F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.2-86.v2 Research Article Articles Female Fertility Regulation Global Health Social & Behavioral Determinants of Health Nigerian secondary school adolescents’ perspective on abstinence-only sexual education as an effective tool for promotion of sexual health

[version 2; peer review: 2 approved, 1 approved with reservations]

 Inyang Mfrekemfon P a 1 Inyang Obonganyie P 2 Department of Human Kinetics and Health Education, Faculty of Education, University of Port-Harcourt, Rivers State, Nigeria Medical and Health Centre, University of Debrecen, Debrecen, 4032, Hungary mfrekemfon@yahoo.com

Obonganyie P Inyang trained research assistants who helped in administering the questionnaire. She coordinated the administration, retrieval and sorting to separate useful copies of questionnaires from those not useful. The title of the work was conceived by Mfrekemfon P Inyang. She planned the research, reviewed the work, did the analysis and wrote the article.

Competing interests: No relevant competing interests were disclosed.

 4 12 2013 2013 2 86 2 12 2013 Copyright: © 2013 Inyang MP and Inyang OP 2013 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The success of any type of sexual education programme depends on the knowledge and preparedness for practice by adolescents. A recent study has found that an ‘abstinence-only’ sexual education programme is effective in reducing sexual activity among adolescents. Knowledge of abstinence-only sexual education and preparedness for practice as an effective tool for promotion of sexual health among Nigerian secondary school adolescents was studied. An analytic descriptive survey design was used for the study. The research population comprised of all public secondary schools in three southern geopolitical zones of the Niger Delta Region of Nigeria. A multistage sampling technique was used in selecting 2020 senior secondary school (SS1-SS3) students as sample for the study. A partially self-designed and partially adapted questionnaire from abstinence-only versus comprehensive sex education debate from debatepedia entitled Questionnaire on Nigerian Secondary School Adolescents’ Perspective on Abstinence-Only Sexual Education (QNSSAPAOSE) was used in eliciting information from respondents. Hypotheses were formulated and tested. Frequency counts, percentage and Pearson Product Moment Correlation were used in analysing data. A greater proportion of secondary school adolescents in this study lacked knowledge of sexual education. About 80% of the respondents could not define sexual education. The general perspective on abstinence-only sexual education is negative, as revealed by larger number of respondents who demonstrated unwillingness to practice abstinence-only sexual education. Specifically, of those who responded in favour of abstinence-only sexual education, the youngest group of adolescents (11–13 years) and the male respondents are more likely to accept this type of education than the other groups. Poor knowledge of sexual education could be responsible for unwillingness to practice abstinence-only sexual education. Sexual education should therefore be introduced into secondary school curriculum and taught by well-prepared teachers to enable an informed decision on practice.

 The author(s) declared that no grants were involved in supporting this work. Amendments from Version 1

We appreciate immensely the efforts of the reviewers of our original manuscript. Their various suggestions have been incorporated accordingly to produce a second version of our work. All pointed out areas such as measures of efficacy of abstinence-only sexual education which were not addressed by the study are put up as suggestions for a follow up study. Conclusion and other areas pointed out have been amended accordingly to rule out any form of confusion. Comparison by religion is ruled out since Christianity is the dominant religion. Some aspects of the work without any negative effect on the entire work are removed to shorten the manuscript to avoid a possible loss of interest by some readers. Some text descriptions are removed where tables are self explanatory. Efforts are made to clarify that this work only examines the perspectives on abstinence-only sexual education which was found by previous studies as an effective tool for promotion of sexual health.

 Introduction

Sexual education is a lifelong process of acquiring information on sex and forming attitudes, values and beliefs. It involves sexual development, sexual and reproductive health, interpersonal relationships, affection and intimacy 1 . Abstinence-only sexual education teaches the adolescents to abstain from premarital sexual intercourse because of the advantages it offers. Such advantages include prevention of unintended pregnancies and prevention of contracting HIV/AIDS and other sexually transmitted infections. According to the Federal Law of the United States of America (USA), every school-aged child should not engage in sexual activity 2, 3 . The USA Federal law further advocates sexual activity within the confines of monogamous marital relationship to guard against adverse psychological and physical effects associated with premarital sexual activity. Bearing children outside marriage has serious effects on the child, the mother and the society as a whole 3– 6 . The Federal Law of United States of America also posited that, abstaining from sexual activity outside marriage allows for maturity and understanding of self 3, 7 .

Studies disclose that it is comprehensive sexual education and not abstinence-only that will delay first sexual activity 2, 3, 8– 14 . Abstinence-only sexual education lacks strong evidence of effectiveness because of faulty designs 3, 15, 16a . Abstinence-only sexual education does not positively affect the sexual behaviour of adolescents, lacks the message of sexually transmitted infections to its recipients and the positive effect in a few cases does not last for a long time 16b, 17 .

According to Bruckner and Bearman 18 and a study by the Alan Guttmacher Institute 19 those that embrace abstinence-only sexual education still have sex before they get married. There is no difference between adolescents that accept abstinence-only sexual education and those who do not in terms of number of sexual partners and ages of first sexual intercourse 17 . Abstinence-only sexual education does not reduce the scourge of HIV/AIDS 16b . Bennett and Assefi saw the failure to provide adolescents with information about contraception as a serious weakness of abstinence only sexual-education 20 .

The proponents of abstinence-only sexual education frown at the role of comprehensive sexual education in emphasising so much on the reliability of contraceptives while de-emphasising their failure rates and the possibility of contracting new sexually transmitted diseases including HIV/AIDS 21 . They further frowned at the double message of comprehensive sexual education such as encouraging the delay of first sexual intercourse and promoting the use of contraceptives 22 . They are also blamed for stressing the possibility of contracting sexually transmitted infections to the extent of falsifying information to establish the negative aspect of comprehensive sexual education 1, 23, 24 . Studies further reveal that sexual educators do not stress enough on sexual intercourse or bring in sensitive issues such as homosexuality and abortions. The adolescents posited that the basic message is that they should not have sex 19, 25– 27 . The proponents of comprehensive sexual education attributed the ineffectiveness of condoms and contraceptives to poor-quality research 28 .

