Sexual and Reproductive Health Knowledge of In-school Adolescents: A Comparative Study of Visually Impaired and Non-visually Impaired Students

Adolescents’ Sexual and reproductive health (SRH) knowledge is important for preventing SRH problems and enabling young people to live a healthy sexual and reproductive life. This study assessed the differences in SRH knowledge between the visually impaired (VI) and non-visually impaired (N-VI) adolescents; and examined the factors contributing to the differences between the two groups. The study was conducted in Ondo State, Nigeria using a multi-stage sampling technique to select 394 visually impaired and non-visually impaired in-school adolescents aged 15-19 years. Quantitative data were collected using Open Data Kit (ODK). Models were fitted with Ordered Logistic Regression (OLR) using Stata 14. Results showed that 89% of N-VI compared with 66% of VI had good access to SRH information, while 63.4% of the VI and 40.3% of N-VI had poor SRH knowledge. Students with good access to information were more likely to have a better SRH knowledge, although the relationship is stronger for the N-VI than for the VI. The OLR results further showed that the respondents who had good access to information were about 116% more likely to have good SRH knowledge than their counterparts with poor access to information (OR = 2.163; C1:1.41–3.32). Also, the likelihood of the N-VI having good SRH knowledge more than doubled (138% more) that of the VI (OR = 2.377; C1:1.14 – 4.00). Extra-curricular activities also increased the likelihood of good SRH knowledge. The study therefore recommends advocacy efforts to provide adolescents with increased SRH knowledge with special focus on VI.


I. INTRODUCTION
Sexual and reproductive health (SRH) knowledge is important for adolescents' healthy behaviour and in helping them to live above the consequences of poor sexual and reproductive (SR) practices.Adolescent health is a major public health concern since the negative effects of their sexual behaviour can linger till latter life.Adolescents in sub-Saharan Africa today constitute about 20% of the global population of adolescent [1].
Today, about 90% of the world's adolescent population live in the developing countries where there is healthcare system too poor to effectively deal with SRH problems such as teenage pregnancy, abortion, HIV & other life threatening SRH problems and death (suicide), according to United Nations [2].One of such countries is Nigeria where adolescents constitute about a quarter of the total population [3].Each year, 1 in 20 of these adolescents' contracts at least one sexually transmitted infection and half of all HIV infections take place among this population group.
Adolescents' SRH problem is largely due to the psychological and social changes peculiar to adolescence and which expose them to unhealthy sexual behaviour such as early sex experimentation, unsafe sex and multiple sexual partners [4], [5].According to the World Health Organisation (WHO), SRH knowledge refers to a good understanding of the complete physical, mental and social well-being (and not just the absence of disease or debility) in all circumstances relating to the sexual and reproductive system and its functions and processes [6].
An aspect of SRH knowledge that is of utmost significance to this study is knowledge of puberty, prevention of pregnancy and sexual transmission of infection.This aspect of sexual and reproductive knowledge entails adolescents having knowledge of when they are old enough to impregnate or be impregnated and how they could safely prevent pregnancy.This aspect is of focus in that it is particularly important to adolescent health [7], [8].It is indispensable to their growth and the impact of such knowledge will greatly influence their lives as they proceed into adulthood [9]- [11].
Adolescents' SRH knowledge is greatly influenced by their perception, beliefs and attitudes [12], [13].One of the factors that influence knowledge is access to information on SRH [14], [15].Most  knowledge through various means.In this era of globalization, adolescents are exposed to unlimited information from numerous resources [16].Peer group, television, movies, music, magazines, and social media play an essential role in providing information on every topic, and most especially SRH [17].However, in many cases, the information provided is not accurately competent.Although several studies [7], [18], [19] have reported the effects of poor access to information on adolescents' sexual behaviour though, evidence remains sparse on the effect of such access on the type of SR knowledgebeing good or poorthat adolescents have.This study found it imperative to provide this information among adolescents, disaggregated by their visual status, in order to examine how the relative disadvantage of visually impaired has impacted their SR knowledge when compared with their non-visually impaired counterparts.
Visually impaired (VI) adolescents are a special group of vulnerable peoplethey are susceptible to manipulation and could easily be abused.They are a special group of people with special needs in terms of SR knowledge but they are always neglected [20].VI people may lack access to health information, as they are unable to read medicine prescriptions, appointments letters and safety notices [21], [22].In Nigeria, social support for the vulnerable people is largely inexistent and many VI face a number of human right abuses including stigma, discrimination, violence and lack of access to sexual and reproductive health information, healthcare and education [23].
Barriers to accessing health information and services arise from restrictive cultural norms, service limitations, lack of mobility aids, poor communication skills of staff, inaccessible buildings, and marginalization in the community and gender inequality [18].These hinder individuals with disabilities from acquiring the knowledge to protect themselves from sexual risk behaviour [24], [25].Moreover, the VI often have poor financial status and low education, which increases dependence, thereby making family and parental support significant to their daily lives [7].Despite VI's disadvantaged position, there is inadequate information on their level of SRH knowledge as compared to their non-visually impaired (N-VI) counterparts.The question of how personal and parental characteristics act as differential factors in influencing the SR knowledge of VI and N-VI remains unanswered.Hence, this study seeks to provide answers to the following research questions -(i) Do the NVI differ from the VI adolescents in their SRH knowledge?(ii) What personal and parental factors contribute to the differences in their level of knowledge?

