Sexual And Reproductive Health Needs Of Street-Involved Young People: Findings From A Baseline Survey In Southwest Nigeria

Background To achieve the 3, require consideration in the strategies for ensuring universal access to sexual and reproductive healthcare. This study aims to determine the age- and sex-specific sexual and reproductive health (SRH) needs of SIYP in Nigeria. Methods This was a cross-sectional study that recruited 1,505 SIYP aged 10-24 years using respondent-driven and time-location sampling. Data were collected on socioeconomic characteristics, access to SRH information, contraceptive knowledge and use, sexual behavior and sexual practice using interviewer-administered questionnaires. The outcome variables were inconsistent condom use, multiple sexual partners and transactional sex. Binomial regression analysis models were developed to determine risk indicators for outcome variables. Results Though 968 (64.3%) participants were sexually active and 1,089 (72.4%) knew about modern contraception, only 300 (31.0%) sexually active respondents use modern contraceptives. Knowledge of modern contraception (AOR: 0.11; 95% C.I: 0.01-0.82, p=0.03) and being employed (AOR: 0.38; 95% C.I: 0.15-0.95, p=0.04) reduced the odds for inconsistent condom use among male SIYPs. For the female SIYPs, knowledge of modern contraception reduced the odds for inconsistent condom use (AOR: 0.26; 95% C.I: 0.08-0.90, p=0.03), while having access to SRH information significantly increased the odds for inconsistent condom use (AOR: 5.06; 95% C.I: 1.67-15.37, p=0.004). Conclusion There are age- and sex- related differences in the factors associated with risky sexual among SIYP. these differences in the delivery of targeted to reduce sexual health risk of SIYP may partners and transactional Findings the despite a relatively high awareness of modern contraception, less than a third of sexually active SIYP use modern contraceptives. were also age and sex differences in the sexual risk behaviors of SIYP. that SIYP need age- and sex- segmented targeted interventions to address their and reproductive needs.

and use, sexual behavior and sexual practice of the respondents. Sexual risk behavior included inconsistent condom use, multiple sexual partners and transactional sex. Findings from the study showed that despite a relatively high awareness of modern contraception, less than a third of sexually active SIYP use modern contraceptives. There were also age and sex differences in the sexual risk behaviors of SIYP. These findings imply that SIYP need age-and sex-segmented targeted interventions to address their sexual and reproductive health needs.

Background
More than half of the global population are young people age 10-24 years [1]. Young people have an innate curiosity and are adventurous, thus making it critical to address their sexual and reproductive health (SRH) needs. Access to information to enable them make informed choices about their sexuality and protect them from unwanted pregnancies, sexually transmitted infections and its sequelae is critical [2]. Access of adolescents and young persons to culturally sensitive messages on SRH is still inadequate, as there is limited context-specific evidence to facilitate the development of culturally appropriate information for the diverse populations of young people [3,4].
To facilitate the development of strategic actions for the non-homogenous population of young persons, appropriate segmentation of the population based on their social context and their vulnerability is necessary [5,6]. Population segmentation facilitates the design and implementation of programs that enhance equitable access to services. A vulnerable segment of young people are street-involved young people (SIYP), described as those who live "on the street" (work on the streets but return home at night or maintain contact with families) and those who live "of the street" (those who never return home or have lost contact with families) [7,8]. A street child is: "Any girl or boy who has not reached adulthood, for whom the street in the widest sense of the word, including unoccupied dwellings, wasteland, and so on, has become his or her habitual abode and/or source of livelihood, and who is inadequately protected, directed, and supervised by responsible adults" [9]. Several millions of children and youths are street-connected, with the largest burden in low and middleincome countries [10][11][12].
SIYP have limited understanding of and access to information on SRH, making it challenging to make healthy choices and thereby increasing their prospect for having risky sexual behavior such as unprotected sexual intercourse, early age of sexual debut, having multiple sexual partners, and engaging in transactional sex [13,14].
The psychosocial framework for understanding adolescent risk behavior described by Jessor [15] helps our understanding of the complex interrelationship of the risk (and protective) factors that influence risk behavior and consequent health or life outcomes of adolescents. Risky sexual behavior of young people has been described at the personal, family, peer, school and community levels [16].
Personal factors such as age, level of education, sexual knowledge and sources of sex information have been implicated. Family structure and relationships, peer influence, religious beliefs, economic constraints and social changes in the community also influence sexual decision-making among adolescents [16,17]. Poor access of adolescents and young persons to SRH services because of social stigmatization and marginalization makes it challenging for SIYP to access SRH-related treatment, with attendant complications [13,18]. These SRH-related risk factors fit into four of the five domains described by Jessor [15] namely: the social environment, the perceived environment, personality, other behavior and biology/genetics. SIYP are often hidden and thus neglected in most public health interventions [19]. SIYP therefore bear a presumably more substantial burden of SRH needs, including unintended pregnancy and unsafe abortion. One of the specific targets of the Sustainable Development Goal 3 is that by 2030, countries should ensure universal access to SRH-care services, including access to family planning, information and education and the integration of reproductive health into national strategies and programs [20].
To meet this goal, it is important to understand how the interplay of social, economic and cultural factors influence the sexual behaviors of young people, including SIYP. This study is an effort to address one of these gaps: to determine age-and sex-specific SRH needs of SIYP in Nigeria.

