Direct and indirect estimation of sexual intercourse and contraceptive use among adolescents in Rajasthan, India: an application of the best friend method | BMC Women’s Health

The aim of this study was to apply a social network-based approach to improve ASRH estimates by reducing potential social desirability biases associated with premarital relationships, sexual intercourse, and contraceptive behavior among adolescent girls in Rajasthan, India, assuming that current direct reports are underestimated. Results are mixed, as overall indirect estimates for sexual intercourse and contraceptive use were not significantly higher compared with direct estimates, while estimates for unmarried adolescents were significantly higher for ever having a partner, but not statistically significantly higher for estimates for sexual intercourse and current contraceptive use. Social patterns of sexual intercourse and contraceptive use were generally comparable using both methods.

Overall, regardless of estimation method, few adolescents aged 15–19 years ever had sexual intercourse, and sexual intercourse occurred primarily within the context of marriage. However, among unmarried adolescents, a greater proportion ever had a relationship (4.3% of respondents and 11.6% of friends) compared with those less frequently reporting sexual intercourse (2.4% of respondents and 3.8% of friends), suggesting a longer period of nonsexual premarital romance in committed or casual partnerships. These findings support the results of previous research (27), including studies across India showing greater romantic interest than sexual encounters among unmarried adolescent girls (1, 28, 29), although some studies conducted in slum areas report higher rates of premarital sex than in the general population (13).

Our low self-reported premarital sex estimates, with friends estimates of 3.8% compared to 2.4% among respondents, may still be underestimated, although we were unable to detect differences of this magnitude. However, indirect estimates remain underestimated as well, which may be due to violations of the assumptions of the social network-based method or may reflect the reality of girls’ sexual transition to adulthood in this socially prescriptive environment. Our replacement sample may have been biased by 12.4% of respondents with no social relationships, who were essentially “imputed” by including respondents without friends in the adjusted replacement sample. However, there were few differences between youth with or without friends, and the distribution of friends’ sociodemographic characteristics generally matched those of respondents, suggesting limited selection bias in the replacement sample. Respondents’ knowledge of their friends’ behavior (transmission bias) was a more serious concern when using this method to measure abortion (20, 21, 30), because the social network-based approach assumes that respondents are aware of their friends’ sensitive behavior. The proportion of respondents sharing their abortion experience with their friends varies across social contexts, depending on the extent to which women rely on their social network to access abortion care in restrictive legal settings (31, 32). These conditions do not apply to intercourse, which does not require help from the social network. However, social context and the significant social restrictions on premarital sex in adolescence are likely to influence sharing among friends. In this study, nearly 80% who reported previous intercourse reported telling their friends about the experience; thus, adjustment for transmission bias was relatively low (1.25). However, this adjustment assumes that the patterns of sharing between respondents who self-report having had previous sexual intercourse and not are taken into account and that the level of sharing between friend dyads is equal in both directions. In addition, due to the small number of unmarried respondents who reported having had sexual intercourse and had a close friend (N= 11) This adjustment factor could not be calculated separately for unmarried young people.

While our estimates of premarital SRH behavior may be low, they may also reflect a unique pattern of nonsexual partnerships in India, particularly among adolescent girls who have internalized social scripts that marginalize adolescent sexuality (1, 33). These scripts also prevent adolescents in need of contraception from seeking SRH services due to fear of social sanctions. In our study, between 63% (friends) and 71% (respondents) of sexually active adolescents seeking to prevent pregnancy did not use contraception. Results from the 2018 PMA Rajasthan survey show that 40% of girls aged 15-19 years agreed with the statement that “adolescents who use contraceptives are considered promiscuous,” which may limit their willingness to seek family planning services or share their contraceptive needs with providers, putting them at risk of unintended pregnancy (2). Given the increasing duration of premarital romantic relationships, it is critical to break down these social barriers, not only through adolescent sexuality education but also through broader community engagement to create an environment where adolescents can experience healthy and safe relationships.

Beyond marital status, findings suggest that social patterns of sexual intercourse are evident, with less educated and poorer adolescents initiating sexual intercourse earlier (although findings were not statistically significant). These patterns reflect national patterns of age at first sexual intercourse, which increases with education (8). Despite expanded educational opportunities for girls in India, they receive on average less than four years of formal education, with 40% dropping out of school before fifth grade, limiting their access to school-based sexuality education (34). These findings highlight the importance of early interventions to deliver age-appropriate, comprehensive sexuality education across the curriculum, reaching adolescents before they drop out of school, and through continued outreach to complement school programs for out-of-school adolescents.

Our results must be interpreted considering several limitations. First, the low prevalence of sexual intercourse reduces our sample size for estimating contraceptive behaviors among sexually active adolescents, leading to significant inaccuracies in the estimates of contraceptive behaviors. Likewise, the analysis of sexual intercourse among unmarried adolescents is limited given the small number of adolescents in this group of respondents and friends. In this regard, the indirect methodology made little difference given the small improvements in the estimates of ASRH indicators. As previously mentioned, if adjustment for transmission bias does not accurately account for the incomplete visibility of these ASRH behaviors, the adjusted friends estimates are biased. Finally, this study does not capture the ASRH experiences or needs of boys and non-binary populations in this context, and we did not collect information on sexual orientation, which limits the generalizability of our results.

Despite these limitations, we believe this study helps extend our methodological search for the quality of ASRH measurement. We found slight advantages of the best friend method in estimating ASRH indicators in Rajasthan, particularly related to premarital relationships, and recommend further qualitative and quantitative work to refine social network-based measures of adolescent sensitive behavior to better understand ASRH needs. We also point to the increasing SRH needs of unmarried adolescents who spend more time in non-sexual premarital partnerships but who, as reported in previous PMA findings, lack the knowledge, agency, and social support to make autonomous decisions about marriage, sexual debut, and contraceptive use (2, 9).