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Table of Contents
Year : 2022  |  Volume : 27  |  Issue : 3  |  Page : 261-269

Health risk behavior of adolescents with sickle cell disease in Nigeria

1 Department of Home Science and Management, Federal University of Agriculture Abeokuta, Ogun, Nigeria
2 Institute of Child Health, College of Medicine University of Ibadan, Ibadan, Nigeria
3 University of Ibadan and University College Hospital, Ibadan, Nigeria
4 Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine PMB 5017, University of Ibadan, Ibadan, Nigeria

Date of Submission01-Feb-2022
Date of Decision02-Mar-2022
Date of Acceptance14-Mar-2022
Date of Web Publication2-Jun-2022

Correspondence Address:
Patience T Ajike
Child Development and Family Studies Unit, Department of Home Science and Management, Federal University of Agriculture Abeokuta Ogun
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_9_22

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Background: The advances in medical practice have increased the average life expectancy of people living with sickle cell disease (SCD) to 54 years. The high prevalence rates of SCD in Nigeria therefore highlights the need for research that will support overall disease management. Objective: To determine the health risk behavior (HRB) of adolescents with sickle cell disease in Nigeria. Materials and methods: In a cross-sectional descriptive survey using purposive sampling method, 122 adolescents with SCD attending sickle cell clubs in Ogun State, Nigeria were selected for the study. A 58-item questionnaire adapted from the Youth Risk Behavior Survey (YRBS) instrument developed by Centre for Disease Control and Prevention (CDC) was used to collect data from the adolescents. Results: The mean age of the respondents was 15.7 ± 2.3 years, there were more females (58.2%) than males (41.2%). Majority were from a monogamous family setting and average to large family size (≥3siblings) (63% and 76% respectively) and only 6% of the parents had no formal education. The mean ages at first sexual intercourse, cigarette smoking and alcohol use were 16 ± 5.7, 15.7 ± 0.7, and 14.9 ± 1.9 years respectively. One-fifth (21.3%) have had sex and half (50%) of them have had sex by the age of 17. Over one-tenth (13.9%) had smoked cigarette while 14.8% had taken alcohol. Adolescents from monogamous family background were more likely to be involved in substance abuse (χ2: 4.99; P=0.008) and exposed to sexual activities (χ2: 10.9; P=0.004) than those from polygamous or single parent family. Conclusion: It was concluded that adolescents with SCD are involved in HRB and may be dependent on family characteristics. It is recommended that regular health care of chronically ill adolescents should include screening and counselling for HRBs.

Keywords: Adolescents, chronic illness, health risk behaviors, Nigeria, sickle cell disease

How to cite this article:
Ajike PT, Adediran K, Kotila TR, Dairo MD. Health risk behavior of adolescents with sickle cell disease in Nigeria. Int J Med Health Dev 2022;27:261-9

How to cite this URL:
Ajike PT, Adediran K, Kotila TR, Dairo MD. Health risk behavior of adolescents with sickle cell disease in Nigeria. Int J Med Health Dev [serial online] 2022 [cited 2022 Aug 12];27:261-9. Available from: https://www.ijmhdev.com/text.asp?2022/27/3/261/346440

  Introduction Top

Adolescents generally look forward to and have expectations for adulthood and they struggle with having a sense of self-identity and independence which make them to adopt a variety of behaviors which may be risky to their health.

Health risk behaviors (HRB) are actions that have compromising or negative effects that may be potentially harmful to the individual.[1] The most common health risk behaviors are physical inactivity, cigarette smoking, alcohol intake, illegal drug use, non- adherence to medication, delinquent behaviors, engaging in self-injurious acts, sexual activity and unbalanced diet.[1] It has been observed that people partake in health risk behaviors because they gain the chance to experience an outcome they perceive as positive or good.[2] These behaviors may end up with deleterious effects as well as death.

Research shows that adolescents’ engagement in risk-taking behavior is prevalent and on the rise both internationally[1] and locally.[2],[3] The most common risk-taking behaviors that adolescents engage in include illicit drugs and alcohol use, cigarette smoking, sexual-risk behavior, and violence.[4]

Sickle cell disease is the most common form of haemoglobinopathy in the world[5] and the disease is most prevalent in Sub-Saharan Africa and Asia.[6]The disease affects 2 to 3% of the Nigerian population of more than 160 million.[7]

Adolescents with SCD experience similar challenges as their healthy counterparts in adjusting to sexual maturation, developing a positive body image, sense of self-esteem and autonomy.[8],[9] The challenges of growing up with SCD include recurrent hospital admissions, frequent visits to hospital for appointments and lifestyle restrictions as a result of secondary complications. These complicated problems could lead to social isolation at a time when peer relationships are becoming more crucial for an adolescents’ social, emotional, and psychological development.[8]

These risky behaviors are rarely addressed by health care providers for adolescents with chronic diseases despite their repeated exposure to health care system and frequent contact with healthcare providers. It is therefore necessary to investigate the health risk behavior of adolescents with SCD and determine the prevalence in the Nigerian setting.

