Sexual Behaviour, Knowledge and Use of Contraceptives Among Undergraduate Students

Sexual activities among young ones are on the increase all over the world with a trend towards early onset. Many of the young adults have initiated their first sexual activity in their adolescent age. In Nigeria, up to 6% of all sexually active adolescent girls may have been pregnant and engaged in induced abortion1. Sexual behaviour has been defined as any activity that induces sexual arousal and two major determinants have been noted to be (1) genetics2 and (2) degree of sociocultural regulation exerted on an individual to express sexuality3,4. The contraceptive is a birth control tool to prevent pregnancy and Sexually Transmitted Diseases (STD) acquisition. Contraceptives are relatively accessible and affordable, with numerous types or options being available. Yet, incidence of unplanned pregnancies and STDs are still high5. Indeed, teenage pregnancies is a global issue and probably highest in sub-Saharan Africa6. While contraceptive remain a preventive measure for both STD and teenage pregnancy, it also known that several factors influence adolescents’ sexual behaviour in relation to the use of contraceptives7–10. Notably, these factors include, but are not limited to peersociocultural pressures to engage in Abstract


Introduction
Sexual activities among young ones are on the increase all over the world with a trend towards early onset. Many of the young adults have initiated their first sexual activity in their adolescent age. In Nigeria, up to 6% of all sexually active adolescent girls may have been pregnant and engaged in induced abortion 1 . Sexual behaviour has been defined as any activity that induces sexual arousal and two major determinants have been noted to be (1) genetics 2 and (2) degree of sociocultural regulation exerted on an individual to express sexuality 3,4 .
The contraceptive is a birth control tool to prevent pregnancy and Sexually Transmitted Diseases (STD) acquisition. Contraceptives are relatively accessible and affordable, with numerous types or options being available. Yet, incidence of unplanned pregnancies and STDs are still high 5 . Indeed, teenage pregnancies is a global issue and probably highest in sub-Saharan Africa 6 . While contraceptive remain a preventive measure for both STD and teenage pregnancy, it also known that several factors influence adolescents' sexual behaviour in relation to the use of contraceptives [7][8][9][10] . Notably, these factors include, but are not limited to peer-sociocultural pressures to engage in premarital sex 11 , albeit without commensurate education against the consequences.
Associated with the problem of unwanted pregnancies has been the concept of unmet needs of family planning. A study on sexual behaviour and contraceptive usage has been done in Delta State University (Figure 1) 5 . However, that study included staff and students without delineation of student subpopulation for special evaluation. It is against this background that this study seeks to examine the literature on sexual behaviour, knowledge and contraceptive use among undergraduate female students in a University in Delta state of Nigeria. The objective is to translate the undergraduates' birth control practice to the non-university community.

Methodology
The research methodology employed for this study was a narrative literature review approach. Firstly, four composite focus of inquiry were defined to include 1. Healthy and risky sexual behaviours, 2. Contraception, 3. Determinants of choice and use of contraceptives, and 4. Knowledge and use of contraceptives among undergraduate students. Secondly, a narrative inquiry to understand the literature as narratives was performed with a view to developing a story that will substantiate or support the need for future research. Literatures on the four composite focus were searched, albeit not in a systematic review paradigm, google scholar and PubMed amongst others.

Sexual Behaviour
Sexual behaviour is any activity between two persons that induces sexual arousal 12 . Sexual behaviour is defined as a person sexual life. Sexual behaviour as it pertains to sex includes courtship, masturbation, estral display and the mating act 13 . It is one aspect of the total pattern of reproductive behaviour in animals 14,15 , including all responses directly associated with genital stimulation and copulation. In the animal, much of the behaviour is visual including posture, feather fluffing, and tail carriage; Some of it is auditory, especially in cats, but chemical communication via pheromones is the clincher 12 .
Sexual behaviour in humans has been defined as the manner in which human's experience and express their sexuality 16 . It encapsulates how people engage in sexual acts in a variety of ways including but never limited to masturbation, romance, and sexual intercourse (which again include various forms such as anal, oral, or vaginal; as well as penetrative ornon-penetrative sex). Sexual behaviour also includes any conduct and activity intended to arouse the sexual interest of another. For instance, beside romance, modes of dressing, personal interactions between individuals and use of body perfumes may be deliberate to seduce a person of interest. In this context, sexual activity or behavior is appreciated to possess cognitive, emotional, and health aspect 17 . Of particular importance in this narrative is the health aspect, which can be delineated dichotomously as either healthy or risky sexual behavior 18.19 .

