Despite widespread awareness of the importance of contraceptive use in Nigeria, unintended pregnancies persist among adolescent girls, leading to events of unsafe abortion, sexually transmitted infections, maternal mortality, and disruptions to education and career, consequently resulting in economic hardships. Negative sociocultural beliefs and attitude serves as a deterrent for girls seeking contraceptives services in Nigeria. This study aimed to determine and describe how sociocultural beliefs and attitudes affect access and usage of contraceptive among unmarried adolescent Nigerian girls.

This study employs a secondary research approach following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Scopus, PsycINFO, and CIHNAL were searched using relevant keywords to achieve and review studies that meet predefined criteria. Quality assessment of selected articles was done using the Critical Appraisal Skill Programme (CASP) and Mix Methods Appraisal Tools (MMAT) for qualitative and quantitative articles, respectively. Each selected article was synthesized thematically to identify patterns relevant to the research question.

Thematic analysis revealed four sociocultural beliefs influencing contraceptive uptake among unmarried adolescent girls in Nigeria. Society's stigmatization of females for pregnancy prevention limits their freedom to access contraceptive services. Other factors include beliefs about sex and age, protective education, and societal intolerance for discussions about sex with adolescents. The study highlights the societal influence on contraceptive decisions for adolescent girls in Nigeria.

Girls in need of contraceptives struggle with societal stigmatization perpetuated by beliefs that adolescent girls should abstain from sex until after marriage, which unfortunately does not align with current trends in sexual relationships among adolescents in Nigeria. it is therefore important to shift societal perspective about adolescent sexuality needs and promote the economic and lifelong benefits of preventing unplanned pregnancies through a multisectoral collaboration.

Keywords: socio-cultural beliefs/attitude, contraceptive, birth control, adolescent girls, Nigeria

Adolescence represents a significant transition between childhood and adulthood, marked by a significant biological maturity and an increased sexual awareness.¹ As such, adolescence is often characterized by a higher sexual vulnerability and risk of unplanned pregnancy.² In Nigeria, there are over 30 million girls aged 10-19 years, accounting for 22.5 percent of the total population,³ with an increasing premarital sexual engagement and low age at sexual debut.¹ The incidence of unplanned pregnancy is often characterized by instances of unsafe abortion and career interruption, resulting in economic hardship and a devastating future for adolescent girls.³

The benefit of contraceptives is particularly notable in Nigeria, like many other nations of the world. Its uptake helps improve the challenges of unplanned pregnancies, promotes maternal health, and reduces childhood and maternal deaths in Nigeria.⁴ Certain methods can also provide infection protection. Oral contraceptives (such as birth control pills), contraceptive vaginal rings, condoms, intrauterine devices (IUDs), and injectable and implanted medicines are all available today and gaining wide recognition and acceptance.⁵ However, despite the widespread availability, education, and effort by the government and other stakeholders to improve access to contraceptive use in Nigeria, the prevalence of adolescent unintended pregnancy attracted researchers' consideration.⁶ Studies have reported the roles of cultural beliefs, religious beliefs, and the role of primary health services providers as factors that modified the ease of using contraceptives among the adolescent population in Nigeria.⁶

Given the number of adolescent girls in Nigeria and the average age at sexual debut, identifying the presence of socio and cultural factors influencing the uptake of contraceptives among adolescent girls is not enough to develop a focus intervention, reduce the prevalence of unplanned pregnancy and improve the overall sexual health of the adolescent population. This study, however, would describe how sociocultural attitudes and beliefs interfere with the use of contraceptives and contraceptive services by unmarried adolescent girls in the region.

This study aims to investigate the impact of sociocultural attitudes and beliefs on the access and utilization of contraceptives among the adolescent female population in Nigeria. The approach involves synthesizing articles from four databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Specific inclusion and exclusion criteria are applied to select articles that describe how identified sociocultural attitudes influence the access and usage of contraceptives and contraceptive services among unmarried girls in Nigeria. Table 1 shows the comprehensive lists of inclusion/exclusion criteria, plus the rationale behind their use in selecting articles used in this review.

