Beyond knowledge: violence as a structural determinant of adolescent sexual and reproductive health in Angola

Beyond knowledge: violence as a structural determinant of adolescent sexual and reproductive health in Angola | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond knowledge: violence as a structural determinant of adolescent sexual and reproductive health in Angola Esperanza Esteban Serna, Irina Alexandra Lopes Almeida, Cláudio Canguele, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9009395/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Evidence on adolescent sexual and reproductive health (SRH) in Angola remains scarce, particularly among younger adolescents who are frequently excluded from research. Context-specific data are needed to understand how SRH knowledge translates into behaviours and how structural factors shape adolescents’ ability to act on this knowledge. This study aimed to describe SRH knowledge, behaviours, exposure to violence, and structural vulnerabilities among adolescents aged 11–17 years in Benguela Province, Angola. Methods: We conducted a school-based cross-sectional study in October 2024 among 382 adolescents from urban (n = 282) and rural (n = 100) settings in Benguela Province, selected through systematic random sampling. A culturally adapted questionnaire assessed key SRH domains, including knowledge, sexual behaviours, contraceptive use, menstrual health, pregnancy and abortion, and experiences of sexual and gender-based violence (GBV). Data were analysed using descriptive and bivariate statistics to characterise patterns by sex and residence. Results: Nearly all participants demonstrated adequate SRH knowledge (98.7%). However, only 18.1% reported using any contraceptive method, with pronounced gender disparities, particularly in urban settings (urban boys 34.0% vs. urban girls 7.7%; p < 0.001). Overall, 29.0% reported having engaged in sexual intercourse, and 8.1% reported risky sexual behaviours, including inconsistent condom use during sexual intercourse. Nearly half of adolescents (45.8%) reported experiences of sexual or GBV, with forced sexual acts disproportionately affecting boys, positioning violence as a key constraint on adolescents’ sexual and reproductive agency. Menstrual-related barriers were widespread, affecting 63.5% of urban girls and 80.3% of rural girls, and included missing school or daily activities. Unintended pregnancy was reported by 2.4% of participants, and all reported abortions occurred in urban settings. Conclusions: Despite near-universal SRH knowledge, adolescents face substantial barriers to adopting protective practices. Widespread exposure to violence emerges as a central structural determinant, operating alongside restrictive gender norms, limited access to youth-friendly services, and menstrual health challenges to constrain adolescents’ ability to act on existing knowledge. Improving adolescent SRH in Angola will require moving beyond information-based strategies toward integrated, gender-responsive approaches that combine education with accessible services, menstrual health support, and comprehensive violence-prevention efforts. Adolescents / early adolescence Sexual and reproductive health Gender-based violence Menstrual health Sub-Saharan Africa / Angola School-based study 1. INTRODUCTION Adolescence is a critical stage in identity formation, the development of autonomy, and the beginning of experiences related to sexuality. During this stage, young people navigate decisions related to consent, protection and the exercise of their sexual and reproductive rights (SRR), in ways shaped by intersecting social, cultural and structural factors that may either enable or constrain their autonomy (1,2) Adolescence is not a homogeneous life stage; early adolescence, in particular, is characterised by limited autonomy, high dependence on family and school environments, and distinct vulnerabilities that shape how sexual and reproductive health knowledge is understood and acted upon (3–5) Access to accurate sexual and reproductive health (SRH) information has been shown to improve knowledge, reduce risk behaviours and increase contraceptive use (6,7). Comprehensive sexuality education (CSE) has therefore been promoted as a key strategy for supporting a safe and informed transition to adulthood (2,8). However, growing evidence indicates that improvements in knowledge alone are often insufficient to produce sustained changes in behaviour, particularly in settings characterised by gender inequality, stigma and limited access to youth-friendly SRH services (1,9,10). This persistent knowledge–practice gap highlights the importance of examining the broader social and structural conditions under which adolescents make SRH-related decisions (11). Across sub-Saharan Africa (SSA), adolescents, particularly girls, continue to face multiple, intersecting barriers to the exercise of their SRR(12). Gender inequality, restrictive social norms and limited access to youth-friendly SRH services have been consistently documented as key constraints across the region. In parallel, adolescents are widely exposed to sexual and gender-based violence (GBV), which further undermines SRH outcomes by limiting agency, increasing biological risk and normalising coercive relationships. Recent studies in SSA report that between 40% and 70% of adolescents have experienced some form of sexual violence, including coercion, harassment or abuse by peers or adults (13,14). Despite its prevalence, violence is often treated as a parallel outcome rather than as a central structural determinant of adolescent SRH (12). This analytical separation risks underestimating how early exposure to coercion, abuse and forced sexual experiences shapes adolescents’ sexual trajectories, particularly among boys. Menstrual health represents another critical yet frequently neglected dimension of adolescent SRH. Across SSA, menstruation remains surrounded by stigma and inadequate resources and many girls miss school or experience shame and social isolation during