Adolescent Sexual Behavior in an Urban Area of a Resource-Limited African Country, Cameroon

Introduction: The substantial changes that occur in adolescence may lead to sexual behaviors that adversely affect their health. We have described sexual patterns in adolescents in various neighborhoods of Yaounde in order to un-derscore the sexual challenges that they face. Methods: We carried out a cross-sectional descriptive study in District number V of Yaounde from Au-gust 1st to 31st 2018. To characterize their sexual lives, we surveyed 1800 adolescents between 10 and 19, and analyzed the data using SPSS version 25.0. Results: In our study, 1023 (56.8%) adolescents were female, and 777 (43.2%) were male. Most of the adolescents were between ages 18 and 19 years (25.4%), unmarried (93.1%), had a secondary level of education (81.9%) and lived with their families (87.3%).


Introduction
Adolescence is characterized by the transition from childhood to adulthood, and the subjects undergo physical, psychological and emotional changes [1]. Sexual awareness that occurs during puberty results in adolescents being interested in sexual intercourse. Worldwide, about 47% of adolescents have already had sex.
In the US, 6% of adolescents had their 1st sexual encounter before age 13 years [2].
Adolescents are physically and emotionally immature. Their lack of experience in human and sexual relations rises their risk of being exposed to circumstances that have adverse consequences on their reproductive health and sexuality [3]. In 2011, 17.9% of adolescents aged 15 -24 years reported having had an STI [4]. Some consequences of STIs include infertility, ectopic pregnancies, and cervical cancer [5] [6] [7] [8].
Actually, adolescents are not only at risk of STI's and HIV infection, but also of unwanted pregnancies [9] [10]. These early pregnancies which often result in unsafe abortions are a major cause of morbidity and mortality in Africa [7] [11] [12]. A report from Cameroon in 2014 showed that 27.5% of women between ages 20 -24 years had at least one live birth prior to being 18 years old [4].
Adolescent sexual behavior is influenced by several factors. Literature reports adolescent sexual decision making as a function of personal, familial and social factors [13] [14] [15] [16] [17]. Individual factors, such as age and gender, that will trigger the onset of sexual activity are not only governed by socio-cultural factors, but also by contextual factors, such as alcohol and drug use, and dropping out of school [15] [18]. According to Sturgeon et al., an intact family unit helps adolescents delay initiation of sex, have fewer sex partners, less STI's or premature pregnancies than their counterparts in broken families [19].
The onset of sexual activity varies according to series in the literature. The average age at first sexual intercourse was 14 Foumane et al. [23] reported that in 2013 21.3% of adolescents schooling in Yaounde were sexually active. MICS in 2014 reported that 16.0% of young women and 9.3% of young men aged 15 -24 years had sex before age 15 [25].

F. Essiben et al. Open Journal of Obstetrics and Gynecology
The development of effective services and policies addressing adolescent health issues should take into account the daily realities of adolescents. Meeting their needs is a challenge requiring being knowledgeable about their sexual and reproductive issues, their specific needs and problems resulting from their sexual behaviors. The goal of our study was to investigate adolescent sexual behavior and to seek determinants of their sexual activity in order to facilitate services rendered to them in a low-income country like Cameroon.