Search strategies

The literature search was conducted across four databases including PubMed, SCOPUS, PsycINFO, and CINAHL and using the selected index keywords. Each keyword is developed by identifying the main concepts within the research question/topic, and a database search was conducted by combining keywords using Boolean connections to target publications that efficiently meet this study's specific objective. The choice of all four databases was based on an initial investigation with the research supervisor for databases with wide coverage, ranging from journal articles to a wide range of books and non-research information. However, the literature search in this study does not incorporate unpublished articles, which can also be a source of valid and most recent evidence on the subject of interest.

Four specific keywords generated from the main concepts within the research question which were combined using Boolean operators (AND, OR, and *). Using the advanced search, the combination of keywords was independently used to pull articles from each database. Journal articles pulled from each database using the different combinations of keywords were imported into Endnote (X9) for screening.

Article selection

Article selection is carried out following the PRISMA flow illustrated in Figure 1. All articles pulled and collected into Endnote X9 were accessed to eliminate duplicates and reviewed with article titles and abstracts to identify and retrieve studies most relevant to the research question. Using pre-specified criterion-relevant articles were screened for specific features that determined their eligibility to be included/excluded in this review. As shown in Figure 1, 2,436 papers were found across the four databases. After the exclusion of duplicates, a total of 2,342 papers remained. After removing duplicates, 2,342 articles were screened by the title and Abstract. A total of 1965 articles were removed. At this stage, there are only 378 articles for further screening. Each of the articles was accessed for the availability of full text. This screening also eliminated 16 articles, leaving only 362 articles to be assessed for eligibility. All 362 full-text articles were assessed for eligibility, and a total of 345 articles were excluded due to: 'article out of scope' (n=266), 'participant no of interest' (n=30), 'Unclear study design' (n=10) and 'limited rigor' (n=43). At the end of the screening, 13 articles met the inclusion criteria and were included in the synthesis.

Figure 1 PRISMA flow diagram illustrating the search for journal articles.

Quality assessment

The quality assessment of identified qualitative studies was carried out using the standard criteria based on the Critical Appraisal Skills Programme (CASP) tool, which examined 10 criteria (CASP, 2022), while studies with quantitative and mixed methods approaches are assessed using the Mixed Method Appraisal tools (MMAT).⁷

The choice of the CASPS and MMAT is based on the opportunity it affords outside of their potential to achieve a descriptive summary of papers. These tools provide an opportunity to question journal articles, including research results and conclusions, without being critical of the paper itself. Table 2 shows the result of the CASP evaluation for articles used in this review. Qualitative and quantitative articles were appraised according to the CASP critical score and MMAT repetitively: If the criteria were completely met, 2 points; criterion partially met, 1 point; and the criterion not applicable/unmet/not mentioned 0 points. Finally, this subjective ranking system classified and ranked the study quality. A total score of 20= high quality, 16-19= is moderate quality, and less than 15 is low quality. All the qualitative articles selected for the synthesis are classed as moderate quality Score = 16 -19 with clear research aim and efficient choice of research methods. The MMAT was used to assess the quantitative and mixed-method articles. The assessment asserts confidence in each of the selected studies used in this review and demonstrates clear and appropriate levels of rigor in its research approach and study design. Using these appraisal tools to access the quality of articles included in this study has helped empower the reliability, validity, and generality of findings synthesized from this review.

Data analysis

The finding in this study is generated by synthesizing the selected articles using the thematic analysis approach.⁸ Thematic analysis of findings was carried out to identify the point of convergence and divergence using themes. The analytic approach identifies and summarises areas of each study that provide evidence of how sociocultural attitudes or beliefs in Nigeria influence the access and usage of contraceptives and contraceptive services among unmarried adolescent girls in Nigeria. The synthesis enhances understanding of questions regarding: 'What sociocultural beliefs challenge contraceptive uptake among adolescent girls and how it exacts its influence? The analysis pulls answers from all selected studies. This is done by separating the findings, interpreting and then combining them all by identifying key themes across studies.

Ethical consideration

Approval was granted from the research faculty's ethical panel at the University of Bradford. The study adheres to the paramount ethical principles supporting the research's objectives, including pursuing knowledge, truthfulness, and avoiding errors. Additionally, the research team is committed to maintaining the integrity of the data by preventing any acts of fabrication, falsification, or misrepresentation, as these practices are antithetical to the pursuit of truth and the minimization of errors.