A. Sample Selection
A multi-stage sampling technique was used to select the study participants.The first stage was the purposive selection of the visually impaired school, which happened to be the only one in the state.This necessitated the choice of a nonvisually impaired school within the same local government area.Both schools were government owned boarding schools.Study participants were systematically selected from both schools to participate in the interviews.
For the school with the N-VI students, since there were more than the desired number of students in the required age range, students were randomly selected across the classes till the required number of participants were reached.For the school with the VI students, since there were limited numbers of students in the required age category, all the students who were available and willing to participate in the study were interviewed.The study participants were boys and girls aged 15-19 years.

B. Schools' Settings
The school for the visually impaired, being the only one in the state, housed both primary & secondary students.Students in the primary section who were within the age bracket of the study participants were also interviewed.On the other hand, the school for the non-visually impaired housed only those who are meant to be in the secondary school -Junior Secondary School 1-3(JSS1-3) & Senior Secondary School 1-3 (SSS1-3).However, due to the fact that most of the students in the JSS 1-3 were less than 15 years, the study participants were limited to the SSS 1-3 students.

C. Instrument
Quantitative data were collected through a questionnaire administered using the Open Data Kit (ODK).This instrument was tested for reliability using data from a oneweek pilot study conducted in a related setting in Ikirun, Osun State.The Cronbach Alpha technique was used, and this gave an overall reliability coefficient of 0.825.Data collection took place between August and October 2019.

D. Variable Measurement and Data Analysis
The outcome variable was SRH knowledge.This was a 3level ordinal composite variable with three categories -good, fair and poor.The composite score was generated by combining the responses to five questions -Can a girl get pregnant the first time she has sex?Can a girl get pregnant if she has sex only once?How old does a boy need to be to be able to physically make a girl pregnant?How old does a girl need to be to be pregnant?Do you know any way a girl can avoid getting pregnant?
The key explanatory variable is adolescents' access to information (on puberty and contraceptives), which was grouped into two categorieshad good access and had poor access.The other explanatory or control variables were adolescents' personal characteristics (visual status, sex, age at starting school, position in family, desired educational attainment, involvement in extramarital activities, ethnicity and who is responsible for upkeep) and their parental characteristics (marital status, father's level of education, mother's level of education, father had a child with another woman and mother had a child with another man).
Ordered Logistic Regression (OLR) was used to assess the effect of the independent variables on sexual and reproductive knowledge.The use of this statistic was hinged on the ordered nature of the 3-level outcome variable.Five OLR models were fitted to test the relationships between the students' access to information, personal and parental characteristics and the outcome variable.The data analysis was done using Stata 14.
Model 1 examined the effect of the main explanatory variable (access to information) on the outcome variable without controlling the effect of any other variable.Model 2 examined the effect of the visual status on the outcome, also without adding any covariate.Model 3 examined the effects of access to information and the visual status on the outcome, while controlling for the effects of respondents' personal characteristics.Model 4 examined the relationships in models 1 & 2, while controlling for the effects of parental characteristics.Model 5(which is a full model) examined the effect of access to information, visual status, personal and parental characteristics on the outcome.

