1 Introduction

Globally, more than 46 thousand adolescent girls give birth daily [1], with the highest rates in sub-Saharan Africa, particularly in West and Central African regions where it is estimated that over one in four young girls give birth before the age of 18 [2]. In these regions, the birth rate is about 10 per 1000 for girls aged 10–14 and 107 per 1000 for those aged 15–19 [2]. In Nigeria, 9.9% of adolescents aged 15–17, 30.6% of those aged 18, and 37% of those aged 19 have begun childbearing [1, 3, 4]. Most of these pregnancies are unintended, leading to severe consequences for adolescents'health and well-being, including, increased risk of maternal morbidity and mortality relating to childbirth complications and unsafe abortion [5]. Additionally, babies born to adolescent mothers face higher risks of perinatal death and low birth weight compared to those born to adult mothers [6].

Beyond health risks unintended adolescent pregnancies often result in several social and economic challenges, such as poverty, limited employment opportunities, poor educational performance, and stigma [1, 2, 4]. Early pregnancy and childbirth can derail adolescent mothers’ healthy development into adulthood [2]. Many pregnant adolescent girls are pressured to drop out of school due to stigmatization and rejection by family and community, or are forced into early marriage [2]. These further hinder their educational and employment prospects and opportunities.

Several factors contribute to unintended pregnancies among adolescents, including inadequate knowledge, misconceptions, and negative attitudes towards contraceptive use, as well as coercive experiences such as rape and forced sex [7,8,9]. Environmental and peer pressure also hinder adolescents from refusing sex when they do not want it.[7,8,9]. These issues predispose them to a higher risk of STIs and unintended pregnancies. Contraceptive use is the most effective method for the prevention of unintended pregnancies [10, 11]. It offers numerous benefits, such as reducing STIs and improving maternal and child health, as well as promoting girls'education and empowerment [10].

Despite its importance, contraceptive prevalence remains low among adolescents [11]. About 5.1% of adolescents aged 15–19 years worldwide have an unmet need for contraceptives, and the sub-Saharan African region records the highest (10.2%) proportion of adolescents with unmet contraceptive needs [12]. In Nigeria, only 22.2% of sexually active unmarried adolescents (15–19 years) use modern contraceptive methods, while 64.5% have unmet contraceptive needs [3]. Adolescents aged 15–19 have the highest unmet contraceptive need and demand for contraceptives among sexually active unmarried women in the country [3].

While there has been growing attention to adolescent SRH, there remains a gap in understanding the effectiveness of interventions aimed at promoting positive SRH outcomes among this age group [1]. A few have been implemented to influence adolescent behaviors and attitudes toward contraceptive use and reduce unintended pregnancies, but data on their success is limited [13, 15]. Studies conducted in West Africa, Cameroon, and Nigeria have shown promising results from peer education interventions in improving adolescents'attitudes toward contraception, increasing their willingness to purchase contraceptives, and boosting their self-efficacy in using them [14, 15]. Literature also highlights that interventions that combine SRH education with access to services, such as comprehensive post-abortion contraceptive counseling and incentivized participation, are particularly effective in changing adolescents'attitudes toward contraceptive use. [16, 17]. Moreover, the active involvement of young people in the design and implementation of these interventions has been shown to better meet their SRH needs and enhance the interventions'overall impact. [17].

This paper contributes new knowledge on the factors that predict positive attitudes towards condom use, contraceptive use, abortion, and intimate partner violence among adolescents in urban and rural communities of Ebonyi State, Nigeria. It is part of the evaluation of a multi-faceted intervention designed to address the unmet SRH needs of adolescents in the state. By assessing these interventions, the study aims to inform strategies for improving adolescent SRH through evidence-based decision-making, providing valuable information for health policymakers, planners, and implementers. The findings will help shape future SRH programs and initiatives, ensuring that they are responsive to the unique challenges faced by adolescents in these communities and contribute to more equitable access to SRH services.

