University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA THE USE OF SOCIAL MEDIA AND RISKY SEXUAL BEHAVIOUR AMONG STUDENTS IN THE UNIVERSITY OF GHANA, LEGON CAMPUS BY DERRICK HOLDBROOK (10351648) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH JULY, 2019 i University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Derrick Holdbrook declare that apart from other researchers’ works, which have been duly acknowledged by means of referencing, this work is the result of my own original research. No portion of this work either in whole or in part has not been presented elsewhere. -------------------------------- …………………………….. Derrick Holdbrook Date (Student) ------------------------------------- ………………………….. Prof. Augustine Ankomah Date (Academic Supervisor) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this body of work to Jehovah God and my family who have supported me in diverse wonderful ways to achieve this. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS My profound gratitude goes to the Almighty God for making it possible to go through this programme successfully. My heartfelt thanks goes to Professor Augustine Ankomah for supervising my work. I am grateful and appreciate his advice, essential and fruitful comments, patience, constructive criticisms, and guidance throughout my research period. To my Head of Department and Mentor, Professor Kwasi Torpey, I say a big thank you for instilling in me a sense of discipline and timeliness, which I will use in further life pursuits. I owe a special gratitude to Professor Richard Adanu, for seeing not just a young man who needed support and guidance but inspiring and encouraging a young man to pursue higher education. Without him, none of this would be possible. I would forever be grateful. To the Director, Post Graduate Training of the WHO HRP Alliance Hub, Dr Adom Manu, I say a big thank you for taking the time to proofread my work and providing me with useful tips. Dr Emefa Modey, Mr Philip Govule (PhD), Ms. Afua Atuobi-Yeboah and my colleagues and friends at work, thank you all for being instrumental in the achievement of this dream, may the Almighty God shower His blessings upon you. Also to my loving Mother, Ms. Felicity Yamuah and Sister Yvette Holdbrook. I say a big thank you, for your ceaseless prayers, support and encouragement. To all my Programme mates, Research Assistants and friends, I say a big thank you to all of you for being there with your assistance and encouragement. Last but not the least, a big thank you to all individuals who contributed in one way or the other to make this work a possibility. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: Behaviours established during youthful and early adult life such as risky sexual behaviours (RSBs) have undesirable effects on the future wellbeing and overall health of adolescents and young adults. Engaging in risky sexual behaviours such as early sexual initiation, multiple partner sexual relationships, unprotected sex, and sex in exchange of money or gifts often lead to undesirable consequences such as contracting sexually transmitted diseases or having unintended pregnancies. Social media use in recent times has evolved to become an integral part of the lives of the youth. It has been found to influence the sexual behaviour of youth in developed countries. To better understand the risky sexual behaviour of youth in Ghana, it is imperative to explore the relationship between social media use and risky sexual behaviour in order to develop programs and initiatives aimed at mitigating this problem and its associated consequences among the youth of Ghana. Objectives: The purpose of this study was to provide information on social media use among students of the University of Ghana and correlates with risky sexual behaviour. Method: This was a cross-sectional analytical study among 422 university students between the ages of 15 and 29 years selected from Hostels within the University of Ghana using the multistage cluster sampling method. A structured self-administered questionnaire adapted from validated questionnaires from previous studies was used as a tool in the study. A univariate analysis was performed on relevant variables and bivariate analysis also performed on the main outcome variables of interest to determine associations between the dependent variable (Sexual behaviour) with the independent variable (social media use) controlling for potential confounders. Results: Of all students sampled in this study, almost all (98.8%) owned a smart device capable of accessing social media. More than half of students engage in high use of social media. Of all iv University of Ghana http://ugspace.ug.edu.gh social media users, the top five applications used were WhatsApp (406/422, 96.2%), Instagram (334/422, 79.1%), Facebook (298/422, 70.6%), Snapchat (285/422, 67.5%) and Twitter (256/422, 60.7%). While Tinder was only used by 20% of participants, it was noted to expose students to sexually explicit media. The results also show that 33.4% of students were involved in risky sexual behaviour with males, twice as likely to engage in risky sexual behaviour compared to females (AOR: 1.9; CI 1.13.1). This study also showed a higher affinity of students aged 2529 years towards engaging in risky sexual behaviour (AOR: 8.3; CI 1.642.5). Students embedded in the use of relatively new social media applications such as Tinder (AOR: 6.0; CI 1.425.9) and students engaged in sexting (AOR: 4.4; CI 2.6- 7.5) were more likely to engage in risky sexual behaviour. Those who either posted or received videos on social media and those who use social media to meet the opposite sex were likely to be exposed to risky sexual behaviour than those who do not. Parental guidance of fathers was found protective of risky sexual behaviour (AOR: 1.9; CI 1.0 3.6). Conclusion: Sex of students and age had an association with risky sexual behaviour among university of Ghana students with male students being twice more likely to be involved in RSB compared to their female counterparts. Parental involvement was indicative of reduced risky sexual behaviour. Keywords: Risky sexual behaviour, Social media, Sexually explicit materials v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION............................................................................................................................ i DEDICATION............................................................................................................................... ii ACKNOWLEDGEMENTS ........................................................................................................ iii ABSTRACT .................................................................................................................................. iv TABLE OF CONTENTS ............................................................................................................ vi LIST OF TABLES ....................................................................................................................... ix LIST OF FIGURES ...................................................................................................................... x DEFINITION OF TERMS......................................................................................................... xii CHAPTER ONE ........................................................................................................................... 1 INTRODUCTION......................................................................................................................... 1 1.0 Background of study ............................................................................................................. 1 1.1. Problem statement ................................................................................................................ 3 1.2. Justification .......................................................................................................................... 6 1.3 Conceptual framework .......................................................................................................... 7 1.4 Objectives .............................................................................................................................. 8 1.4.1 General Objective: .......................................................................................................... 8 1.4.2 Specific Objectives ......................................................................................................... 8 CHAPTER TWO .......................................................................................................................... 9 LITERATURE REVIEW ............................................................................................................ 9 2.0 Introduction ........................................................................................................................... 9 2.1. Young and young adulthood period ..................................................................................... 9 2.2. Description of social media ................................................................................................ 11 2.2.1 Social network sites and how young adults use them .................................................. 11 2.2.2. Social media and risky sexual behaviour .................................................................... 12 2.3 Risky sexual behaviour ....................................................................................................... 13 2.3.1 Multiple sexual partners ............................................................................................... 14 2.3.2 Cross-generational sex .................................................................................................. 14 2.3.3 Condom use at last sexual intercourse .......................................................................... 15 2.4 Socio-demographic characteristics and risky sexual behaviour .......................................... 15 2.4.1 Gender and risky sexual behaviour .............................................................................. 15 2.4.2 Age at sexual debut ....................................................................................................... 17 vi University of Ghana http://ugspace.ug.edu.gh 2.4.3 Ethnicity and RSB ........................................................................................................ 17 2.4.4 Marital status and RSB ................................................................................................. 18 CHAPTER THREE .................................................................................................................... 20 METHODOLOGY ..................................................................................................................... 20 3.1 Study Design ....................................................................................................................... 20 3.2 Study Site ............................................................................................................................ 20 3.3 Study Population ................................................................................................................. 20 3.3.1 Inclusion Criteria .......................................................................................................... 20 3.3.2 Exclusion Criteria ......................................................................................................... 21 3.4 Study variables .................................................................................................................... 21 3.4.1 Dependent Variable ...................................................................................................... 21 3.4.2 Independent Variables .................................................................................................. 22 3.5 Sample Size Calculation...................................................................................................... 24 3.6 Sampling Technique ............................................................................................................ 24 3.7 Training of research assistants ............................................................................................ 25 3.10. Ethical Considerations...................................................................................................... 27 3.11. Funding............................................................................................................................. 28 3.12. Quality Control ................................................................................................................. 28 3.13. Dissemination of study information ................................................................................. 28 CHAPTER FOUR ....................................................................................................................... 29 RESULTS .................................................................................................................................... 29 4.0 Introduction ......................................................................................................................... 29 4.1 Background characteristics of students ............................................................................... 29 4.2 Accessibility and usage of major social media platforms among study participants .......... 31 4.3 Level of social media use .................................................................................................... 32 4.4 Perception of sexually explicit materials on social media .................................................. 32 4.5 Sexual behaviour among University of Ghana students ..................................................... 33 4.6 Risky sexual behaviour among students ............................................................................. 35 4.7 Association between key socio-demographic characteristics and risky sexual behaviour . 35 4.8 Association between social media activity of students and risky sexual behaviour ........... 38 4.9. Bivariate association between viewing sexually explicit material and risky sexual behaviour ................................................................................................................................... 