Adolescents’ sexual and reproductive health (ASRH) burden have been progressively on national programmes for some decades. This burden is passionately motivated by the increasing rate of early childbearing, Human Immuno Deficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) and other sexually transmitted infections (STIs) and risky sexual behaviours found among adolescents [1]. There is a global increase on adolescents’ sexual and reproductive health burden; it is growing wild in Africa, Nigeria inclusive due to poor health care delivery system, poor mode of information dissemination and dearth of appropriate information on reproductive health [2]. Adolescents’ global population of 1.2billion, which is 18% of the world population, makes ASRH a public health concern [3].

In Nigeria and other developing countries, the period of adolescence development faces a problem of poor access to information on sexual issues. Health professionals, tutors and parents refused to address adolescents on SRH due to societal norms around purity. There is also a transfer of responsibility among parents, healthcare providers and teachers on who should provide information on sexual and reproductive health (SRH). Therefore, adolescents are prone to making poor decisions on SRH which may have negative outcomes [3]. The recorded unfavourable aftermath of these negative outcomes are highly destructive, it affects adolescents, the nation as an entity, members of the community, and finally family members. According to Patton et al. [4] triple dividends can be created if there are investments on adolescents. Benefits are accruing during adolescence in their life time which may also extended into successive generations. In Nigeria, adolescents in the age range 15-19 years are involved in high risky sexual behavior. The percentage of sexually active boys and girls that were involved in unprotected sex in twelve months of a survey are 56.4 and 39.6% respectively [5]. Adolescents make unprotected sex a habit, which may result in unintended pregnancy leading to unsafe abortion with complications. This act also predisposes them to STIs including HIV with a predominance of seventeen (17) percent among adolescents in South-eastern Nigeria while those in the Northern part have a predominance of fourteen (14) percent [6,7].

Current trends in the society brought about by growing wave of westernization in Nigeria have greatly affected adolescent’s behaviour. Uncontrolled internet access and other mass media have predisposed adolescents to pornography, sexting, nudity, incorrect information on sex education and other risky sexual behaviours. Adolescent students want to practice what they watch on the internet and other media; therefore, they are predisposed to unprotected sex leading to unintended pregnancy and unsafe abortions, rape, early child bearing, STIs and HIV/AIDS. Culture of parents not discussing sex education with their children have made them rely on peer groups, friends, mass media and other sources which do not necessarily give correct information. Adolescent students’ perception of sex education varies among groups due to the following reasons: religious belief, family upbringing, major perception in communities and the culture of the society in which adolescents grew up. These factors either combine or individually influence the adolescent students. Students’ opinion on sex education is either positive or negative. While some students see it as solution to problems of adolescents others view sex education as a problem that is immoral in the eyes of the elderly people and primitive rural community at large [8].

Annually, one in twenty (20) of Nigerian adolescents contracts STIs and people below 25years account for half of all cases of HIV infection [9]. This can be viewed as the outcome of early sexual debut that have increased adolescents’ HIV susceptibility. 11.9% of young people in Nigeria had experienced sexual intercourse before the age of 15years [2]. 60% of all abortions are accredited to adolescents. Adolescents need to have the right perception of sex education in order for the education received to be transformed into behavioural changes. Adolescent students in Ondo State seemed to have been well informed on sex education.  This is because of their exposure to curricula sex education and other sources of information (home, peers, friends, religious bodies, FMC etc.). Despite profound technological development and improved means of communication in the state, there seems to be a mismatch between knowledge and behaviour due to increase in STIs, teen’s pregnancy and complications during childbirth. Though, there are a few documented reports on adolescents’ sexual activities in Ondo state, yet the research conducted by Akintuyi and Adesegun [10] on secondary schools in Akure metropolis (Ondo State capital) revealed that twenty-two percent of the adolescent students had been involved in sexual intercourse.  This report agreed with that of Durowade [11] and Adeomi [12]. Adolescents disregard principal knowledge at the expense of sexual risks. Hence, there is a need to assess the “Perception of Adolescents on Unprotected Sex among Students in Public Secondary Schools in Owo Local Government”.

Research Design and Study Area

A cross-sectional survey among adolescent students using a quantitative approach was conducted in public secondary schools in Owo local government area of Ondo State. This design was adopted for the following reasons: convenience, economical and more manageable for the researcher because a huge volume of data can be collected at one point and the results are more readily available.