Abstinence-only sexual health education is also blamed for withholding information on the positive aspects of sexual relationships, while magnifying the emotional risks and pitfalls associated with premarital sexual activity 1, 24 . Modern lifestyle is characterised by a high rate of broken marriages, predisposing an individual to having many sexual partners 1 . According to some studies the age of first marriage has risen to 30 years, with a fifth of such marriages ending in divorce within a period of five years 29 . Conversely the age at first sexual intercourse has dropped to 16 years with very few people having their husbands as their first sexual partners 30, 31 . The data on adolescents’ sexual behaviour in the developing world with a high prevalence of HIV/AIDS suggests unacceptability of abstinence-only sexual education. Some countries do not accept abstinence-only sexual education even in the face of the high prevalence of HIV/AIDS. Some countries expect sexual educators to encourage adolescents to delay their first sexual experience while also providing education on contraception and sexual health services 32 . In some countries, the requirements for teaching any type of sexual education are clearly outlined for the sexual educators 33 .

Most studies reveal comprehensive sexual education as the preference of parents and adolescents 34– 36 . Studies advocate comprehensive sexual education for unmarried sexually active adolescents 3 . Studies also recommend abstinence-only sexual education with information on contraception and risk-reduction behaviour for the few sexually inactive adolescents. These align with the position of Collins and Priya that parents and adolescents prefer comprehensive sexual education to abstinence-only sexual education 37 . Most studies revealed that the opinion of adults differs on the type of sexual education to teach adolescents. Most of the adults feel 7 th to 9 th graders should be taught ‘abstinence only’ while some advocate the teaching of contraception use 38 . Most studies also show that a greater percentage of adolescents prefer sexual orientation that will teach them about the use of contraception and sexually transmitted infections than abstinence-only sexual education 39 . Other studies reported the positive outcome of abstinence-only sexual education ranging from reduced sexual activity, pregnancies, abortions to more successful deliveries 40 . In line with this, John and Jemmott disclosed the success of abstinence-only sexual education in reducing sexual activity among youths 41 . In support of the findings of this new study, Rector submitted that out of 15 scientific evaluations of abstinence-only sexual education, 11 of them demonstrated its effectiveness in reducing adolescent sexual activity 42 .

A survey of the National Campaign to Prevent Teen Pregnancy in 2001 showed that 93% of abstinence sexual education came from the society 43 . They concluded that abstinence-only sexual education is the only 100% effective method to prevent teenage pregnancy and sexually transmitted diseases 4 . They further reminded that condoms cannot provide 100% protection against unplanned pregnancy and sexually transmitted infections and also that premarital sex can lead to life threatening health problems such as abortion and its associated complications 5 . They feel burdened that sexual, contraceptive and HIV information can provoke early sexual initiation among the adolescents 5 . Abstinence-only sexual education has positively produced a corresponding decrease in teenage pregnancy 4 . Studies have demonstrated that religion acts as a deterrent to early sexual activity 5 . In line with this, many adolescents submitted that morals, values and religious beliefs significantly influence the decision to have sex or not.

In deciding whether or not to have sex, the Organization of Concerned Women for America also decried the outcome of sex without love or responsibility supported by public policies. This results in the breakdown of nuclear families, increases crime, poverty, teen births and AIDS which in turn negatively affects the health of the general public. This only shows lack of values 5 .

 Statement of the problem

Adolescents are the future and so they require proper guidance that will propel them into responsible productive adults useful to themselves and their nations. Adolescence is a remarkable period characterised by the quest for experimentations with drugs, alcohol and sexual activity saddled with numerous life threatening adverse effects. The Nigerian Association for the Promotion of Adolescent Health and Development, (NAPAHD) found that, a hospital based research study revealed that 80% of patients with abortion complications in hospitals are adolescents. Studies in Nigeria have also shown that most female adolescents by the age of 15 have already had their first sexual intercourse 6, 45 . The same applies to male adolescents. In Nigeria, complicated abortion, sexually transmitted infections and HIV/AIDS, sexual coercion, unplanned and unwanted sexual activity and unwanted pregnancies and babies, drop outs from schools and homelessness abound and are very common features with the adolescents 6 . Most Nigerian adolescents do not receive correct sexual information while some are ignorant. Hold back their potentials and also affect the nation negatively 6 . The intense outcome associated with adolescent sexual activity necessitates the search for a positive way out and thus, the main objective of this study.

 Purpose of the study

According to Focus on the Family group, sex should be avoided the same way as the use of guns, tobacco, alcohol and drink-driving 46 . They sternly condemn the advocacy for the use of condoms against unwanted pregnancies and sexually transmitted diseases in favour of abstinence-only sexual education 47 . Previous studies document the advantages of abstinence-only sexual education in reducing adolescent sexual activities and the associated health problems. This study investigated the perspective of secondary school adolescents in Nigeria on abstinence-only sexual education as an effective tool for promoting adolescent sexual health. The findings will help in planning informed corresponding intervention programmes.