Characteristics of studies

As Table 3 shows, most studies were conducted in 2020 (4 studies) that is followed by 2021 (3 studies) and 2022 (3 studies). Seven studies used focus group discussion to collect data while 3 studies applied structured questionnaire as a tool to collect data.

Identification of Themes

The critical reviews of selected articles resulted in identifying and developing patterns that provide insights into cultural, traditional, and social attitudes/beliefs that influence the access and use of contraceptives in Nigeria while also describing how it does so. Four themes were merged as listed and explained below.

Theme 1: Differences in the societal expectation for pregnancy prevention

The synthesis of research in this review revealed a unique societal expectation concerning pregnancy prevention in Nigeria. There is a prevalent belief assigning the primary responsibility for preventing pregnancy in a sexual relationship to the female gender.⁹ This belief is also reported among adolescents in Nigeria. Adolescents in Nigeria acknowledged the possibility of an agreed adolescent sex, but a substantial 66.5% believed it was solely the girl's duty to avoid pregnancy after sexual intercourse.¹⁰ This belief and attitude are linked to traditional gender norms in Nigeria, where female sexuality is shaped by a deep-rooted belief perpetuating an unequal power dynamic, reinforcing male dominance, and emphasizing independence in sexual relationships.¹⁰

These beliefs identified in this study highlight a significant discrepancy in expectations regarding the roles of male and female adolescents in sexual relationships, despite the general societal expectation that sex should wait until marriage.¹¹ This finding is further highlighted by the percentage of adolescent boys reported to be engaging in sex compared to girls in Nigeria, further illustrating the subtle impact of societal expectations on adolescent sexuality and rights.¹²

The expected gender roles significantly affect the rights and confidence of adolescent girls in Nigeria to approach contraceptives service providers in Nigeria. The perspective subjects the girls to social and cultural stigmatization when seeking contraceptive services, particularly in a cultural environment where sexual abstinence is the cultural norm. Adolescent girls seeking contraceptives are confronted with challenge of being labelled as promiscuous and criticized for engaging in unacceptable sexual relationships.^9,13 Therefore, adolescent girls are shy, timid and fear the social judgments of being seen around contraceptive service provider in Nigeria. The significance of this perspective about adolescent girls approaching contraceptive service is also underscored by the need for privacy and confidentiality as a recommendation to encourage more adolescent girls have a free and uninfluenced access to contraceptive service in Nigeria.¹⁴

Theme 2: Intolerance for sex and sex-related discussions with adolescent girls

The synthesis of the studies in this review draws attention to societal intolerance surrounding discussions about sex and contraceptives with adolescent girls in Nigeria. A study investigating the adolescents' knowledge of contraceptive use in southeast Nigeria, revealed a widespread cultural aversion to discuss sex-related matters, including contraceptives, with unmarried adolescent girls.¹⁵ The study highlighted that such discussions are frowned upon, inappropriate, immoral, and taboo. Another study found that there is a belief that adolescent girls are too young and innocent, leading to parents and religious leaders withdrawing from discussing sex or contraceptives with them.¹⁴ Intolerance to sex and sex-related discussion have also been reported to be due to a strong support for sexual abstinence, and found to contribute to negative attitudes and lack of support for adolescent sexuality and contraceptive needs.¹⁶ The reluctance to share knowledge about contraceptives due to the belief that girls aged 13-17 are too young and discussing such matters may lead to promiscuity or promote their interest in engaging in sexual intercourse.⁹ The events of intolerance to adolescent sexual needs in Nigeria manifests as yelling and scolding, as well as denial of services from providers at various levels from community to religious and parental perspectives.¹⁴

The reluctance to discuss contraceptive options arises from the belief that adolescents are too young and need protection for their innocence. However, the report of a lower age of sexual debut challenge this perception and highlight a discrepancy with current trends in adolescent sexual needs in Nigeria.¹ The intolerance to discussing sex or contraceptive needs, as identified in this review, creates a disconnect between adolescents and their right to use contraceptives, despite their awareness and the availability of contraceptives in Nigeria. This disconnect often manifests as timidity, lack of courage, and mistrust in society and contraceptive service providers.¹⁷ Emphasizing the significance of poor communication as a hindrance to contraceptive decision-making in Nigeria.