Methods
Study design, population and study sites This is a cross-sectional study conducted to determine the SRH needs of SIYPs in two states in southwestern Nigeria. It was a follow-up to the water access, sanitation and hygiene community engagement program reported by Folayan et al [21]. The two States -Lagos and Osun -were purposively selected based on their level of industrialization. Lagos is an industrialized cosmopolitan State while Osun is a less industrialized State.
The study population were male and female adolescents aged 10 to 24 years, living 'on' and 'of' the street. At each study location, places where SIYPs aggregate in large numbers such as major streets, market places and motor-parks were identified through a mapping exercise conducted by the research team along with officials of the State Ministry of Health. These locations were grouped as clusters. The clusters in Lagos State were Bariga and Ajah while that for Osun State were Oke-Baale, Olaiya and Sabo.

Sample size
The determination of sample size for this study was guided by Turner [22] recommended estimates to derive sample size for surveys on orphaned and vulnerable children (OVC) in homeless situations.
Considering the unavailability of data to generate a prevalence rate of OVC in the proposed study environment, the suggested minimum sample size of 800 to 1000 was adopted and 1,505 streetinvolved young people were enrolled in this study.
Study recruitment procedure: Following community engagement, the study participants were recruited using respondent-driven sampling and time-location sampling methods [23,24]. The respondent-driven sampling developed by Heckathorn [25] is a sampling process whereby participants recruit their peers, in hard-to-reach study populations [26]. In this study, the first ten seeds recruited through the respondent-driven sampling were given a labelled tag with generated identity numbers. After their enrollment, they were given two additional tags to recruit friends/peers. Each referred respondent was checked for eligibility, enrolled and interviewed once the eligibility criteria were met. The eligibility criteria were: aged 10-24 years, living 'on' or 'of' the street in Lagos or Osun State and mentally stable.
Study participant recruitment through respondent-driven sampling was slow, as there were identified boundaries within street groups and low density of social networks. The research team then adopted time-location sampling to recruit the target population at specific times, days and venues where SIYP gather [27]. To limit selection bias with this method, we ensured that the venue-day-time options with possible large turnouts of SIYP were selected for the recruitment of participants.
Through the respondent-driven sampling, 34 seeds were recruited, and 465 coupons were given out over six recruitment waves within five days. Only 120 respondents were recruited and interviewed through this method. In contrast, the time-location sampling method resulted in 1,800 coupons given, The questionnaire was administered in a place the respondent identified to be most comfortable to respond to questions. Data were collected by the field worker electronically using REDcap -a secure web application used to build and manage online surveys/databases.

Study instrument
The research instrument was adapted from the "Illustrative questionnaire for interview-surveys with young people" designed by John Cleland for the World Health Organisation [28]. The content of the questionnaire was revised by two experts in sexual and reproductive health, to address the study objectives and fit within the Nigerian cultural context. The revised questionnaire was pre-tested with 20 purposively selected SIYPs at two locations aside the study sites (Ile-Ife and Ibadan), to ascertain the clarity and conciseness of the questions. The tool was revised for language and procedural clarity, then translated into the local dialect (Yoruba) for respondents that do not understand English language. Field workers that speak the other national languages -Ibo and Hausa -were made available to interpret key concepts to study participants where necessary.