 Material and methods

An analytic descriptive survey design was used for the study. The research population comprised of all public secondary schools in three southern geopolitical zones of the Niger Delta Region of Nigeria. The States were Rivers, Akwa Ibom and Cross River. A multistage sampling technique was used for selecting 2020 senior secondary school (SS1-SS3) male and female students from the three states. Proportionate sampling technique was used in selecting the number of participating schools from the metropolis of each state. Five schools were selected from each of Cross River and Akwa Ibom States. Ten schools were selected from Rivers State. Respondents from each school were also selected proportionately. A total of 702 respondents were drawn from Akwa Ibom State, 510 from Cross River State and 808 from Rivers State. Participants were within the age range of 10–19 years. A questionnaire entitled Questionnaire on Nigerian Secondary School Adolescents Perspective on Abstinence-Only Sexual Education (QNSSAPAOSE) was used in eliciting information from respondents. The test/re-test reliability method was used to establish the internal consistency of the instrument. The instrument had a reliability coefficient of 0.75 established with Pearson Product Moment Correlation Coefficient (r). The instrument was divided into sections A and B. Section ‘A’ sought information on respondents’ demographic characteristics. Section ‘B’ sought information on respondents’ perspectives on Abstinence-Only sexual education. Questions were closed and open ended. The YES/NO questions attracted two points for positive responses and one point for negative responses. Questionnaires were administered with the aid of ten trained research assistants. Questionnaires were administered and collected on the spot to enhance a high return rate. Completion of the questionnaire was voluntary. Out of a total of 2020 questionnaires sent out, 2013 were returned and 13 questionnaires were not usable yielding a usable number of 2000 questionnaires. The return rate, therefore, was 99.1% (2000/2020). Hypotheses were formulated and tested. Frequency counts, percentage, Standard Deviation and Pearson Product Moment Correlation were used in analysing data. Approval of individual school management was obtained prior to execution of this study in their schools. Participants’ consent was also obtained. Participation was voluntary and anonymity was also assured and maintained.

 Results

All of the participants in this study were adolescents between the ages of 10 and 19 years ( Table 1).

Demographic characteristics of study participants by frequency and percentiles.
Variable N (%) N (%)
Age Class
11–13 years 176 8.8 SS1 1413 70.7
14–16 years 1223 61.15 SS2 486 24.3
17–19 years 601 30.05 SS3 101 5.1
Total 2000 100.0 Total 2000 100.0
Gender N (%) Religion N (%)
Male 702 35.1 Christianity 1877 93.9
Female 1298 64.9 Islam 86 4.3
Total 2000 100.0 Pagan 31 1.6
Ethnicity Traditional 6 0.3
Ikwerre 800 40 Total 2000 100.0
Ibibios 700 35
Efiks 500 25
Total 2000 100.0

Three research questions and six hypotheses were formulated in this study. Each one of them is addressed as follows:

What are the perspectives of adolescents on the advantages of abstinence-only sexual education?

Seven positive statements representing the advantages of abstinence-only sexual education were made ( Table 2). The general perspective of Nigerian secondary adolescents on the advantages of abstinence-only sexual education was negative. A greater number of the respondents did not agree with the statements highlighting the advantages of abstinence-only sexual education. However, taking into consideration the number of respondents from each age group that agreed with the statements highlighting the advantages of abstinence-only sexual education, it was found that the youngest age group (11–13 years) of adolescents ranked first. This implies that this group had the highest number of positive respondents in line with their total number when compared with the young (17–19 years) and younger (14–16 years) groups. Age group 11–13 years therefore demonstrated the likelihood of accepting abstinence-only sexual education.

Perspective of adolescents according to age group on the advantages of abstinence-only sexual education.
Item 1 Abstinence-only sexual education promotes responsible sexual culture
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 62 35.2 114 64.8 176 100
14–16 years 212 17.3 1011 82.7 1223 100
17–19 years 79 13.1 522 86.9 601 100
Total 353 17.7 1647 82.4 2000 100
Item 2 Abstinence-only sexual education promotes healthy fulfilling relationship
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 89 50.6 87 49.4 176 100
14–16 years 168 13.7 1055 86.3 1223 100
17–19 years 170 28.3 431 71.7 601 100
Total 427 21.4 1573 78.7 2000 100
Item 3 Abstinence-only sexual education discourages youth sex and risk taking
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 78 44.3 98 55.7 176 100
14–16 years 280 22.9 943 77.1 1223 100
17–19 years 157 26.1 444 73.9 601 100
Total 515 25.8 1485 74.3 2000 100
Item 4 Abstinence-only sexual education helps youth avoid emotional damage of sex
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 72 40.9 104 59.1 176 100
14–16 years 186 15.2 1037 84.8 1223 100
17–19 years 120 20.0 481 80.0 601 100
Total 378 18.9 1622 81.1 2000 100
Item 5 Abstinence-only sexual education helps discourage out-of wedlock pregnancies
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 65 36.9 111 63.1 176 100
14–16 years 313 25.6 910 74.4 1223 100
17–19 years 174 29.0 427 71.0 601 100
Total 552 27.6 1448 72.4 2000 100
Item 6 Abstinence-only sexual education is very good in preventing sexually transmitted infections (STIs) because condoms are not effective at protecting against STIs
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 58 33.0 118 67.0 176 100
14–16 years 171 14.0 1052 86.0 1223 100
17–19 years 84 14.0 517 86.0 601 100
Total 313 15.7 1687 84.4 2000 100
Item 7 Abstinence-only sexual education effectively reduces rate of teen sex and pregnancy
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 59 33.5 117 66.5 176 100
14–16 years 215 17.6 1008 82.4 1223 100
17–19 years 170 28.3 431 71.7 601 100
Total 444 22.2 1556 77.8 2000 100
What are the perspectives of adolescents on the disadvantages of abstinence-only sexual education?

The same number of statements was also made on the disadvantages of abstinence-only sexual education ( Table 3). Generally, more respondents agreed with five while disagreeing with the last two of the seven statements highlighting disadvantages of abstinence-only sexual education. Of the total number of respondents that disagreed with the statements of disadvantages, the young adolescents (17–19 years) ranked first followed by the younger ones (14–16 years). More of the young adolescents out of their total number disagreed with the statements of disadvantages when compared with the responses of the other two groups. This might be a factor of a better understanding than the younger age groups. Moreover, the problem might not be with the type of sexual education but mostly the willingness to practice.