The study was conducted in Owo Local Government Area of Ondo State. Owo local government area lies on the Northern Senatorial district of Ondo State. It is bounded by Akure to the East and South respectively, Emure - Ise - Orun Local Government Area of Ekiti State to the North, while Ose Local Government forms the border to the West and part of the South. Owo is the administrative headquarters of Owo local government, which comprises eleven wards. The dominant occupation in the local government is farming (subsistence farming). The presence of the Federal Medical Centre, Rufus Giwa Polytechnic and Polytechnic Staff Secondary School, the state Technical College and Achievers University (a private university) in the local Government Headquarters can be attributed to the rapid increase in population of the local Government. There are private hospitals owned by individuals and missionaries, general hospital, basic health centres that meet the health needs of the inhabitants at the grass root. Roman Catholic, Protestant and Pentecostal Churches, Mosques are also found across the local Government. Commercial banks are concentrated in the local government headquarters with a few that spread across the communities in the local government. Twenty public secondary schools are located across the local government and a good number of private schools with I made College being one of the oldest and most popular secondary schools in Owo metropolis.

Study Population

Students in Senior Secondary School 2-3 within the age range of fourteen to sixteen years (boys and girls) who registered for the current academic session in the public secondary schools in Owo local government area formed the study population.

Inclusion Criteria: All Adolescents attending public secondary schools within age range of fourteen (14) to sixteen (16) years who registered for the current academic session and are in senior secondary school 2-3

Exclusion Criterion: All adolescents within the age range of fourteen (14) to sixteen (16) years that are not in secondary school.

Sample Size

The sample size for the study was calculated using Taro Yamane equation with 95% confidence level [13].

The number of participating students in each selected school was determined by simple proportion.

Sampling Technique

Multistage sampling technique was used to select samples from participating schools. The sampling was done till the proportion allocated for each school was completed.

Stage One: Names of all the public secondary schools in the local Government was written out under the political wards they fall into. The eleven political wards were stratified into three educational zones based on the geographical closeness of the wards to each other. Two educational zones were selected randomly using balloting.

Stage Two: Four schools were selected in all using simple random technique, two schools from each educational zone.

Stage Three: Samples were drawn through ballot system after the exclusion of those not participating in the study; the number for the school reflected “YES” while the remainder carried “NO”. The folded papers were kept in a container after shuffling, the students were made to pick. Those who picked yes were the participants from that school. This simple random sampling was used in all the schools.

Data Collection Instrument

A Sex Education and Unprotected Sex Questionnaire (SEUSQ) was developed after extensive revision of relevant literature on the subject.  Reference is also made to Amu and Adegun [14]. Data were collected by the researcher and trained research assistants using structured self- administered questionnaire written in English Language. The SEUSQ contained four (4) different sections named A-D.

Section A: This consists of the demographic, social and economic characteristics of the participants.

Section B: This section assessed the level of knowledge of adolescents on unprotected sex; it contained five (5) items.

Section C: This section measured the perception of adolescents on sex education. It contained ten (10) items.

Section D: This section measured factors influencing unprotected sex among adolescents, it contained ten (10) items. Four-point Likert scale which is an interval scale of measurement i.e. Strongly Agree, Agree, Strongly Disagree, Disagree was used to stratify responses of the respondents’ perception of sex education and unprotected sex among adolescents. Decision rule was >2.50 as positive perception.

Validity of Instrument

Face and content validity of the instrument was established through the consultation with the researcher’s supervisor, other professionals in the field of nursing research, Statisticians, experts in Adolescent Medicine and Reproductive health, and all corrections/suggestions were effected.

Reliability of Instrument

Data collected on the pilot study was statistically analyzed for the purpose of reliability coefficient. The Cronbach-alpha reliability coefficient was used. Thirty-nine (39) copies of the questionnaires were administered to and collected from the adolescents in Methodist High School, Owo, and a secondary school in Owo local government with comparable characteristics of the population of the study.

Ethical Consideration

A letter of introduction was obtained from The Department of Nursing Science, University of Benin, Benin City. A written permission with reference number ZEO/OW/AD/02 was obtained from the Zonal Education Office, Ondo State Ministry of Education, Owo and verbal consent was obtained from heads of the schools. Signed consent was obtained from the parents/ guardians of the respondents, while verbal consent was obtained from the respondents. The aims, objectives and significance of the study were explained to the participants. Verbal consent was obtained from the study participants before data were collected. Names of participants for the purpose of confidentiality were excluded and other personal information were kept confidential during the data collection. The participants were informed about the right to or not to participate in the study or to leave the question(s) they do not want to respond to.

