Almost one-third of Ghana’s population are aged between 10 and 24 years, many of whom are at risk or have experienced or are experiencing the negative impacts of unwanted pregnancies and Sexually Transmitted Infections (STI), including HIV/AIDS [1, 2]. Research evidence show that early sexual debut is one of the major predisposing factors to elevated risk of STIs [2, 3]. Although there are studies that have examined the correlates of early sexual debut in sub-Saharan Africa, there are no systematic studies that identify hotspots of these practices and their spatial correlates, which are important for target interventions. Given the high sociocultural diversity and economic inequalities within countries of sub-Saharan Africa, generalisation of adolescent sexual behaviour even at the country level does not provide comprehensive knowledge of attitudes and behaviours of young people. In this regard, this study using data from the 2017 Ghana Maternal Health Survey (GMHS) examines geographic hotspots of early sexual debut (sex before the legal age of consent) among women of reproductive age in Ghana and their spatial correlates. Identifying geographical hotspots of early sexual debut and their correlates at the district level where health interventions are planned, implemented and monitored are essential for promoting targeted interventions.
The Ghana Criminal Code (amendment) Act, 2003 (Act 646) states the legal age of sexual consent as 16 years and prohibit sexual intercourse before the attainment of this age, be it consensual or not . Further, the children’s Act of 1998 state the legal age of marriage as 18 years and prohibit marriage or union formation before the attainment of this age . Although the laws of Ghana allow freedom of worship and customary practices, the legal age of sexual consent and marriage are the same for all. It is also worth noting that, the laws of the country are superior to any religious doctrine or cultural practices. In this regard, chapter 1(2) of the 1992 Constitution of the Republic of Ghana, states: “The Constitution shall be the supreme law of Ghana and any other law found to be inconsistent with any provision of this Constitution should, to the extent of this inconsistency, be void” . It is therefore illegal in Ghana and against the sexual rights of young people to engage in sexual intercourse before attaining the legal age of 16 years.
Studies have shown that early sexual debutants are more likely to have multiple, concurrent sexual partners, transactional and unprotected sex, exposing them to acquiring STIs [7, 8]. Early sexual intercourse increases risk of unwanted pregnancy, predisposing young girls to maternal mortality and morbidity including higher risks of eclampsia, puerperal endometritis, systemic infections, low birthweight, preterm delivery and severe neonatal outcomes [9, 10]. Further, they face social challenges including limited opportunities for education and economic prospects . Young people who initiate sex early are more likely to be exposed to sexual coercion, systemic physical and psychological violence [12, 13]. The effects are not only limited to the formative years of young people but also in their adult lives. It is reported that early sexual debut leads to poor psychosocial health and risky behaviours in later life, including alcoholism, drug use, antisocial and violent behaviours, low self-esteem and poor mental health, among others .
Early sexual initiation varies by sex and across the countries of sub-Saharan Africa. A study in five sub-Saharan African countries covering adolescents aged between 18 and 24 years revealed that in Kenya (boys = 16.3%, girls = 6.7%), Malawi (boys = 22.0%, girls = 14.1%) and Uganda (boys = 15.0%, girls = 10.4%) more boys initiate early sex compared to girls, whilst in Tanzania (boys = 6.8%, girls = 10.1%) and Nigeria (boys = 5.4%, girls = 14.5%) more girls than boys initiate sex early . A multicounty study of 24 sub-Saharan African countries using nationally representative datasets, found large variations in the proportion of men and women aged 15–19 years who initiated sex before the age of 15 years, ranging from 2.0% to 27.0% for men and 5.0% to 26.0% for women . The study further reported that, in Western African countries, females were more likely than men to initiate sex before age 15 years, whilst in Central, Eastern and Southern Africa a mixed pattern was observed, with early sexual initiation being more common in rural than urban areas in most countries . In addition, a declining median age at first sex among young people has also been reported across many sub-Saharan African countries .
In Ghana, a recent study reported that 10.8% of women and 6.8% of men aged 15–24 years, reported having sex before age 15 years . The 2014 Ghana Demographic and Health Survey, reported that among women age 25–49 years, 11% had their first sex by age 15 years, with a median age at first sex of 18.4 years, more than two years lower than the median age (20.7 years) at first marriage . Substantial variations in median at first sexual intercourse was also reported by region (ranging from 17.6 years in the Northern region to 19.0 years in the Greater Accra region), place of residence (urban = 18.8 years, rural = 17.8 years) and wealth status (poorest = 17.6 years, richest = 19.8 years) . Ethnic variations in early sexual intercourse have also been reported in Ghana, with ethnic groups (Mande, Grusi and Mole-Dagbani) in the northern part of the country initiating sex at a later age than other groups .
Studies have identified multifaceted factors at the individual, family and community levels that predict early sexual debut. Observed individual level predictors include low aspiration and self-esteem, lack of knowledge on sexual and reproductive health including STIs and attitudes to premarital sex . At the family level, family structures and parental participation in adolescent sexual activities including supervision, sexual education, family dysfunction and socioeconomic situation are observed predictors of early sexual debut [7, 21]. In a study in Burkina Faso, Ghana, Malawi and Uganda, it was revealed that community factors such as adolescent marriage, wealth, religious affiliation, membership in adolescent social groups and use of alcohol were potential risks factors for early sexual initiation .
The Government of Ghana over the years has enacted a number of policies to address the sexual and reproductive health needs and challenges of young people. These include the 1999 National Youth Policy, the 2000 Adolescent Reproductive Health Policy, and the 2010 National Youth Policy of Ghana [23,24,25]. These policies provide comprehensive strategies for addressing the health challenges of young people, including their sexual and reproductive health needs and issue of STIs including HIV/AIDS. In 2016, the Government of Ghana enacted the 2016–2020 Adolescent Health Service Policy and Strategy to address the multiple challenges faced by young people, including their sexual and reproductive health needs and other factors that expose them to negative health and social outcomes . This policy was to provide a framework for the efficient use of resources for providing health and other related services towards achieving wide-ranging health sector goals for adolescents and young people in Ghana. Despite all these policy efforts, Ghana is one of the countries in sub-Saharan Africa where young people continually face sexual, reproductive health and rights challenges . Key limitations to all these policies initiatives are that they fail to identify at risk groups and geographic areas where targeted interventions are needed. Thus, identifying hotspots of early sexual debut and their spatial correlates are essential for designing and implementing target interventions to reduce its consequential negatives effects including unwanted pregnancies, maternal mortality and morbidity and STIs among adolescents and young people in Ghana.