Perspective of adolescents according to age group on the disadvantages of abstinence-only sexual education.
Item 8 Abstinence-only sexual education sometimes encourages oral and anal sex as alternatives
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 98 55.7 78 44.3 176 100
14–16 years 562 46.0 661 54.0 1223 100
17–19 years 248 41.3 353 58.7 601 100
Total 908 45.4 1092 54.6 2000 100
Item 9 Abstinence-only sexual education is Not effective at reducing teen sex rate
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 111 63.1 65 36.9 176 100
14–16 years 557 45.5 666 54.5 1223 100
17–19 years 278 46.3 323 53.7 601 100
Total 946 47.3 1054 52.7 2000 100
Item 10 Abstinence-only sexual education discourages condom use and increases risk
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 89 50.6 87 49.4 176 100
14–16 years 584 47.8 639 52.2 1223 100
17–19 years 284 47.3 317 52.7 601 100
Total 957 47.9 1043 52.2 2000 100
Item 11 Abstinence-only sexual education does Not help decrease HIV infection rate
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 77 43.8 99 56.3 176 100
14–16 years 587 48.0 636 52.0 1223 100
17–19 years 261 43.4 340 56.6 601 100
Total 925 46.3 1075 53.8 2000 100
Item 12 Condoms and Not abstinence-only sexual education decrease teenage pregnancy
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 113 64.2 63 35.8 176 100
14–16 years 363 29.7 860 70.3 1223 100
17–19 years 249 41.4 352 58.6 601 100
Total 725 36.3 1275 63.8 2000 100
Item 13 Telling teens to abstain from sex makes them want it more
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 97 55.1 79 44.9 176 100
14–16 years 623 50.9 600 49.1 1223 100
17–19 years 286 47.6 315 52.4 601 100
Total 1006 50.3 994 49.7 2000 100
Item 14 Abstinence-only sexual education wrongly teaches suppression of sexual impulses
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 128 72.7 48 27.3 176 100
14–16 years 673 55.0 550 45.0 1223 100
17–19 years 293 48.8 308 51.2 601 100
Total 1094 54.7 906 45.3 2000 100
What are the perspectives of adolescents on the acceptance of abstinence-only sexual education?

The general perspective of the respondents to five statements representing the acceptance of abstinence-only sexual education was negative. More respondents were against abstinence-only sexual education demonstrating a negative perspective on the acceptance of abstinence-only sexual education ( Table 4). For instance 1686 out of the total respondents of 2000 objected to wanting a strong abstinence-only message. The youngest adolescent group (11–13 years) had the highest number of respondents out of their total number of those in favour of abstinence-only sexual education. For instance, more of them when compared with other age groups wanted sex to be saved until marriage. More of them (11–13 years) also wanted a strong abstinence message and education. This indicates that the youngest group of adolescents were more likely to accept abstinence-only sexual education than other age groups.

Perspective of adolescents according to age group on the acceptance of abstinence-only sexual education.
Item 15 Abstinence-only sexual education provides some information on STIs and contraception
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 71 40.3 105 59.7 176 100
14–16 years 307 25.1 916 74.9 1223 100
17–19 years 141 23.5 460 76.5 601 100
Total 519 26.0 1481 74.1 2000 100
Item 16 Abstinence-only does Not have value
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 137 77.8 39 22.2 176 100
14–16 years 843 68.9 380 31.1 1223 100
17–19 years 373 62.1 228 37.9 601 100
Total 1006 50.3 994 49.7 2000 100
Item 17 Abstinence-only sexual education is for religious people and Not for people like us
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 125 71.0 51 29.0 176 100
14–16 years 895 73.2 328 26.8 1223 100
17–19 years 421 70.0 180 30.0 601 100
Total 1441 72.1 559 28.0 2000 100
Item 18 I like abstinence-only because it advocates that sex should be saved until marriage
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 77 43.8 99 56.3 176 100
14–16 years 135 11.0 1088 89.0 1223 100
17–19 years 148 24.6 453 75.4 601 100
Total 360 18.0 1640 82.0 2000 100
Item 19 I want a strong abstinence message and education
Age groups YES NO TOTAL
N (%) N (%) N (%)
11–13 years 59 33.5 117 66.5 176 100
14–16 years 168 13.7 1055 86.3 1223 100
17–19 years 87 14.5 514 85.5 601 100
Total 314 15.7 1686 84.3 2000 100
Descriptive analysis of age and gender distribution.
Age Gender Total
Male Female
N (%) N (%) N (%)
11–13 years 105 59.7 71 40.3 176 100.0
14–16 years 389 31.8 834 68.2 1223 100.0
17–19 years 208 34.6 393 65.4 601 100.0
Total 702 35.1 1298 64.9 2000 100.0
Is there any significant relationship between age and perspective on abstinence-only sexual education?

A significant relationship existed between age and the students’ perspective on abstinence-only sexual education. (r = 0.123**, N = 2000, P < 0.01) ( Table 7). Young age specifically had an influence on the respondents’ perspective on abstinence-only sexual education in this study. Null hypothesis is rejected.

 Is there any significant relationship between religion and perspective on abstinence-only sexual education?

Respondents belonged to different religious organisations but only 31 out of the total respondents of 2000 were pagans ( Table 6). A greater proportion were Christians which numbered up to 1877 out of 2000 total number of respondents. Muslims were 86 while traditional worshippers were only 6. According to the total number of each age group, the highest number of Christians came from age group 14–16 years followed by age group 17–19. Age group 11–13 years which has demonstrated the likelihood of accepting abstinence-only sexual education had the least number of Christians relatively.