menstruation due to pain, lack of sanitary materials or restrictive cultural norms (15–17). These barriers reinforce gendered educational and health inequalities from early adolescence. In Angola, deep social inequalities, cultural barriers, and limited investment in adolescent health exacerbate these challenges. Despite increasing awareness of SRH, structural barriers continue to hinder the translation of knowledge into practice (6,10,18). National assessments, including the 2022 UNFPA evaluation (19) and the 2023–2024 IIMS survey (20) reported persistently high adolescent fertility rates and low use of modern contraceptives, particularly in rural areas. Although studies across SSA have examined aspects of SRH knowledge and behaviour, most have been conducted in anglophone countries and focus on older adolescents or specific issues such as human immunodeficiency virus (HIV) or contraception (1,7,9). Evidence from Portuguese-speaking African countries, particularly Angola, remains extremely limited, and very little is known about how younger adolescents understand SRH, negotiate sexual relationships or experience violence and structural constraints within school settings. This study is framed within the CHANCE project ( Strategies to Improve the Knowledge and Attitudes of Young Angolans Regarding Sexual and Reproductive Health ) (21), funded by the European Union. The project aims to strengthen Sexual and Reproductive Health (SRH) among young people in Cubal and Lobito, with particular attention to girls and socially vulnerable groups. This baseline study aimed to describe SRH knowledge, behaviours and structural vulnerabilities among adolescents aged 11–17 years in Benguela Province, Angola. By examining the intersection of knowledge, gender, violence and menstrual health, the study explicitly positions sexual and GBV as a core structural factor influencing adolescents’ sexual and reproductive health trajectories. 2. MATERIAL AND METHODS Study design and setting This cross-sectional descriptive study was conducted in Benguela Province, Angola, within the framework of the CHANCE project (NDICI HR INTPA/2023/450 − 200). Data collection took place in October 2024 in two municipalities representing contrasting socioeconomic and service-access contexts. Lobito is a predominantly urban and peri-urban municipality with higher population density, greater school enrolment and comparatively better access to SRH services. Cubal represents a largely rural context characterised by greater socioeconomic vulnerability and more limited availability of youth-friendly health services. The study design allows for the simultaneous assessment of knowledge, behaviours, and structural vulnerabilities among adolescents, providing a comprehensive snapshot of SRH outcomes in different context. Population and sampling The target population comprised 65,507 adolescents aged 11 to 17 years enrolled in lower and upper secondary education in the municipalities of Lobito (n = 55,799) and Cubal (n = 9,708). A representative sample of 382 adolescents was calculated using the Raosoft® statistical calculator, with a 95% confidence level and a 5% margin of error. Although initial proportional allocation was 85% for Lobito and 15% for Cubal, the final sample (282 urban; 100 rural) was adjusted to reduce sampling error in the rural site and enable comparisons. Rural schools were therefore intentionally oversampled to enable urban–rural comparisons; analyses were not population-weighted. Sampling strategy Systematic random sampling was used. In each municipality, schools were selected in coordination with local educational authorities. Within selected schools, specific classes (turmas) were chosen based on scheduling feasibility and coordination with school staff and students were selected from class attendance lists using a fixed interval (every 5th student), with replacement when absent. Data collection instrument A structured questionnaire was developed by the research team, drawing on validated instruments from previous studies on SRH (22) and adapted to the Angolan context. To ensure the ethical formulation of sensitive questions and the appropriateness of language for adolescents, the questionnaire underwent a comprehensive expert review by the Child Abuse Unit and the STIs Unit of Vall d’Hebron University Hospital (Barcelona, Spain), with particular attention to items addressing sexuality, pregnancy, and experiences of violence. Local project partners also evaluated the tool for cultural relevance. A pilot test was conducted with 38 adolescents (approximately 10% of the intended sample) in both urban and rural areas. Based on this feedback, the final questionnaire included 89 items across nine thematic sections: sociodemographic variables, pregnancy and abortion, SRH knowledge, sexual behaviour, GBV, menstruation, contraceptive use, sexual orientation and gender equality. The full questionnaire is provided as online supplemental material (Supplementary file 1). Operational definitions SRH knowledge was measured through statements on sexuality, pregnancy, menstruation, puberty, STIs, contraception, and fertility risks. Correct answers were scored as one and incorrect or “don’t know” as zero (maximum score: 14), with scores ≥ 7 indicating adequate knowledge. Conceptually, knowledge was treated as a necessary but insufficient condition for protective practices and was therefore analysed in conjunction with behavioural and structural indicators rather than as a primary outcome. Contraceptive use was defined as self-reported use of any pregnancy prevention method. Practices were assessed using a composite score (preventive behaviours = 1; risk behaviours = 0). Barriers were measured with a yes/no item, and attitudes toward contraception with Likert-scale items, where higher scores indicated more favourable views toward universal access. Risky sexual behaviour was defined as self-reported behaviours associated with increased biological risk of sexually transmitted infections or unintended pregnancy,: including sex with an