39 vii University of Ghana http://ugspace.ug.edu.gh 4.10. Multiple logistic regression of risky sexual behaviour and selected independent variables ................................................................................................................................................... 41 CHAPTER FIVE ........................................................................................................................ 43 DISCUSSION .............................................................................................................................. 43 5.1 Discussion of findings ......................................................................................................... 43 5.2 Level of social media use .................................................................................................... 44 5.3 Social media use and sexually explicit media ..................................................................... 45 5.4 Proportion of students engaging in risky sexual behaviours ............................................... 46 5.5 Association between social media use and risky sexual behaviour .................................... 47 5.6 Limitations of the study....................................................................................................... 48 CHAPTER SIX ........................................................................................................................... 49 CONCLUSION AND RECOMMENDATIONS ...................................................................... 49 6.1 Conclusion ........................................................................................................................... 49 6.1 Recommendations ............................................................................................................... 49 REFERENCES ............................................................................................................................ 50 APPENDICES ............................................................................................................................. 58 Appendix A: Participant information sheet ............................................................................... 58 Appendix B: Consent Form....................................................................................................... 61 Appendix C: Questionnaire ....................................................................................................... 62 Appendix D: Ethical clearance .................................................................................................. 69 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4.1: Sociodemographic characteristics of study participants .............................................. 30 Table 4.2: Accessibility and usage of major social media platforms among study participants .. 31 Table 4.3 Risky sexual behaviour among University of Ghana students ..................................... 34 Table 4.4: Association between socio-demographic characteristics and risky sexual behaviour. 37 Table 4.5: Association between social media activity of students and risky sexual behaviour .... 38 Table 4.6: Association between sexual social media content and risky sexual behaviour ........... 40 Table 4.7: Simple (crude) and adjusted multivariate regression model summary ........................ 42 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1.1: Framework for factors associated with risky sexual behaviour among youth ............. 7 Fig 4.1: Level of social media use among study participants ....................................................... 32 Fig 4.2: Perception towards sexually explicit materials on social media ..................................... 33 Fig 4.3: Prevalence of RSB among students ................................................................................. 35 x University of Ghana http://ugspace.ug.edu.gh LIST OF ACRONYMS AIDS Acquired Immunodeficiency Syndrome CBT Cognitive Behavioural Therapy GDHS Ghana Demographic and Health Survey GHS Ghana Health Service GSN Geosocial Networking GSS Ghana Statistical Service HIV Human Immunodeficiency Virus IBFT Integrated Behavioural and Family Therapy RSB Risky Sexual Behaviours SEMs Sexually Explicit Materials SNS Social Networking Sites STDs Sexually Transmitted Diseases STIs Sexually Transmitted Infections WHO World Health Organization SM Social media xi University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS University students For the purposes of this study, this refers to adolescents, young adults and late adults between the ages of 15 to 29 years Social media use For the purpose of this study, this refers to a composite variable formed from ownership of a smart device, the number of social media applications used and frequency of use Risky sexual behaviour This is a composite variable derived from (Ever had sexual intercourse, condom during last sexual intercourse, multiple sexual partners in last 6 months, casual sex, sex with a person 10 years older or more, sex for cash/gifts, you or one of your partners ever been pregnant) Regular students Students of the university who are enrolled in the normal university calendar and take classes on the Legon campus. Social media Defined as a site or digital platform that facilitates text- messaging, blogging, Video sites, forums, wikis, social networks and more and allows one to engage both local and global communities with the click of a button WhatsApp An application which incorporates the use of internet/data to make communication and the distribution of multimedia messaging more easily and faster via smartphones, laptops. The WhatsApp application is a messenger and voice platform which is extremely interactive in nature. It can be used multi purposefully for making and receiving phone calls both internationally and locally with internet (Wi-Fi). This connection at relatively low cost when compared to normal phone calls and messaging services. Instagram Instagram is a mobile phone photo-sharing, video-sharing social networking site that provides its users the ability to take pictures and videos then share them to an online, to other platforms Twitter Twitter is a free social networking tool that allows people to share information, in a real-time follow and read news feed and post brief comments about their experiences and thoughts. Snapchat Snapchat is a mobile app and service for sharing photos, videos, and messages with other people. It can also be used to send quick text messages that disappear once the recipient reads them xii University of Ghana http://ugspace.ug.edu.gh Facebook Facebook is a popular free social networking website that allows registered users to create profiles, upload photos and video, send messages and keep in touch with friends, family and colleague Tinder Tinder is a location-based social search mobile app most often used as a dating site. It allows users to like (swipe right) or dislike (swipe left) other users and allows users to chat if both parties like each other (a "match") Grindr Is a social networking and online dating application geared towards gay, bisexual, transgender, and queer people. Sexting Sexting is defined as “sending, receiving, or forwarding sexually explicit messages, pictures (nude or seminude) or videos via cell phone, computer, or other digital devices Sexually explicit materials Sexually explicit materials refer to content depicting sexual behaviour in the form of nudity, pornography, flirting. The sexual behaviour involved may be explicit, implicit sexual behaviour such as flirting, Web 2.0 Second stage of development of the internet characterized especially by the change from static web pages to dynamic or user-generated content and the growth of social media. xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background of study Behaviours established during youthful and early adult life, including risky sexual behaviours (RSBs) have undesirable effects on impending health and well-being (Asrese & Mekonnen, 2018). Young people experience varying desires during different stages of their development into adulthood (Manu, 2011). This largely youthful time, entails identity formation as a norm, seeking and establishing relationships with persons other than the immediate family, trying to understand and experience their sexuality while, preparing themselves for their professional lives amidst vulnerabilities to biological and socio-cultural problem (Asrese & Mekonnen, 2018). Engagement in RSB is common during the youth time has gained prominence as a public health concern. Risky sexual behaviour is described as an activity that places one at risk of one or more sexually transmitted diseases as well as one or more unintended pregnancies (Mensch, 2007). These are often influenced by several factors; contribute in different ways to moulding one’s sexual behaviour. Significant proportions of the youth in sub-Saharan Africa (SSA), engage in RSBs such as early initiation of sexual intercourse, engaging in sexual relationships with multiple partners, having unsafe sex, and having transactional sex for cash or gifts. Available evidence indicates that in their formative years, young people pick up behaviours relating to sex predominantly from their network of friends, the environment within which they grow up, and their personal perception of acceptable behaviour (Bingenheimer & Asante, 2015). The impact of social networks on young people is significant. Social networks have increasingly become part of people’s lives. In order to better understand the risky behaviour of young people, we must first, understand the social contexts which shape sexual behaviour among young people 1 University of Ghana http://ugspace.ug.edu.gh (Akram & Kumar, 2018). Research conducted over the years suggests that sexual activity among young people can be greatly accelerated by viewing sexual content on television, in movies and magazines, and from music. Extant research, further adds that in recent years, social media, i.e. the internet and geosocial networking (GSN) applications have been cited as new avenues for meeting sexual partners (Shapiro et al., 2017). Furthermore, it is hypothesized that social media networks tend to influence the sexual behaviour of its users by exposing them regularly to sexually explicit materials as well as providing information about specific sexual behaviours (Akram & Kumar, 2018). These new social platforms show current ways through, which people communicate with one another positively or negatively. Sociologists have often asked whether there might be long-term effects of replacing face-to-face interaction with social media (Akram & Kumar, 2018) Social media (SM) or the participative internet is defined as “a wide range of internet-based communications, tools, and aids offering easy, cost-effective access to large numbers of people across geographic distances” (Calhoun & Friel, 2013). In the current media landscape, SM has taken on a very conspicuous role with its evolution stemming from a mainstream information channel and growing into an online platform through which people organize their lives. Media can be broadly classified into “old media” and “new media”. The traditional old media includes radio, newspapers and television, whereas new media refers to the term used in the 21st-century to describe the internet and its correlation with technology, images, and sound (Abdullahi & Abdulquadri, 2018). These new media applications can be accessed by use of smartphone devices and gadgets and include “WhatsApp, Facebook, Twitter, LinkedIn, Instagram, blogs, YouTube, Snapchat, and Tinder” (Lindsay, 2011). Globally, there are over 2.77 billion users of SM, an increment of 0.31 billion from 2.46 billion in 2017 (Bingenheimer & Asante, 2015). Social media constitute 64% of all internet users, with a 2 University of Ghana http://ugspace.ug.edu.gh clear market leader, Facebook, having 1.59 billion active users alone and other popular platforms such as Instagram and WhatsApp having more than 900 million active users in 2012 and 2014 (Nato, 2016) respectively. The youth form a distinct population of social network subscribers since they have a specific desire for exploring new exciting information through communication technologies. With the flexibility and versatility of social media serving as a channel of direct communication among youth, they are able to extensively share information at unexpectedly high rates (Lilley, Grodzinsky, & Gumbus, 2012). University students are among those considered to be high-level users of social network sites (SNS) (Rachakonda, 2016; Guse et al., 2012). Technological diffusion, which is the advancement of technological innovation from one country to the next has led to the technological globalization we see now (Mcgivern, Currie, Ferlie, & Fitzgerald, 2015). The increased technological advancement in low-and middle-income countries (LMICs) has been documented and both positive and negative consequence results from the utilization of technology, and in particular, social media (World Bank, 2008). Though there are marked infrastructural challenges with poor roads, no or limited electricity supply, poorly equipped health facilities, and schools in these countries, the access to telephones in the last decade, has instead, increased remarkably with a fivefold increase in access to mobile phones. Now, it is estimated that about one-third of the population in SSA have access to mobile phones, either owned or shared (Deloitte & Groupe Speciale Mobile Association, 2012). 1.2. Problem statement Over the past few years, the proportion of young people accessing SM platforms has been noted to have drastically increased. On a global scale, over 3 billion individuals log on to SM monthly, 3 University of Ghana http://ugspace.ug.edu.gh with 9 out of every 10 using mobile devices (Simon Kemp, 2018). Brown’s Media Practice Model of how young people select a preferred social networking site suggests that they choose and react to sexual media content that speak to an emerging sense of themselves as sexual human beings. It is clear that SM may have a huge impact on adolescents sexual well-being (Brown, 2000; Cookingham & Ryan, 2015). Risky sexual behaviours have been associated with young people for a long time. Students, aged 18-24 years are progressively considered to be in the developmental stages of emerging adulthood and this period is made more complex by the additional freedom of being in college and the university setting, where adult supervision is almost nonexistent. During this stage, young people encounter opportunities to manage their sexuality and growth as individuals (Benson & Furstenberg, 2019; Bartzanas & Kittas, 2014; Claxton & Dulmen, 2013; Furstenberg, 2005). Unfortunately, these extra opportunities have oftentimes been associated with drug and alcohol use, sexual violence, STIs, and unintended pregnancies (Scholly, Katz, & Holck, 2005). Undoubtedly, this has earned the youth the characteristic of being hard to reach, especially, in the area of health promotion and disease prevention (Lilley et al., 2012). A growing body of knowledge has demonstrated that sexual initiation at younger age has been associated with unintended adolescent pregnancy, risk of contracting STIs, including HIV/AIDS and associated risk behaviours later in life, including having multiple sexual partners and negative attitudes towards condom use (Sopheab, Fylkesnes, Lim, & Godwin, 2008). Sexually transmitted diseases (STDs) constitute a serious public health concern worldwide and are a major cause of illness, infertility, disability and death with STDs, responsible for 17% of economic losses in LMIC (Mesenburg, Muniz, & Silveira, 2014). 