Descriptive analysis of age and religion distribution.
Age Religion Total
Christian Muslim Pagan Traditional
N (%) N (%) N (%) N (%) N (%)
11–13 years 159 90.3 7 4.0 10 5.7 - - 176 100.0
14–16 years 1165 95.3 34 2.8 21 1.7 3 0.2 1223 100.0
17–19 years 553 92.0 45 7.5 - - 3 0.5 601 100.0
Total 1877 93.9 86 4.3 31 1.6 6 0.3 2000 100.0

Null hypothesis 1: There is no significant relationship between age and their perspective on abstinence-only sexual education.

 Relationship between age and perspective on abstinence-only sexual education.
Variable Mean Std. Dev. N* R*** P**** Remark
Perception of abstinence-only sexual education on 31.2350 3.5702 2000 .123** .000 Sig.
Age 15.6390 1.7565

*No of participants.

**Sig. at 0.01 level.

***Pearson’s.

****'p' value.

 Perspective of adolescents according to gender on the advantages of abstinence-only sexual education.
Item 1 Abstinence-only sexual education promotes responsible sexual culture
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 120 17.1 582 82.9 702 100
Female 233 18.0 1065 82.0 1298 100
Total 353 17.7 1647 82.4 2000 100
Item 2 Abstinence-only sexual education promotes healthy fulfilling relationship
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 191 27.2 511 72.8 702 100
Female 236 18.2 1062 81.8 1298 100
Total 427 21.4 1573 78.7 2000 100
Item 3 Abstinence-only sexual education discourages youth sex and risk taking
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 192 27.4 510 72.6 702 100
Female 323 24.9 975 75.1 1298 100
Total 515 25.8 1485 74.3 2000 100
Item 4 Abstinence-only sexual education helps youth avoid emotional damage of sex
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 166 23.6 536 76.4 702 100
Female 212 16.3 1086 83.7 1298 100
Total 378 18.9 1622 81.1 2000 100
Item 5 Abstinence-only sexual education helps discourage out-of wedlock pregnancies
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 182 25.9 520 74.1 702 100
Female 370 28.5 928 71.5 1298 100
Total 552 27.6 1448 72.4 2000 100
Item 6 Abstinence-only sexual education is very good in preventing sexually transmitted infections (STIs) because condoms are Not effective at protecting against STIs
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 127 18.1 575 81.9 702 100
Female 186 14.3 1112 85.7 1298 100
Total 313 15.7 1687 84.4 2000 100
Item 7 Abstinence-only sexual education effectively reduces rate of teen sex and pregnancy
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 135 19.2 567 80.8 702 100
Female 309 23.8 989 76.2 1298 100
Total 444 22.2 1556 77.8 2000 100
Perspective of adolescents according to gender on the disadvantages of abstinence-only sexual education.
Item 8 Abstinence-only sexual education sometimes encourages oral and anal sex alternatives
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 317 45.2 385 54.8 702 100
Female 591 45.5 707 54.5 1298 100
Total 908 45.4 1092 54.6 2000 100
Item 9 Abstinence-only sexual education is Not effective at reducing teen sex rate
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 338 48.1 364 51.9 702 100
Female 608 46.8 690 53.2 1298 100
Total 946 47.3 1054 52.7 2000 100
Item 10 Abstinence-only sexual education discourages condom use and increases risk
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 351 50.0 351 50.0 702 100
Female 606 46.7 692 53.3 1298 100
Total 957 47.9 1043 52.2 2000 100
Item 11 Abstinence-only sexual education does Not help decrease HIV infection rate
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 313 44.6 389 55.4 702 100
Female 612 47.1 686 52.9 1298 100
Total 925 46.3 1075 53.8 2000 100
Item 12 Condoms and Not abstinence-only sexual education decrease teenage pregnancy
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 242 34.5 460 65.5 702 100
Female 483 37.2 815 62.8 1298 100
Total 725 36.3 1275 63.8 2000 100
Item 13 Telling teens to abstain from sex makes them want it more
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 394 56.1 308 43.9 702 100
Female 612 47.1 686 52.9 1298 100
Total 1006 50.3 994 49.7 2000 100
Item 14 Abstinence-only sexual education wrongly teaches suppression of sexual impulses
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 381 54.3 321 45.7 702 100
Female 713 54.9 585 45.1 1298 100
Total 1094 54.7 906 45.3 2000 100
Perspective of adolescents according to gender on the acceptance of abstinence-only sexual education.
Item 15 Abstinence-only sexual education provides some information on STIs and contraception
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 175 24.9 527 75.1 702 100
Female 344 26.5 954 73.5 1298 100
Total 519 26.0 1481 74.1 2000 100
Item 16 Abstinence-only does Not have value
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 477 67.9 225 32.1 702 100
Female 876 67.5 422 32.5 1298 100
Total 1353 67.7 647 32.4 2000 100
Item 17 Abstinence-only sexual education is for religious people and Not for people like us
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 498 70.9 204 29.1 702 100
Female 943 72.7 355 27.3 1298 100
Total 1441 72.1 559 28.0 2000 100
Item 18 I like abstinence-only because it advocates that sex should be saved until marriage
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 171 24.4 531 75.6 702 100
Female 189 14.6 1109 85.4 1298 100
Total 360 18.0 1640 82.0 2000 100
Item 19 I want a strong abstinence message and education
Gender YES NO TOTAL
N (%) N (%) N (%)
Male 154 21.4 548 78.1 702 100
Female 160 12.3 1138 87.7 1298 100
Total 314 15.7 1686 84.3 2000 100

Null hypothesis 2: There is no significant relationship between gender and their perspective on abstinence-only sexuality education.

 Gender and perspective on abstinence-only sexual education?

A greater number of male and female adolescents demonstrated a negative perspective to the advantages of abstinence-only sexual education. This is deduced from their responses to the statements reflecting the advantages of abstinence-only sexual education. Out of the total number according to gender that responded in favour of the advantages of abstinence-only sexual education, more females were in favour of three statements while more males were in favour of four statements.