2 Methods

2.1 Study design and study area

The study was a cross-sectional research that used a mixed-methods study approach to evaluate the effects of community-embedded intervention that focused on improving adolescents’ attitudes towards contraception, abortion, and sexual violence. The study was undertaken in three rural and three urban local government areas (LGAs) in Ebonyi State, southeast Nigeria. About 8.2% of adolescents in Ebonyi state have begun childbearing and the state records the second highest unmet contraceptive need (23%) among sexually active adolescents aged 15–19 years [3]. The study sites were six (6) communities where sexual and reproductive health (SRH) interventions have been implemented and six (6) other communities where sexual and reproductive health (SRH) interventions have not been implemented. These communities were selected from three urban and three rural LGAs representing the three senatorial zones in the state. These LGAs were selected based on the prioritization of the state government for interventions in adolescent sexual and reproductive health and enlistment by stakeholders as having the highest rate of unwanted teenage pregnancy in the State.

2.2 Intervention

Community-based and school-based interventions were implemented in six purposively selected communities. In collaboration with experts at the State and LGA levels, the researchers co-created and implemented these interventions over a period of 2 years. The intervention included training Formal and informal SRH service providers and they included: school teachers, peer health educators, primary healthcare workers, patent medicine vendors, and community health volunteers. These service providers were trained to provide comprehensive adolescent-friendly SRH information and services in schools, communities, and healthcare facilities. In six schools, health clubs were established and, in the community, a series of group awareness campaign sessions were organized and facilitated by trained health workers, school teachers, and peer health educators. The research team and the state-level stakeholders provided routine supportive supervision to the trained service providers to ensure that the intervention strategies are implemented as planned. A detailed description of the interventions can be found in a previously published article [18].

2.3 Sampling and data collection

The study population consisted of unmarried adolescent boys and girls who were either in school or out of school. A total of 855 adolescents aged 13 to 18 years who reside in the 317 selected households were interviewed from the twelve selected communities. The quantitative study participants were selected from the communities using a modified cluster sampling technique. The cluster was defined as a community governed by a traditional leader. Households were selected consecutively, and as the starting point, the closest public facility identified from the main community entrance was used. All eligible adolescents from selected households were invited to consent to study participation. The formula for cross-sectional studies involving two populations (urban and rural) was used to calculate our sample size [19]. Assuming a confidence interval of 95%, power of 80%, and non-response of 10%, a minimum sample size of 820 was estimated. In order to allow sub-group (urban–rural) data analysis, check the robustness of data, and as well account for incomplete data or errors, data was collected from 855 adolescents.

A pre-tested interviewer-administered questionnaire was used to interview the 855 unmarried adolescent boys and girls aged 13–19 that were selected using simple random sampling. The respondents were 413 adolescents from six intervention communities and 442 from six non-intervention communities. Adolescent visitors within the age group of the study population that were medically unfit/impaired and those whose parents/caregivers were not available to consent at the time of the survey were excluded from the study.

For the qualitative study, adolescents were purposively selected to participate in focus group discussions (FGDs) based on their participation in school-based or community-based adolescent SRH intervention activities. A total of four (4) FGDs were conducted for in-school adolescents. Two FGDs were conducted for male adolescents and another two for female adolescents in school. Another four FGDs were conducted for adolescents in the community, two for adolescent boys, and another two FGDs conducted for adolescent girls in the community.

2.4 Data collection instruments

The interviewer-administered pre-tested questionnaire was adapted from the WHO illustrative questionnaire for interview surveys with young people [20]. The questions focused on adolescents’ perceptions of sexual practices about abortion and contraception.

The qualitative data were collected using a pre-tested FGD guide that was developed for the study. Before the FGDs, all participants were informed of the study's objectives, and written consent was obtained for participation and recording of the interview. The FGDs were facilitated by a moderator and a note-taker, and the discussions were audio-recorded. The interviews and discussions were held in participants’ convenient venues.