Method of Data Collection

Two Biology teachers and two Health Education teachers from the Public Secondary Schools in Owo local government were recruited as Research Assistants due to their familiarity with the school system, the study area and the students. Research assistants recruited were trained on the objectives of the study, contents of the questionnaire and maintenance of confidentiality and privacy. With the help of trained assistants, adolescents with the inclusion criteria were selected from participating schools.

Method of Data Analysis

Data collected were rechecked for completeness before entry. Data were collated using tables and graphs accordingly. Frequency/Percentages for categorical variables, mean and standard deviation for continuous variables were used to describe the dataset, while inferential statistics was used to test the stated hypotheses. Independent sample t-test was used to compare knowledge between Male and Female. Chi-square (X2) was used to test for association between categorical variables. Logistic regression (Univariate/Multivariate) was used to control for associated variables with level of education or attitude towards sex education. The level of significance is set at p<0.05. The different analyses were conducted using the IBM Statistical Package for the Social Sciences (SPSS) version 24.0 for windows.

Sociodemographic of Adolescents

Table 1 shows sociodemographic of respondents. School of respondents shows that a majority 119(30.3%) were students of Owo High School, 71(18.1%) were students of New Church Grammar School, 97(24.7%) were students of St. Louis Grammar School, while 106(27.0%) were students of I made College. A majority of the respondents 284 (72.3%) were males, the remaining 109(27.7%) were females. A majority of the respondents 206 (52.4%) were in SS II, while the remaining 187(47.6%) were in SS III. Highest level of parents’ educational level/attainment shows that 55(14%) had no formal education, 160(40.7%) had primary education, 169(43%) had secondary education, the remaining 9(2.3%) had tertiary education.  A greater number of the respondents 188(47.8%) reported that their parents/guardians were traders, 112(28.5%) reported they were self-employed, 93(23.7%) reported they were business people. It was reported by the majority 288(73.3%) that they live with both parents, 26(6.6%) live with their father only, 50(12.7%) live with their mother only, 20(5.1%) live with their grandparents, 6(1.5%) live with their relatives, 3(0.8%) live with other people.

Table 1: Sociodemographic of adolescent students in Owo Local Government Area, Ondo State.

Field survey, 2020

Knowledge of Respondents

Table 2 shows the level of knowledge of sex education of adolescents on unprotected sex. It was reported by 101(25.7%) that penetrative sexual intercourse includes the following except penis inside vagina, 33(8.4%) reported it was except oral sex, a majority 231(58.8%) reported it was except hugging, the remaining 13(3.3%) reported that they don’t know. It was reported by a majority 244(62.1%) that unprotected sex is sex without condom, 22(5.6%) reported it was sex with condom, 88(22.4%) reported it was sex before marriage, the remaining 39(9.9%) reported that they don’t know. It was reported by 64(16.3%) that the following actions could result in pregnancy except unprotected sexual intercourse, 58(14.8%) reported it was except sexual intercourse with broken condom, a majority 271(69%) reported it was except not having sex at all. It was reported by 140(35.6%) that the most effective method for controlling STIs was male condom, a majority 170(43.3%) reported it was abstinence, 45(1.5%) reported that it was oral contraceptive, 25(6.4%) reported that it was IUCD, the remaining 13(3.3%) reported that they don’t know. It was reported by the majority 342(8%) that oral sex could expose one to HIV and other STIs, the remaining 51(13%) disagreed.

Table 2: Level of Knowledge of Sex Education of Adolescents and Unprotected Sex.

Field Survey, 2020

Figure 1: Showing Distribution of Level of Knowledge of Sex Education of Adolescents on Unprotected Sex.

Figure 1 shows distribution of level of knowledge of adolescents. A Majority 181(46.1%) had good knowledge, 1.3(26.2%) had fair knowledge, 109(27.7%) had poor knowledge.