More male and female respondents disagreed with five of the statements reflecting the disadvantages of abstinence-only sexual education and agreed with two of the statements. Out of the total number of those that did not agree with the disadvantages of abstinence-only sexual education, more males responded to four of the statements while more females responded to three of the statements.

An outright negative perspective on the acceptance of abstinence-only sexual education was demonstrated by both male and female adolescents. A greater number of male and female respondents reacted negatively to statements which were in favour of abstinence-only sexual education.

More females responded in favour of acceptance of abstinence-only sexual education in two statements out of five. More males responded to three of the statements. Specifically, more males than females advocated for sex to be saved until marriage and also wanted a strong abstinence message and education. This study found that boys are more likely to accept abstinence-only sexual education than females. This finding might be connected with the larger number of males among age 11–13 year group of adolescents with a likelihood to accepting abstinence-only sexual education than other older adolescents ( Table 16).

There was no significant relationship between gender and perspective of the adolescents on abstinence-only sexual education. (r = 0.051, N = 2000, P < 0.05) ( Table 11). Gender had no influence on perspective of abstinence-only sexual education in the study. Null hypothesis is therefore retained.

Relationship between gender and perspective on abstinence-only sexual education.
Variable Mean Std. Dev. N** R*** P**** Remark
Perception of abstinence-only sexual education on 31.2573 3.5702 2000 0.022 0.051* N.Sig.
Gender 01.6500 0.4800

*Not. Significant. at 0.05 level.

**No of participants.

***Pearson’s.

****'p' value.

Null hypothesis 3: There is no significant relationship between religion and their perspective on abstinence-only sexual education.

 Relationship between religion and perspective on abstinence-only sexual education.
Variable Mean Std. Dev. N* R*** P**** Remark
Perception of abstinence-only sexual education on 31.2350 3.5843 2000 -0.122** 0.000 Sig.
Religion 01.0800 0.3500

*No of participants.

**Sig. at 0.01 level.

***Pearson’s.

****'p' value.

Null hypothesis 4: There will be no joint effect of independent variables (age, gender, religion, ethnicity and parent’s occupation) on perspective of abstinence-only sexuality education.

 Was there any joint effect of independent variables (age, gender, religion, ethnicity and parent’s occupation) on perspective of abstinence-only sexual education?

A significant joint effect existed between the independent variables (age, gender, religion, ethnicity and parent’s occupation) and perspective on abstinence-only sexual education (F (5, 1994) = 13.085; R = 0.178, R 2 = 0.032, Adj. R 2 = 0.029; P < 0.05) ( Table 13). About 3% of the variation was jointly accounted for by the independent variables. The null hypothesis is therefore rejected.

Joint effect of independent variables (age, gender, religion, ethnicity and parent’s occupation) on perspective of abstinence-only sexual education.
Model Sum of squares DF* Mean square F** Sig.
Regression 815.864 5 163.173 13.085 0.000
Residual 24865.686 1994 12.470
Total 25681.550 1999

R = 0.178.

R 2 = 0.032.

Adj R 2 = 0.029.

*Degree of freedom.

**F-ratio.

 Would there be any relative effect of independent variables (age, gender, religion, ethnicity and parent’s occupation) on perspective of abstinence-only sexuality education?

There is a relative contribution of each of the independent variables on the dependent: age (β = 0.115, P < 0.05), gender (β = 0.042, P > 0.05), religion (β = -0.117, P < 0.05), ethnicity (β = -0.016, P > 0.05) and Parent’s occupation (β = 0.021, P > 0.05) ( Table 14). Hence, while age and religion made a significant contribution, gender, ethnicity and parent’s occupation were not significant.

Relative contribution of independent variables (age, gender, religion, ethnicity and parent’s occupation) to perspective on abstinence-only sexual education.
Model Unstandardised coefficient Standardised coefficient T Sig.
B Std. error β
(Constant) 30.422 0.488 62.369 0.000
Age 0.705 0.136 0.115 5.168 0.000
Gender 0.319 0.166 0.042 1.918 0.055
Religion -1.187 0.225 -0.117 -5.269 0.000
Ethnicity -5.179E-02 0.073 -0.016 -0.714 0.475
Parent’s occupation 5.77E-02 0.061 0.021 0.954 0.340
Would there be any significant relationship between perspective of abstinence-only sexual education and age, gender, religion, ethnicity and parent’s occupation?

A positive significant relationship existed between perspective on abstinence-only sexual education and age, a negative significant relationship between perspective of abstinence-only sexual education and religion but no relationship between perspective of abstinence-only sexual education and gender, ethnicity and parents’ occupation ( Table 15).

Correlation matrix showing the relationship between perspective of abstinence-only sexual education and age, gender, religion, ethnicity and parent’s occupation.
Abstinence-only sexual education Age Gender Religion Ethnicity Parent’s occupation
Abstinence-only sexual education 1
Age 0.123** 1
Gender 0.051* 0.083** 1
Religion -0.122** -0.020 0.007 1
Ethnicity -0.022 0.055* 0.034 0.128** 1
Parent’s occupation 0.039 0.117** 0.021 -0.031 0.039 1
Mean 31.2573 2.22 1.65 1.08 2.21 2.20
S.D 3.5702 0.58 0.48 0.35 1.11 1.33

**Sig. at 0.01 level.

*Sig. at 0.05 level.

 Discussion

Young age is an important factor in the success of abstinence-only sexual education. According to Massey, three significant periods exist where values are learnt. They are the imprint period, modelling period and socialisation period 48 .