2.5 Data analysis

2.5.1 Survey (quantitative data)

Both descriptive and logistic regression analyses were employed to examine the survey data. Descriptive statistics utilized means and proportions, while the regression model enabled a more detailed analysis by isolating specific outcome variables—adolescents'attitudes towards condom use, contraceptive use, unsafe abortion, and intimate partner violence. This analysis accounted for variations in individual socio-demographic characteristics (such as intervention groups, age, gender, highest level of education completed, location of residence, and employment status) and non-demographic characteristics (including beliefs, awareness, and behaviors/participation).

Each individual variable was coded as 1 if the respondent exhibited a positive response to a given statement, and 0 otherwise. The overall outcome variable in Table 4 encompasses all dimensions of adolescents'attitudes towards condom use, contraception, abortion, and sexual violence (a total of eight outcome variables as detailed in Table 2) across both intervention and non-intervention groups. An average score was calculated for this table and dichotomized into positive and negative attitudes. The outcome variable for each individual is a dummy variable, assigned a value of"1"(positive attitude) if the individual's score is above the median, and"0"(negative attitude) if the score is at or below the median.

2.5.2 Qualitative data

Firstly, the audio recordings were transcribed verbatim, edited and compared with hand written notes to ensure accuracy. The eight transcripts were imported into NVivo software (version 12). A thematic analysis was carried out using a deductive-inductive approach. Initially, a generic coding framework was developed by the research team guided by the project’s evaluation objectives. This provided a structure for the analysis and was applied to the data using NVivo software. To further refine the findings, word query outputs were generated and thoroughly reviewed to identify the themes presented in this manuscript. A total of four (4) themes emerged, and these are highlighted in Fig. 1.

Fig. 1
figure 1

Emerging themes for analyzing adolescents’ attitude towards condom use and sexual violence

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2.5.3 Ethical considerations

The protocol for the project was approved by the Health Research Ethics Committee of the University of Nigeria Teaching Hospital Enugu and the Research and Ethics Committee of Ebonyi State Ministry of Health. All methods were carried out in accordance with relevant guidelines and regulatory standards. Informed written consent was obtained from parents/guardians of adolescents aged 13 to 17 years who participated in the survey. In addition, written assent was obtained from adolescents aged 13 to 17 years, while older adolescents aged 18 years and above consented for themselves.

3 Results

All the respondents completed the questionnaires giving a 100% of response rate. Table 1 shows the socio-demographic and non-demographic characteristics of surveyed adolescents in the communities. Many adolescents in intervention (58%) and non-intervention (57%) communities are female. Most of the adolescents in intervention (59%) and non-intervention (67%) groups reside in the rural communities 68.3%. A total of 48% of the adolescents received SRH intervention, but only 19.3% had heard about the SRH intervention that was implemented. Among those that heard about the SRH intervention, 60% of them participated in the campaign.

Table 1 Socio-demographic and non-demographic characteristics of surveyed adolescents
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Table 2 shows that 67% of adolescents in intervention group and 62% in non-intervention group agreed that they would refuse to have sex with someone unprepared to use a condom. Approximately, 52% of adolescents in intervention group and 48% in non-intervention group reported that it is a woman’s responsibility to ensure that contraception is used regularly. A higher percent (92%) of adolescents in intervention group reported that they would never contemplate having an unsafe abortion or their partner having one compared to the 78% of adolescents in non-intervention group who agreed to this statement.

Table 2 Adolescents’ attitude towards condom use, contraceptive use, unsafe abortion, and intimate partner violence
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Table 3 presents the logistic regression analysis of factors influencing adolescents'attitudes towards condom use, contraceptive use, unsafe abortion, and intimate partner violence. The findings indicate that adolescents in the intervention communities (OR = 2.29; CI 1.46–3.62) are twice as likely to exhibit positive attitudes towards contraceptive use compared to their counterparts in non-intervention communities. Furthermore, adolescents who have completed senior secondary education (OR = 1.64; CI 1.12–2.40) are nearly twice as likely to demonstrate a positive attitude towards engaging in unsafe abortion services compared to those with lower educational qualifications.