Perception of Adolescent

Table 3 shows perception of adolescent students on sex education. Adolescents’ risky sexual behaviour can be reduced through sex education had a mean and Std. of 2.85 ± 1.06, knowledge of sex education will prevent the exposure of adolescents to unprotected sexual activities had a mean and Std. of 2.95 ± 1.00, discussion about sex should be permitted had a mean and Std. of 2.58 ± 1.08, sex education can encourage adolescents to abstain from sex till marriage had a mean and Std. of 2.88 ± 1.02, sex education will empower adolescents with skills to negotiate and practice safer sex had a mean and Std. of 2.55 ± 1.04, religion permits the discussion of sex education had a mean and Std. of 2.53 ± 1.04, sex education can prevent Sexually Transmitted Infection (STIs) including HIV/AIDS had a mean and Std. of 2.96 ±1.01, unintended pregnancy, illegal abortion, early child bearing among adolescents can be reduced through sex education had a mean and Std. of 2.79 ± 1.11, the overall mean and standard Std. was 2.66 ± 1.04. From the above stated means which were > 2.5, give an indication that the adolescent students had a positive perception on sex education.

Table 3: Perception of Adolescent Students on Sex Education.

Field survey, 2020

Figure 2: Perception of Adolescents’ Students on Sex Education.

Factors Influencing Unprotected Sex among Adolescents

Table 4 shows factors influencing unprotected sex among adolescents in Owo local government. The highest mean of 3.09 suggests from the table that pleasure is a major factor influencing unprotected sex among adolescents in Owo Local Government; the least factor influencing unprotected sex with a mean score of 2.38 is poverty. All the mean values are above the cut off of 2.50; hence they are major influencing factors, aside poverty with a mean score below the cut off.

Table 4: Factors Influencing Unprotected Sex among Adolescents in Owo Local Government.

TVLE = to a very large extent; TLE = to a large extent; TSE = to a small extent; TVSE = to a very small extent.

Field survey, 2020

Mean Comparison of Male and Female Adolescents’ Knowledge and Perception

The level of knowledge of sex education of adolescents particularly on unprotected sex in the Public Secondary Schools in Owo Local Government shows no significant difference. Table 5 shows mean comparison of knowledge of sex education and respondents’ gender, male respondents had a mean and Std. of 64.23 ± 23.58 while the females had a mean and Std. of 63.49 ± 28.78,  their  p-value  was  0.739  which  was  higher  than  p>0.05  this  indicates  that  the  level  of  knowledge of sex education and unprotected sex among male and female adolescents in the Public Secondary Schools in Owo Local Government shows no significant difference, the null hypothesis is therefore accepted. Association between perception of male and female adolescents about sex education and unprotected sex, male respondents had a mean and Std. of 2.65 ± 0.44 while the females had a mean and Std. of 2.70 ± 0.50, their p-value was 0.7341 which was higher than p>0.05 this indicates that the perception of adolescents about sex education and unprotected sex among male and female adolescents in the Public Secondary Schools in Owo Local Government shows no significant difference, the null hypothesis is therefore accepted.

Table 6 shows association between level of knowledge of sex education and unprotected sex and socio-demographic characteristics. Of all the social demographic variables listed only that of school was significant because it had a p-value of 0.000 (p<0.05), all other variables of sex, class, parents’ highest level of education etc. showed no association as their p-values were greater than 0.05.

Table 5: Mean Comparison of Knowledge Score of Sex Education and Unprotected Sex among Male and Female Adolescents in the Public Secondary Schools in Owo Local Government.

Field survey, 2020

Table 6: Association between the level of knowledge of sex education of unprotected sex and the socio-demographic characteristics of adolescents.

Field survey, 2020

Level of Knowledge of Sex Education of Adolescents and Unprotected Sex

The distribution of the level of knowledge of sex education of adolescents and unprotected sex among adolescents in public secondary schools in Owo local government revealed that the majority had good knowledge. The result above is at variance with Ajibade [15] in Osun state, Nigeria where the majority had poor knowledge of sex education. The result obtained in this study could be attributed to exposure of the adolescents to curricular sex education and sex education from other sources (home, periodic seminars and workshops from governmental and non-governmental agencies). Furthermore, the presence of tertiary institutions in the local government (Achievers University, Rufus Giwa Polytechnic, Margaret Mosunmola College of Health Technology, Technical College) and the Federal Medical Centre, Owo, could have increased the awareness of the adolescents about sex education and reproductive health related issues through periodic seminars, workshops and campaigns thereby contributing to the increased knowledge of the adolescent students. This finding is however in agreement with the report of Ozuri and Akarah [16] in Delta state, Nigeria. The proportion of adolescent students that had good knowledge of sex education is not encouraging (Figure 1); there is a need to increase the awareness on sex education at home, school, and the media by relevant authorities.

