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Background: Difficulty in accessing sexual and reproductive healthcare is one of the challenges young refugee women face worldwide, in addition to sexual exploitation, violence and abuse. Although Ghana hosts several refugees, little is known about their sexual behaviour and contraceptive use. This study assesses sexual behaviour and contraceptive use among female adolescent refugees in Ghana. Methods: A cross-sectional survey was conducted between June and August 2016. Respondents comprised 242 female adolescent refugees aged 14-19 years. Structured validated questionnaires were used to collect data. Descriptive statistical methods and multivariate logistic regression statistical analyses methods were used to analyze data. Findings: Over 78% of respondents have had penetrative sex; 43% have had coerced sex; 71% have had transactional sex; 36% have had sex while drunk, 57% have had 4-6 sexual partners in the last 12 months before the study, and 38% have had both coerced and transactional sex. Factors that predicted ever having transactional sex included being aged 14-16 compared to those aged 17-19 (AOR =4·80; 95% CI = 2·55-9·04); being from Liberia compared to being from Ghana (AOR = 3·05; 95% CI = 1.69-13·49); having a mother who had no formal education compared to having a mother with tertiary education (AOR = 5.75; 95CI = 1.94-14.99); and living alone (self) compared to living with parents (AOR = 3.77; 95CI = 1.38-10.33). However, having 1-3 sexual partners in the last 12 months as against having 4-6 partners significantly reduced the odds of ever having transactional sex (AOR = 0·02; 95% CI = 0·01-0·08). Awareness about contraceptives was 65%, while ever use of contraceptives was 12%. However, contraceptive use at last sexual intercourse was 8.2%, and current use was 7.3%. Contraceptive use was relatively higher among those who have never had sex while drunk, as well as among those who have never had transactional sex and coerced sex. Contraceptive use was similarly higher among those who had 1-3 sexual partners in the last 12 months compared to those who had 4-6 during the same time period. Conclusion: In this time of global migration crises, addressing disparities in knowledge and access to contraception as well as high risk sexual behaviours in refugee situations is important for reducing inequalities in reproductive health outcomes and ensuring both universal health coverage and global health justice. Sex and contraception education and counselling, self-efficacy training, and skills acquisition are needed to help young refugee women negotiate and practice safe sex and resist sexual pressures.
A cross-sectional survey was conducted, using validated structured questionnaires as data collection instruments. The design, implementation and reporting of results followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies. The Budumburam Refugee Camp was the study’s site. The Camp is located in the Central Region of Ghana, 44 km west of Accra [22]. The UNHCR, together with the Ghana Refugee Board (GRB), opened the Camp in 1990, and it is currently the largest of four refugee camps in Ghana [21]. The camp is home to some 42,000 refugees and internally displaced persons [21]. Most refugees are from Liberia, who fled their country during the First Liberian Civil War (1989–1996) and the Second Liberian Civil War (1999–2003) [21]. Refugees from Sierra Leone who also escaped from the civil war (1991–2001) are present. Refugees from Ivory Coast and other internally displaced Ghanaians also live in the camp. The camp however is not a highly restricted zone, and this allows mixing of refugees and non-refugees on regular basis. In terms of healthcare, the St Gregory Catholic hospital, also known as the Budumburam hospital, is the only hospital at the camp [22]. Sexual and reproductive health services, including family planning and contraception counselling and services, are generally available as part of broader maternal and child health services offered at the hospital. There is however considerable pressure on the services offered at the Budumburam hospital. Consequently, other auxiliary service providers such as community pharmacies often serve as important sources of contraceptive information and services. Female adolescent refugees aged 14–19 years were included in the study. To be included, a respondent aged 14–19 must have been resident (irrespective of years of residence) in the camp, and be registered with the GRB as a refugee or internally displaced person. To determine a minimum sample size that could allow for any significant statistical association between independent variables and the outcome variable to be detected, we assumed that 19% of the adolescent refugees have ever used modern contraceptives. This assumption is based on contraceptive use prevalence among adolescents reported in Ghana’s most recent demographic and health survey [20]. Based on this assumed prevalence of modern contraceptive use, and assuming a confidence level of 95%, a statistical power of 80%, and a 5% margin of error, we estimated a minimum sample size of 227 using Cochran’s statistical formula [23]. To ensure that the stud was powered enough however, we aimed to include all young refugee adolescents who met our inclusion criteria. To do this, we approached the GRB to request for data covering all female refugees and internally displaced persons aged 14–19 years at the time we approached the Board. The GRB has a database covering nearly all refugees and internally displaced persons in the Camp. A total of 322 potential respondents were obtained after the researchers were given access to the entire database to screen all registered refugees and internally displaced persons in the camp. All the 322 female adolescent