Table 3 Logistic regression of factors associated with adolescents’ attitude towards condom use, contraceptive use, unsafe abortion, and intimate partner violence
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Logistic regression of factors associated with adolescent’s overall attitude towards SRH issues across the intervention and non-intervention groups is shown in Table 4. Overall, adolescents who work for pay in intervention (OR = 2.25; CI 1.22–4.17) group were approximately 2 times more likely to improve in their attitudes towards SRH issues. Adolescents in the intervention group who attended SRH campaign sessions (OR = 1.61; CI 0.78–3.30), discussed sex-related topics with someone afterward (OR = 2.37; CI 1.30–4.32), and believe that SRH services should be provided for adolescents (OR = 1.55; CI 0.09–26.88), were twice as likely to show a positive attitude compared to those who did not in the same group.

Table 4 Logistic regression of factors associated with adolescents’ attitude towards issues on SRH (condom use, contraceptive use, unsafe abortion, and intimate partner violence) across the intervention and non-intervention groups
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3.1 Qualitative findings

The qualitative findings are structured to present the changes in attitude according to the emerging themes from the coding outputs.

3.2 Bold in making decisions on condom use

Adolescents were of the opinion that previously they could not take strong decisions concerning the use of condoms. However, they revealed that the SRH community intervention enabled them to boldly make informed choices/decisions to use condoms and avoid risky sexual behavior. See below supporting quote;

“It has made me valued because in the past I hardly stand firm and make decisions but now I can stand firm and make decisions on my own to use condoms and avoid taking risks”—Female adolescent FGDAF 08

3.3 Now make use of condoms for casual sex and to prevent sexually transmitted diseases (STDs), unplanned pregnancy, and unsafe abortion

3.3.1 Adolescents now make use of condoms when engaging in casual sex

Adolescents described that prior to the SRH intervention, they engage in casual sexual intercourse without the use of contraceptives during social gatherings in the community. However, adolescents now buy and carry condoms when going to community social gatherings to avoid unsafe sexual practices. See a supporting quote:

“When we go to the playground, we used to have sexual intercourse with them [girls] there without using anything, sometimes we will be touching their breasts and other things but now we carry a condom in our pocket in case anything [casual sexual intercourse] happen” – male adolescent FGDAB 05.

3.3.2 Adolescents now make use of condoms to prevent unplanned pregnancies and unsafe abortion

Adolescents’ attitude towards the use of condoms was observed to be positive following the SRH community campaign implemented in their communities. Adolescent boys and girls were of the opinion that previously many adolescent girls in the community were victims of unplanned pregnancies. Also, adolescents described that prior to the SRH information campaign, there was a frequent occurrence and record of parents arresting male sexual partners of the girls who are victims of unplanned pregnancies in the community. However, after the SRH intervention, there are records of positive attitudes toward the use of condoms to avoid unplanned pregnancies among adolescents. See some supporting quotes:

  • “It is very good on the side of boys and girls, before now, many of our girls enter into the trouble of unwanted and teenage pregnancy but since the commencement of the campaign in the community, teenage pregnancy reduced drastically. For any boy that wants to have sexual intercourse with a girl, he will use a condom to ensure that the girl will not get pregnant” – Male adolescent FGDIZ 03

  • “Yes, we were told to use condoms when having sex with girls and we do that now” – Male adolescent FGDIZ 02

  • “Some things changed because before now, you will see several cases where the family of a girl will arrest a boy because he is responsible for their daughter’s pregnancy but it is no longer happening now in this community” – Male adolescent FGDIZ 07

The establishment of the school health club to provide comprehensive sex education to students increased adolescents’ awareness of condom use to prevent pregnancy, as described in the following quote. “It has made an impact on many students in our school like those who normally engage in sexual intercourse now know the consequence and impact. That when they do it without a condom, they can get unwanted pregnant”.—Female adolescent FGDAF 06.

Adolescents mentioned that the reason for attitudinal change in condom use was to focus on their career achievements and avoid circumstances that could jeopardize their future successes. Hence to avoid the occurrence of unplanned pregnancy, he makes use of condoms.