  Materials and Methods Top

Study area

The study was conducted in Ogun State which is situated in Southwestern Nigeria. The state is notable for being a high concentration of industrial estates and being a major manufacturing hub in Nigeria. It shares borders with Lagos, a cosmopolitan city and the former capital of Nigeria and Benin Republic, a francophone country in Sub-Saharan Africa

Study population

The study recruited members of the two Sickle Cell Clubs in Ogun State who were between the ages of 11–19 years of age. The sickle cell club is a specialized centers which combines the medical care of persons with SCD with meeting their social and psychological needs. Sickle cell clubs are located in all states of the federation. There are two of such clubs in Ogun State, these are the Aglow Sickle Cell Club, Ijaiye and the Sickle Cell Club at the Iyesubomi Child Care Centre, Ijebu Ode. These Sickle Cell Clubs are affiliates of the Sickle Cell Foundation of Nigeria (SCFN), a not-for-profit Non-Governmental Organization dedicated to proper care of people living with Sickle Cell. The objectives of the foundation are research, patient care and education.

Study design

The design is a cross-sectional descriptive study investigating the relationship between socio-demographic variables, and health risk behaviors of adolescents with SCD.

Sample size determination

The required sample size for this study was estimated using Leslie Kish’s formula (N = Z2pq/d2) for prevalence studies.[9] Where N = desired sample size, Z= The standard normal deviate set at 1.96 which correspond to 95% confidence level. An estimated sample size of 292 participants was determined based on a precision of 0.05, adjusting for a non-response rate of 10% and a prevalence of 77.7% from a study of prevalence of HRB of adolescents with SCD in Jamaica.[10]

However, the total population of adolescents available for the study was 122. Since the number of participants available for the study was far less than the calculated sample size of 292, all the adolescents were recruited into the study. At the end of the study, the power of the study was calculated using the formula below:


A Z value of 1.03 which corresponds to a power of 85% was obtained. Therefore, this study has a power of 85%.

Data collection instrument

Data was collected using a semi-structured interviewer administered questionnaire. The research instrument consisted of a combination of items adapted from a validated instrument. The items selected were divided into the following sections:

Section A

focused on the socio-demographic characteristics of the study participants such as age, gender, class, employment status, level of education, religion and ethnicity was obtained. Other variables include family characteristics such as living with parents, number of siblings, family type, parent’s occupation and parent’s educational qualification.

Section B

This section contains questions relating to the health risk behaviors including alcohol use, tobacco use, sexual activity, unhealthy dietary behavior, physical inactivity adopted from the Youth Risk Behavior Questionnaire (YRBS) 2017.[11] The YRBS is an instrument created by CDC in the United States in the 1980s. The instrument contains 78 HRB related items; composed of multiple choice questions, where the interviewer selects the option that best match the situation they experience. Response options are dichotomous (10 items) or ordinal polytomous (66 items) that express the frequency of HRB in different time frames (previous day, past 7 days, past 12months. Most questions contain 5 to 7 categories of responses corresponding to increasing levels of use. Items are distributed over 11 domains- personal safety, violence, suicide, tobacco use, alcohol consumption, cannabis use, other drug use, sexual activity, body weight, feeding, physical inactivity.[12],[13],[14] The scores of each domain of the instrument can be calculated to correspond to the average of its items, and the higher the score the higher the HRB.

Data collection procedure

Prior to recruiting participants for the study and data collection, permission was received from the Medical Directors of the government-owned hospitals where the sickle cell clubs are domiciled as well as the Directors of the sickle cell clubs. Ethical approval was received from the State Health Research and Ethics Committee (SHREC), Ministry of Health Ogun State (HPRS/381/329). Two health workers were trained for one week on data collection methods. During the training, participatory methods and approach was used to ensure everyone is carried along.

After an informed consent, data were collected using the interviewer-assisted questionnaire. The researcher or the health worker assigned asked the questions and recorded the responses of the participants. The researcher also provided any clarifications to queries raised by the participants.