The Healthy Sexual Behaviour
Sexual activity is a normal physiological function and a person's sexual behaviour is considered healthy if it can be controlled. Sexual Behaviour (SB) develops over time from childhood; and at a particular time of a person's life, SB can be termed appropriate/healthy or inappropriate/unhealthy 19 . The characteristics of a healthy sexual behaviour can grouped into communication, relationship, and self-worth. Others are education and values 20 . However, it is noteworthy that the team from Minnesota has described these characteristics of 'sexually healthy' , which is probably a misnomer.
An adult with a healthy sexual behaviour interact with partner and considers all stakeholders (family and friends amongst others) in appropriate and respectful manner. This include appropriately expressing desires to have sex, or not to have sex; as well as negotiating sexual limits and accepting refusals of sex without hostility or feeling insulted 20 . Relative to rape and sexual assault, healthy sexual behaviour involves being consciously and conscionably sensitive to the feelings of other persons' nonverbal cues and boundaries 21,22 .
A person with healthy sexually behaviour develops friendship with any gender without necessarily having any sexual agenda. In sexual relationships, healthy behaviour Sexual Behaviour, Knowledge and Use of Contraceptives........ is devoid of exploitation, but a tool prevents mental stress on either member of the relationship and buildsecurity 18 . For instance, an intellectually handicapped individual is prone to exploitation, yet capable of having a healthy sexual behaviour to build safe, constructive sexual expression and healthy relationships, if appropriately empowered with behavioural knowledge [23][24][25] .
A person with healthy sexual behaviour esteems herself/ himself and exhibits self-control, whilst being able to indulge in pleasurable sensual and sexual activities. For instance, people with higher self-esteem are less likely initiate sex 26,27 . Self-esteem in in sexual behaviour transcends self-worth and sexual self-concept. It is attitudinal and a reflection of mental ability 28 .
In relation to education, a healthy sexual behaviour is characterized by knowledge of the consequences of different forms of sex and sexual activities. For instance, oral sex is associated with risk of preventable infections 29 ; including HIV per se. Adopting the knowledge is attitudinal vis-àvis a behavioural change wheel [30][31][32] .Hence the required healthy sexual behaviour is adopting a HIV prevention consciousness that being sexually healthy enough to engage in oral sex requires having a healthy oral cavity 33 , as well as the HIV-negative and/or positive partner taking medicine 34 . Other educational characteristics of healthy sexual behaviour include comprehending the impact of media messages and understanding that the drive for sex is powerful and can be integrated into one's life in positive and healthy ways 20 .
Considering values, a healthy sexual behaviour involves their identifying or standing by practices that is "right" on the basis of both personal and sociocultural values, which may include compromise, self-control or tolerance. This also includes issues on use contraception to avoid unplanned pregnancy or sexually transmitted disease 21 .Values may also encompass spirituality 20 . For instance, religious people abstain from sexual intercourse during their time of 'prayer and fasting' . Hence, it has been advocated as possible approach to HIV prevention 35 .

Risky Sexual Behaviours
Risky sexual behaviours can be defined or determined by the level of potential negative outcome [36][37][38] . Some authors have defined it as behaviours that increase risk of STD or unwanted pregnancies, especially being in a sexual relationship in early teenage years i.e., before being matured enough to understand the concepts of healthy relationship -is acknowledged as a risky sexual behaviour 39 . Common examples of risky sexual behaviour include unprotected intercourse, sexual promiscuity and sex involving unwanted pregnancy 40 . Other sexual behaviours considered inappropriate or unhealthy include inappropriate sexual exposure such as the concept of pedophile, engaging in sexual behaviours in public or with animals, and precocious sexual gestures amongst others 19 .
It is believed that young people hardly need education to engage in sexual behaviour as it is normal physiological response to puberty. Nevertheless, it is known that certain factors encourage sexual activities that constitute risky or unhealthy sexual behavior [7][8][9][10] . For instance, fashion has been a paradoxical feature in sexuality and attractiveness. While a shoddily dressed person may unattractive or unsexy, the attractively dressed person may be viewed as inappropriate and seductive in certain situations. This is essentially based on the fact that appearance objectifies a person as well as forms the basis of attractiveness and sexual appeal. Importantly, it is acknowledged that unachieved level of attractiveness can lead to unhealthy behavior 41 . Associated with this social trend are peersociocultural pressures to engage in premarital sex 11 . In this narrative, focus is henceforth on unprotected sexual intercourse as a risky sexual behaviour.

Contraception
Contraception, which is otherwise known as birth or fertility control, has been defined as the deliberate prevention of conception. It has been used since ancient times-e.g., Egyptian Ebers Papyrus involving use of honey and acacia was adopted in the first century 42 , but safer methods probably became available in the 20th century 43 . There are up to fifteen methods of contraception that can be grouped into two broad types, which includes barrier and hormonal methods 44 . The barrier methods such as condoms and diaphragm help to protect against pregnancy as well as Sexually Transmitted Infection (STI), while hormonal methods prevent pregnancy, only.
Beside the barrier and hormonal methods, there is also the behavioural methods 45,46 . This includes sexual abstinence that is the most effective preventing pregnancy as well as STI 46 . Another behavioural method of contraception is coitus interruptus that has a failure rate similar to barrier methods. Other behavioural methods include fertility awareness, lactational amenorrhea and natural family planning amongst others.

Determinants of the Choice and Use of Contraceptive
The schematic presentation in Figure 1   In this framework, programme activities play a role in contraceptive method adoption that is similar to the roles of social, familiar and spousal support. The psychological, logistical and social constraints to contraceptive adoption are offset by programme activities that enhance service accessibility, improve the climate of information exchange and legitimise contraceptive behaviour 13,49 .