Methods
This was a cross-sectional descriptive study over a 5 months period, from May to This district is comprised of 11 neighborhoods, 7 in urban areas and 4 rural settlements. We included all adolescents age 10 -19 years living in the study area and who accepted to participate in the study. Adolescents who did not have parental or guardian consent were excluded.
After approval of the authorities of the district of Yaoundé V, adolescents in our study area were invited to participate in the study. Adolescents were recruited during the vacation period at leisure spots and public places in the district. We performed simple stratified sampling.
We randomly chose 4 out of 7 neighborhoods in the urban areas and 2 out of 5 villages of the district. In each of these locales we identified adolescent leisure spots and places of gathering. Adolescents between age 15 and 19 years who voluntarily agreed to participate in the study were enrolled.
As a first step, fact sheets were given to participants to help them better understand the objectives of the study and ask questions. Adolescents less than 18 years received an additional consent form requesting parental approval. Secondly, after consent was received, the data sought were collected and recorded in a pre-established and pre-tested data collection form.
Participation in the study was entirely voluntary with free and informed consent of parents or guardians, and after completing the questionnaire, the participants placed them in envelopes which they sealed themselves to maintain confidentiality and anonymity.
We studied socio-demographic factors (age, ethnic origin, level of education, marital status of parents, location of home), factors pertaining to reproductive life (number of pregnancies, number of deliveries, number of spontaneous or induced abortions, number of living children), and sexual habits of boys and girls. The latter factor was further classified resulting in 7 variables to evaluate adolescent sexual behavior. These were sexual status (whether or not sexually active), age at first intercourse: premature (prior to age 16) or late (≥16 years), multiple partners (more than 1 partner), frequency of sex (occasionally or once a month), type of sex (vaginal, anal, oral), sexual orientation (heterosexual, ho-Open Journal of Obstetrics and Gynecology mosexual or bisexual), use of male condoms during sexual intercourse (always or occasionally/never).
Early sexual intercourse, multiple partners and unprotected sex were considered high risk behaviors in our study.
The data obtained were registered and analyzed using Excel  and SPSS version 2.5. The data are expressed in numbers and frequencies for the qualitative variables, and in means with respective standard deviations for the quantitative variables. Pearson's Chi square test was used to compare qualitative variables, and the Fisher test to analyze variance. Spearman's test was used for correlation of quantitative variables, and Pearson for qualitative variables. Significance levels were set at 5%.

Results
We contacted 2200 adolescents, of which 230 did not participate in the study for personal reasons, or parental prohibition. 1970 adolescents filled out the questionnaire but we excluded 170 surveys because they were filled improperly. Finally, a total of 1800 adolescents participated in the study, 1023 girls (56.8%) and 777 boys (43.2%). Table 1 describes the adolescents' socio-demographic characteristics. The age range most represented of either gender was 18 -19 years, 27.8% girls (284/1800) and 25.4% boys (196/1800). Mean age of girls surveyed was 14.8 years (±3.08) versus 14.6 years (±3.03) for boys. The level of education most represented was secondary for both genders, for girls (82.0%; 839/1800) and for boys (81.8%; 636/1800). Of the adolescents who participated in the study, none of the boys were married while 6.9% girls (71/1800) were. Most of the adolescents surveyed were in secondary school.
Characteristics of reproductive life Table 2 describes the distribution of adolescents as a function coitarche and gender. The first sexual intercourse occurred at age 8 in boys and 9 in girls. The mean age at first sex was 15.1 ± 2.2 years, specifically 15.11 ± 2.4 for girls and 15.06 ± 2.2 for boys. We observed that 54.03% of boys had their first sexual encounter prior to age 16 years, and 58.48% of girls. Early intercourse occurred at similar ages in both sexes (p = 0.324). Open Journal of Obstetrics and Gynecology   of pregnancies led to a termination that was voluntary in 67.3% (37/55) of cases.

