Sexual Behaviour of Congolese Teenagers

Introduction: Sexual risk behaviour among adolescents is a public health problem worldwide. Widely studied in the Western countries, this problem has only been addressed partially in Brazzaville. Thus, 12 years later, we conducted this study with the aim of analysing the sexual behaviour of adolescents in Congo. Patients and Methods: This was a cross-sectional and analytical study from January to August 2019 (8 months). It involved 2000 adolescents residing in the departments of Brazzaville and Pointe-Noire consti-tuting the urban population, and those of Cuvette and Bouenza, the rural population. Results: A total of 1167 adolescents reported being sexually active. The mean age at first sexual intercourse differed between the two sexes (p < 0.0005). Of the adolescents surveyed 96.1% (n = 1122) claimed to have ever heard of HIV/AIDS infection and 8.7% (n = 101) to have ever contracted sexually transmitted infections. The main channel of information was school in 57.7%. Condoms were the only means of protection (85.5%). The factors associated with risky sexual behaviour were, on the one hand, those related to the adolescent (lack of schooling, orphan status, alcohol and tobacco consumption, paid employment and possession of a mobile tion marked by the abundance of mass media in urban areas favours the predominance of these behaviours in the city. The consequences are serious and can compromise the future of adolescents; hence the importance of prevention.


Introduction
Adolescence is a period of life that marks the gradual transition from childhood to adulthood, is accompanied by physical, biological and psycho-emotional transformations that lead to profound changes, particularly in sexual behaviour.
Sexual behaviour is conduct aimed at the satisfaction of sexual pleasure; it is said to be "risky" when it exposes adolescents to serious and sometimes dramatic consequences [1]. According to the WHO, sexual risk behaviour (SRB) in adolescence is a worldwide concern and a real public health problem [2]. In the West, this widely studied issue shows a significant reduction in the rate of SRB in adolescent populations [3] [4]. In Africa, SRB is likely to lead to multiple complications in adolescents considered as "immature", such as sexually transmitted infections (STIs) including HIV/AIDS, early and unwanted pregnancies with all their consequences [5] [6]. In Congo, after a piecemeal study carried out 12 years ago in Brazzaville, we conducted this study with the aim of analysing the sexual behaviour of adolescents in Congo. More specifically, to describe adolescent sexual behaviour at the national level, to identify factors associated with RSB in adolescents and to assess the influence of place of residence on the sexual behaviour of Congolese adolescents.

Materials and Methods
This is a cross-sectional, descriptive and analytical study conducted from January to August 2018 (8 months). It was conducted in four (two urbans and two rurals) of the country's 12 departments. The sampling method was a randomized two-stage cluster survey, stratified by sex and residence borough or district. The sample was drawn from households in the selected boroughs or districts of the departments. Adolescents in Brazzaville and Pointe-Noire (the most populated departments of the country as they account for more than 60% of the national population [7]) constituted the urban population, and those in Bouenza and Cuvette (selected randomly because of their demographic similarities) the rural population. For each borough (urban area), all neighborhoods were identified and each neighborhood constituted a cluster. The selection of clusters was done by a simple random draw. A total of 30 clusters were selected for the study and distributed proportionally to the size of each borough. Using the map of the de-Open Journal of Pediatrics partments, the boundaries and centers of each selected cluster were identified.
From the center of the cluster, the direction of travel was randomly selected. The first plot was selected by a simple random draw among those counted in the center of the cluster. Then, one plot out of five was selected, once to the right and once to the left. At the intersection of two streets the choice of the next direction was made by the same process. Thus, in each household, only one adolescent aged 10 to 19 was interviewed. A total of 1560 adolescents (900 in Brazzaville and 660 in Pointe-Noire) were included. In the rural area, for each district all villages were identified and each village constituted a cluster. The selection of clusters per sample was done by simple drawing. A total of 30 clusters were selected and distributed in proportion to the size of each village. The limited budget did not allow us to visit all the districts of the two departments. Thus, one district per department was selected randomly. For Bouenza it was the district of Kayes and for Cuvette the district of Boundji. In each household, only one adolescent aged 10 to 19 was interviewed. A total of 440 adolescents were interviewed (220 in Cuvette and 220 in Bouenza). In all cases, parental or legal guardian permission was required to participate in the study. Adolescents who agreed to answer the questionnaire objectively, after obtaining parental permission, were included in the study. We excluded adolescents whose parents or guardians did not consent, and those who did not complete the questionnaire.
Data were collected by the same investigators at the different study sites using a pre-designed survey form. The survey form was designed by the research team in consultation with the statistician. Of note, these data were taken from a research dissertation submitted to the faculty of health sciences of Brazzaville as part fulfilment of award of diploma of doctorate in medicine. For each adolescent who met the inclusion criteria, the variables studied were socio-demographic; firstly, in relation to the child (age, sex, religious practice, schooling, marital status, place of residence, social status, paid employment, existence of a mobile phone), secondly in relation to the parents (level of education, employment status, household structure). Qualitative variables related to sexual behaviour (first sexual intercourse, knowledge and use of means of protection against STIs, sexual orientation, sexual violence, sexual practice) and quantitative variables (age at first sexual intercourse, number of partners) were also taken into account.
The statistical analysis was done with Microsoft Excel version 2013 and Epi info version 7.1.1.1. The results were expressed as mean and standard deviation for quantitative variables and as headcount or percentage for qualitative variables. The Pearson chi-square test was used to compare the rates with significance if p < 0.05 and a 95% confidence interval (CI).