Use of Contraception
Contraceptive usage is the percentage of women (and/or sexual partner) that is currently using at least any one of the methods of contraception. According to the World Health Organization, it is based on women within the age range of 15-49 years old. It has been estimated that globally 54 ; about 60% married women of child-bearing age are using contraception, but the frequency of usage of the different methods varies widely between countries (Table 1). Not with standing the figures indicated on Table  1, other reports have suggested that most common method in the developed world is condoms and oral contraceptives, while in Africa it is oral contraceptives 52 . Contraceptive use among women in sub-Saharan Africa has risen from about 5% in 1991 to about 30% in 2006 50 , which means a reduction in unmet needs. Yet, comparison of contraceptive usage in sub-Saharan Africa, especially West Africa leaves much to be desired when compared to the world's average (Figure 3). Of particular note is that less than 20% of Nigerian women are using any method of contraception 53 . In Nigeria, various studies show the pattern of contraceptive usage. In a study of 500 youth participants 51 , only 34.2% claimed to have used contraceptives out of which a vast majority used condoms (Table 1). Another report about Nigerian women aged 15-49 in the period of 1981 to 2013 is presented graphically in Figure 4.

Knowledge and Usage of Contraceptive among University Students
The result of the study on contraceptive knowledge and usage among female secondary schools in Lagos State, showed that 5% of 1155 students with knowledge of contraception are users of contraception, 85% of sexually active respondents were non-users while condom is the most common contraceptive method used 49 . This data regarding condom usage is in agreement with the report from Abuja presented in Table 1. It has been found that most of the students have knowledge of contraception, but the rate of contraception use is still low 17 . Yet, it is suggested that the depth of the knowledge may be poor or just fair 22 , and probably dependent on parental socioeconomic status 55 . It was argued: • Parents' levels of education and income are significant predictors of a student's use of contraceptives. • The students from low socioeconomic background are less likely to use contraceptives is low, especially where the contraceptives are neither free of charge, nor readily available.
Thus, there may be issue of behavioural change wheel vis-à-vis capacity, motivation and opportunity surrounding the unmet needs of family planning among undergraduate students. This probability of behavioural change wheel is supported by reports of other studies indicating that socioeconomic background to students influences their access to and use of contraceptives [56][57][58] . Perhaps, what seems to be missing in the discourse is that pregnancy rates among the girls in university community is apparently very low, which is indicated by a highly maintained uninterrupted education. Whether abortion rate is higher (compared to non-students subpopulation) is unknown.
Further from a study conducted in Delta State of Nigeria, there is a negative attitude towards the use of contraceptives with a good fraction of people explaining either that it interferes with pleasure during sex, or they just would not use condoms in sexual relationships with trusted partners 5 . This also hinges on behavioural change wheel, but it is of different perspective from socioeconomic status factor. For instance, non-users influenced by low socioeconomic status may become users, if given the affordance/capacity, whereas those with negative attitude may already have the capacity but lack motivation. This does not explain the apparent success in pregnancy prevention among female students, though.

Implication for Further Studies
There is a plethora of research that has been going on to improve 'Family Planning Methods and Services' (FPMS). A cursory search of PubMed, alone, for FPMS, yields thousands of published articles including hundreds arising from any single Low-Mid Income Country (LMIC). Several factors, methods and programs are already known including but not limited to ideas such as behavioural change motivation 21,59 , getting closer to the people 60 , and family education 61 . Other issues of barriers, generational change and provider behaviour have also been identified 62,63 . Yet, there is still the problem of unmet needs, which seems to be confounded by the mix-up of sexual behaviour vs sexual health. For instance, erectile dysfunction is a state of being sexually unhealthy and constitutes a sexual health issue that may be helped with a healthy sexual behaviour. A young married man suffering erectile dysfunction can be treated with aphrodisiac 64 . Evaluation of sexual behaviour, knowledge and the frequency of usage of contraceptive as well as the behavioural change wheel of undergraduate university community will be one step in this direction. The knowledge of how the undergraduate students are handling their contraception in order to maintain uninterrupted education will help in propagating the prevention of sexually transmitted diseases and unwanted pregnancy.

Conclusion
Among the undergraduate students, the prevailing studies have been on first sexual intercourse among undergraduate student, the level of awareness of contraceptives at first intercourse and if being un undergraduate student comes with higher level of awareness; it may be useful to re-evaluate 1. Whether the use of contraceptive by undergraduate students in Delta State differ by age, gender, level of study, religion or marital status; and 2. If the knowledge of contraceptives by the students influences their sexual behavior. These investigations could identify the unmet needs of family planning.
There is also the need to differentiate being sexually healthy from a healthy sexual behaviour. These two phrases seem to be used interchangeably, but it is pertinent they are differentiated. In our opinion, being sexually healthy or unhealthy relates to ability, whereas healthy or risky sexual behaviour is about 'how' attitude. That is, Sexual health relates to an underlying pathophysiology that impacts negatively on sexual activity; whereas in healthy sexual behaviour relates to attitude.