A. Background Characteristics of the Adolescents and Their Parents
The results presented in Table I show that 53.6% of all the respondents were male, while the rest were female.The age at school debut shows that by age 5, about 70% of the N-VI had started school, compared with 30.3% of the VIindicating that the N-VI started school earlier than their VI counterparts.The differing ages at school debut notwithstanding, about the same proportions of the two groups desired to have up to university education.
The same pattern shown in the age at school debut was reflected in the respondents' current class -all (100%) of the N-VI were in the senior secondary classes, while the vast majority (67.6%) of the VI belonged to the junior classdespite the fact that the average age of the VI was higher than that of the N-VI (17.0years vs 15.5years).It was also found that 73.1% and 64.8% of the N-VI and the VI, respectively, were involved in extra-curricular activities.
The adolescents' orphanhood status shows that 90.7% of the N-VI as well as 76.1% of the VI had their both parents alive.Equal proportions (58.3% and 57.2%) of both groups of adolescents were their parents' 1 st or 2 nd order births, but more of the VI (35.2%) ascribed the responsibilities for their schooling and upkeep to non-parents than did the N-VI (27.6%).Furthermore, the results show that for 77.2% of the adolescents, the parents were married and living together but this was disproportionately so among the N-VI (85.1%) compared to the VI (40.8%).
Similarly, slightly fewer of the N-VI (16.4%) than the VI (20.4%) had fathers who had child(ren) with women than the respondent's mothers.A similar pattern was found with respect to the respondents' mothers having children for men other than the respondents' fathers.Therefore, more of the VI had step brothers and sisters than their N-VI counterpart.In addition, the N-VI had more educated parents: 64.1% and 54.7% of them have fathers and mothers, respectively with higher education relative to 48.2% and 38.4% of the VI.

B. Access to Information and SRH Knowledge
The results in Table II show that 84.5% of the respondents had attended classes on puberty.However, more of N-VI than VI attended such classes (88.5% vs 66.2%).Adolescents' responses to questions about their sexual and reproductive knowledge show that about 68% of the N-VI and 52.1% of the VI had correct knowledge that a girl of their age could get pregnant if she had sex for the first time.
Similar results were observed with respect to the question on whether a girl of their age could get pregnant if she had sex only once.Although, knowledge about the average age at male puberty was generally poor, it was poorer amongst the VI (4.3%) than among the N-VI (11.2%).A similar situation is notable for knowledge about the average age at female puberty; 18.3% for the VI and 24.2% for the N-VI.The results also show that while 90.3% of the N-VI reportedly knew a way a girl could avoid getting pregnant, much fewer of the VI (66.2%) did.
Finding from the composite measure of SRH knowledge (Table II) further show that 18.0% of the respondents had good SRH knowledge, 37.6% had fair knowledge while 44.4% had poor knowledge.Disaggregated between the two groups, analysis showed that 19.2% of the N-VI and 12.7% of the VI had good sexual and reproductive knowledge.While more than three fifths (63.4%) of the VI had poor knowledge, 40% of N-VI had poor knowledge.The factors associated with the observed knowledge disparity between the VI and N-VI are analysed in the proceeding sections.

C. Relationship Between Access to Information on Puberty and SRH Knowledge
The relationship between adolescents' access to information and their SRH knowledge was examined using chi-square (see Table II).The findings show that although many of the participants had poor sexual and reproductive knowledge, this was more prevalent among those with poor access to information.In other words, 79.2% of the VI with poor access to information had poor sexual and reproductive knowledge, while 55.3% of those with good access had poor knowledge.Also, among the N-VI, while 21.3% of those with good access had good knowledge, only 2.7% of those with poor access were found to have good knowledge.Furthermore, the relationship between the two variables (access and knowledge) was tested using chi-square analysis.The result gave a chi-square value of 10.618 for the VI and 24.87 for the N-VI at p-values of 0.07 and 0.01 respectively, indicating a significant relationship between adolescents' access to information and their SRH knowledge.The association is, however, stronger for the N-VI (p=0.01)than for the VI (p=0.07).
The results in Table III show associations between adolescents' socio-demographic characteristics and their SRH knowledge.The findings show that amongst the N-VI, sex was significantly associated with the sexual and reproductive knowledge (χ 2 = 13.52;p=0.01) but the association was not significant amongst the VI.The desired future educational attainment was significantly associated with sexual and reproductive knowledge of both the VI (χ 2 = 21.2;p=0.02) and the N-VI (χ 2 = 20.39;p=0.00).
Furthermore, for both groups (VI and N-VI), involvement in extra-curricular activities was significantly associated with sexual and reproductive knowledge whereas, none (0%) of those not involved in extra-curricular activities had good SRH knowledge (p=0.05 and p=0.01, respectively).Having parents being responsible for schooling and upkeep had significantly positive association with having good SRH knowledge among the N-VI (χ 2 = 12.62; p=0.02).However, this association was not significant among the VI (χ 2 = 0.02; p=0.99).
Furthermore, for both groups, respondents with both parents married and living together were significantly more likely to have good SRH knowledge, (χ 2 = 19.11;p=0.00 for the VI and χ 2 = 15.24;p=0.00 for the N-VI) (Table III).In addition, the results indicated that mothers' level of education were significantly associated with the two groups of adolescents' SRH knowledge for the VI and N-VI (χ 2 = 8.40; p=0.04 for the VI and χ 2 = 9.47; p=0.02 for the N-VI, respectively.The findings were somewhat similar for father's education (χ 2 = 13.64;p=0.03 for the VI and χ 2 = 8.98; p=0.06 for the N-VI).The analysis also shows that for both groups, respondents whose fathers had child(ren) with other women were more likely to have poor SRH knowledge (χ 2 = 10.27;p=0.04 for the VI and χ 2 =10.45; p=0.04 for the N-VI).