It was observed that over fifty percent of the respondents could describe penetrative sexual intercourse. This is in consonance with Envuladu [17] in the study conducted in Plateau state on Forms of Sexual Conducts and Risks Perception of in -school and out-of-school adolescents, where most of them mentioned vaginal sex, anal sex, oral sex, masturbation using cucumber, carrot, snooker stick as penetrative sexual practices. A majority of the respondents identified unprotected sex as sex without using protective devices such as condom. This finding agreed with Afolaranmi [18] in Plateau State, Northern Nigeria where 90.6% and 93.5% of out-of-school and in-school adolescents respectively are informed on sexual practices that are protected and unprotected.

The respondents are aware of actions that could result in pregnancy, a majority of the respondents mentioned abstinence as the only way they could be free from unwanted pregnancy while unprotected sex and sex using broken condoms are potential actions that could result to unwanted pregnancy. This finding correlates with Henok [19] on their research in Ethiopia where 84.5% of the studied participants knew that condom prevents unwanted pregnancy. This finding is compatible with that of Titiloye and Ajuwon [20] in Ibadan, Nigeria where 89.8% of the studied participants identified abstinence as a means of pregnancy prevention.

The respondents largely identified condom and abstinence as effective methods of controlling sexually transmitted infections. This observation is supported by Thapa and Chand [21] in Nepal, where 96% and 47% reported condom and abstinence as preventive measure of STIs respectively. Makwe and Adenyuma [22], Nwatu [23] documented similar observation. More than three-quarters of the respondents believed that oral sex could expose them to HIV and other STIs. This supported a study by Azuike [24] in Anambra state, South-east Nigeria where adolescents believed that oral sex could expose them to sexually transmitted infections (STIs) including HIV.

Perception of Adolescent Students on Sex Education

Adolescents in public secondary schools in Owo local government have positive perception on sex education as evidenced by the respondents strongly agreeing to eight of the ten items. This finding is in line with Sanni [25] in Lagos and Omale [8] in Dekinna both in Nigeria. Adolescents in these areas are much interested in sex education and their perception towards it was positive. This finding also agreed with Kumar [26], in Njoku and Josiah [27] who revealed that the perception of sexuality education by students in Andoni was positive as evidenced by the respondents agreeing to nine out of the twelve items examined. It was an indication that sexuality education was embraced by biology students, also sexuality education is not against their religion. The findings are in contrast with Mustapha [28], in Bauchi state, Nigeria. Both parents and teachers were of the opinion that sex education should not be incorporated into the senior secondary school curriculum for following reasons: sex education could expose the students to sexual promiscuity, it is contrary to the teachings of their religion, and could degenerate to immorality among the students.

Factors Influencing Unprotected Sex

Respondents agreed that all factors listed influenced them to have unprotected sex in varying degrees. The results also showed that adolescent students in Owo local government are mostly influenced to engage in unprotected sex to a very large extent for pleasure (with a mean of 3.09) followed by influence of what they read/watch on social media, (a mean of 3.04), watching pornography, (a mean of 3.04), attending night club (a mean of 3.02), substance use e.g. alcohol (a mean of 2.91) in that order. A greater number of adolescents want to be totally independent of adults, they are involved in try-outs, want to experiment out of curiosity, could not handle attraction to opposite sex, thereby falling into unprotected sex. The media have a great influence on adolescents, they portray sex arousing images and programmes which influence adolescents to have unprotected sex. This finding is in line with Oladeji and Ayangunna [29]. There are night clubs in Owo local government, mostly concentrated in Owo (the local government headquarters), adolescents visit the clubs, invite their peers for late night activities that may lead to unprotected sex.

Respondents mentioned pleasure and poverty as factors that influence unprotected sex in adolescence. This finding is in consonance with Envuladu [17] where adolescents cited pleasure, love and monetary gifts as factors that influence unprotected sex among adolescents. Envuladu [17] also found that adolescents engage in unprotected sex due to inability to control their sexual urge, catching fun and an avenue to show love for their boyfriend. Secretion of sex hormones in adolescence creates a pleasurable sexual feeling which adolescents want to exploit regardless the consequences; many of them are not well informed about safe sexual practices. Economic hardship in the country is also a factor that lures adolescents into unprotected sexual practices. Moreover, respondents indicated that peer pressure influences unprotected sex among adolescents. This is compatible with previous findings by Bingenheimer [30] in Ghana, Fearon [31] and Widman [32]. Adolescents get information from their peers and friends, most often that information is not correct and misleading. Adolescents want to feel belong, believe their peers and want to have a taste of what they do, thereby engaging in unprotected sex not minding the consequences.