4 University of Ghana http://ugspace.ug.edu.gh In Ghana, the proportion of condom use at first sexual intercourse among 15-19-year-olds are 25.9% and 31.4% for female and male (GSS, GHS, & ICF International, 2014) respectively. Regardless, females are more vulnerable and burdened by unintended pregnancy. Women aged 18-24 years have been found to have the highest rates of unintended pregnancies. These staggering facts indicate that the youth are generally at risk of mental, social problems, and other multitude of risks since their emotional development may not match their physical maturation (Krebs, Lindquist, Warner, Fisher, & Martin, 2009). Regrettably, as youth indulge in more sexual activities with multiple partners, the protective aspects are neglected. Whereas various findings in literature have demonstrated how SM has negatively influenced teenagers and young adults’ sexual behaviours in the developed world (Landry, Turner, Vyas, & Wood, 2017; Asrese & Mekonnen, 2018), less research has ventured into establishing whether an association exists between use of social media and RSB among young people aged 15 to 24 years in LMIC. In. Ghana, few studies have tried to explain how the youth interpret the sexual content and messages within the various SM channels and how these interpretations impact their decisions to indulge in RSB. Failure to understand this, therefore, means that we risk missing out on important information that could be utilized in designing and implementing targeted measures aimed at improving the age of sexual debut, incidence of casual sex without condoms, multiple sex partners etc. Besides, it would also mean missing out on understanding how university students utilize social media from a sexual and reproductive health point of view. It is assumed that sexual content on SM could trigger various responses, which could either be positive or negative. Negative influences would call for practising or experimenting what has been viewed and hence lead to RSB. While positive interpretation of sexual content portrayed in the various social media would 5 University of Ghana http://ugspace.ug.edu.gh mean that the teenager delays indulging in RSB. However, all these are relatively unknown in the Ghanaian context. 1.3. Justification Ghana, like most LMICs, currently faces a problem of low condom use among university students. A recent study by Sakeah (2017), revealed that among sexually active students in the University of Ghana, there was moderate intention to use condoms in their sexual encounters with only 46% using condoms during sexual encounters. This rather alarming statistic may be associated with an increase in cases of unintended pregnancies and risk of STI’s/HIV (Sakeah, 2017). It is suggested that social media use by young people stems from identity development, moral and physical growth and emerging sexuality. This fosters a need to stay connected to their own peers, behave and act in a manner that is deemed trendy, fashionable or acceptable at the same time exposing users to sexually explicit media (Abdullahi & Abdulquadri, 2018). Determinants of RSB are numerous and have been studied extensively worldwide. The relationship existing between sexual practices and the acquisition of STD’s has been well-documented globally, with several studies showing an association between STDs and risky sexual behaviours, such as multiple sex partners, early sexual initiation and sex practices without condoms (Mesenburg et al., 2014; Center for Disease Control, 2007). However, the influence of SM on RSB has not been studied widely in the Ghanaian setting. This, therefore, makes this study quite relevant. Information on sexual behaviour is important in designing, implementing and monitoring appropriate interventions to control and manage the spread of HIV and other STDs in our setting 6 University of Ghana http://ugspace.ug.edu.gh (GSS et al., 2014). This study would further add and re-orient already existing information on the association that exists between social media patronage and sexual practices. 1.4 Conceptual framework INDEPENDENT VARIABLE DEPENDENT VARIABLE SOCIAL MEDIA USE RISKY SEXUAL C ontent – Content BEHAVIOURS – F requency – Condom use at last – Sexually Explicit sex M aterials – Sex for cash/gift – Sexting – Cross generational sex – Multiple sex partners P latform – Casual sex – Whatsapp – Facebook – Instagram – Snapchat – Twitter – Tinder Socio-Demographics – Age – Sex Interpretation – Religion – Arousal – GPA – Disgust – Education – E ducative – Employment – Informative – Parental involvement Source: Adapted from (Kirby, Ph, Laris, & Rolleri, 2007; Jaccard, Dittus, & Gordon, 1998; Odimegwu, 2018; Gardner & Steinberg, 2005). Figure 1.1: Conceptual Framework for factors associated with risky sexual behaviour among youth 7 University of Ghana http://ugspace.ug.edu.gh The conceptual framework illustrates the complexity of the factors that influence RSB in young adults. Studies indicate that social media, education, parental control and connectedness, demographics and socioeconomic status, all have some influence on RSB in young adults (Kirby, Ph, Laris, & Rolleri, 2007; Jaccard, Dittus, & Gordon, 1998; Odimegwu, 2018; Gardner & Steinberg, 2005). Research has proven that an important measure of sexual activity is the timing of initiation of sex. Information communication technology (ICT)on which social media heavily relies has been noted to hasten or delay sex in young people. This is a result of content to which they are exposed. A combination of positive and negative media (sexually explicit material) pervade our media platforms oftentimes unsupervised/ regulated. Every day, new social media are developed to teach one seeking an upper hand over the other. These provide access to videos, pictures, audio, messaging services etc. with ease and at little or no cost. Interpretation of these content by young people in their developmental years of emerging sexuality might lead to arousal, information, education or disgust which can lead to practicing RSB. 1.5 Objectives 1.5.1 General Objective: The general objective of this study is to assess the association between social media use and risky sexual behaviour among students of the University of Ghana. 1.4.2 Specific Objectives 1) To assess the level of social media use among University of Ghana students. 2) To determine the proportion of students who engage in risky sexual behaviour 3) To examine the relationship between social media use and risky sexual behaviour 8 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction In this chapter, the literature examines risky sexual behaviours (RSBs), use of social media (SM) and related factors. This includes the definition and description of key concepts, relating these to relevant health promotion and theories guiding an understanding of the subject. The literature review is organized by describing the key concepts, followed by relevant literature on the theoretical framework and study objectives. 2.2. Young and young adulthood period In 2012, about 3.5 billion young people, 30 years and below (classified as young people and young adults) formed a high per cent (50.2%) of global population (UNICEF, 2011). This is, however, expected to further increase in the coming years with a greater number in developing countries (UNICEF, 2011). The WHO defines young people as the period in human life that arises between childhood and adulthood, 15 to 24 years and young adults as persons ranging in age from their late teens or early twenties to their thirties (WHO, 2011). In the lives of most growing individuals, the youthful stage is notably one of excitement and exploration in many areas of life. These include the home, family, school, work and community. Marked by a continuous change in physical, cognitive and social wellbeing, and sexual identity. This integrates a personal sense of manliness or femininity in one’s identity, creating norms about sexual behaviour and skills development for romantic relations (O’Keeffe & Clarke-Pearson, 2011). Generally, sexuality is defined as “a central aspect of being human throughout life encompassing sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. 9 University of Ghana http://ugspace.ug.edu.gh It is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships” (WHO, 2011). While sexuality can include all of these aspects, not all of them are always experienced or expressed. Sexuality is influenced by a blend of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors (WHO, 2011). Sexuality, sexual relationships and sexual behaviour are important and a necessary part of human development. Responsible sexual behaviour, e.g. choosing caring and respectful partners, delaying initiation of sexual intercourse, increasing the use of condoms, and using effective contraception, is an important public health concern (WHO, 2011). Since young people are at an age of experimentation, this becomes an issue as they encounter several pressures from society, peers and the media, especially, in this age where the world has become a global village. The young stage is also thought to be related to a person’s ability to think abstractly and hypothetically, thereby leading to decisions about life, health and one’s sexuality that are made regardless of the positive or negative consequences it may bring or opinions of others. The decision to get involved in sexual behaviour has been shown to have a relation with various factors (Martin- Yeboah, 2012). Some of the factors include peer influence through existing networks. With the rise of digital and mobile technologies, interaction on a large scale has even become easier for individuals than ever before; and as such, a new media age has been born where interactivity is placed at the center of new media functions (Harvey, 2014). The rapid dissemination of information given today’s world has necessitated investigations from scholars in different fields of study into popular SM platforms such as WhatsApp, Twitter and Facebook and the challenges they pose for society in general, interpersonal relations, psychological well-being and politics. 10 University of Ghana http://ugspace.ug.edu.gh 2.3. Description of social media Social media is usually used to denote all current forms of media that involve interactive participation (Villi & Matikainen, 2016). It requires a form of digital platform for use and can be mobile or stationary in nature. Extant literature defines it as a widespread tool that requires online connectivity to communicate and share information. It facilitates online sharing, publication and endorsement of media content such as videos, pictures, blogs etc. by users, and their online network (Whitaker, Stevelink, & Fear, 2017). Access to this new form of media requires web- based technologies either on a desktop, laptop or digital device that offers SM function as part of its mobile services. Evidence from research portrays a number (22%) of teenagers use SM sites more frequently as compared to other adolescents (Common Sense Media, 2011). Globally, most (75%) teenagers own cell phones and use social media for texting and messaging (Dilci & Eranıl, 2018). Thus, a greater portion of these teenagers’ emotional and social growth occurs whilst engaged in SM. In 2014, the Ghana Statistical Service reported an increase in mobile phone use in Ghana has been noted from 57% in 2008 to 85% in 2014. Surprisingly, more of this increase in mobile phone ownership has been noted in rural households, from 37% to 76% (GSS et al., 2014). 2.3.1 Social network sites and how young adults use them Social media sites allow young people to accomplish online, many of the tasks that are important to them offline; staying connected with friends and family, making new friends, sharing pictures, and exchanging ideas. Social media participation also can offer young people deeper benefits that extend into their view of self, community, and the world (Boyd & Ellison, 2007; Juszczyk, 2015). This includes opportunities for community engagement through raising money for charity and 11 University of Ghana http://ugspace.ug.edu.gh volunteering for local events, including political and philanthropic events and fostering one’s individual identity and unique social skills (Boyd & Ellison, 2007; Juszczyk, 2015). When young people join Facebook, a personal profile is created. This profile shows details as name, personal interests, religion, photographs, connection status, and occupation (Chinn, 2014; Ellison, 2007). This enables connection from friends and other users thus, permitting users to view profiles navigating a wider social network. Profiles, friends and navigating of friend lists form the crust of SNS. 2.3.2. Social media and risky sexual behaviour In a study, aimed at assessing the association between sexual behaviour and SM in Mecha and Bahir, Dar of North-Western Ethiopia, the authors found that social networks predicted RSB more than an individual’s attributes alone (13%). Also, young people belonging to social networks, which approve sexual practices can be predictive of risky sexual behaviour. This, however, is dependent on the nature of the social networks and an increase in network size of sexual issue discussions (Asrese & Mekonnen, 2018). Over the past two decades, SM has gained so much growth and fame worldwide to an extent that many researchers are now interested in learning more about these social platforms and their effects on the community (Lemoine, Hackett, & Richardson, 2016). The use of social media, therefore, has both negative and positive impacts on our youth today. The second millennium, in which we are, brings with it a merging of two eminent forces, old and new. The old called by many names; Eros, romance, sexuality is arguably the oldest. The new known as the Information Age is driven by computers is allied into one World Wide Web (known as the www or internet). It is estimated that nine million people log on daily and growth rates are 12 University of Ghana http://ugspace.ug.edu.gh also estimated to be 25% every three months. Computers and the internet are claimed to be the defining stimuli of the coming millennium (Wang et al., 2018). A study by Schnarch (2015), revealed that social media affords one the opportunity to pursue online relationships without revealing much about themselves. It affords people the luxury of putting up a façade without the truth of one’s identity being known. This is increasingly becoming a popular means of dating, especially, in this current generation of ‘’techie’’ individuals (Schnarch, 2015). 