Discussion
The reproductive health needs of adolescents require special attention because their psychological and social vulnerability may expose them to high-risk sexual behaviors. These risky behaviors may be associated with decisive consequences in the future. This often leads parents and society to introduce coercive measures aimed at limiting adolescent exposure to vulnerable situations. There are scarcely any health programs available for adolescents in our milieu. In this community-based study, we offered a perspective on the sexual behavior of 1800 adolescents and illustrated some of the components of adolescent sexuality. The average age of the adolescents in our study was similar for the sexes, 14.7 years for boys and 14.8 years for girls. The most represented age range for both sexes in the study was 18 to 19 years (26.7%). These results are similar to those published in 2013 by Kobelembi et al. in the CAR [26], and Foumane et al. in Cameroon [21], which reported an average age of 14.7 years. The majority of our participants were in secondary school since we recruited in urban or peri-urban areas where the school enrollment rate of 87% [4].
There were 6.9% married girls versus no married boys. This figure is double that reported in 2013 by Foumane et al. that showed 2.5% married girls in secondary school [23]. This discrepancy can be explained by the population sampled; whereas Foumane et al. surveyed only secondary school adolescents, our study for inclusive or all adolescents, irrespective of schooling. However, our percentages were less than the national average. In 2012 according to UNICEF 24.2% of adolescents in Cameroon were married or in cohabitation [24]. In Côte d'Ivoire, these figures are more alarming because 36% of women were already cohabiting before the age of 18 years [27]. Schooling limits the risk of early marriage, which explains the low proportion of married teenagers in our study.
In our study, 13.4% of boys and 11.9% of girls no longer lived at home. Living at home depends not only on the level of education but also on the living conditions. Adolescents living outside the home are often students who break free from parental control upon university admission. In our study adolescents not living at home were usually in a university (p < 0.001). According to Rwenge M, and a pregnancy interruption rate of 33.3% [29]. Early pregnancy among school girls will often lead to an abortion because they are mostly unwanted and unplanned. The higher rate of abortions in this more educated population can be explained by the fact that pregnancy could interfere with the adolescents' plans for school. 30.5% of the adolescent had early sex, specifically 27.6% boys and 33.4% girls reported one sexual encounter. This finding is lower than that reported in Burkina Faso by Adohinzin et al. which showed 54% [6]. The number of sexually active girls was comparable to that of boys (p = 0.17). The mean age at first sex was 15.1 years in both genders. We noticed a significant number of girls who are sexually active before age 16 years. Many studies describe a progressively decreasing age at first sexual intercourse [4] [11] [30]. An explanation of early sex may be that young people grow up in a rapidly changing environment that continually offers new discoveries. Globalization, access to new communication techniques, rapid urbanization and changing social norms are all factors that arouse young people's curiosity and thus expose them to early sexual encounters. Like other authors [6], there was a positive correlation between school attendance and early sex because only 6.7% of adolescents beyond the secondary level of education were sexually active compared to 82.3% of those in secondary school. We can assume that the educational environment is a milieu that creates opportunities for young people to network and make good decisions pertaining to their sexuality. Educated youth are likely to have the knowledge and attitude necessary to resist peer pressure and take responsibility for their lives. Information on sexuality as well as essential skills should be integrated early in the schooling process such that adolescents reap the benefits thereof. As such, even young people who drop out of school be able to benefit from such early integration.
Multiple sexual partners were observed in adolescents at 41.2%, albeit more in boys than girls but without statistical significance (p = 0.26  [26]. Boys are more likely to use condoms during sex than girls (p < 0.001), probably because the male condom is more popular and easier to use. The other reason could be the challenge girls face in insisting that their partners use condoms since sex if often occasional and unplanned.

Study Limitations
Our study had certain limitations. We did not research the prevalence of STIs-HIV in our study population, which would have given us a better perspective on the consequences of these risky behaviors and endorse our recommendations.

Conclusion
The high enrollment rate of adolescents in the Yaoundé V district should help to improve adolescents' sexual behavior because they have early sexual relations.
Adolescents' high-risk behaviors may expose them to unwanted pregnancies and abortions. The low rate of condom use also exposes them to sexually transmitted infections. The factors associated with these high-risk behaviors, and the primary sources of information of these adolescents need to be considered in the development of youth sexuality education programs and these programs need to be implemented early in the community. Open Journal of Obstetrics and Gynecology pated in the study design and collection of data. Ngo Um Meka Esther has been involved in analysis and interpretation of data and drafting the manuscript. Mve Koh Valère and Nsahlai Christiane reviewed of the article and Foumane Pascal reviewed and supervised the study. All authors have read and approved the final manuscript. Apart from the personal contribution of each author, the study was not funded.

Conflicts of Interest
The authors declare no potential conflicts of interest.