Repetition reliability of the instrument

Although The Youth Risk Behavior Survey Instrument has been used widely and found to be reliable, the questionnaire was pretested using 15 adolescents attending sickle cell clinic at Federal Medical Centre, Idi-Aba, Abeokuta. The responses were coded, entered into the statistical software and analyzed. The questions in the instrument yielded a minimum Cronbach Alpha value of 0.861.

Data management and analysis

Health Risk Behavior Measures: Questions in the Youth Risk Behavior Survey (YRBS) instrument contain multiple response categories. The responses in the standard YRBS reports were dichotomized into “no risk” and “at risk”. For example, adolescents who answered that they smoked cigarettes on 0 of the past 30 days are classified as “no risk”, whereas those who reported that they smoked 1 or more cigarettes in the past 30 days are classified as “at risk”. Data in the questionnaire were coded and analyzed using STATA statistical software (Stata Corp, College Station, Texas, USA). Descriptive statistics such as mean, standard deviations, frequencies and percentages were used to summarize study variables and to evaluate distribution of responses. Chi-square test was used for inferential analysis between categorical variables. Results obtained were presented in tables.

  Results Top

Respondent’s socio-demographic characteristics

A total of 122 adolescents attending sickle cell clubs in Ogun State were interviewed. The age of the respondents ranged between 11–19 years with a mean of 15.7 ± 2.32. Eighty (65.57%) of the respondents were within the age of 15–19 years. About half (71, (58.2%)] were females and majority of the respondents (91(75%)) were HbSS but 31 (25%) did not know their haemoglobin phenotype [see [Table 1]].
Table 1: Socio-demographic characteristics of the respondents (n = 122)

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Family characteristics of the respondents

More than half (63.11%) of the respondents were from monogamous families [Table 2]. Twenty-nine (36.1%) of the respondents had, between one or two siblings, 59 (48.4%) had about four siblings while some had five or more siblings [Table 1]. The level of the parents’ education and occupation are shown in [Table 1]. Twenty percent of the respondents do not live with their parents.
Table 2: Health Risk Behavior among the adolescents

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Respondent’s health risk behaviors

About a quarter of the respondents had one or more risky behavior, with about one -fifth (21.3%) having had sex before, of which half 13 (50%) have had sex by the age of 17. The preferred method of contraception in half of those who have had sex before is condom [Table 3]. Majority of the adolescents 92 (75.41%) had not been tested for HIV in the past twelve months, and only 10 (8.14%) have been tested for other STDs [Table 3]. Seventeen (13.93%) had smoked cigarette before while, 18(14.8%) had taken alcohol and 3 (2.5%) had taken Marijuana [Table 4]. Narcotics like tramadol and pentazocine were used by 12 (9.84%) respondents, 2(1.64%) had sniffed glue, 6 (4.92%) had used steroids while 5(4.10%) have had to inject drugs but none had taken heroine [Table 5].
Table 3: Pattern of sexual risk behavior among Adolescents with SCD (n = 122)

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Table 4: Pattern of cigarette, alcohol and marijuana consumption among Adolescents with SCD (n = 122)

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Table 5: Non-prescription drug use among Adolescents with SCD (n = 122)

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Socio-demographic factors associated with substance use

This study showed that females 65 (58.0%) had higher prevalence of substance use compared to their male counter parts 47 (4.2%) [Table 6]. This difference was not statistically significant (P = 0.904). More respondents within the age group 11–14 years 39/42 (92.9%) had engaged in substance abuse in the past, more than those in the age group 15–19 (73/80 (91.3%). Adolescents from monogamous family backgrounds were more likely to be involved in substance abuse than those from polygamous or single parent families.
Table 6: Sociodemographic factors and level of substance use among adolescents with SCD

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Socio-demographic factors associated with risky sexual behaviors

A higher proportion of respondents living with their parents 23(79.3%) had a low level of risky sexual behaviors compared to their counter parts who were not living with their parents 6(20.7%) (P = 0.67). Females 17 (58.6%) had higher level of risky sexual behavior compared to males 12 (41.1%), (P = 0.958). Adolescents from monogamous family backgrounds were more likely to be involved in substance abuse than those from polygamous or single parent families. (χ2:10.9; P=0.004) [Table 7].
Table 7: Sociodemographic factors and level of risky sexual behaviours among adolescents with SCD

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  Discussion Top

This study showed that 25% of the adolescents had one or more health risky behavior and half of them have had sex by the age of 17 years. The mean age at first alcohol intake of 14.9 years is similar to that of first tobacco use of 15.7 years and that of age at first sex of 16 years. Though more than 60% of the participants were from a monogamous home, 20% do not live with their parents. Male participants and those who lived with their parents had a lower level of risky sexual behavior, though this was not statistically significant. Adolescents from monogamous family background were more likely to be involved in substance abuse and exposed to sexual activity than those from polygamous or single parent families.

