Early Adolescents’ Knowledge, Beliefs and Behaviours Regarding Gender and Sexuality in Rwanda: Implications for Their Sexual Experiences and Health Outcomes

Abstract

Background: Access to sexual and reproductive health and rights (SRHR) information during adolescence is a fundamental human right and helps adolescents fully develop their potential. Due to developmental changes, early adolescence (10-14 years) offers an opportunity to shape early adolescents' sexual behaviours through various opportunities for education about their sexual and reproductive health before their behaviours become well-established in late adolescence and adulthood. Their sexual and reproductive health and rights knowledge, beliefs and behaviours play a significant role and may affect their sexual experiences and health outcomes. Rwanda has established several policies to promote adolescents' sexual and reproductive health and introduced comprehensive sexuality education (CSE) in schools in 2016 to enhance young people's knowledge, skills, and values to allow them to decide responsibly about their sexual and social relationships, and to promote and sustain risk-reducing behaviours. There has been a significant focus on older adolescents’ sexual and reproductive health and rights and limited focus on early adolescents. Limited evidence on the sexual knowledge, beliefs, and behaviours of young adolescents resulted in framing this research, and there are no similar studies for this age group. This research explores the extent to which early adolescents aged 12-14 years are knowledgeable about their SRHR and assesses whether this knowledge and attitudes have implications for their sexual experiences and health outcomes. This study aimed to assess how SRHR policies in Rwanda address the specific information needs of early adolescents in general and explore the extent to which SRHR knowledge influences sexual behaviours, sexual experiences and health outcomes among this age group (12-14 years). Methods: This research was conducted in three phases, including the desk review, the survey with early adolescents aged 12-14 years (phase 2), and focus group discussions to complement findings from phases one and two and the integration of findings (phase 3). The study used a social- ecological framework adapted for adolescent sexual and reproductive health, whereby multiple factors at the individual, relationships, community and societal levels interact to influence early adolescents' SRHR knowledge, beliefs, behaviours, sexual experiences and health outcomes. The research started with the policy review using the policy triangle framework. This framework identifies four key elements of a policy: context, content, process and actors. The policy review process facilitated engagement with gender and sexuality education stakeholders. This allowed them to share their perspectives on best enabling access to gender and sexuality information for viii early adolescents. Findings from these stakeholders also allowed us to explore the content of SRHR messages conveyed to early adolescents in Rwanda through a review of the CSE as embedded in the competence-based curriculum. The International Technical Guidance on Sexuality Education guided this review. Finally, a survey with 811 early adolescents and 13 focus group discussions with 108 early adolescents allowed us to explore the extent to which this age group were knowledgeable about SRHR, their sexual experiences and health outcomes. Quantitative data were analysed using descriptive and inferential statistics, while qualitative data were analysed thematically. This research obtained ethical and other necessary approvals from research institutions controlling research in Rwanda and from the Human Research Ethics Committee (HREC - Medical) of the University of the Witwatersrand. Furthermore, signed informed consent from SRHR stakeholders and participants' parents or legal guardians and written informed assent from early adolescents were obtained from those who had received parental consent. Findings: SRHR policies generally focus on adolescent health and have little focus on gender and sexuality information and knowledge for early adolescents. SRHR stakeholders indicated that access to gender and sexuality information was determined by factors at the individual level, such as curiosity and age; the relationship level, such as parent-child interaction; the community level, such as the sources of information available, the scope of SRHR programmes, and the general SRHR stakeholders’ misunderstanding about gender, norms; and the societal level such as limited resources, policy-making pathways, unfriendly laws. The CSE review showed that, of the eight areas recommended by UNESCO, CSE for early adolescents in Rwanda focuses mainly on four areas: sexual and reproductive health; human body and development; values, rights, culture and sexuality; and understanding gender, respectively. There was little or no emphasis on the topics of the four other recommended areas of sexuality education, which were violence and staying safe, skills for health and