D. Associated Factors (Parental and Personal) in Adolescent SRH Knowledge
Table IV presents the result of the Ordered Logistic Regression models showing the influence of adolescents' personal, parental characteristics and access to information on their sexual and reproductive knowledge.The result from model 1 shows that without controlling for the influence of any other factors, the respondents who had good access to information were about 116% (OR=2.163;CI: 1.41-3.32)more likely to have good sexual and reproductive knowledge than their counterparts with poor access to information.In other words, access to information had a significant influence on the respondents' SRH knowledge.The result in model 2 shows that the N-VI were about 137% (OR=2.377;CI: 1.41-4.00)more likely than their N-VI counterparts to have good sexual and reproductive knowledge.This indicates that impairment status had significant influence on sexual and reproductive knowledge in the absence of the effect of any other variable.In model 3, when the effects of respondents' personal characteristics were controlled for, results show that the model coefficient for access to information fell somewhat to 1.81 (CI: 1.09 -3.01), while that of impairment status remained virtually unchanged.Yet, both access to information and impairment status maintained significant associations with SRH knowledge.None of the personal characteristics were significant in model 3, except for the involvement in extra-curricular activities.Respondents who were involved in extra-curricular activities were about 18% (OR=1.176;C1:1.04-4.88)more likely to have good SRH knowledge than their counterparts who were not involved in extra-curricular activities.
Results from model 4 show that while the influence of parental characteristics were controlled for, both access to information (OR=1.799;C1:1.12-2.88)and impairment status (OR=2.368;C1:1.25-4.49)maintained significant influence on SRH knowledge.The final model (model 5), which is the full model shows that having controlled for personal and parental characteristics, the N-VI's chance of having good SRH knowledge more than doubled (OR=2.707;C1:1.33-5.51)that of their VI counterparts.Similarly, those who had good access to SRH information were about 69% more likely to have good sexual and reproductive knowledge (OR = 1.693;C1:0.98-2.94)than those who had poor access.
In addition, involvement in extra-curricular activities had significant influence on SRH knowledge.IV.DISCUSSION Irrespective of their diversities, adolescents need appropriate sexual and reproductive knowledge to live healthy sexual and reproductive lives.Our study shows that adolescents with visual impairment had poorer SRH knowledge relative to those who were non-impaired.This was as a result of their relatively poor access to information compared with their N-VI counterparts [23].This study also shows that many VI adolescents never attended classes on puberty and other SRH topics.Although there is sparse evidence on the impact of visual disability on SR knowledge in Nigeria, the WHO's world disability report alluded to the fact that disabled people deserve much better than they get in societies [25].The poor access to information and the attendant poor SR knowledge were not unconnected to their inability to independently access information.They would have to rely on people without visual impairment who could help them with physical mobility and with locating the sources of information and in some cases have the information relayed or interpreted to them.Most times, people with disability are neglected [20].When programmes are organized for adolescents, it is not unlikely that no special arrangements are made for the visually impaired.As such, they are marginalized in terms of knowledge and social support, and this affects their ability to avoid or overcome SR problems and their consequences.This explains why N-VI adolescents were shown to have better access to information and SR knowledge than their VI counterparts.Furthermore, because of the sensitive and private nature of SRH issues and behaviour, people often prefer to seek related information independent of others.This is particularly the case for adolescents in countries with high social stigma against sexual activities and access to SRH services by unmarried young people.It is therefore not surprising that visually impaired adolescents will be doubly affected since they are limited in how much they can independently obtain information on SRH.While audio media are a potential way to address this issue, the VI still need someone to help them tune to those stations on the radio, TV or their handheld devices.
The significant association between adolescents' involvement in extra-curricular activities and SRH knowledge suggests that, irrespective of their visual status, adolescents' involvement in extra-curricular activities could be an avenue for them to access information or increase their knowledge on SRH issues.The significant association between the two variables when personal and parental characteristics were controlled for further corroborates the findings of a previous study [15], that reported that when adolescents have equal access to SRH information, little would other factors such as parents' marital status, living arrangement, age and education affect their SRH knowledge.Similarly, organizers of extracurricular activities do provide information on a range of topics, including SRH, prior to beginning their activities.When adolescents are involved in these activities and are well informed, they tend to be better than their counterparts who lacked access to such information and/or not involved in the activities (extra-curricular).These underscore the importance of adolescents' access to information and involvement in extra-curricular activities, particularly, among the Visually Impaired adolescents.