2.4 Risky sexual behaviour Risky sexual behaviour is commonly defined as any activity that increases one’s risk of acquiring sexually transmitted infections and experiencing unintended pregnancies (Epsteina, et al, 2008). They include having sex at an early age, having multiple sexual partners, having sex while under the influence of alcohol, or drugs, and unprotected sexual behaviours (Center for Disease Control, 2007). A study highlighted that adolescents, who abuse substances, are more likely to engage in RSB and stand a higher chance of contracting HIV/AIDS (WHO/UNAIDS, 2005). Another study by Wafula and Kaseje (2017), in Kenya, reported that 22% of adolescents, who had ever had sex, had their first sexual encounter between ages 14 and 16. Also, while a greater proportion of males (69%) and females (72%) used contraceptives during their first sexual encounter, contraceptive use had dropped to 52%. Factors accounting for these were familiarity among adolescents and young adults who had one sexual partner. Other factors such as alcohol consumption and substance abuse were cited as contributors (Wafula & Kaseje, 2017). Currently, the universe is home to 1.8 billion young people aged 10 to 24 years (UNFPA, 2000) Young people aged 10-24 years constitute 25% of the population in developing countries (Sawyer et al., 2012). There are 5.5 million adolescents (10-19 years) in Ghana constituting 22% of the 13 University of Ghana http://ugspace.ug.edu.gh total population (GSS et al., 2014). Surveys conducted on minority youth suggest that sexual activity is initiated at an early age, protective measures such as condoms are not consistently used, and that use of protective measures may decline with age (Hannah-Lise, Schofield, Heinrichs, & Nix, 2012). The youth living in poverty have also been found particularly at great risk with regards to their high rates of sexually transmitted diseases and adolescent pregnancies. In the absence of effective medical interventions, educational programmes designed to delay the onset of sexual contact, and to encourage the use of condoms when contact occurs, are needed to protect young people from exposure to HIV and other sexually transmitted diseases. 2.4.1 Multiple sexual partners According to Epstein and colleagues (2014), adolescents are more likely than adults to report having had multiple sexual partners in the recent past (Epstein, Bailey, Manhart, Hill, & Hawkins, 2014). Adolescent males are more likely than adolescent females to report multiple sexual partners and multiple concurrent partners (Ritchwood, Ford, DeCoster, Lochman, & Sutton, 2015) The number of lifetime sexual partners among adolescents is strongly related to the length of time since the first partner (Adebanji, 2008). 2.4.2 Cross-generational sex This refers to relationships between older men and younger women, even though some cross- generation relationships include older women and younger men. In the first type of relationship, young women are usually below age 20 years and their male partners at least 10 years older. Gregson and his colleagues argued that the risk of infection with HIV increases with the age of a partner (Gregson et al., 2002). On the other hand, Epstein and colleagues observed that gender, age and economic disparities increase risky sexual behaviour and reduce a young woman’s ability 14 University of Ghana http://ugspace.ug.edu.gh to negotiate safer sexual behaviours (Epstein et al., 2014). Research has shown that girls who become pregnant or present with induced abortions have much older partners on average (Kurz, 2002). 2.4.3 Condom use at last sexual intercourse Condoms remain an effective way to prevent contraction of STIs and prevent unintended pregnancies. In spite of the protective benefits associated with the use of condoms during sexual intercourse, it is not highly patronized amongst sexually active individuals (Shafii, Stovel, & Holmes, 2007). In a study conducted by Exavery and colleagues (2011), in Tanzania, found that the prevalence of condom use at the last sexual intercourse among the sexually active respondents between the ages of 10-19 years ranged from 14% to 56%, with an overall prevalence of 39% (Exavery et al., 2011). Also, results from the 2003 Ghana Demographic and Health Survey revealed that 89.9% of women aged 15 years and above in the rural area and 84.8% of women aged 15 years and above in the urban area reported not using a condom during last sexual intercourse (Baiden, Rajulton, Baiden, & Rajulton, 2012). Furthermore, in a study conducted in Ghana among sexually active youth (aged 15–19 years), only 28% reported using condoms the first time they had sex and 30% reported using condoms during their last sexual intercourse (GSS et al., 2014). 2.5 Socio-demographic characteristics and risky sexual behaviour 2.5.1 Gender and risky sexual behaviour A cross-sectional gender-based study by Mahdavian & Zolala (2016), showed that attaining a higher educational level increased the risk of negative sexual behaviour in boys. Whilst boys who 15 University of Ghana http://ugspace.ug.edu.gh have a mother at home without work were discovered to reengage less in risky sexual behaviour (Alimoradi, Kariman, Simbar, & Ahmadi, 2017; Tarkang, Pencille, Dadah, Nzegge, & Komesuor, 2018). In girls, having permissive or authoritarian parents was found to increase the risk of sexual behaviours. The same study also indicates, both boys and girls were more likely to engage in sexual behaviours when they involved in leisure activities (Alimoradi et al., 2017; Tarkang et al., 2018). Research into the gender differences in relation to RSB among adolescents in Catalonia found more prevalence among boys than girls. The study revealed a significantly higher number of students had one-time sexual relations 82% of boys and 63% of girl (Wendy & Cohan, Lorena, Naudeau, Sophie, McGinnis, 2008). Factors related to unsafe sexual activity in boys were noted to be foreign origin and alcohol consumption. Among girls, only foreign origin was a significant risk factor Alcohol consumption was also a risk factor in boys (Wendy & Cohan, Lorena, Naudeau, Sophie, McGinnis, 2008). Evidence from a study in Spain by Gil-Lacruz (2016), on gender and risky sexual behaviour, found condom use and alcohol consumption to be linked to risky sexual behaviour among the male youth. Other factors linked to RSB were being in relationships and number of sexual partners an individual had (Gil-Lacruz, 2016). Letamo (2011), sought to show the association between gender role attitudes and risky sexual behaviour to support the assertion that moderate gender roles are linked to safer sexual practices. The data showed traditional gender role attitudes were not significantly associated with risky sexual behaviour of non-use of condoms and engagement in multiple sexual relationships. This suggests that there was no significant difference between people who hold traditional and egalitarian gender roles (Letamo, 2011). Gender differences have been particularly reported to show males indicating more positive consequences as opposed to females following their most recent sexual experience. Other factors associated with this finding are the 16 University of Ghana http://ugspace.ug.edu.gh theory of sexual double standards, men’s likelihood of experiencing orgasm and the nature of the relationship with a sexual partner (Vasilenko, Sara, Eva Lefkowitz, 2008) 2.5.2 Age at sexual debut Sexual activities among youth have been reported to be on the increase worldwide. During the transition from childhood to adulthood, youth establish patterns of behaviour and make lifestyle choices that could affect both their current and future health (El Achhab et al., 2016). Most youth throughout the world engage in sexual intercourse by age 20, whether married or unmarried (UNFPA, 2016). The youth are at high danger of risky sexual behaviours and reproductive health problems. However, these problems are not considered health priorities by young people who have lower morbidity, mortality and good knowledge than older and adult age groups (Cale & Lussier, 2016). They have limited access to reproductive health services and risky. Thus, their reproductive health strategies demand a multi-sector and integrated approach for risky and unsafe sexual factors and behaviours (Cooper, Shapiro, & Powers, 2014). In Ghana, the median age for women between 20 and 24 is 18.4 years and for men, it is 20 years. However, some initiate sex as young as 10 years in some societies although earlier ages of onset have been reported (Boislard & Zimmer-gembeck, 2012). The age at which young adults begin sexual activities is of significant public health importance, as it has been found to expose them to potential sexual risky outcomes both in the short and long terms (Sandfort, Orr, Hirsch, & Santelli, 2008). 2.5.3 Ethnicity and RSB A study that looked at the differences in ethnicity and risky sexual behaviour found a strong and consistent effect of ethnicity on sexual behaviour among youth. For instance, in Zimbabwe, ethnic- 17 University of Ghana http://ugspace.ug.edu.gh specific differences in sexual behaviour were reported between the Shona and Ndebele youth. They found that the Shona youth were more likely to be abstinent compared to the Ndebele youth. In addition, the Ndebele youth were found to more likely be engaged in risky sex, though they had used condoms at last sex (Sambisa, Curtis, & Stokes, 2010). The median age at first sexual activity was 16 years for females and 17 years for males and a higher number of males (81%) reported to have had multiple sexual partners compared to females (35%). There is evidence of higher elevated risks of first sex for females among the Hausa and Fulani aged 15–19 years and for males among the Yoruba (Odimegwu & Somefun, 2017). Rashid and Mwale (2016), in their study, reported similar findings in Malawi among the adolescents of the Jando and Nsondo tribes. During their rites of passage, adolescents from the Jando and Nsondo tribes are circumcised, given information on the pleasures of sex and encouraged to experiment with sex. As a result, promiscuity is practiced, increasing the chances of contracting HIV/AIDS, other STIs and teenage pregnancy. On the contrary, sex education is not taught in schools because it is seen to promote experimentation with sex by students (Rashid & Mwale, 2016). 2.5.4 Marital status and RSB A number of studies looking at the association between the family structure and risky sexual behaviour among young people have hypothesized that two parental relationships are protective compared to one parental relationship in a family setting. It elaborates the type of family has some influential factors on sexual risk-taking of the children. Findings show that the quality of parent guardian relationship with their children decreases the odds of risky sexual behaviour by 36% in neither, 65% in one parental presence and 50% in two parental families respectively. It further reports parental control acts as a significant protective factor decreasing the odds of risky sexual 18 University of Ghana http://ugspace.ug.edu.gh behaviour by 41% (Dimbuene & Defo, 2011). Except for girls in single-parent families in which association has been shown with sexuality, family structure has no statistically significant relationship with adolescents' sexual initiation. The study further found mother-child relationships, the level of interaction, and the mothers’ attitudes toward and discussion of sex associated with adolescent sexual debut. Conversely, according to a study by Davis and co-author, neither family structure nor family context was found to have an impact on the sexual partnerships of boys, and they explain little in terms of girl's sexual partnering (Davis & Friel, 2004). Indeed, all these studies show there is a relationship between social media and risky behaviour and negatively influences young adult involvement in RSB. From the relatively limited evidence in sub-Saharan Africa, most importantly, Ghana, it shows information gaps in knowledge on factors contributing to risky sexual behaviour amongst young people most especially the influence of social media. Further research in this area is certainly warranted. 19 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Study Design The study was cross-sectional (quantitative). It was conducted between May-June 2019 among the students of the University of Ghana, Legon. 3.2 Study Site This study was conducted at the University of Ghana (UG), Legon, in the Accra Metropolis. UG is the oldest and largest of the Ghanaian public universities in Ghana, with a student population of over 38,000. It is located within the Ayawaso sub-Metro area. The Legon campus is the main campus among other satellite campuses. The UG operates a Collegiate System made up of five Colleges, each comprising Schools, Departments and Research Institutions/Centres. The UG admits students with diverse backgrounds; religious, demographic, social, cultural, and gender. This study, therefore, provides information on the youth who form the majority of the student population. Currently, there are 15 Halls of residence in the university, which house both local and foreign students from varied backgrounds with social media use as a common unifying factor. 3.3 Study Population The study population was undergraduate students resident on the University of Ghana campus, Legon. 3.3.1 Inclusion Criteria Participants were selected if you are an undergraduate student resident on the main campus of the UG, Legon. 