During the imprint and modelling periods, children learn through instructions and modelling. During these periods, the behaviour of children is formed from instructions given to them and examples before them. Therefore, if abstinence-only sexual education is taught between the imprinting to modelling period, it might produce positive results in adolescent lives. During the period of socialisation which starts from 13–21 years, a child is already exposed to different types of views and influences. Introducing abstinence-only sexual education might not be successful at this stage because for several reasons. Probably, most of the adolescents would have become sexually active by this age. Secondly, they might have a conviction already for sexual intercourse outside the confines of marriage as an ideal way of life. It is possible to accept instructions at a younger age. Those within the age range of 11–13 years were 8.8% (N = 176) of the total population and they were the youngest group in this study. Most of them would have constituted the population in senior secondary one. The largest number of respondents was within the age bracket of 14–19 years. They might have established their beliefs about premarital sex and are probably sexually active already. This could be an explanation for the larger number of respondents that opposed abstinence-only sexual education.

The major finding of this study shows that Nigerian secondary school adolescents generally have a negative perspective towards abstinence-only sexual education. Out of a total population of 2000 respondents, abstinence-only sexual education was accepted by only 314 respondents and rejected by 1686. Those that had the tendency to accept abstinence-only sexual education were within the age bracket of 11–13 years and are the youngest group of adolescents The highest number of those that advocated for sex to be saved until marriage and also wanted abstinence-only sexual message and education belonged to the youngest group of adolescents. A greater number of respondents that were not in favour of abstinence-only sexual education belong to the 14–19 years age bracket and are the older adolescents. These are the ones within the age of socialisation already. With their exposure to different views about premarital sex, it is likely that most of them are already sexually active and have already taken a position for premarital sex. The message of abstinence-only sexual education at this stage might not be accepted with ease.

Religion had a negative significant influence on the adolescents' perspective on abstinence-only sexual education with the highest number of respondents being christians. Previous studies revealed that almost no religion supported premarital sexual activities. The studies of Concerned Women for America, demonstrated that religion acts as a deterrent to early sexual activity 5 . Many adolescents in previous studies posited that morals, values and religious beliefs significantly influence the decision of whether to have sex 3– 5 . Probably, those that accepted abstinence-only sexual education would have been influenced by their religious beliefs. This also implies that teaching of religious values could be a useful tool for inculcating the values of sexual intercourse within the confines of marriage. Fortunately 93.9% (N = 1877) of the total respondents were Christians 4.3% (N = 86) were Muslims and 1.6% (N = 31) belonged to traditional religion. Only 0.3% (N = 6) were pagans. Christianity should therefore teach abstinence-only sexual education period.

A greater number of male and female Nigerian secondary school adolescents generally have a negative perspective towards abstinence-only sexual education. Out of the number that favoured abstinence-only sexual education, more females than males were in favour of some statements period, in other statements more males than females were in agreement. Surprisingly, more males than females advocated for sex to be saved until marriage and also wanted abstinence-only sexual message and education. One would have expected a more positive response from the females than the males because a greater proportion of the respondents in this study were females 64.9% (N = 1298) of the total respondents. This finding is also sad because it is the females that suffer most from the adverse effects of premarital sexual activities. They are the ones that drop out from schools in the advent of pregnancy. They suffer the adverse effects of early pregnancy and child birth or abortion so one would have expected more females than males to advocate for sex to be saved until marriage. At the other hand more males than females advocating for sex to be saved until marriage and also wanting strong abstinence message and education might not be unconnected with the high number of males among the 11–13 years adolescents ( Table 16). This study has revealed age 11–13 years as the group with a more likelihood of accepting abstinence-only sexual education than the other two groups of adolescents.

Descriptive analysis of age and gender distribution.
Age Gender Total
Male Female
N (%) N (%) N (%)
11–13 years 105 59.7% 71 40.3% 176 100.0%
14–16 years 389 31.8% 834 68.2% 1223 100.0%
17–19 years 208 34.6% 393 65.4% 601 100.0%
Total 702 35.1% 1298 64.9% 2000 100.0%

Ethnicity did not make any significant contribution to perspective of adolescents on abstinence-only sexual education. This shows that adolescents are all the same anywhere and everywhere. This study also revealed that about 80% of the total respondents could not define sexual education. Probably most of the responses would have been informed by ignorance.

 Conclusion

This study therefore concludes that young adolescents within the age bracket of 11–13 years demonstrated the likelihood of being more receptive to abstinence-only sexual education. This finding suggests the need to teach abstinence-only sexual education at an early age by parents who are the first contacts, in religious organizations by sunday school teachers and then by teachers in schools where abstinence-only sexual education is preferred. This will in turn form a part of the values and belief system of the child which might not be easily compromised.

 Translations to health education practice

Knowing the perspective of adolescents on abstinence-only sexual education is the key to knowing the right intervention programme to design and the approach to adopt for the implementation of such programme. This study reveals that abstinence-only sexual education will not work for majority of the respondents because it is not acceptable to them. For instance, only 314 out of 2000 respondents agreed with statements reflecting acceptance of abstinence-only sexual education while 1686 respondents disagreed. A very important finding of this study is that abstinence-only sexual education might only impact positively on those within the imprint and modelling periods of development. This includes those within the age range of 11–13 years. Those within the age bracket of 14–19 years seem to have formed their opinion already from different socialisation processes. This finding suggests the need for a second study only for those within the imprint and modelling period. A new study should address the efficacy of abstinence-only sexual education and the willingness by the young adolescents to practice messages of abstinence-only sexual education. The intervention programme based on the findings of this study recommends a two-dimensional approach. Comprehensive sexual education for the older age group (14–19 years) and abstinence only for the younger ones (11–13 years).

The implications of this study are directed specifically to parents who are the primary caretakers of the children. They have the first contact with the children during the early years. The religious organisations and the school health educators are also very important role players. Findings from this study suggest the introduction of different programming strategies aimed at teaching abstinence-only sexual education as a way of life within the early ages. This might help in safeguarding adolescents especially the females from the numerous life threatening adverse effects associated with premarital sexual activities.