As a consequence, adolescents seeking contraceptives are discouraged by the widespread aversion from religious, community, and parental perspectives to discussing contraceptive options. This discouragement leads adolescent girls to consider the opinions of service providers before seeking contraceptives in Nigeria. This aligns with findings that parents’ attitude of avoiding to discuss contraceptive choices with their adolescents but promote sexual abstinence instead are prevalent in Nigeria.¹⁸ This review emphasizes the urgent need to address the intolerance surrounding discussions about sex and reproductive health needs with adolescent girls in Nigeria. To tackle these issues, community-based initiatives promoting respectful and open discussions about sex and comprehensive sex education in schools and communities are recommended.

Theme 3: Protective education among parents to uphold cultural and religious norms

The analysis of studies in this review highlights the impact of protective education, aimed at maintaining cultural standards and sexual expectations among unmarried girls, on the access and usage of contraceptives among adolescent girls in Nigeria. It appears that parents and other informal education platforms, such as churches and families, have been sharing misleading information on contraceptives. This information serves as a caution against engaging in sexual relationships or using contraceptives.

A study by exploring parental knowledge and attitudes on contraceptive usage among unmarried adolescents in Nigeria revealed that parents often provide protective education based on cultural and religious beliefs, and not offering the needed support unmarried adolescent girls from considering contraceptive options.² The findings from this review identified that parents in some parts of Nigeria, only discuss contraceptives or sex-related matters when there is an unpleasant incident related to contraceptive use or sex-related subjects in the community. These discussions serve as deterrents, aiming to protect adolescent girls from sexual involvement and discourage the desire for contraceptive uptake.¹⁵ The cultural belief that parents should not openly discuss preventing unplanned pregnancy (contraceptives) with adolescent girls, as it may lead to promiscuity and impact the moral stance on sexual abstinence until marriage, is prevalent.⁹ However, adolescents seeking information about contraceptives gets discouraged by learning only about complications associated with adolescent sex crises within the community.

There is also a widespread belief that avoiding discussions about contraceptives with adolescent girls will keep them unaware of pregnancy prevention methods. In cases where girls insist on having information, scary details, such as infertility issues due to contraceptive use, are emphasized.¹⁹ Adolescents' fear of side effects associated with some contraceptive methods, such as prolonged or irregular menstrual cycles and weight gain/loss, and therefore educating them of this side effects has been used effectively to serve as a barrier to the uptake contraceptives.¹⁴ The importance of fertility in Nigerian society are of significant cultural importance²⁰ and the cultural ideology to share negative circumstances of contraceptive uptake will significantly influence the use of contraceptive among adolescent girls. These findings underscore the role of parental protective education in shaping the reproductive behaviour of unmarried adolescent girls. Although cultural and religious views frequently influence parents' intentions, the lack of open dialogue regarding contraception negatively impacts adolescent girls' attitudes toward contraceptives.

Theme 4: Norms about sex and age

The compilation of studies in this review identified the influence of cultural beliefs about the permissible age for sexual relationships as a significant hindrance for adolescent girls seeking access to contraceptives in Nigeria. A study conducted to investigate contraceptive service provider-imposed restrictions in urban Nigeria, revealed that some service providers harbour beliefs suggesting it is absurd for unmarried adolescents of a specific age to have access to contraceptives.²¹ This belief stems from cultural perceptions about premarital sex and age-appropriate sexual behaviour. Consequently, unmarried adolescent girls within this age encounter obstacles when trying to obtain contraceptives from such providers.²²

Another similar study on the role of cultural and religious norms on the age at which girls are deemed suitable for sexual activity or seeking contraceptive uptake, revealed that in many Nigerian societies, the decision for adolescent girls below 16 years to use contraceptives is not supported.⁹ The report identifies a clear community resistance to sexual behaviour at an age younger than 16 years. According to these studies, there exists a barrier preventing adolescents from approaching contraceptive service providers to inquire about contraceptive options due to the prevailing acceptable age for sexual activity. The community perspective often question why an adolescent girl, considered a child below the age of 19 or 18, would seek contraceptives, leading to advice aimed at preventing sex or even discontinuing dating.⁹ This cultural stance serves as a deterrent, eroding the confidence of adolescent girls to access and use contraceptives in Nigeria.

