A survey conducted in Sri Lanka reveals low levels of sexual and reproductive health knowledge among students aged 16–19.1 For example, only one in 10 could correctly identify a method of contraception, and fewer than 1% correctly answered all four of the survey’s primary sexual knowledge questions. The survey also examined sexual attitudes and behaviors, and found that males were more likely than females to consider sexual relationships acceptable among youth their own age (21% vs. 8%). Just 2% of the adolescents had had sexual intercourse; 57% of these youth had used contraceptives at first sex, and 63% had ever used contraceptives.

The lack of information on the reproductive and sexual health needs of adolescents in Sri Lanka has been highlighted as an area of national concern. To help identify these needs and to inform reproductive health policy, in 2010 researchers conducted the first survey in 10 years to assess the sexual and reproductive health knowledge, attitudes and behaviors of in-school teenagers. Students from randomly selected government schools in Badulla District (an area socioeconomically similar to the rest of the country) were eligible for inclusion if they were aged 16–19, were attending grades 11–13 and had been registered in a state school between July 2007 and June 2009. The self-administered survey, which was completed by 2,020 students (response rate, 90%), included questions on social and demographic characteristics, socioeconomic status, sexual and reproductive knowledge, attitudes toward premarital sex, and sexual behaviors. The researchers computed descriptive statistics and used chi-square testing to identify statistical differences between males and females in sexual knowledge, attitudes and behaviors.

Overall, 26% of the respondents were male and 74% were female, reflecting the sex ratio in state schools. The majority of students were aged 16–17; almost all of the students were Sinhalese (97%) and Buddhist (96%). Nine percent characterized their home environment as poor, most often because of financial difficulties or paternal alcoholism. Levels of parental closeness were high: Nine-tenths of participants reported being very close to their mother, and two-thirds reported being very close to their father. Although 57% of females and 34% of males identified their parents as their most important source of general support, only 45% of females and 3% of males identified them as their most likely source of support and information concerning sex. About one-third of males and one-fifth of females said they had no one with whom to discuss sexual matters; their most preferred sources of information on sexual issues were health personnel (midwives and public health inspectors; 20%) and doctors (18%).

The four questions that served as indicators of reproductive health knowledge revealed substantial deficits. Fewer than 25% of respondents were aware that it is possible to acquire an STI at first sex, and a similarly small proportion knew that it is possible to become pregnant at first sex. Just one in 10 correctly identified a contraceptive method, and even fewer (6%) could identify a way to prevent STI transmission. Only 0.4% of respondents answered all four questions correctly.

The respondents also fared poorly when asked to identify the phase of the menstrual cycle during which conception is most likely to occur; most said they did not know, and none of those who answered did so correctly. Moreover, although 83% of students had heard of AIDS and 77% of gonorrhea, much smaller proportions had heard of syphilis (22%) and trichomoniasis (7%).

Attitudes toward sex were assessed with questions about the acceptability of various types of relationships. Males were more likely than females to believe that it is acceptable for youth their own age to have relationships that are more than friendship (39% vs. 24%) or to have sexual relationships (21% vs. 8%). Eighty-three percent of young women agreed or strongly agreed that females should be virgins at marriage, and 53% believed that males should be. Among young men, 66% believed that females should be virgins at marriage, while 44% believed that males should be.

Three percent of respondents said they themselves had engaged in some sort of sexual activity; 23% of these youth said the experience had been nonconsensual. Two percent of students indicated that they had had intercourse. Among these respondents, more than half of males reported that they had wanted their first intercourse to occur and were glad it had happened; none of the females expressed similar sentiments, because all felt they had been too young. Contraceptive use at first sex was reported by 57% of sexually experienced respondents, and ever use by 63%.

The authors note several limitations. The results cannot be generalized to adolescents who do not attend state schools or to Sri Lanka’s ethnic minorities, who were underrepresented in the survey. Students may have underreported sexual activity. Furthermore, to assuage the anxiety of stakeholders, the most sensitive survey questions were phrased in ways that might have resulted in ambiguity for the respondents (and hence in reporting errors); for example, the phrase “intimate sexual relationship” was used to indicate intercourse. Despite these limitations, the researchers note that their findings indicate an “alarmingly low” level of sexual knowledge among surveyed youth. Given the high degree of school attendance in Sri Lanka, they suggest that the country is well-equipped to provide adequate sex education to the majority of adolescents; the characteristics of effective sex education programs in other developing countries could be used to develop “a more comprehensive and effective programme.” The researchers note that greater efforts are needed to provide sexually active students with information, support and access to contraceptives (which in Sri Lanka are typically available only to married individuals), and conclude that to address the needs of adolescents, “it is essential that the [study] findings are translated into concrete action at policy and practice levels.”—L. Melhado

REFERENCE

1. Rajapaksa-Hewageegana N et al., Sexual and reproductive knowledge, attitudes and behaviours in a school going population of Sri Lankan adolescents, Sexual and Reproductive Healthcare, 2015, 6(1):3–8.