V. CONCLUSION
This study established that VI adolescents had poorer SRH knowledge than their N-VI counterparts, and one factor responsible for this was their differential access to SRH information.This study therefore recommends advocacy efforts to provide adolescents with SR knowledge with special focus on adolescents with disability, generally, and specifically those with Visual Impairment.In particular, inschool VI adolescents should be encouraged to be actively involved in extra-curricular activities, to the extent permitted by their disability and possible or affordable human and technological aids.

B. Availability of Data and Materials
The datasets generated and/or analysed during the current study have been deposited in a public domain at data dryad website.The link is https://doi.org/10.5061/dryad.dr7sqv9z1.

C. Conflict of Interest
Authors declare that they do not have any conflict of interest.

D. Authors' Contributions
OOB contributed to the conception of the manuscript, was involved in literature review, data analysis, writing, review & editing.TOO also contributed to conception of the manuscript; was involved in data analysis and writing the original draft of the manuscript.TGK was also involved with the literature review and writing the original draft of the manuscript.AB mainly contributed to writing, review and editing of the original draft of the manuscript.All authors have read and approved the manuscript.

E. Acknowledgements
The research team would like to acknowledge the field workers who assisted in the data collection; and the students who willingly participated in the study.
www.ejmed.orgDOI: http://dx.doi.org/10.24018/ejmed.2023.5.5.1701Vol 5 | Issue 5 | September 2023 40 This research was supported by the Consortium for Advanced Research Training in Africa (CARTA).CARTA is jointly led by the African Population and Health Research Center (APHRC) and the University of the Witwatersrand and funded by the Wellcome Trust (UK) (Grant No: 087547/Z/08/Z), the Carnegie Corporation of New York (Grant No. G-16-54067), Sida (Grant No: 54100113).The statements made and views expressed are solely the responsibility of the authors.

ABSTRACT Adolescents' Sexual and reproductive health (SRH) knowledge is important for preventing SRH problems and enabling young people to live a healthy sexual and reproductive life. This study assessed the differences in SRH knowledge between the visually impaired (VI) and non-visually impaired (N-VI) adolescents; and examined the factors contributing to the differences between the two groups. The study was conducted in Ondo State, Nigeria using a multi-stage sampling technique to select 394 visually impaired and non-visually impaired in-school adolescents aged 15-19 years. Quantitative data were collected using Open Data Kit (ODK). Models were fitted with Ordered Logistic Regression (OLR) using Stata 14. Results showed that 89% of N-VI compared with 66% of VI had good access to SRH information, while 63.4% of the VI and 40.3% of N-VI had poor SRH knowledge. Students with good access to information were more likely to have a better SRH knowledge, although the relationship is stronger for the N-VI than for the VI. The OLR results further showed that the respondents who had good access to information were about 116% more likely to have good SRH knowledge than their counterparts with poor access to information
adolescents want to explore and seek Sexual and Reproductive Health Knowledge of Inschool Adolescents: A Comparative Study of Visually Impaired and Non-visually Impaired Students Olufunmilayo O. Banjo, Tosin O. Oni, Temitope G. Kumolu, and Akinrinola Bankole (OR = 2.163; C1:1.41-3.32).Also, the likelihood of the N-VI having good SRH knowledge more than doubled (138% more) that of the VI (OR = 2.377; C1:1.14 -4.00).Extra-

curricular activities also increased the likelihood of good SRH knowledge. The study therefore recommends advocacy efforts to provide adolescents with increased SRH knowledge with special focus on VI.
Consent to Participate This study was approved by the Health Research Ethic Committee (HREC) of the Institute of Public Health, Obafemi Awolowo University (OAU), Ile Ife, Nigeria (IPH/OAU/12/1162); and the Ondo State Health Research Ethics Committee (OSHREC), Ministry of Health, Ondo State, Nigeria (OSHREC/12/02/2019/102). Informed consent was gotten from the students aged 18-19 to participate in the study.Verbal ascent to participate was obtained from students below age 18.Both VI and N-VI gave written consent before participating in the study.

TABLE III :
ADOLESCENTS' PERSONAL CHARACTERISTICS AND SEXUAL AND REPRODUCTIVE KNOWLEDGE