through clinics specially tailored to adolescents' needs.

Training providers in low-cost diagnosis and treatment techniques is a central component of increasing access for adolescents, who frequently lack money to pay for health care. One male focus group participant thought that cost was more important than confidentiality: "Even if the location isn't hidden, if it is free, teenagers will come around."

Programs targeting young people's sexual and reproductive health cannot ignore the potential of parental involvement, a theme that emerged several times in the focus groups and that is supported by other studies of the sexual behavior of Nigerian adolescents.¹³ The focus groups demonstrated the need to improve parents' knowledge and their ability to communicate with their children about sexual and reproductive health, since students agreed that few parents know more than their children about STDs, condom use and other reproductive health topics.

Programs should not overlook the possible negative influence that parents can have on their children's sexual and reproductive health. Focus group participants discussed parental behaviors they perceived as detrimental to young people's health, including modeling risky behavior by having sexual relationships with different partners or with strangers, and by encouraging their children, sometimes inadvertently, to become involved in sexual relationships. One student explained: "Some girls get involved in sexual acts because [their] parents...neglect their children to the extent of not giving them money for basic needs such as toiletries." Another added: "Maybe a father of about 50...[has] a little girlfriend somewhere.... He is the one that spends for the girl, he will kind of encourage his own daughter to go towards that same line."

One focus group participant was dismissive toward education programs. He asserted, "It is what I like that I will do, no matter how much any person or group of persons preaches." However, involving young people in program development and implementation is one way to increase program effectiveness, particularly when those resistant to change participate. Peer-based approaches are a common way of improving young people's sexual and reproductive health, although the students' comments about their limited reach should not be overlooked. Using young people's language to describe STDs and STD symptoms would make educational messages more meaningful, given that focus group participants were more familiar with local names for STDs than with their medical names.

The focus group discussions indicate that gender differences should be considered when targeting young people with educational interventions, since our analysis of the transcripts revealed differences in males' and females' knowledge about STDs. For example, in the focus groups, female participants were more likely to identify electronic and print media and public and school-related events as sources of STD information, while males were more likely to rely on friends or peers. Females were more likely to name abstinence and monogamy as STD prevention methods, while males were more likely to use locally available preparations. Programs are likely to be more effective if tailored to these differences.

Conclusion

The focus group discussions provided insight into adolescents' knowledge and attitudes about STDs; several points emerged that should be integrated into programs designed to increase safer sex and treatment-seeking behavior among adolescents. Increasing the perception of risk adolescents associate with some sexual activities and highlighting the connections between STDs and HIV could be two components of an STD control program in this setting. To promote effective behavior change, interventions should include the participation of young people in innovative ways. Educational activities should target parents as well, which would enable them to play a more beneficial role in the sexual and reproductive health of their children. The alarming perception that people intentionally spread STDs should be further explored and addressed.

The results of these focus group discussions improve our understanding of why adolescents become involved in sexual relationships at a young age, and why they engage in risky behavior even when they know the risks. The participants discussed the difficult economic reality they face, especially as a motivation for sexual relationships. Finding ways to encourage STD prevention and treatment in settings where resources for health care and basic necessities are limited is a challenge that must be met. Focused action to increase STD awareness, knowledge, prevention and treatment among young people is critical in Nigeria, where 48% of the population is younger than 15 and the number of reported AIDS cases is still low.¹⁴