Results
In total two thousand adolescents were included, with a M/F ratio of 0.84. Adolescents were aged from 10 to 19 years; divided into two groups according to age.  Table 1, and those of the parents of the adolescents surveyed are shown in Table 2.
Of the adolescents surveyed, 1167 claimed to be sexually active, a frequency of 58.4%. The mean age of first sexual intercourse differed between the two sexes (p < 0.0005). It was 14.6 ± 1.8 years (extremes 10 -19)

Discussion
First of all, it is important to note that comparing the results of this study with those of other authors must be done with caution because of methodological differences. Indeed, the interrogative method used involves certain hazards insofar as it relies on the good faith of the respondent; in this case, the adolescent may voluntarily provide a false negative answer in order to hide a reprehensible response (even if anonymity has been previously guaranteed). However, this method does not offer any alternatives. Another possible cause of over-reporting of sexual behavior could be the boastfulness or braggart of adolescents, but we agree with Morris et al. [8] that anonymity and the use of a questionnaire made  Today's increasingly liberated sexual behaviour among adolescents seems to defile the morality of abstinence until marriage. Several reasons have been put forward to explain the high proportion of adolescents who have sexual relations at an early age [11]: the erotic and sexual explosion in the media (television and cinema with the broadcasting of pornographic films, radio, internet, smartphone) which now play a major role in the education of young people and encourage them to engage in certain sexual practices. Similarly, physical maturation is always accompanied by a surge in sexual impulses with a desire for affirmation and a great thirst for discovery of the other sex; the lack of distinction in sexual activity between procreation and pleasure.
In this study 58.4% of adolescents declared to be sexually active. This prevalence is similar to that of Mabiala Babela et al. [6] who found a frequency of 52.7%. On the other hand, Grondin et al. [12] reported a rate of 40.3% which is lower than ours. This result could be explained by methodological differences in the choice of the study population.
The mean age at first sexual intercourse differed between genders. Sexual activity was earlier in boys (14.6 years) compared to girls (15.5 years) with a highly significant difference (p < 0.001). Male precociousness was also found by Mabiala Babela et al. [6] in Brazzaville. Masmoudi-Soussi et al. [13] in Tunisia found a mean age of 16.5 years. This difference could be explained by the particularity of their study population, which included university students. However, the weight of habits and customs should not be neglected in the occurrence of first sexual relations. The conditions and lifestyles are also often mentioned to explain this new behaviour, as the environment in which adolescents live is subject to numerous changes (media, television, cinema) influencing their sexual behaviour. Moreover, the study by Udry et al. [14] on the links between "age, hormones, pubertal development" and sexual response in adolescence, reports a differential effect according to sex. In boys, the main determinant of the onset of sexual intercourse is the rise in hormonal (androgen) concentrations during puberty. It can therefore be assumed that an early-maturing boy is more prone to  This difference can be explained by the economic and socio-political context of the country in this post-conflict period, where 24.1% of adolescent girls used sex for economic reasons [6]. The high rate of sex with multiple partners more frequently observed among boys in our study could necessarily be linked to other risk factors, notably a paid job, the fact of having a mobile phone, alcohol and tobacco consumption, and the mother's professional situation.
Being interviewed on sexual orientation can be a source of anxiety and shame, especially in our society. In our study, homosexual activity with or without penetration was found in 45 (3.9%) adolescents, mostly girls (2.8%) compared to boys (1.1%). Khemakhem et al. [15] in Tunisia found the same trend, with a higher frequency of 15.4% for adolescent girls and 11.5% for adolescent boys.
This difference can be explained by the fact that this "shameful" practice remains taboo in our country, which is strongly anchored in religion and under the weight of tradition. Moreover, this activity is much more a matter of discovery than of real identification with the other sex.  [16], 18.5% of which one in four girls and one in ten boys, and that of Glowacz et al. [17], who reported 11.9% among adolescent girls. The lack of experience and the intensity with which adolescents experience their first romantic relationships may lead them to commit or tolerate certain acts of violence [18] and sexual coercion [19] [20] [21].
Incestuous sex, found in 5.7% of this study, was a more frequent practice Open Journal of Pediatrics among girls. No particular comment can be made with regard of these findings due to the lack of data on the field in the literature.
Comparing the sexual behaviour of urban and rural adolescents in this study, we found a similar frequency of sexually active adolescents in both settings. The rates of adolescents having heard of HIV/AIDS are almost identical, with a slight predominance in urban areas. Sexual risk behaviour such as early sex and/or sex with multiple partners are more common in rural than in urban areas, while homosexuality, incestuous sex, non-consensual sex and extra-vaginal sex are more common in urban areas. The abundance and effect of the mass media, more predominant in the city, certainly justifies this difference.
Finally, these findings support the need to address this problem through serious and high-quality sexual health education and prevention services in other to improve adolescent sexual health outcomes, especially in the early adolescent. Several models engaging adolescents in sexual health, including education counseling, cultural, social and spiritual interventions, and computer program could be implemented, as they have been proven to be efficient [22]. Another component that should be taken into account when addressing this issue is that parents, peers and teachers are important human resources of influence on adolescent' sexual behaviors that should not be left aside.

Conclusion
Sexual risk behaviour is real in the Congo, both in rural and urban areas. The advanced modernisation marked by the abundance of mass media in urban areas favours the predominance of these behaviours in the city. The consequences are serious and can compromise the future of adolescents; hence the importance of prevention, which involves setting up a national programme to fight against the risk factors, coupled with sex education.