The issue of adolescent sex, pregnancy, and contraception in Nigeria is faced by a sociocultural aversion deeply rooted in the belief that adolescent girls should abstain from all forms of sexual activities until after marriage. This perspective conflicts with the reported current trends in adolescent sexual needs.¹ Studies on adolescent sexual behaviours reveal a low age at sexual debut. Consequently, a high number of unplanned pregnancies among adolescent girls in Nigeria is prevalent. This highlights the necessity to understand how this belief influence adolescent sexual rights and develop intervention to shift the sociocultural perspective to improve the adolescent reproductive health circumstance. This study aims to identify sociocultural beliefs and elucidate how they impact adolescent girls' access to and use of contraceptives and contraceptive services in the country.

Findings from this review identified that despite the widespread availability and the acknowledged importance of contraceptives in Nigeria, the reports of adolescent pregnancies underscore the influence of sociocultural aversion on adolescent contraceptive choices. Stigmatization of adolescent girls accessing contraceptive services as unworthy and promiscuous has played a significant role in limiting courage and promoting timidity among those in need. This finding is in line with other studies that considered the role of stigmatization on contraceptive behaviours among girls.^23–25 Sexual health education through reproductive health facilities that focuses on families, students and communities can help adolescents and young women to overcome this issue. They should be confidential, friendly and non-judgemental and based on the cultural belief of people.^26,27 Cultural beliefs associating girls with the responsibility of preventing pregnancy contribute to social stigma for those seeking contraceptive services. The magnitude of stigma varies based on criteria such as age, marital status, trust in service providers, and the level of privacy enjoyed.^28,29

This review reveals that extreme stigma leads adolescent girls to focus on the social and cultural consequences of approaching a contraceptive service provider rather than considering the actual benefits of contraceptive use on their health, career, and future. Deliberate misinformation and prevention of adequate knowledge sharing on the importance of contraceptives also interfere with their usage. False or unverified information can induce fear among adolescent girls, hindering the use of contraceptives. This finding is supported by other studies that focused on barriers to contraception uptake among adolescent girls.^30,31

Sociocultural beliefs, particularly those linked to age appropriateness on sex-related matters, interfere with attitudes in various cultural and social settings regarding adolescent rights and contraceptive needs.^32,33 The notion that sex at certain age as an unacceptable norm affects the trust adolescent girls have in service providers, influencing the type of contraceptive interventions accessible to them. Instances have been reported where service providers advise adolescent girls to quit dating instead of providing information on the benefits of contraceptive choices. This has been highlighted in other studies.^34,35

Neglecting or inadequately addressing the contraceptive needs of adolescents poses a significant reproductive health challenge. This study discusses the role of sociocultural beliefs on the adolescent girls' population in accessing contraceptives and how these beliefs influence their choices. However, the study's exclusive focus on published articles related to Nigerian adolescent girls may limit its relevance to the country of study, and application may only serve to understand how the sociocultural attitude and belief influence contraceptive used among adolescents in Nigeria.

The findings of this study highlight the impact of sociocultural attitudes on the access and usage of contraceptives among adolescent girls in Nigeria. The study revealed a sociocultural ideology that unfairly labels adolescent girls seeking contraceptives as promiscuous, implying a failure to meet cultural expectations of abstinence until marriage. This stigma acts as a deterrent for adolescent girls seeking contraceptives.

To address this issue, it is recommended to shift societal perspectives on adolescent sexual rights and needs, supporting the autonomy of adolescent girls in making choices regarding abstinence or contraceptive use. This effort should involve educating the community about girls' rights to contraceptives and emphasizing the economic and career implications of unplanned pregnancies. By promoting contraceptive autonomy, a multisectoral approach is essential to challenge societal perceptions regarding contraceptives and adolescent girls consistently.

This study had some limitations. There were a relatively small number of studies to review. Moreover, among those studies that met criteria, there were few quantitative studies so we were not able to conduct a meta-analysis. As this study focused on a sensitive topic and most of them applied qualitative design, the results can be affected by the participants' response so, measuring the accurate social norms was not possible..

None.

The authors declare no conflict of interest.

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