Measurement of variables
The explanatory variable in this study was 'knowledge of SRH' measured by (i) knowledge of modern contraceptives; and (ii) access to SRH information. A knowledge of modern contraceptives was deduced from responses to a question asked from respondent -"do you know of any of these methods which men and women can use to prevent pregnancy?" There were seven options -(i) injection, (ii) condom, (iii) emergency contraception, (iv) traditional method, (v) withdrawal method, (vi) safe period and (vii) periodic abstinence. Options i-iii were recoded as '1' implying knowledge of modern method of contraception; and others were recoded as '0'. Further, respondents were asked 'if they ever attended/or were given a talk on SRH'; a positive response was assigned "1", and otherwise "0". The respondents were also asked to state the contraceptive method used at last sexual activity by self or partner.
The variables adjusted for in this study were selected background characteristics of respondents: age [10-14, 15-19, 20-24years], educational status [none, primary, secondary] and employment status [not working, working]. The outcome variable was 'sexual risk behavior' proxied by three variables: (i) inconsistent use of condom, (ii) multiple sexual partners; and (iii) transactional sex. Both male and female respondents who were sexually active were asked if they used condom at the last sexual activity. An answer in the affirmative was assigned "1"and a negative response was assigned "0".
Respondents were also asked the number of sex partners they currently had. Those who responded they had one were assigned "1" while those with more than one sex partner were assigned "0". Also, two questions were asked to probe for transactional sex: "have you ever paid or exchange gift for sex?", and "have you ever been paid or receive gift in exchange for sex?
". An answer in the affirmative to either of the questions was assigned "1" and a negative response was assigned "0".

Analysis
Data analysis was conducted using Stata SE 15.1 (Stata Corporation, College Station, Texas). The univariate analysis was conducted to determine the percentage distribution of participants by age in grouped years [10-14, 15-19, 20-24], sex, educational level, employment status, knowledge of modern contraception and access to SRH information. Bivariate analysis was conducted to test associations between the explanatory and outcome variables using Pearson chi-square test. The inferential analysis was conducted using logistic regression to determine the risk indicators for the outcome variables by sex. Two models guided the regression analysis. The first model regressed each of the outcomes against the explanatory variables, while the second model adjusted for confounders (age, literacy level, and work status).
Based on the Pearson chi-square significant association test, we set the p-value cut-off point of 0.20 (p ≤ 0.20) for the inclusion of confounders in the regression model. The Hosmer-Lemeshow goodnessof-fit test was conducted to ascertain all study variables fulfilled the underlying assumption of a

Results
Background characteristics of study participants The distribution of the respondents by age, level of education, and work status is shown in Table 1.
Most of the respondents were in the 15-19 years age group (41.3%), had no formal education (50.8%) and were unemployed at the time of the interview (57.2%).
Knowledge of sexual and reproductive health Table 2 also shows the age and sex distribution of respondents by their knowledge about SRH issues.
Most (72.4%) of the respondents knew about modern methods of contraception, though the majority (84.0%) had no access to SRH information. Those that had access to information (16%) received it through formal talks or at health facilities. More female than male respondents knew about modern contraceptive methods (75.9% vs 69.8%; p = 0.01) and had access to SRH information (21.6% vs 11.9%; p < 0.001). Also, significantly more SIYPs who were 10-14-years-old did not know about modern contraception (p < 0.001) and had no access to SRH information (p < 0.001) when compared with those 15-19years-old and 20-24years-old.    Table 3 highlights the sex differences in the sexual risk profile of sexually active SIYPs, while Table 4 highlights the age differences. Significantly more male than female SIYP who were 20-24 years old (p < 0.01), more females than males who were 15-19 years old (p < 0.01), and more females than males who knew about modern contraception (p < 0.001), used condom inconsistently. More 20-24-year-old males and 15-19-year-old females (p < 0.01) had multiple sex partners. Also, more male SIYP who were 20-24-years-old and more females 15-19-years-old (p = 0.02), more males who can read and write (p = 0.02), more 10-14-year-olds who cannot read and write (p = 0.02), and more 10-14-yearolds who had knowledge of modern contraception (p < 0.001) engaged in transactional sex. Table 4 Background Characteristics, SRH Knowledge and Sexual risk profile of sexually active SIYPs by Age