20 University of Ghana http://ugspace.ug.edu.gh 3.3.2 Exclusion Criteria Participants were excluded if you are you are not a ‘regular’ student (full-time student enrolled for the main academic calendar of the University, frequently and daily attended classes on the UG premises, Legon). 3.4 Study variables 3.4.1 Dependent Variable The dependent variable was risky sexual behaviour. It was computed as a composite variable derived from the following eight (8) questions:  Ever had sexual intercourse?  Did you use a condom during your last sexual intercourse?  How many sexual partners have you had in the last 6 months?  Ever engaged in casual sex?  Ever had sex with a person 10 years older or more?  Ever had sex for cash/gifts?  Ever had sexual intercourse under the influence of drugs or alcohol  Have you or one of your partners ever been pregnant? The above questions were originally coded No = 0 and Yes = 1. Condom use during last sexual intercourse was reverse coded as Yes = 0 and No = 1. The extent of use of social media was assessed by daily/weekly/monthly basis. This was combined with ownership of a smart device and number of applications used by a student. The composite variable formed was further classified into three categories: ‘high use’, ‘some use’ and ‘no use’ 21 University of Ghana http://ugspace.ug.edu.gh and adapted from the 2016 American Academy of Paediatrics (AAP) methodology of grading level of use of social networks (Hill et al., 2016) The proportion of students engaged in risky sexual behaviour was assessed using a composite variable (risky sexual behaviour) created to represent this behaviour. From responses to eight key questions. Each question was categorized as Yes (1) and No (0). During the analysis of results, number of sexual partners was recoded as (0,1) = 0 and (2 and above) = 1. The overall score was then summed up and the scale classified into two categories, with 0 to 1 as the least risky sexual behaviour and 2 to 8 as high- risk sexual behaviour. A score of 0 was classified as not engaged in risky sexual behaviours. This is because zero (0) represents the section of students who answered No (0) for all eight questions. A special condition was introduced into the coding for all students who answered ‘Yes’ to the question ‘Ever had sex’ but had used protection during first sexual intercourse. Students who scored between 1 to 8 were said to be engaged in risky sexual behaviour. 3.4.2 Independent Variables Background characteristics measured in the study included socio-demographic information such as sex, age, employment, ethnicity, current Grade Point Average (GPA), level of study and parental involvement (fathers’/mothers’ involvement/control in teen upbringing). Social media use was the independent variable; a composite variable derived from the following three questions:  Own a smartphone or smart device?  Use any of the specific social media apps in question: – 0. WhatsApp – 1. Twitter – 2. Facebook 22 University of Ghana http://ugspace.ug.edu.gh – 3. Instagram – 4. Snapchat – 5. Tinder – 6. Grindr  How often do you use the following social media applications (never, a few times a month, a few times a week, once a week, once a day, to several times a day)? Own a smartphone/device was coded No =0 Yes=1. Use any of the specific social media apps in question were originally scored 1 for each application selected. An assumption was set for all users of WhatsApp application as users of social media several times a day. The WhatsApp application is a messenger and voice platform which is extremely interactive in nature. It can be used multi purposefully for making and receiving phone calls both internationally and locally with internet (Wi-Fi). This connection at relatively low cost when compared to normal phone calls and messaging services. Considering the age bracket of students in the University and the need for constant communication at low-cost, WhatsApp lends itself as the application of choice. Hence, during analysis, all students who used WhatsApp were classified as avid users of social media. On a scale of ‘Never’ to ‘Several times a day’ were coded as Never = 0 to Several times a day = 6 and calculated for the 7 social media applications provided. These 3 levels were then scored a total of 50. This scale was then classified into 3 categories No use = 0-1, Some use = 2 to 36, High use = 37 to 50. 23 University of Ghana http://ugspace.ug.edu.gh 3.5 Sample Size Calculation The formula by Cochrane (1977), was used for calculating sample size: The sample size for the study was given by 𝑍2𝑝𝑞 𝑛 = 𝑒2 Where z = 1.96 The z-value is found in a Z table P = 0.5 p is the (estimated) proportion of the population which has the attribute in question, Q = 0.5 q is 1 – p e = acceptable sample error of (5% was used). It is the desired level of precision (i.e. the margin of error), Following the equation, the total sample size is calculated to be 384. (1.96)2(0.5 ∗ 0.5) = (0.05)2 However, to account for non-response rate to specific sensitive questions, size was increased by approximately 10% to 423. 3.6 Sampling Technique The University of Ghana was purposively selected because data on the lifestyles of University students in Ghana is sparse. A stratified and simple random sampling technique was used in the sampling process. The 15 Halls were grouped into 3 clusters based on their respective locations within the University campus. Four (4) out of 6 Halls were selected from Cluster 1, 3 out of 5 from 24 University of Ghana http://ugspace.ug.edu.gh Cluster 2 and 2 out of 4 from Cluster 3. An equal number of participants (n=47) were selected from each of the 9 Halls to make up the total sample size 423. The total number of students in each Hall were obtained from the Hall authorities including, information on the number of undergraduate rooms in each Hall. An interval, determined by the total number of undergraduate rooms in a Hall was used to randomly select which rooms were used. Once the interval was determined, selection began, selecting randomly at the starting point and then for every nth number, an undergraduate room was selected. Using this random selection until 47 students were selected from each of the selected Halls. In the likelihood of meeting more than one undergraduate student a room, a simple balloting method was used to select one person for interviewing. A self- administered questionnaire was used. 3.7 Training of research assistants A one-day training was organized for the research assistants to guarantee that they understood the research topic and set objectives. The training also ensured they were adequately equipped for the fieldwork. The trainees were trained on the following:  Objectives of the study and the level of sensitivity involved.  Sampling method used.  The need to obtain informed consent  The importance of confidentiality 3.8 Pre-Testing A structured self-administered questionnaire was given to willing participants at the University of Professional Studies (UPSA), in Accra. These questionnaires included general socio-demographic 25 University of Ghana http://ugspace.ug.edu.gh information from the students as well as questions on social media platforms patronized, frequency of use, nature of content and interpretation of content, including questions on RSB. A total of 25 students were randomly selected for this purpose. This was done to test the sampling procedure, reliability of the data collection questionnaire, reaction of the students and the empower assistants for data collection. Appropriate corrections were made after the pretesting was done and the questionnaires readied for use on the UG campus, Legon. 3.9 Data Collection Structured questionnaires were used in data collection. The questionnaire contained mostly closed- ended questions and was organized into three sections namely (A) demographic characteristics (B) risky sexual behaviour (C) social media use. The questionnaire was designed and administered in the English Language. The questionnaires were numbered and distributed to the selected students by the trained research assistants. These were collected later the same day as a follow-up and checked for completeness. 3.10 Data Analysis Data were entered into SPSS software templates which was predesigned and fully coded ready for analysis. Data were imported to STATA version 15.0® for analysis. The results including other outputs from correlation matrices were presented in tables. Descriptive and inferential statistics were used in the analysis. Frequency distribution tables, mean, percentages and cross-tabulations were used to describe the findings in univariate analysis level. A bivariate analysis was conducted using Chi-square to determine associations between the dependent variable (risky sexual behaviour) with the independent variable (social media use). Confidence level of 95% and p < 0.05 26 University of Ghana http://ugspace.ug.edu.gh was used. Spearman’s rank correlation analysis was performed before the regression analysis was completed. To determine the relative importance of factors that influence risky sexual behaviour and social media, a multivariate regression (Logistic regression analysis) was performed. The independent variables included in the analysis were: sociodemographic factors (age, gender, educational level, marital status). Odds ratio and their 95% confidence intervals were used to assess the strength of association. In all analyses, a p-value of 0.05 was used to assess statistical significance. 3.10. Ethical Considerations Ethical clearance was obtained from the Ghana Health Service Ethical Review Committee with ID: GHS-ERC 042/03/19. Hall authorities were then contacted by visiting the Administration office of each Hall, and permission obtained before the start of the study. Informed consent was obtained from all participants. The purpose and voluntary nature of the study was explained to participants. Participants were also informed that they could withdraw at any time if they so desired. While the study posed no physical risk to the participant, they were informed about the sensitive nature of the questions and the discomfort it might cause. Students were assured of confidentiality in this study and also that all questionnaires will be kept under lock and key with no one aside the PI who had access to the data. Students identities remained anonymous by providing unique identifiers for each questionnaire and no personal identifiers would be linked to the data should the work be published. Data was stored on a password-protected laptop and an external hard drive only accessible by the PI. Hard copies were locked in a file cabinet with access limited to the PI. There was no conflict of interest by the researcher. After 5 years the data will be moved to the national data storage center for storage. 27 University of Ghana http://ugspace.ug.edu.gh 3.11. Funding This study was self-funded. 3.12. Quality Control Two well-trained research assistants were used for pre-testing the questionnaires. Training was done for a day to ensure that they were familiar with all questions, set objectives, sensitivity and context of the research. All questionnaires were checked for completeness after each day’s work. Data was adequately cleaned before analysis. 3.13. Dissemination of study information The following groups are headlined for the relay of findings: The School of Public Health Library, University of Ghanaian library. A scientific paper will be written for publication in a reputable journal. 28 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Introduction This chapter presents findings of the study. Descriptive information on socio-demographic characteristics, social media activity and social media content of participants. It also illustrates the proportion of the University of Ghana students who engage in risky sexual behaviour and further shows the results of inferential statistics that explored the relationship between social media use and risky sexual behaviour of participants. 4.2 Background characteristics of students A total of 430 eligible students received questionnaires during the data collection stage and 422 completed questionnaires were received, yielding a response rate of 98.1%. The results are, therefore, based on completed questionnaires obtained from the 422 eligible students. Table 4.1 presents information on the background characteristics of students. Of the total number of participants (N=422), 53.6% were males and 46.4% females. Nearly all the students (97.6%) were young people aged 15 to 24 years, while a few (2.4%) were in their young adult ages, between 25 and 29 years. In reference to parental involvement, about 5 in 10 participants (51.7%) had fathers involved in their lives during teen years, while more than 8 in 10 participants (84.1%) had mothers involved in their teenage upbringing. The predominant ethnic group of students in this study was Akan (54%) and Christianity as the dominant religion (85.5%). Nearly all (96.9%) were never married and only about 9% were gainfully employed. 29 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Socio-demographic characteristics of study participants Variable Frequency Percentage Sex Male 226 53.6 Female 196 46.5 Age group 15-19 160 37.9 20-24 252 59.7 25-29 10 2.4 Religion Christian 361 85.6 Muslim 22 5.2 Others 39 9.2 Others 38 9.0 Level of education level 100 93 22.0 level 200 170 40.3 level 300 97 23.0 level 400 62 14.7 Marital status Never married 409 97.0 Currently/Ever married 13 3.1 Ethnicity Akan 228 54.0 Ga/Adangme 74 17.5 Ewe 68 16.1 Others 52 12.3 Father's involvement Always 218 51.7 Often 70 16.6 Sometimes 62 14.7 Rarely/Never 40 9.5 Mother's involvement Always 355 84.1 Often 34 8.1 Sometimes 16 3.8 Rarely/Never 17 4.0 Employment status No 385 91.2 Yes 37 8.8 Others – refers to Hausa, Guan, Mole-Dagbani, Grusi, Gurma, Mande P<0.05 30 University of Ghana http://ugspace.ug.edu.gh 4.3 Accessibility and usage of major social media platforms among study participants With the exception of 5 students who did not own any smart device, all students, (98.8%) owned a smart device capable of accessing social media platforms (Table 4.2). Regarding the usage of social media platforms, WhatsApp is the primary platform for these youthful University students, nearly all reported to use it (96%); approximately (79%) of the respondents reported to use Instagram and slightly lower than three-quarters (70.6%) of the respondents access Facebook. Using Snapchat was also relatively gaining popularity with its use at 67.5%. None of the participants use Grindr as a social media platform. Table 4.3: Accessibility and usage of major social media platforms among study participants Accessibility/ Social Media Platform No (%) Yes (%) Own a smart device 5 (1.2) 417 (98.8) WhatsApp 16 (3.8) 406 (96.2) Twitter 166 (39.3) 256 (60.7) Facebook 124 (29.4) 298 (70.6) Instagram 88 (20.9) 334 (79.2) Snapchat 137 (32.5) 285 (67.5) Tinder 402 (95.3) 20 (4.7) Grindr 422 (100.0) 0 (0.0) P<0.05 31 University of Ghana http://ugspace.ug.edu.gh 4.4 Level of social media use A majority of the University students (61.1%) were high users of SM, while only 1.2% were classified as non-users of SM (Figure 4.1). 