refugees/internally displaced persons were included in the study. Following this initial screening and identification of potential respondents, we made several recognizance visits to the camp to identify these adolescents. The identification process started with initial engagement with Camp managers, and country representatives of refugee associations. Management of the hospital was also engaged in this initial process. This engagement gave the researchers an opportunity to explain the purpose of the research to camp managers and leaders and to gain their support. Following this engagement, leaders of various refugee associations helped the researchers to identify the respondents. A total of 238 adolescents were successfully identified through this process. Some 84 potential participants could not be traced for a variety of reasons, including relocation outside the camp and back to their home country. However, a total of eight (8) additional potential respondents were identified. These were not initially part of the list the Board gave the researchers access. In all, 246 female adolescent refugees/internally displaced persons were included as the final sample size. Finally, the researchers visited each of the selected adolescents in the camp, where the purpose of the study and sampling procedures were thoroughly explained. They were then given one week to decide on their participation if they were alone or aged 18+ or discuss their participation in the study with their parents/guardians/partners if they were living with one and aged below 18 years. They were each re-contacted via telephone after the one-week period. Where the decision was in favour of participation, survey dates were arranged. However, where the decision was against participation (and there were only four such cases), such adolescents were dropped from the study. Empirical research involving human subjects, particularly vulnerable groups like adolescent refugees, is a moral and an emotional encounter much as it is a scientific and intellectual enterprise. This makes the process of data collection and analysis dialectic, between moral judgment and intellectual rigour. Therefore, issues of ethics must be taken seriously. For this reason, the protocol for this study was submitted to the Ghana Health Service Ethical Review Committee for ethical review and approval (ETHICS APPROVAL–ID NO.: GHS-ERC:12/12/2015). In addition, written permission to conduct the study was obtained from the Ghana Refugee Board, and UNHCR. Before each potential study respondent was surveyed, she signed or thumb-printed a written consent form after detailed explanations. Consent of parents/guardians were obtained for respondents below 18 years, and such respondents then assented to their parents’/guardians’ consent. The informed consent form contained names and telephone numbers of the Principal Investigator and the administrator of the Ghana Health Service Ethical Review Committee. Prior to all surveys, the interviewers reviewed the informed consent form with each respondent. Respondents were particularly told about the rational of the study, the procedures and amount of time they will be required to spend on answering survey questions. Also, the benefits and risks of the study and how they were selected to take part in the study were communicated to each respondent. All such information was presented or communicated in a language that was understandable to each respondent. A copy of the signed or thumb-printed consent form was given to the participant and another one kept by the lead investigator for future reference. Respondents were told individually that participation in the study was purely voluntary, and that they were free not to participate in the study (even if their parent/guardian had given consent), withdraw consent at any time, and refuse to answer any question in the course of the survey. Respondents were also informed that their decision not to participate in the study will not have any negative consequences for them or their families. The confidentiality of all study respondents was protected. Respondents were not identified by name on any survey questionnaire or any other documentation. All study records were also kept in a locked file cabinet. All computer entry and networking programmes only identified respondents with coded identification numbers. Respondents were also not reported by name in any report or publication resulting from data collected in this study. The privacy of all respondents was ensured. Surveys were conducted in venues that ensured maximum privacy of respondents in addition to being convenient to every respondent. Neither the name/address of respondents nor any voice identifiers were used to identify individual respondents. Data from this research were entered into access-controlled and password protected databases, accessible only to the research team, and members of the Ghana Health Service Ethical Review Committee based upon request. All respondents were informed that there were no direct benefits of participating in this study. They were however informed that the information that they will each provide may help improve access to sexual, reproductive and maternal healthcare services for women and girls living under refugee situations. Also, no compensation was paid to respondents for participating in the research. However, transport reimbursement was provided to those who travelled to take part in the survey. No biological samples were collected, and respondents were not exposed to any physical danger when they took part in the study apart from the time they spent answering the questions. However, some respondents did feel uncomfortable discussing their sexual health issues, especially in contexts where sexual abuse had occurred. In such situations, arrangements were made