Parents must have a sound knowledge of sexual education so that they can serve as effective teachers to the children. This is the reason it is very good also to empower today’s adolescents with the knowledge of sexual education and the benefits as future parents. Preparing the adolescents of today to become knowledgeable parents of tomorrow might assist in creating a subsequent future of reduced cases of teenage pregnancies, deliveries, abortions and sexually transmitted infections. Whatever is wrong today can be corrected through adequately prepared adolescents who are the future of any nation.

Religious organisations should never relent in teaching the morals and values of abstinence-only sexual education to the youngest group of adolescents with the likelihood to accept. This should be commenced early enough right from their Sunday school classes with negative beliefs and design some remedial programmes for them to reduce the negative influence on other adolescents through the process of socialisation. It can be seen from this study that many problems faced by adolescents as a result of pre-marital sexual activity are avoidable.

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Competing interests: No competing interests were disclosed.

 10 3 2014 Copyright: © 2014 Baxi L 2014 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

Reviewer Expertise:

NA

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.3146.r2650 Reviewer response for version 2 Bahamondes Luis 1 Referee Department of Obstetrics and Gynaecology, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, Brazil

Competing interests: No competing interests were disclosed.

 11 12 2013 Copyright: © 2013 Bahamondes L 2013 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

I am comfortable with the modifications made by the authors and I have no further comments.

Reviewer Expertise:

NA

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.1210.r970 Reviewer response for version 1 Bahamondes Luis 1 Referee Department of Obstetrics and Gynaecology, School of Medical Sciences, Universidade Estadual de Campinas, Campinas, Brazil

Competing interests: No competing interests were disclosed.

 30 5 2013 Copyright: © 2013 Bahamondes L 2013 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The authors submitted a manuscript in which they assessed the perspectives of Nigerian secondary school students on abstinence-only sexual education. They applied a questionnaire to obtain the information. The sample size is correct and the analysis of the data is well conducted. However, my specific comments are that the title does not reflect what the authors did, as the authors did not evaluate the efficacy of abstinence-only sexual education; in fact, there is no evidence of whether the abstinence-only sexual education changes the attitudes of the students. Furthermore, the comments on religion are inappropriate because most of the interviewed students practiced only one religion.

In my opinion, the following statement is strongly speculative and inappropriate because the authors did not obtain any evidence for it: “Preparing the adolescents of today to become knowledgeable parents of tomorrow can assist in creating a subsequent future of reduced cases of teenage pregnancies, deliveries, abortions and sexually transmitted infections. Whatever is wrong today can be corrected through adequately prepared adolescents who are the future of any nation.”

Reviewer Expertise:

NA

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Inyang Mfrekemfon University of Port-Harcourt, Nigeria, Nigeria

Competing interests: There are no competing interests.

 4 6 2013

Much thanks to the referee for the comments. In this study the authors only looked at the Nigerian secondary school adolescents' perspective on abstinence-only sexual education. The purpose of this study is also clearly stated. The authors have not indicated anywhere in the study of evaluating the efficacy of abstinence-only sexual education, but only intend to do that in a follow up study. This study is not an intervention study so it could not have shown if abstinence-only sexual education could change attitude. It is always necessary to clarify needs before following up with appropriate intervention. The intent for a follow up intervention study has been indicated. The aspect of religion has been earlier addressed. The statement is a recommendation to educate the adolescents with the knowledge of what is right or wrong early in life. Numerous studies have proven the transforming power of information. It has also been established that most of the wrong-doings of adolescence are either due to wrong information or outright ignorance.

Thanks.

Dr. M. P. Inyang

 10.5256/f1000research.1210.r971 Reviewer response for version 1 Baxi Laxmi 1 Referee Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, NY, USA

Competing interests: No competing interests were disclosed.

 30 5 2013 Copyright: © 2013 Baxi L 2013 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The title gives the impression that it refers to the entire population; however, it is true only for the youngest group - further clarification is needed.

The majority of individuals in this study are Christian, so comparison by religion does not appear to be adequate. The authors need to emphasise this and may describe such findings in a single statement.

The manuscript is too long, as is the introduction. It should be shortened to ensure the reader does not lose interest.

Several text descriptions should be omitted as tables are self explanatory, e.g. table 1.

Furthermore, it should be mentioned that the data only refers to a particular group of the population.

Reviewer Expertise:

NA

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Inyang Mfrekemfon University of Port-Harcourt, Nigeria, Nigeria

Competing interests: There are no competing interests!

 4 6 2013

Much thanks to the referee! The title of the work is what was studied. Title of the work is different from findings.These findings are clearly spelt out in the work.The religion aspect has been addressed already. Other observations are all addressed accordingly.

Thanks.

Dr. M. P. Inyang

 10.5256/f1000research.1210.r877 Reviewer response for version 1 Foster Warren 1 Referee https://orcid.org/0000-0001-5762-7371 McMaster University, Hamilton, Canada

Competing interests: No competing interests were disclosed.

 8 4 2013 Copyright: © 2013 Foster W 2013 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The authors examined secondary school student perspectives on abstinence-only sexual education through the use of a questionnaire. The sample size is robust, the statistical methods are appropriate, and overall the paper is well written. Unfortunately, the title of the paper is misleading. Specifically, the authors only examined student perspectives and there were no measures of efficacy of abstinence-only sexual education. The data suggests only that students of the youngest age group are more likely to be receptive to abstinence-only sexual education but no evidence is presented on whether the students would or in fact do incorporate these messages into their lives. The authors also suggest that the data shows that there is a significant relationship between religion and student perspective; however, the numbers of students in other religions than Christianity is too small to make meaningful conclusions. Moreover, it is unclear if the students simply identify with a particular religion or actively participate in the religion.  Finally, the conclusions reached and the implications for health education practice are overstated. The most that can be concluded from this study is that young adolescents are potentially more receptive to abstinence-only sexual education. It cannot be concluded that abstinence-only sexual education will be more or less effective than no education or alternative education messages in shaping student sexual practices.

Reviewer Expertise:

NA

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.