100.0 90.0 80.0 70.0 61.6 60.0 50.0 37.2 40.0 30.0 20.0 10.0 1.2 0.0 No usage Some usage High usage Level of social media usage Fig 4.1: Level of social media use among study participants 4.5 Perception of sexually explicit materials on social media This study examined the perception of the respondents on seeing sexually explicit materials (SEM) on social media (Figure 4.2). Respondents were asked whether they felt SEM on social media were informative, arousing, disgusting or educative. All responses were viewed as mutually exclusive of each other. Of all respondents, 37.7% thought sexually explicit material seen on social media were informative, 37.4% perceived it as disgusting, while 30.1% regarded such material as arousing in nature. 32 Percentage of respondents University of Ghana http://ugspace.ug.edu.gh 100.0 80.0 60.0 37.7 37.4 40.0 30.1 26.5 20.0 0.0 Informative Disgust Arousal Educative Perception towards sexually explicit material on social media Fig 4.2: Perception of sexually explicit materials on social media 4.6 Sexual behaviour among University of Ghana students Results revealed that 167 (39.6%) respondents reported that they had ever had sexual intercourse (Table 4.3). Among sexually active students, about 55.1% used a condom during their last sexual activity preceding survey, 10.2% had sex for cash/gifts and14.4% had sex under the influence of alcohol. Amongst all the students who participated in the study, 33.4% engaged in RSB. 33 Percentage of respondents University of Ghana http://ugspace.ug.edu.gh Table 4.3 Risky sexual behaviour among University of Ghana students Variables Frequency Percentage (%) N= (167) Ever had sex No 255 60.4 Yes 167 39.6 Condom use at last sex No 92 55.1 Yes 75 44.9 Number of sex partners last 6 months 0 3 1.8 1 98 58.7 1-2 44 26.3 3-5 16 9.6 6-9 1 0.6 more than 10 5 3.0 Sex for cash/gift No 150 89.8 Yes 17 10.2 Sex with someone 10years older (Cross-generational sex) No 143 85.6 Yes 24 14.4 Sex under the influence of Drugs/Alcohol No 143 85.6 Yes 24 14.4 Casual sex No 79 47.9 Yes 87 52.1 Have you/partner ever been Pregnant No 153 91.6 Yes 14 8.4 P<0.05 34 University of Ghana http://ugspace.ug.edu.gh 4.7 Risky sexual behaviour among students Figure 4.3 presents the proportion of university students who indulge in risky sexual behaviour. Risky sexual behaviour was a composite variable created from responses summed up from eight (8) sexual behaviour questions. A score of 0 implies the absence of risky sexual behaviours while students who scored between 1 to 8 were engaged in RSB. Among the study participants, approximately 33.4% are involved in RSB. 100.0 90.0 80.0 70.0 66.6 60.0 50.0 40.0 33.4 30.0 20.0 10.0 0.0 No risk High risk Prevalence of risky sexual behaviour among students Fig 4.3: Prevalence of RSB among students 4.8 Association between key socio-demographic characteristics and risky sexual behaviour Table 4.4 presents the results of a Chi-square analysis of the association between risky sexual behaviour and key socio-demographic characteristics of students. Male students (p<0.001), students aged 20-24 (p<0.001), employment status (p=0.040) and fathers’ involvement in teen upbringing (p=0.003) were significantly associated with risky sexual behaviour. However, 35 Percentage of respondents University of Ghana http://ugspace.ug.edu.gh educational level, marital status, type of family, ethnicity and religion were not associated with RSB. 36 University of Ghana http://ugspace.ug.edu.gh Table 4.4: Association between socio-demographic characteristics and risky sexual behaviour. Variables Total No risk High risk Chi-square P-value n (%) n (%) Sex 23.6 <0.001*** Male 226 127 (56.2) 99 (43.8) Female 196 154 (78.6) 42 (21.4) Age group (years) 16.6 <0.001*** 15-19 160 123 (76.9) 37 (23.1) 20-24 252 155 (61.5) 97 (38.5) 25-29 10 3 (30.0) 7 (70.0) Religion 1.2 0.558 Christian 361 244 (67.6) 117 (32.4) Muslim 22 13 (59.1) 9 (40.9) Others 39 24 (61.5) 15 (38.5) Ethnicity 0.9 0.824 Akan 228 149 (65.35) 79 (34.7) Ga/Adangme 74 48 (64.86) 26 (35.1) Ewe 68 48 (70.59) 20 (29.4) Others 52 36 (69.23) 16 (30.8) Level of education 6.8 0.079 level 100 93 64 (68.8) 29 (31.2) level 200 170 123 (72.4) 47 (27.7) level 300 97 58 (59.8) 39 (40.2) level 400 62 36 (58.1) 26 (41.9) Marital status 0.6 0.422 Never married 409 271 (66.3) 138 (33.7) Currently/Ever married 13 10 (76.9) 3 (23.1) Father involvement 13.9 0.003** Always 218 162 (74.3) 56 (25.7) Often 70 45 (64.3) 25 (35.7) Sometimes 62 35 (56.5) 27 (43.6) Rarely/Never 72 39 (54.17) 33 (45.8) Mother's involvement 2.0 0.6 Always 355 237 (66.8) 118 (33.2) Often 34 23 (67.7) 11 (32.4) Sometimes 16 12 (75.0) 4 (25) Rarely/Never 17 9 (52.9) 8 (47.1) Employment 4.2 0.04* No 385 262 (68.05) 123 (31.95) Yes 37 19 (51.35) 18 (48.65) *: p<0.05. **: p<0.01. ***: p<0.001 37 University of Ghana http://ugspace.ug.edu.gh 4.9 Association between social media activity of students and risky sexual behaviour The association between risky sexual behaviour and various social media usage characteristics of students was analysed using Chi-square (Table 4.5). Students who often watched and post videos on social media (p=0.014) and meet people of the opposite gender (p=0.001) were significantly associated with RSB. Meanwhile, social media activities such as chatting and watching/posting pictures on SM were not associated with RSB. Overall, students who engaged in high social media use (p=0.029), were more associated with risky sexual behaviour compared to those who were not. Table 4.5: Association between social media activities and risky sexual behaviour Variables Total No risk High risk Chi-square P-value n (%) n (%) Level of social media use 7.1 0.029* No 5 3 (60.0) 2 (40.0) Some 157 117 (74.5) 40 (25.5) High 260 161 (61.9) 99 (38.1) Chatting 3.2 0.198 Never/rarely 36 25 (69.4) 11 (30.6) Sometimes 59 45 (76.3) 14 (23.7) Often/Always 327 211 (64.5) 116 (35.5) Watching and posting videos 8.5 0.014* Never/rarely 106 80 (75.5) 26 (24.5) Sometimes 91 65 (71.4) 26 (28.6) Often/Always 225 136 (60.4) 89 (39.6) Watching and posting picture 4.6 0.099 Never/rarely 131 95 (72.5) 36 (27.5) Sometimes 85 59 (69.4) 26 (30.6) Often/Always 206 127 (61.7) 79 (38.4) Meeting people of opposite gender 13.4 0.001** Never/rarely 238 173 (72.7) 65 (27.3) Sometimes 61 42 (68.9) 19 (31.2) Often/Always 123 66 (53.7) 57 (46.3) *: p<0.05. **: p<0.01. ***: p<0.001. 38 University of Ghana http://ugspace.ug.edu.gh 4.10. Bivariate association between viewing sexually explicit material and risky sexual behaviour Table 4.6 presents the bivariate relationship between viewing SEM and risky sexual behaviour. Results from the analysis shows that students who viewed sexually explicit material on Twitter (p=0.002), Instagram (p=0.007), Snapchat (p=0.001) and Tinder (p<0.001) were statistically associated with RSB. Significantly more students (80%) who viewed SEM on Tinder, were associated with RSB compared to their counterparts who did not. More of the students who practised sexting were involved in RSB compared to their colleagues who did not engage in sexting (p<0.001). Overall, viewing sexually explicit materials on SM was significantly related to risky sexual behaviour, with the relatively new social media platforms i.e. Tinder exposing more users to SEM than the more commonly used platforms. 39 University of Ghana http://ugspace.ug.edu.gh Table 4.6: Association between viewing SEM and risky sexual behaviour Variables Total No risk High risk Chi-square P-value N n (%) n (%) Exposure to sexually explicit material 4.6 0.032* No 39 32 (82.1) 7 (17.95) Yes 383 249 (65.0) 134 (34.99) SEM WhatsApp 1.3 0.247 No 247 170 (68.8) 77 (31.2) Yes 175 111 (63.43) 64 (36.6) SEM on Twitter 5.4 0.02* No 300 210 (70.0) 90 (30.0) Yes 122 71 (58.2) 51 (41.8) SEM of Facebook 0.3 0.569 No 289 195 (67.5) 94 (32.5) Yes 133 86 (64.7) 47 (35.3) SEM of Instagram 7.2 0.007** No 239 172 (72.0) 67 (28.0) Yes 183 109 (59.6) 74 (40.4) SEM Snapchat 11.0 0.001** No 330 233 (70.6) 97 (29.4) Yes 92 48 (52.2) 44 (47.8) SEM on Tinder 15.2 <0.001*** No 407 278 (68.3) 129 (31.7) Yes 15 3 (20.0) 12 (80.0) SEM Grindr 1.5 0.22 No 419 280 (66.8) 139 (33.2) Yes 3 1 (33.3) 2 (66.7) Engaged in sexting on social media 62.6 <0.001*** No 224 187(67.0) 37(26.2) Yes 196 92(26.2) 104(73.8) *: p<0.05. **: p<0.01. ***: p<0.001. Sexting refers to the act of “distributing, accepting, or promoting sexually explicit messages, pictures (nude or seminude) or videos via phones, computer, any digital device. Sexually explicit materials refer to content depicting sexual behaviour in the form of nudity, pornography or flirting. 40 University of Ghana http://ugspace.ug.edu.gh 4.11. Multiple logistic regression of risky sexual behaviour and selected independent variables Using simple logistic regression (crude) and multiple logistic regression (adjusted), the association between RSB and various individual levels and social media usage characteristics of respondents was determined (Table 4.7). Male students in the study (AOR: 1.9; 95% CI 1.1-3.1) were more likely to engage in RSB compared to females. Adjusting for gender as a cofounder, students in the age group 25-29 were 8 times more likely to engage in risky sexual behaviour compared to other age groups. The odds of engaging in RSB were higher among students whose fathers were ‘never/rarely’ involved in their teen upbringing than those whose fathers were. Adjusting for the combined effects of sex, age group, employment and social media use, students who viewed sexually explicit materials on Tinder were about 6 times as likely to engage in risky sexual behaviour (AOR: 6.1; 95% CI 1.4- 25.9) compared to students who did not. When age, sex of participants and exposure to sexual materials on Tinder were jointly accounted for, students who ‘sext’ were about 4 times more likely to engage in risky sexual behaviour (AOR: 4.4; 95% CI 2.6- 7.5) compared to their colleagues who did not. After controlling for a number of covariates, overall exposure to sexually explicit material did not reveal a significant relationship with RSB at multivariate level. 41 University of Ghana http://ugspace.ug.edu.gh Table 4.7: Simple (crude) and adjusted multivariate regression model summary Unadjusted Adjusted COR (95% CI) P-value AOR (95% CI) P-value SOCIAL DEMOGRAPHIC RELATED FACTORS Sex <0.001*** 0.013* Female 1.00 (reference) 1.00 (reference) Male 2.86 (1.9- 4.4) 1.88 (1.1-3.1) Age group 0.012* 15-19 1.00 (reference) 1.00 (reference) 20-24 2.08 (1.3- 3.3) 1.72 (1.0 -2.9) 25-29 7.76 (1.9-31.5) 8.31 (1.6 -42.5) Fathers involvement 0.004** 0.047* Always 1.00 (reference) 1.00 (reference) Often 1.61 (0.9 - 2.9) 2.16 (1.1- 4.3) Sometimes 2.23 (1.2-4.0) 1.94 (1.0- 3.9) Rarely/Never 2.45 (1.4- 4.3) 1.91 (1.0- 3.6) Employment 0.043* 0.096 No 1.00 (reference) 1.00 (reference) Yes 2.02 (1.0 -4.0) 2.03 (0.9- 4.7) SOCIAL MEDIA RELATED FACTORS Social media Use 0.030* 0.601 No use 1.00 (reference) 1.00 (reference) Some use 0.51 (0.1-3.2) 0.45 (0.1- 3.8) High Use 0.92 (0.2-5.6) 0.56 (0.1-4.6) Watching/posting videos 0.014* 0.484 Never/rarely 1.00 (reference) 1.00 (reference) Sometimes 1.23 (0.7- 2.3) 0.76 (0.34-1.6) Often/Always 2.01 (1.2 - 3.4) 1.12 (0.6-2.2) Meet people of opposite gender 0.001** 0.786 Never/rarely 1.00 (reference) 1.00 (reference) Sometimes 1.2 (0.7- 2.2) 1.01 (0.5-2.1) Often/Always 2.3 (1.5-3.6) 1.22 (0.7-2.2) Sexually explicit material 0.037* 0.675 Not seen 1.00 (reference) 1.00 (reference) Yes/Seen 2.46 (1.1 -5.7) 0.81 (0.3-2.2) SEM Instagram 0.008** 0.247 No 1.00 (reference) 1.00 (reference) Yes 1.74 (1.2-2.6) 1.36 (0.8-2.3) SEM on Snapchat 0.001** 0.63 No 1.00 (reference) 1.00 (reference) Yes 2.2 (1.4- 3.5) 1.16 (0.6 -2.1) SEM on Tinder 0.001** 0.016* No 1.00 (reference) 1.00 (reference) Yes 8.62 (2.4-31.1) 6.01 (1.4 -25.9) SEM on Twitter 0.02* 0.772 No 1.00 (reference) 1.00 (reference) Yes 1.68 (1.1-2.6) 1.09 (0.6 -1.9) Sexting on social media <0.001*** <0.001*** No 1.00 (reference) 1.00 (reference) Yes 5.71 (3.6 – 9.0) 4.42 (2.6 -7.5) COR: crude odds ratio. AOR; adjusted odds ratio. CI: confidence interval. *: p<0.05. **: p<0.01. ***: p<0.001. 42 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Discussion of findings The age and sex distribution of participants in this study are similar to reports of other studies (Villanti et al., 2017; Asrese & Mekonnen, 2018). Some studies have revealed a link between poor student academic performance and their involvement in RSB. However, this was not supported by the findings of this study. On the contrary, students with high-grade point average rather engaged in RSB. This indicates that other factors do contribute to RSB and indeed include peer influence, adventure and thrill-seeking, inadequate education, alcohol consumption, liberation from moral surveillance, culture and religious beliefs (Chanakira, O’Cathain, Goyder, & Freeman, 2014). In the University, one is less hindered by rules, parental control and monitoring. In the Ghanaian setting, unlike the western world, culture and upbringing play significant roles in people’s lives. Young people are constantly monitored and reprimanded by parents and older siblings. The University, therefore, serves as a new stage where one can freely explore and experiment. This coupled with the curiosity and urge for experimentation that accompanies being young can lead to indulgence in risky sexual behaviour. In this study, gender was also seen to influence risky sexual behaviour. This was supported by (Letamo, 2011). Beliefs that a man has the right to have as many women as he prefers among others have been ingrained in the minds of males, especially in the African setting. This, however, complex factor coupled with the natural thrill-seeking and adventurous nature of males could account males engaging more in RSB than females. Parental involvement/guidance in the lives of participants was seen to be associated with less RSB with increased presence of fathers found to elicit protective sexual behaviour. These are consistent with other findings (Ajayi & Okeke, 2019; Defo & Dimbuene, 2012). Conversely, it 43 University of Ghana http://ugspace.ug.edu.gh found that parental involvement and family context has no impact on the sexual behaviour of young people ( Calhoun & Friel, 2013). 