Respondents in this study largely agreed that substance use could influence adolescents to be involved in unprotected sex. This finding agreed with Cheng [33], in Canada that adolescents who drink alcohol were most likely to have unprotected sex. The study revealed that transactional sex also influences unprotected sex among adolescents. This finding is in line with Odeigah [34] who found that factors influencing involvement in transactional sex include poverty, broken homes, peer influence and the desire to make cheap money. Most students who engaged in transactional sex rarely used measures of protection such as condoms and most of the partners who engaged students in unprotected sexual behaviour were of higher social and economic status. This inequality in social and economic status is an obstacle for the students to bargain for safe sex, hence, susceptible to STIs including HIV. With regard to watching pornography and attending night clubs, about three- quarters of the respondents indicated that watching pornography and attending night clubs influence unprotected sex among adolescents. This finding is in consonance with Kamaruddin [35], who found in Malaysia that premarital and unprotected sexual activities were positively associated with watching pornography and films. Watching pornography is a common practice among adolescents [36, 37]. Adolescents are sexually aroused while watching pornographies, images of what they watch create a strong sexual urge in them, then they tend to experiment what they watch whether safe or unsafe.

Results from this study also revealed that what adolescents read and watch on social media influence them to engage in unprotected sex. This finding agrees with Oladeji and Ayangunna [29], in Ibadan, South-west Nigeria, who found that adolescents are being influenced to engage in unprotected sex through the social media. Parents’ refusal to engage their children on sex education also influences unprotected sex among adolescents. This finding is in agreement with a study conducted in Indonesia by Suwarni [38]. Parents are the first teachers of their children; sex education at home is an empowerment to overcome unprotected sex.

The result of the hypotheses testing revealed no significant difference in the level of knowledge of sex education and unprotected sex among male and female adolescents in the public secondary schools in Owo local government. Moreover, there is no significant difference in the perception of adolescents about sex education and unprotected sex among male and female adolescents in the public secondary schools in Owo local government area. Male and female students have similar thoughts and positive perception on sex education. This result is in agreement with Adaobi [39] and Onongha [40]. The school was the only variable that was significant in association between the level of knowledge of sex education and unprotected sex and the socio-demographic characteristics of adolescents in the public secondary schools in Owo local government, others showed no association. This finding is in line with Adigun [41]. The result of the study is evidence that adolescents in public secondary schools in Owo local government have positive perception towards sex education and unprotected sex.

The majority of the respondents in public secondary schools in Owo local government area have good knowledge and a positive perception on sex education. Despite the knowledge and positive perception, adolescents still mentioned some factors that lured them into unprotected sex, with pleasure, media and watching pornography being the leading factors. This may be due to their inability to take firm decisions on their sexuality because of their age. Therefore, recommendations regarding precautionary measures to reduce unprotected sex among adolescent students are highlighted as follow. There should be a review of the topics and content of sex education in the present secondary school curriculum. Periodical seminars and workshops for teachers that handle sex education in secondary schools should be encouraged by relevant educational authorities at local, state and federal levels. Parents should control materials adolescents read, programmes which they watch on television, hand phones and the social media. Parents should create time to watch and monitor their adolescents’ movements, screen their friends and make adequate provisions for them to avoid transactional sex. Effective communication between adolescents and their parents. Activities of night clubs in Owo local government should be controlled to exclude adolescents.

Conflict of Interest

The authors declare no conflicts of interest. The authors alone are responsible for the content and the writing of the paper.

Funding

This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

The authors would like to acknowledge the management of Department of Nursing Science, School of Basic Medical Sciences, College of Medical Sciences, University of Benin, Benin-City, Edo State, Nigeria for creating the enabling environment for this study. Thanks to all the Director and technical staff of St Kenny Diagnostic and Research Consult, Ekpoma, Edo State, Nigeria for their excellent assistance and for providing medical writing support/editorial support in accordance with Good Publication Practice (GPP3) guidelines.

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