“Before I only think about the girls I will befriend and have sex with even without buying a condom but recently, I pay more attention to what I need to become a successful person in life, and if I want to have sex with my friend, I make sure that I buy condom to avoid stories”—Male adolescent FGDAB 01

Also, adolescents revealed that they use condoms to prevent their engagement in unsafe abortion resulting from unplanned pregnancies. See the following quote: “Using condoms is important, it helps us not get unwanted pregnancy or to commit abortion”—Female adolescent FGDAB 04.

3.3.3 Adolescents now make use of condoms to avoid contracting sexually transmitted diseases (STDs)

In addition to pregnancy prevention, adolescents mentioned that their change in attitude toward the use of condoms is to also prevent them from contracting sexually transmitted diseases (STDs). The finding reveals that adolescents can now insist that their sexual partners make use of condoms before any sexual activity.

“We were taught about sexually transmitted diseases and since then, diseases have decreased because many people that were involved in the teaching take care of themselves, just like me I make sure that my partner buys condom to avoid contracting disease”—Female adolescent FGDIZ 06

3.4 More awareness of sexual violence

The establishment of school health clubs in some schools to provide comprehensive sexuality education to adolescents and their engagement in the club activities increased adolescents’ awareness of sexual violence. This resonated among adolescent girls who are in school. They have become aware of how and where to report sexual harassment issues following the establishment of the school health club in their school. As described by an adolescent girl- “My view about the school health that is taking place in our school is that it has helped young girls to be educated about sexual harassment and how to report it if we are harassed sexually by anybody.”- Female adolescent FGDAF 07.

3.5 Now assertive to say no to sexual violence and forced sex

Predominantly, adolescent girls were of the opinion that they were not bold to say no to sexual advancement from the opposite sex previously. However, after the SRH intervention which included the establishment of the school health clubs, it changed their attitude towards sexual harassment as they have become bold to say no to sexual violence and also can refuse sex if they do not want to engage in it. See the following quotes:

  • “It helps us to be bold to say no to sexual violence and even harassment”—Female adolescent FGDIZ 01

  • “Yes, it has added value to me because before the school health club was established, I was not bold enough to say no to sex, but now I’m bold enough. Sex is not by force.”—Female adolescent FGDAF 07

4 Discussion

This study shows that implementing SRH interventions in communities could promote having positive attitudes toward condom use, contraception, and engagement in unsafe abortion among adolescents. Both the qualitative and quantitative findings of this study support the potential effectiveness of the intervention approach in similar settings for the promotion of contraceptive use, prevention of sexual violence, and increasing demand for SRH services among adolescents. A recent study in India also reported attitudinal change after implementing school-based SRH interventions [21]. Another study showed that interventions promoting sex education significantly govern adolescents’ awareness, attitude, and behavior in SRH matters [15]. The use of multiple strategies to implement SRH intervention is more effective in changing adolescents'attitudes and SRH behaviors [14, 15].

Following the SRH intervention in schools and communities, adolescents who were interviewed revealed that they have become bolder in making decisions on condom use to prevent unplanned pregnancies and sexually transmitted diseases (STDs). This finding aligns with the quantitative results of our study, which showed that adolescents in the intervention group were twice as likely to exhibit a positive attitude towards contraceptive use. Adolescents’ decision to use condoms was shaped by their choice to focus on career achievements and successes. This is comparable to other studies that revealed that adolescents’ condom use decision-making was mostly formed by concerns about their future expectancies [22, 23].

Our findings that age predicts adolescents’ attitudes towards the use of condom and other contraceptives validate a previous study [11] that reported associations between the age of sexual debut and maintaining a decision on condom use during sexual intercourse. This previous research suggests that a delay in sexual intercourse among older adolescents is often associated with adolescents’ decisions to use condoms [11].