5.2 Level of social media use This study reported a universal ownership of smartphone device. This is similar to a report from the most recent Ghana Demographic and Health Survey (GSS et al., 2014) that revealed a significant upsurge in the use of mobile phones in Ghana from 57% in 2008 to 85% in 2014. In a related study, it posited that smartphone usage in urban areas with internet connectivity and regular access to social networking sites is now an essential device in the life of ‘cool youth’, often from their early teenage years (Porter et al., 2015). This increased access to mobile phones and complimentary internet connectivity has led to an increased use of social media platforms among students. More than half of students indicated ‘use of social media’ and further revealed a high usage of WhatsApp, followed by Instagram and Tinder by only 20%. Conversely, studies among similar-aged students, ranked the top five most used applications like Facebook, YouTube, Instagram, Snapchat, and Twitter (Villanti et al., 2017). One reason that could account for the high use of WhatsApp in the Ghanaian setting, is the ability to chat and make calls at little to no cost i.e. a data bundle compared to using the pay as you go services provided by telecommunication networks. A majority of students sampled revealed that their social media activities consisted predominantly of chatting. These findings are similar to Ito (2008) and Boyd (2007), who stated that social media sites allow teens to accomplish many of the online tasks that are important to them. These tasks include staying connected with friends and family, making new friends, sharing pictures, and exchanging ideas. 44 University of Ghana http://ugspace.ug.edu.gh 5.3 Social media use and sexually explicit media Motivating factors for social media use are numerous. In literature, social media has been revealed to expose university students to sexually explicit media. Akinwale (2009), is of the opinion that in SSA, Internet-based applications are promoting individualism, secrecy and exposing the youth to sexually explicit materials (Akinwale, 2009). Other researchers alluded that the social media has amplified access to SEM that promotes profanity, vulgarity and obscenity. Sexting and amplified online sex seeking proliferation among students are also on the rise (Kimemia, 2016; Lemoine et al., 2016). This is in tandem with findings from this study as nine out of every ten students confirmed exposure to sexually explicit media on at least one social media platform. Among students who answered yes to being exposed to sexually explicit media, almost half 183 (47.7%) reported seeing it on Instagram followed by WhatsApp 175 (45.7%) and Facebook 133 (34.7%). It is important to note that despite Tinder being the least commonly used social media application in this study, the few student users of this platform were exposed to sexually explicit media. While Tinder had very little student patronage in terms of active users, student exposure to SEM on Tinder app was significantly related with a six-fold increase in RSB compared to students who were not exposed to Tinder. This study supported findings by other authors who alluded to tinder use as predominant among students having higher level of education, reporting more need for sex, interested in casual sex, or having more than five previous sexual mates (Sevi, 2019; Timmermans & Courtois, 2018; Shapiro et al., 2017). This is seen to be true in this study as students with high GPA did indulge in risky sexual behaviour. A significant relationship existed between sexting and RSB. Sexting involves mainly sending/receiving sexually explicit messages, nude or seminude pictures or videos such as pornography for the purpose of enticing or arousing one’s sexual urges. Where communication is 45 University of Ghana http://ugspace.ug.edu.gh involved, it also requires individuals to talk about sex or use sexually suggestive language. This can lead one into sexual acts otherwise unplanned. Evidence from an earlier study among University of Ghana students explains that motivations for sexting among students include sending sexts to be noticed by others, to feel sexy and receive compliments. The author shows that sending sexually suggestive messages or images to either a boy/girlfriend was also perceived as a sexually enticing gift (Ahiataku, 2016). Further, while females are under more pressure to engage in sexting, a lot more people send or receive sexts in consensual relationships or as youthful experimentation (Fleschler Peskin et al., 2013). 5.4 Proportion of students engaging in risky sexual behaviours Another objective of this study was to determine the proportion of students who were engaged in RSB’s. Overall, a low proportion of students were involved in RSB with all behaviours considered. Condom use at last sex recorded the highest per cent with a little over half of students reporting that they did not use condoms during their last sexual intercourse. For all students who had ever had sex, nonuse of the condom was the riskiest sexual behaviour. This implies a high risk of STIs/ HIV/AIDS and unplanned pregnancies among students. Several barriers might hinder the use of condoms such as shyness and lack of confidence, peer pressure and fear of judgement in the student settings. These factors also hinge on the setting of an individual. These results are consistent with findings reported on 59.8% and 27% condom use during last sex from two other studies (Ahiataku, 2016; Kalina, 2012) respectively. Regarding the composite variable risky sexual behaviour, which was attained through putting all questions considered together to score a ‘Yes’ in one question classified you as engaged in RSB, 33% of students were engaged in RSB. Sex of students (males more than females) revealed a significant relationship with RSB. Males in youthful years are high 46 University of Ghana http://ugspace.ug.edu.gh in adrenaline and more susceptible in most cases to peer influence. This leads to incidence of substance abuse, gang behaviour and RSB. This is consistent with findings by (Tapert et al., 2001; Odimegwu & Somefun, 2017; Ritchwood, et.al., 2015). 5.5 Association between social media use and risky sexual behaviour Accounting for all other variables, sex of respondents was significantly associated with RSB. Male students are more adventurous by nature making them more susceptible to risky behaviour compared to females. It was evident from this study that university students between the ages 25 and 29 were four times more prone to RSBs than their younger counterparts within 15 and 19 years of age while those between the ages of 20 and 24 years were twice at risk compared to younger ones. This is consistent with findings from studies carried out by Ahiataku as well as Temple and co-authors (Ahiataku, 2016; Temple et al., 2014). This observation could be due to the age the young adults begin sexual acts, which potentially exposes them to risky sexual outcomes. In Ghana, the median age for sexual debut among women and men within the ages of 20 and 24 years are 18.4 and 20 respectively. As a result, by age 25, most young people are actively involved in sexual activities, exposing them to more risky sexual outcomes (MacQuarrie, Mallick, & Allen, 2017). Sensation seeking has also been associated with RSB among young adults (Horvath & Zuckerman, 1993). In addition, study findings show that University students who had high paternal involvement in teen years are more involved in protective sexual behaviour as compared to those with low paternal involvement. This could mean that fathers who are more involved and concerned about their children invest time in educating them on protective sexual behaviour resulting in positive outcomes with issues related to their sexual reproductive health. 47 University of Ghana http://ugspace.ug.edu.gh Furthermore, social media use had some effect on RSB. It was evident that students who were exposed to sexually explicit media on Tinder were six times more likely to engage in RSB. This can be explained by Tinder being a social media app specifically designed for online dating and sexual solicitation, which is mostly used among young people who have attained higher levels of education, report more need for sex, are interested in casual sex, or have had more than five previous sexual partners. A similar association is seen with students who engaged in sexting (Sevi, 2019; Timmermans & Courtois, 2018; Shapiro et al., 2017). This implies an increase in risky sexual behaviour with increased use of Tinder, especially when combined with reduced condom use among students. 5.6 Limitations of the study Due to the sensitive nature of the questions, this study employed self-administered questions. It is plausible that social desirability may have influenced some of the answers given, however, respondents were assured of confidentiality and anonymity. The quantitative nature of the study did not allow for the collection of more in-depth information for further inference. 48 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATIONS 6.1 Conclusion This study established that more than half of the students at the University of Ghana, Legon campus engaged in high use of social media. A little over a third of the students (33.4%) were involved in risky sexual behaviour. Sex of students (predominantly, males were more likely to engage in RSB than females) and age (25-29 years more likely to engage in RSB than younger ones) were seen to be significantly associated with RSB. There was no significant association between use of social media and RSB, students involved in sexting, and use of Tinder application were more likely to engage in risky sexual behaviour. 6.2 Recommendations  The Ministry of Education and Ghana Education Service should introduce age-appropriate and timely comprehensive sexuality education (CSE) at the secondary and tertiary level to reduce RSB among adolescents and young adults.  The University of Ghana, should partner with local and international NGOs such as PPAG, UNFPA etc. to organize talks, seminars, workshops aimed at shedding light on social media patronage and RSB among this generation, which relies heavily on information communication technology (ICT).  Existing policy structures and campaigns aimed at curbing adolescent and young adult risky sexual behaviour should be re-oriented to incorporate health education transmitted via Social Media.  Further qualitative research should be done to explore the relationship between use of social media and risky sexual behaviour. 49 University of Ghana http://ugspace.ug.edu.gh REFERENCES Abdullahi, A. 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The Effects of Sex Education on the Risky Sexual Behaviour of School Going Adolescents: A Case Study of Mbenjere Secondary, Ntaja and Nsanama Community Day Secondary Schools. Psychology and Developing Societies, 28(1), 126– 138. https://doi.org/10.1177/0971333615622910 54 University of Ghana http://ugspace.ug.edu.gh Ritchwood, T. D., Ford, H., DeCoster, J., Lochman, J. E., & Sutton, M. (2015). Risky sexual behavior and substance use among adolescents: A meta-analysis. Children and Youth Services Review, 52, 74–88. https://doi.org/10.1016/j.childyouth.2015.03.005 Sakeah, J. K. (2017). Determinants of Condom Use Intentions Among University Students In Ghana. Sambisa, W., Curtis, S. L., & Stokes, C. S. (2010). Ethnic Differences In Sexual Behaviour Among Unmarried Adolescents And Young Adults In Zimbabwe. Journal of Biosocial Science. https://doi.org/10.1017/S0021932009990277 Sandfort, T. G. M., Orr, M., Hirsch, J. S., & Santelli, J. (2008). 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Association between condom use at sexual debut and subsequent sexual trajectories: A longitudinal study using biomarkers. American Journal of Public Health, 97(6), 1090–1095. https://doi.org/10.2105/AJPH.2005.068437 Shapiro, G. K., Tatar, O., Sutton, A., Fisher, W., Naz, A., Perez, S., & Rosberger, Z. (2017). Correlates of Tinder Use and Risky Sexual Behaviors in Young Adults. Cyberpsychology, Behavior, and Social Networking, 20(12), 727–734. https://doi.org/10.1089/cyber.2017.0279 Simon Kemp. (2018). Digital 2018: Global Digital Overview. Retrieved from https://datareportal.com/reports/digital-2018-global-digital-overview Sopheab, H., Fylkesnes, K., Lim, Y., & Godwin, P. (2008). Community action for preventing HIV in Cambodia : evaluation of a 3-year project. (July). https://doi.org/10.1093/heapol/czn014 Tapert, S. F., Aarons, G. A., Sedlar, G. R., & Brown, S. A. (2001). Adolescent substance use and sexual risk-taking behavior. 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Situational Analysis of Adolescent Girls and Young Women in Ghana- Synthesizing Data to Identify and Work with the Most Vulnerable Young Women. Retrieved from http://www.ghbook.ir/index.php?name=رهنگ ه و ف سان های ر ن وی option=com_dbook&task=readonline&book_id=13650&page=73&chkhashk=ED9C&ن 9491B4&Itemid=218&lang=fa&tmpl=component UNICEF. (2011). UNICEF Annual Report 2011. https://books.google.com.gh/books?hl=en&lr=&id=gSk8eiLMylIC&oi=fnd&pg=PA2&dq= UNICEF+Annual+Report+2011&ots=TYZP6DIhXA&sig=L9sJQUrjwHOWTNEeKijIP9M Odac&redir_esc=y#v=onepage&q=UNICEF%20Annual%20Report%202011&f=false.Page 2 Vasilenko, Sara A, Eva Lefkowitz, J. M. (2008). Short-term Positive and Negative Consequences of Sex Based on Daily Reports among College Students. Bone, 23(1), 1–7. https://doi.org/10.1038/jid.2014.371 Villanti, A. C., Johnson, A. L., Ilakkuvan, V., Jacobs, M. A., Graham, A. L., & Rath, J. M. (2017). Social media use and access to digital technology in US Young Adults in 2016. 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Retrieved from http://siteresources.worldbank.org/intlacregtoplabsocpro/Resources/SupportingYouthAtRis k.pdf Whitaker, C., Stevelink, S., & Fear, N. (2017). The use of Facebook in recruiting participants for health research purposes: A systematic review. Journal of Medical Internet Research, 19(8). https://doi.org/10.2196/jmir.7071 56 University of Ghana http://ugspace.ug.edu.gh WHO/UNAIDS. (2005). Alcohol Use and Sexual Risk Behaviour: A Cross-Cultural Study in Eight Countries. 