and respondents were referred to appropriate health facilities or healthcare providers for psychological counselling and support. Where the psychological counselling and support services came with cost, the PI provided appropriate financial support to help defray the cost of such services. Structured questionnaires were designed and administered to collect data. The questionnaire included validated questions on contraceptive knowledge and use from the Ghana Demographic and Health Survey 2014 [20]. Relevant additional questions were included based on previous studies in Tanzania [6], Kenya [7], and Finland [3]. To avoid any misinterpretations of questions and to further validate the instrument, draft questionnaires were pre-tested in one of the three other smaller refugee camps not included in this study. We tested the reliability of the instrument and realised a Cronbach’s alpha coefficient of 0.89. This level of reliability of our data collection tool is considered in literature to be good [24]. The actual data were collected between June and August 2016. Interviews were conducted in three languages: English, French and Twi (the most commonly spoken local dialect in Ghana). The administered questionnaires were first manually examined for completeness, then hand–coded and entered into Microsoft Excel. To ensure data quality, the second and third authors independently entered the data. The first author then compared the two data entries. Errors and inconsistencies that were detected were discussed and resolved before a single database was created and exported into Stata 14 version software for further cleaning. Cleaning of the data was done by running frequencies on each variable. This checked inconsistently coded data. All inconsistently coded data were double-checked with raw data from the questionnaire, and all inconsistencies and errors were resolved. The main outcome variable was ever use of modern contraceptive. We defined modern contraceptive use in line with the Ghana Demographic and Health Survey as the use of any of these methods: female sterilisation, male sterilisation, intrauterine device (IUD), implants, injectable, the pill, male condoms and female condoms, and lactational and amenorrhoea method (LAM) [20]. This was measured as a categorical variable with a dichotomous outcome, and coded as 1 if respondent has ever used any of the modern contraceptive methods above, and 0 if the respondent has not. A secondary outcome variable was risky sexual behaviour, which we broadly defined to include multiple sexual partnerships, drunk sex, coerced sex (e.g. rape), and transactional sex (that is, trading sex for food, protection or other material and psychosocial benefits). We measured multiple sexual partnership in terms of the number of sexual partners a respondent has had in the last 12 months before the survey. The measurement was originally done using an ordinal scale (i.e. 1, 2, 3 tec.), but we recoded this ordinal scale into an interval scale as 1 if the respondent had 1–3 sexual partners in the last 12 months before the survey, and 2 if the respondent had 4–6 sexual partners. Drunk sex was measured as a categorical variable with a dichotomous outcome, and coded as 1 if respondent has ever had sex while drunk, and 0 if the respondent has not. Coerced sex was also measured as a categorical variable with a dichotomous outcome, and coded as 1 if respondent has ever had coerced sex, and 0 if the respondent has not. Furthermore, transactional sex was measured as a categorical variable with a dichotomous outcome, and coded as 1 if respondent has ever traded sex for food, protection or other material and psychosocial benefits, and 0 if the respondent has not. Several independent variables were also measured, including socio-demographic factors like age and education; sexual behavioural factors like age at first sexual debut; health facility and community level factors such as knowledge of places to get contraceptives. Categorical variables were summarised into frequencies and proportions. Continuous variables were summarised into mean and range. We checked for the skewedness of the distribution of the sample as well as all variables, and all were normally distributed. Socio-demographic characteristics of respondents, risky sexual behaviours and use of modern contraceptives were summarised using descriptive statistics. Bivariate analyses (i.e. chi-square test of independence and fishers exact test) were first performed to examine association between a total of 26 socio-demographic, knowledge/awareness, perception, health system, behavioral and socio-cultural factors, and modern contraceptive use on the one hand, and ever having transactional sex on the other hand. Following from this bivariate analysis, binary and multiple logistic regression models were fitted and odds ratios were estimated to further assess the strength of association among variables that were significantly associated with ever having transactional sex at the bivariate level. For the multivariate analysis, we followed a combination of two approaches to include variables in the multivariate regression model. First, we followed a data-driven approach, where variables that showed statistical association in the bivariate analysis were included in the multivariate model as potential covariates. Second, we also followed a theory-driven approach, where we drew on theoretical literature that suggested there could be a direct relationship either between an independent variable and the outcome variable of interest or that one independent variable could potentially confound the association between another independent variable and the outcome of interest. Confidence level was held at 95%, and P < 0·05 was considered statistically significant.
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