Participation in the SRH intervention was a strong predictor of adolescents'attitudes towards SRH issues. Adolescents in the intervention group who discuss sex-related topics with someone afterwards were twice as likely to show a positive improvement in their attitude towards SRH issues, with a statistically significant effect. Contrary to this finding, a 2010 study carried out in San Francisco reported that the intervention involving multiple follow-up calls to adolescent clients did not influence their attitudes and behaviors toward contraceptive use [24]. However, consistent with our findings, an African study conducted in northern Ghana revealed that implementing a comprehensive sex education program significantly improved knowledge and attitudes toward pregnancy prevention among adolescents [25]. Wondimagegene and colleagues reported that school-based peer-led sexuality intervention effectively created demand and improved contraceptive use among sexually active adolescent girls [11]. Also, previous assessments in South Africa and Mexico revealed that young people who received the intervention reported significantly higher use of condoms at follow-up [26, 27].

Adolescents who participated in the SRH campaign, discussed sex-related matters with someone in the community after the intervention, and believe that SRH information and services should be provided to them were more likely to have a positive attitude towards SRH issues. The inference from these findings implies that in designing and implementing adolescent SRH interventions, parents and adults should also be targeted. Culturally appropriate community based SRH intervention targeting adolescents and individuals who could influence their SRH decisions significantly determines their attitude towards the demand for contraception [28]. In the communities where SRH interventions were implemented, community leaders and influencers, parents, and guardians of adolescents were recruited and engaged to improve their SRH communication skills with adolescents. This is because when adolescents discuss SRH matters with parents or adults, it increases their likelihood of exhibiting safe sexual behavior [29].

Adolescents residing in rural areas and those who have completed their secondary education are more likely to have a more positive attitude towards abortion, implying that educational qualifications and geographic location often play a role in shaping adolescents’ attitudes towards abortion. However, restricted abortion laws and negative social constructions of premarital sex and abortion could lead to adolescents’ conservative attitudes toward abortion [30]. Vongxay and colleagues found that only about 12% of adolescents held positive attitudes toward induced abortion [30]. They further revealed that adolescent’s ethnicity and educational qualification of mothers significantly associated with their positive attitudes toward abortion [30].

Adolescent girls are now assertive enough to say ‘no’ to sex if they do not want to engage in sexual intercourse. Adolescent girls were of the opinion that the establishment of a school health club that provided comprehensive SRH information and services in secondary schools increased awareness of their SRH rights and where and to whom to report cases of sexual violence and harassment. Consistent with our qualitative findings, the quantitative data indicated that female adolescents and those in the intervention group were twice as likely to have a positive attitude towards addressing intimate partner violence. However, this association was not statistically significant. This study is comparable to Deshmukh and Chaniana’s study, which found that about half of adolescents surveyed were aware of their right to decide when to have sexual intercourse [31]. Sherman’s recent observation revealed that over the years, female adolescents experience more forceful sex when compared to male adolescents [32]. The author reported that 12% of adolescents in 2011 experienced forced sex in the United States, which increased to 14% in 2021; however, the 4% recorded among males remained stable over the same period of time [32].

This study finding is unique as it provides useful evidence that assessed adolescents’ attitudes towards condom use, contraception, abortion, and sexual violence in communities where SRH interventions have been implemented and non-SRH intervention communities. Also, using a qualitative method, an in-depth assessment to understand the impact of the SRH intervention on adolescents’ attitudinal change was investigated. We do not dispute the fact that there could be information bias due to the sensitive nature of the questions. However, this was put in check from the beginning, as most research assistants whose capacities were built for this study were trained to create a relaxing and non-judgmental atmosphere for discussion.

5 Conclusion

Following the SRH information campaign and school-based intervention, the adolescents showed positive attitudinal changes toward condom use, contraception, abortion, and sexual violence. Adolescents have become bold in condom use decision-making as they now make use of condoms when engaging in causal sexual intercourse to prevent unplanned pregnancy, unsafe abortion, and, as well, avoid contracting sexually transmitted infections (STIs).

Our findings suggest that implementing interventions such as SRH information campaigns in the community and the establishment of school health clubs to provide SRH education prompts adolescents’ positive attitudes towards condom use, contraception, abortion, and sexual violence, thereby decreasing adverse SRH outcomes among adolescent boys and girls. It is recommended that further research and the implementation of interventions reflect the different adolescent diversity to ensure that the adolescent SRH interventions effectively address a variety of demographic and non-demographic factors that predict their SRH attitudes.