well-being, sexuality and sexual behaviour, and relationships. Findings from stakeholder interviews support these results and suggest other topics to be included in the CSE curriculum because of controversies surrounding these topics in Rwanda. Of the 811 participants involved in the quantitative survey, the majority were females (51%) and 49% males. Their age range was 12-14 years (n=802), and most were 14 (55.4%). Early ix adolescents showed that their knowledge of SRHR was generally low: scores about knowledge of sexuality were below 50% (mean score: 2.8 out of 6, 95% CI: 2.7-2.9), 42% (mean score: 4.9 out of 12, 95% CI:4.8-5.1) about contraceptive methods, 65% (mean score: 8.4 out of 13, 95% CI: 8.2- 8.5) about HIV/AIDS and sexually transmitted infections, and 54% (mean score: 7.1 out of 14, 95% CI: 6.9-7.3) about condoms. Concerning attitudes, 90% of participants exhibited favourable attitudes (>50% score) towards sexual norms, and 97% had a gender-equitable attitude (>50% score). In the survey, about 81% of early adolescents reported a lifetime involvement in any of the nonpenetrative sexual experiences (hugging, holding hands, caressing, kissing on the lips, touching or being touched on genitals, stroking or being stroked genitals to climax). In comparison, 7% of participants reported having experienced penetrative sexual experience involving oral sex, anal and/or vaginal intercourse. Attendance at parties where young people dance and fathers having a lower level of education were associated with higher odds of non-penetrative sexual experience. Factors associated with the experience of penetrative sexual intercourse were being male, drinking alcohol, watching pornographic films three or more times, being a double orphan, discussing sex matters often with one’s father and being forced to have sexual intercourse. High scores on knowledge about condoms and positive attitudes towards sexual norms were associated with both non-penetrative and penetrative sexual experiences. Those with high scores on HIV/AIDS and STDs were less likely to report penetrative sex. Positive gender attitudes were associated with non-penetrative experiences. Concerning participants’ sexual behaviours, periodic abstinence and condoms were the commonly used methods of contraception by the participants, and a significant proportion of them reported having a boy/girlfriend/partner. None of the girls had been pregnant, but four of 311 boys (1.3%) reported impregnating girls or a woman. Nearly 70% of the participants have had an HIV test, and a few reported having had an STD. Knowledge about sexuality, contraceptive methods, and condoms, attitudes towards gender and sexual norms were associated with testing for HIV. Qualitative findings from the focus group discussion revealed that early adolescents benefited from the SRHR information and knowledge that shaped their sexual behaviours and improved their health outcomes. Concerning the relationship between various sources of SRHR information and participants' knowledge, beliefs and behaviours, this research found that schoolteachers were the primary and x preferred sources of SRHR information on puberty and reproduction. Girls preferred their mothers, female schoolteachers, sisters and other extended family members, such as aunts, as sources of SRHR information. In contrast, boys preferred obtaining SRHR information from their fathers and brothers, as well as from films, the internet and television. Conclusion: SRHR knowledge, attitudes, behaviours, experience and health outcomes of early adolescents should be put in their context for interpretation. SRHR policy does not adequately address their specific information needs, and most early adolescents access SRHR information but have a low level of SRHR knowledge. However, this knowledge is vital for their complete and safe sexual health development. Some early adolescents have started engaging in sexual experiences and face challenges related to poor sexual health outcomes. Recommendations include the use of a multi-sectoral approach to promote early adolescents' access to SRHR information and to address their specific needs by involving more stakeholders (e.g. early adolescents and community members) in SRHR policy-making processes, addressing the social-ecological factors hindering proper access to good quality of SRHR information, those associated with sexual experiences; and delivering comprehensive sexuality education as per recommended standards. Future research should focus on integrating the specific needs of early adolescents in the SRHR policies, exploring the challenges related to implementing comprehensive sexuality education (CSE) in school settings and assessing the effects of CSE on the learners’ behaviours and sexual experiences. Future research should also examine the role of faith-based organisations in imparting CSE and explore approaches to delivering high-quality SRHR information to early adolescents. Similar research should be conducted among out-of-school early adolescents aged 10-11 years and those attending schools using international curricula in Rwanda.