The findings of the study show that about one fifth of the respondents (21.31%) have had a previous history of sexual intercourse, a prevalence lower than that of Asani et al, 2014 and Britto et al. 1998 who reported that about half of the adolescents with SCD had been involved in sexual activity.[10],[16] The sociocultural environment in which the adolescents grow up may play a role in the differences in prevalence of sexual risk behaviors. Given that the other studies were conducted in Western nations with high rates of sexual risk behaviors. However, the mean age at first sexual intercourse of 16 years is similar to age at first sex of 17 years reported by Asani et al, and Britto et al.[10],[16] Adolescents with SCD may have a later onset of sexual activity compared with peers without SCD because of the delay in attaining puberty. The most popular source of sexual information for the respondents was from friends, followed by mothers of the respondents. Despite the fact that SCD adolescents reported greater access to sexual information, none of them obtained this information from their health care providers. Previous studies indicate that sexuality and related subjects are not discussed by health care providers of these chronic illnesses in spite of its significance in this age group.[10],[17],[18]

Findings from the study also revealed that the most commonly reported substance of abuse was alcohol. The reported prevalence of alcohol consumption of 14.75% is lower than previously reported among Jamaican SCD adolescents, where a prevalence of 77% was reported[10] and that of North Carolina, USA[17] who reported a prevalence of (36.9%) and the report of Levenson et al. (2007) of 31% in alcohol abuse.[19]

Again, the prevalence of cigarette smoking is lower than previously reported among Jamaican SCD cohort[10] and their North Carolina counterparts.[17] The differences in the prevalence of alcohol consumption and cigarette smoking may be related to the prevalence in the larger community where the patients are domiciled. Only three (2.46%) SCD adolescents in this study reported ever taking marijuana again this is low when compared to a study conducted among adolescents and young adults in US where 16.9% was reported.[20] Although there are reports to show that SCD adolescents who use marijuana, uses it to alleviate their pain.[10],[20],[21] About 10% of the adolescents in our study used pain medications without prescription which corroborates the need to see drug abuse as an emerging and understudied health problem among SCD patients.[22]

We did not find an association between age and health risk behaviors of the adolescents with sickle cell disease. It has previously been reported by Suris et al, 2008 that factors such as age, gender, academic track, and parents’ education level was not found to be significantly associated with health risk behaviors.[23] This was also in agreement with the findings of Britto et al, (1998) that there are no significant differences in the age, gender, or racial distribution between the chronically ill adolescents with SCD or cystic fibrosis and health risk behaviors.[16]

This study observed that family type plays a significant role in the health risk behaviors of SCD patients which is in consonance with the finding that social factors such as school attendance and living with a parent, have been implicated in the absence or presence of risky behavior in their study.[10] Moreover, parenting and family background could also significantly influence the experience and pain management in adult sickle cell disease patient.[22] Surprisingly, monogamy was more associated with HRB than polygamy or single parenthood. This could be because of emotional absence of one of the parents in a monogamous setting, though our questionnaire did not probe further on this.

The result from this study showed that more of females (71%) engaged in health risk behaviors. This is in contrast with a similar study carried out in Australia where chronically ill adolescent males and females engaged in health risk behaviors at an almost equal frequency.[23][24] This is also different from the findings of Asani et.al who found that more males engaged in health risk behaviors than females.[10]

  Conclusion Top

Health care professionals may assume that health risk behaviors are less in adolescents with a chronic disease, however many studies have reported otherwise. This study presents the findings that adolescents with SCD engage in health risk behaviors. The prevalence was lower than those reported by the general population of adolescents, nonetheless, this result may have more dangerous consequences in them than their healthy peers. After controlling for other factors such as age, gender and family type, family type was found to be a determinant of health risk behaviors of adolescents with SCD. It is recommended that regular health care of chronically ill adolescents should include screening and counselling for health risk behaviors.


This study was based on Sickle Cell Clubs in Ogun State, Nigeria. We would like to appreciate all participants, Mrs. Oyeneye of the Aglow Sickle Cell Club and Mrs. Adebanjo of the Sickle Cell Club at Iyesubomi Child Care Centre, Ijebu Ode for providing the opportunity and support for the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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