135. https://doi.org/10.1073/pnas.1103746108 WHO. (2011). Youth and health risks Report from Sixty-Fourth World Health Assembly. WHO, (April), 1–7. WORLD BANK. (2008). The World Bank Annual Report 2008 Year In Review Operational Summary | Fiscal 2008. 57 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix A: Participant information sheet INFORMATION SHEET THE USE OF SOCIAL MEDIA AND RISKY SEXUAL BEHAVIOUR AMONG STUDENTS IN THE UNIVERSITY OF GHANA, LEGON CAMPUS Background and Purpose of research The purpose of this research is to better understand risky sexual behaviours among university students and association between social media use and sexual experiences. This study is important because it sheds light on the social media applications frequently subscribed to by students in the University of Ghana and the nature of sexually explicit content they are exposed to as well whether or not an association exists between exposure to SEM and risky sexual behaviour of students. Introduction: My name is Mr Derrick Holdbrook. A master’s student at the Department of Population Family and Reproductive Health in the School of Public Health, University of Ghana, Legon. I can be contacted on Tel: 0247627832 and email: rickkholdbrook@gmail.com. Nature of research: This study seeks to gather knowledge on the content a student is exposed to on the various social media platforms and whether or not content exposure i.e. what is viewed and heard leads to risky sexual behaviour of university of Ghana students. We ask that you read this form and ask any questions you may have before agreeing to be in the study. The category of people involved in this study are undergraduate University of Ghana students on the Legon campus between the ages 15 to 24 years. A total of 423 students are being recruited for participation in this study Participants involvement: If you agree to be part of this study, you will be required to give consent in writing by signing or thumb printing a consent form. After you have given your consent, you will be asked to complete an anonymous self-administered questionnaire that asks about your background (e.g., age, gender) as well as your feelings and experiences related to sexual activity, social media app use and viewing of sexually explicit material on social media. It may take approximately 15-20 minutes to complete the survey. 58 University of Ghana http://ugspace.ug.edu.gh Potential Risks: There are no physical risks or harm in participating in this study. However, there will be some level of discomforts, emotional upset due to the sensitive nature of some of the questions asked. Benefits: There are no direct benefits of participating in this research to the participant. There would however be scientific benefits as it would add to the body of knowledge on the association that exists between social media patronage and sexual practices. Further, it intends to identify factors for which meaningful strategies aimed at improving these risky sexual behaviours could be based on. Cost: There will be no cost incurred in participating in this study. Compensation: You will not receive payment for participation in this study. As this study involves the anonymous completion of questionnaires, we ask that you do not type your name or any other identifying information into the survey. As such, your survey responses will not be able to be connected to your identity in any way. Efforts will be made to keep your personal information confidential. Your personal information may be disclosed if required by law. Voluntary participation: Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty. Your decision whether or not to participate in this study will not affect your current or future relations with the investigators. Confidentiality: Participant personal information would be kept in a locked drawer. No one apart from the investigator and his supervisor will have access to participant information Data collected would be coded in such a way that no responses could be tied to anyone specific participant. Any and all key identifies will be removed if the work is published. There will be no way whatsoever for anyone (except the PI) to be able to identify participants by their answers to any part of the questionnaire. Feedback will not directly be given to participants. However, upon publication of the work, participants may have access to all results and findings. Funding information: This study is being done as part of my research for the award of a Master of public health degree and is being self-funded. 59 University of Ghana http://ugspace.ug.edu.gh Persons to Contact For questions about the study, contact the Principal investigator, Mr Derrick Holdbrook, at 0247627832 or rickkholdbrook@gmail.com. Department of Population Family and Reproductive Health, School of Public Health, Legon For further clarification on ethical issues and their rights as participants if need be, please contact Ghana Health Service Ethics Review Committee Administrator, Hannah Frimpong Ghana Health Service Ethics Review Committee Tel: 0507041223 and email: hannahfrimpong@ghsmail.org 60 University of Ghana http://ugspace.ug.edu.gh Appendix B: Consent Form PARTICIPANTS’ STATEMENT I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and satisfactorily explained to me in a language I understand (English). I fully understand the contents and any potential implications as well as my right to change my mind (i.e. withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Name or Initials of Participant………………………….. ID Code …………………………….. Participants’ Signature ……… OR Thumb Print………… OR Mark (Please specify)…………. Date: ……………………………. INVESTIGATOR STATEMENT AND SIGNATURE Brief statement or declaration that investigator has given enough information to participants to make informed decisions. Example: I certify that the participant has been given ample time to read and learn about the study. All questions and clarifications raised by the participant have been addressed. Researcher’s name………………………………………. Signature …………………………………………………. Date…………………………………………………………. 61 University of Ghana http://ugspace.ug.edu.gh Appendix C: Questionnaire Individual Survey Questionnaire The use of Social Media and Risky Sexual Behaviour among Students in the University of Ghana, Legon campus. Section A: Preliminary Questions: PARTICIPANT: Interviewer ID Questionnaire ID 01 This section will ask you a few questions about yourself Please complete the following questionnaire with specific regard to the above enquiry, by ticking in the appropriate box Section B: Socio-Demographic Characteristics Qn. 1 Are you? 0. MALE………. 1. FEMALE……… Qn. 2 What was your age at your last birthday? …………………………………………………Years Qn.3 What day, month and year were you born? (DOB) DD /MM / YYYY Date Month Year Qn. 4 Please select your ethnicity 1. AKAN 7. MOLE-DAGBANI 2. TWI 8. GRUSI 3. GA/ADANGME 9. GURMA 4. EWE 10. MANDE 5. HAUSA 11. OTHERS (Ps 6. GUAN Specify)…………. Qn. 5 What is your current GPA (As 1. 3.6-4.0…... 4. 2.0 – 2.49…… of last completed semester)? 2. 3.0 -3.59........ 5. Below 2.0……. 3. 2.5 – 2.9….... Qn. 6 Which religious denomination do you belong to? 1. Catholic ………….. 5. Muslim ………………… 2. Anglican/ Methodist/ /Presbyterian…. 6. Traditional/Spiritualist 3. Pentecostal / 7. No religion Charismatic..... ……………. 4. Other Christian 8. OTHERS: ………………… 1. Level 100 3. Level 300 What level are you in? Qn. 7 2. Level 200 4. Level 400 MARITAL STATUS 3. SEPARATED/DIVORCED 1. NEVER MARRIED ………. Qn. 8 2. CURRENTLY 4. WIDOWED……………… What is your Marital status MARRIED/COHABITING … 62 University of Ghana http://ugspace.ug.edu.gh What is your family set – 1. Extended Qn. 9 up/background? (Are you from an extended or nuclear family?) 2. Nuclear 63 University of Ghana http://ugspace.ug.edu.gh SOMETIM ALWAYS OFTEN ES RARELY NEVER (1) (2) (3) (4) (5) Was your father part of your Qn. 10 teenage years (How involved was he in your upbringing) 1 2 3 4 5 Was your mother part of your Qn. 11 teenage years (how involved was she in your upbringing) 1 2 3 4 5 Is there an adult figure you look 1. No………. 2. Yes……… Qn. 12 up to (role model?) Is this person a male or female? 1. MALE………. If 2. FEMALE……… Qn. 13 If male skip to #15 Are you currently in any form of Qn. 14 employment? 1. No………. 2. Yes……… Educational background This section will ask you questions about your educational background (secondary school events) Qn. 15 Did you attend a same-sex Senior High School? 1. No………. 2. Yes……… If yes, were you resident 1. Boarding Qn. 16 (boarding student) or not (day student)? 2. Day student Section C: Sexual Behaviour This section will ask you about your sexual behaviour Have you ever been in a Qn.17 relationship with a male or 1. No………. 2. Yes……… female (boyfriend or girlfriend) Do you currently have a sexual Qn.18 partner? 1. No………. 2. Yes……… What gender is your partner? My 0. MALE………. 2. BOTH……… Qn.19 partners are : 1. FEMALE………. Have you ever had sex? Qn.20 1. No………. 2. Yes……… Qn.21 How old were you the first time you had sexual intercourse? Qn.22 The first time you had sex did you use protection? 1. No………. 2. Yes……… Have you had sex within the last Qn.23 3 months? 1. No………. 2. Yes……… The first time you had sexual Qn.24 intercourse; did you or your 1. No………. 2. Yes……… partner use a condom? 64 University of Ghana http://ugspace.ug.edu.gh When was the last time you had Less Less Less Less than 12 Qn.25 sex? than a than a than 3 months week month months The last time you had sex did Qn.26 you use a condom? 3. No………. 4. Yes……… Have you been sexually active in Qn.27 the past year (sexual activity 1. No………. 2. Yes……… refers to any type of genital contact or sexual stimulation between two persons, including, but not limited to sexual intercourse)? Qn.28 If you are sexually active or have 1. 1 …………….. 4. 6-9 …………… ever been sexually active, how 2. 1-2 ……………. 5. 10+…………… many partners have you had total? 3. 3-5……………. How many sexual partners have 1. 1 …………….. 4. 6-9 …………… Qn.29 you had in the past 6 months 2. 1-2 ……………. 5. 10+…………… 3. 3-5……………. Have you ever had sexual Qn.30 intercourse with an individual 0. No………. 1. Yes……… you were not in a relationship with? Have you ever had sex for Qn.31 cash/gifts No………. Yes……… Have you ever had sexual Qn.32 intercourse with somebody who No………. Yes……… is 10 years or older than you? Have you ever had sexual Qn.33 intercourse while under the No………. Yes……… influence of drugs or alcohol? Have you ever had oral sex Qn.34 while under the influence of No………. Yes……… drugs or alcohol? Have you or one of your sexual Qn.35 partners ever become pregnant No………. Yes……… 65 University of Ghana http://ugspace.ug.edu.gh Please indicate on a scale of 0(never) to 100 %( often) how consistently you currently engage in the following contraceptive behaviours. Please select N/A if the question does not apply to you. 0 25 50% 75% 100% N/A % Qn.36 Use of other contraceptive methods e.g. Pills, injectable etc. Qn.37d Use of a male condom Qn.37g Intercourse without any form of Contraceptive Qn.38 During the last time you were sexually active did you use a 0. No……… 1. Yes……… 2. N/A… form of contraceptive? . Qn.39 During the last time, you had Birth Condom Withdrawal Rhythm Other None N/A sexual intercourse what form(s) control method form of of contraceptive did you use? barrier method (diaphr agm, cervica l cap) Section E: Social Media This section will ask you about your social media app use Qn.40 Do you own a smartphone, laptop, 1. Yes……… tablet, an electronic book, or similar 0. No………. device? Qn.41 If yes, specify ……………………………………………………………………… ……… Qn.42 Do you use any of the specific 0. Whatsapp 1. Twitter 2. Facebook social media apps in question 3. Instagram 4. Snapchat (Check all that apply) 5. Tinder 6. Grindr Qn.43 Please indicate on a scale of Never Never Few Few Few Once a Once Seve to multiple times a day how often (0) times times a times a week a day ral you engage in the use of social a year month week (4) (5) time media (1) (2) (3) s a day (6) Qn.44a Whatsapp Qn.45b Instagram Qn.45c Twitter Qn.45d Snapchat Qn.45e Facebook Qn.45f Tinder Qn.45g Grindr Qn.45h Other 66 University of Ghana http://ugspace.ug.edu.gh Qn.45i Years of social media use …………………. What comprises your use of social 0 25% 50% 75% 100% N/A media Qn.46a Chatting Qn.46b Watching and posting videos Qn.46c Meeting new friends Qn.46d Watching and posting pictures Qn.46e Meeting people of the opposite sex Qn.47 Have you ever seen any Sexually Explicit Materials (porn, nudity in pictures, nudity in videos, sex tapes, sexual conversations, information 0. No………. 1. Yes……… about sex) on any of your social media platforms? Qn.48 On which social media platform are Whatsapp Twitter Facebook you exposed to sexually explicit Instagram Snapchat materials the most? List all that Tinder apply. Grindr Qn.49 How often? (Daily, weekly, 1. Daily 2. Weekly 3. Monthly 4. Rarely monthly, rarely??? Qn.50 Which of these adjectives describe 1. Arousal how explicit sexually explicit 2. Disgust material viewed on social media 3. Educative makes you feel. Tick all that apply. 4. Informative ……. 5. Other………….. Specify…………………………………………………………… Qn.51 Has social media been a source of 0. No……… information on sex for you? 1. Yes……… Qn.52 If yes, kindly explain how? ………………………………………………………………………………… SOURCES OF INFORMATION ON SEX? Qn.53 Traditional media i.e. TV, radio, print media e.g. magazines & newspapers, music What is your source of information Family( Parents & siblings) on Sex? List all that apply Peers Religious bodies Education in School (Sex education) Social media Other: Specify…………………………………………………… Qn.54 What is your source of information Traditional media i.e. TV, radio, print media e.g. magazines & on contraception use? List all that newspapers, music apply Family( Parents & siblings) Peers Religious bodies Education in School (Sex education) Social media 67 University of Ghana http://ugspace.ug.edu.gh Others: Specify………………………………………………… Perceived Percentage social media Sexually Explicit content Qn.55 What percentage of your knowledge 0 25 50% 75% 100% NA Othe on Sex / Sexually Explicit content % rs did you obtain from social media? Qn.56 If Others please specify: …………………………………………………………………………………….. Have you ever met a sexual partner 0. No……… via any social media platform? 1. Yes……… Qn.57 If so specify Qn.58 Are you ever engaged or have you 0. No……… ever engaged in sexual 1. Yes……… conversations on social media? Qn.59 If yes, with whom….. 1. Family ………………………………… 2. Friends/ peers ………………………………. 3. Sexual partner ………………………………… 4. Others …………………………………………. (Specify)………………………………….. Thank you for your time 68 University of Ghana http://ugspace.ug.edu.gh Appendix D: Ethical clearance 69