Discussion
The study indicates that the age-and sex-related SRH risk indicators for SIYPs differed. The older the age group, the less likely female SIYPs were to use condom inconsistently and have multiple sexual partners; and the less likely male SIYPs were to use condom inconsistently. While knowledge about modern contraception and education level were risk indicators for male SIYPs to engage in transactional sex, they were not for female SIYPs. Access to SRH information was a risk indicator for inconsistent condom use by female SIYPs and not male SIYP.
One of the strengths of this study is the large sample of SIYP recruited for the study. This makes it possible to conduct a robust analysis. The study also recruited participants from different cluster areas in each state and from two states with different economic profiles, thereby reducing the risk for non-representation of study participants. The fewer positive responses on some variables however, resulted in wide confidence intervals. Also, the face-to-face interviews increased the risk for social desirability response bias [29]. Despite these limitations, the study highlights the age and sex differences in SRH intervention needs for SIYPs in Nigeria.
First, the study highlights that there is a high unmet need for contraception among SIYPs. The proportion of sexually active female SIYP not using any form of contraception was higher than the 48.4% national estimate of unmet contraception need among sexually active unmarried women [30], and higher than the 40.5% reported for 10-24 year olds living in households in Sierra Leone [31].
Unmet need for contraception among adolescents in developing countries is high -more than 40% in most countries in sub-Saharan Africa [32] -with sex, marital status, age, education and environment variations [33,34]. This high unmet need for contraception -a rate higher than the national averageis an indication that critical attention needs to be paid to this large population of adolescents. The 2019 draft national adolescent health policy recognizes the need to attend to the SRH need of streetinvolved young people for the first time. However, the translation of this policy into programs and interventions for this population once the policy is ratified, remains to be seen.
Second, we found that the contraception option used by SIYP is highly limited to condoms. Similar observations had been made in an earlier study, and the reason adduced is that condoms are relatively inexpensive and accessible [35]. The large proportion of sexually active SIYPs who use condom inconsistently significantly reduces its usefulness in the prevention of unintended pregnancy in this population. As SIYP are already in a precarious situation of increased vulnerability to SRH problems, the occurrence of unintended pregnancy may likely lead to unsafe abortions with its attendant adverse consequences. It is therefore essential to actively promote the use of more effective, user-independent long-acting reversible contraception (LARC), such as intrauterine devices and implants, in sexually active SIYP that want to delay childbearing [36].
LARC requires a visit to the health facility for insertion and removal. The low utilization of clinics for uptake and use of contraception by adolescents and young persons in Nigeria [37][38][39] will likely be a barrier for LARC access by SIYP. Poor attention paid to the SRH needs of SIYP will further limit their use of healthcare services to address their SRH needs. Where young persons access clinics for SRH services, the discordance between the national policy documents and hospital family planning protocols on LARC further reduces the chances of SIYP accessing LARC. In Nigeria, though the full range of contraceptive services is theoretically available, contraception counseling for young people is often limited to barrier methods, pills and emergency contraception [19]. Efforts are needed to promote not only access of adolescents and young persons to SRH services, but also access of SIYPs to these services. Opportunities should be created for the healthcare providers to screen and counsel SIYP on SRH issues to promote support for making healthy choices [40].
Third, this study identified significant age and sex differences in the sexual risk behavior of SIYPmore females inconsistently use condom, while more males engage in transactional sex. Also, more of the younger adolescents SIYPs engage in risky sexual behavior. This information is important for the design of targeted and segmented interventions for SIYP. Such interventions will best be conducted by adapting SRH risk-reduction messages for different age-and sex-segmented populations. Parental consent was waived for children below 18 years from all the ethics committees. This was because the study was non-invasive, the children were street kids, many being matured minors, and the associated challenges of locating parents for study approval purposes.

Consent for publication
Not applicable Availability of data and materials The datasets analysed during the current study are available from the corresponding author on reasonable request.