STI-positive partner, multiple concurrent partners, sex under the influence of alcohol or drugs, sex under threat or coercion, transactional sex, or lack of condom use in casual encounters. Menstrual health barriers were assessed through four yes/no items asking whether menstruation had ever caused girls to miss school, miss work, avoid leaving home or other daily activities. Pregnancy and abortion were assessed by asking whether respondents or their partners had ever experienced an unintended pregnancy and, if so, whether abortion had been used. Two binary variables were created: history of unintended pregnancy and history of abortion, with abortion analysed only among those reporting an unintended pregnancy. Experiences of sexual and GBV were defined as reporting any of the following in childhood: inappropriate touching, forced sexual acts, exposure to sexual acts at home, sexual advances by adults, attempted or completed penetration, forced participation in sexual activity, or inability to consent due to intoxication. These experiences were analysed independently from sexual risk behaviours to avoid conflation of distinct constructs. Although items on sexual orientation and gender equality were included in the questionnaire, they were excluded from the analysis due to ethical and developmental considerations related to participants’ age (11–17 years). Data collection procedures Before the study began, approval was obtained from the National Directorate of Public Health of Angola and communicated to the municipal education authorities in Lobito and Cubal, who authorised the selected schools to participate. Community activists then met with school principals to explain the study procedures, and school administrators coordinated the collection of parental informed consent for participating students. Fieldwork took place in October 2024. In Cubal, surveys were conducted from 8–11 October; in Lobito, from 22–26 October. Teams included 14 data collectors in Cubal and 40 in Lobito, working in pairs under supervision. Each interview lasted approximately 35 minutes and was conducted in a private setting within school premises to ensure confidentiality. The questionnaire was administered with individual assistance from trained community activists experienced in working with children and sensitised to sexual and reproductive health topics. To safeguard participants’ wellbeing, the instrument followed a progressive structure, so that children were not exposed to more sensitive sections unless necessary. All data were collected in a confidential environment and in a language familiar to the participants. Data Management and Statistical Analysis Categorical variables were described using absolute frequencies and percentages. Continuous variables were presented as means and standard deviations or medians and interquartile ranges, depending on the distribution. Normality was assessed using the Shapiro–Wilk test. For bivariate analysis, Chi-square or Fisher’s exact test was used to compare categorical variables, and Student’s t-test or Mann–Whitney U test was applied to compare continuous variables, depending on their distribution. A p -value < 0.05 was considered statistically significant. Data were entered into a secure database and analysed using IBM SPSS Statistics v.26 (IBM Corp., Armonk, NY, USA). There were no missing data for the main study variables, as non-responding students were replaced during data collection to achieve the target sample size. Replacement was conducted using the same sampling interval to preserve randomness. This study is reported in accordance with the STROBE guidelines for cross-sectional studies. Patient and Public Involvement Community stakeholders and adolescents contributed to the design and conduct of this study. The questionnaire was culturally adapted in partnership with local organisations and community activists with expertise in adolescent health to enhance contextual relevance, comprehension, and acceptability of sensitive measures. A pilot conducted with adolescents from urban and rural settings informed the refinement of the data collection tool. Community activists facilitated data collection within schools, supporting ethically grounded and context-sensitive research practices. Adolescents were not involved in data analysis or interpretation. Findings will be disseminated to participating schools and local partners to promote community engagement and inform adolescent sexual and reproductive health programming. Ethical considerations The study protocol was approved by the relevant ethical and educational authorities in Angola (MINSA, n.º 25/CEMS/2024). Parental consent and student assent were obtained prior to participation. Participation was voluntary, and anonymity and data confidentiality were ensured throughout the process. Interviewers received specific training in child safeguarding and the ethical management of sensitive disclosures. A predefined referral pathway was in place to ensure that any disclosure of abuse, violence or immediate risk was managed confidentially and referred to appropriate local health or social protection services in accordance with national child protection protocols. The questionnaire included sensitive items on violence; the full instrument is available as supplementary material. 2. RESULTS Seventeen schools were included in total (ten in Lobito and seven in Cubal), with a total of 382 adolescents aged 11 to 17 years (mean 14.3 SD ± 1.8). Most participants resided in urban areas 73.8%, (n = 282), while 26.2% (n = 100) lived in rural settings. SRH knowledge was high overall, with 98.7% (n = 377) demonstrating adequate knowledge. Table 1 presents SRH indicators stratified by sex and place of residence. In urban settings, boys were significantly more likely than girls to report having initiated sexual intercourse (45.0% vs 10.4%; p < 0.001) and contraceptive use (34.0% vs. 7.7%; p < 0.001). A similar pattern was observed in rural areas, although differences did not reach statistical significance (43.6% vs 28.6%; p = 0.143); contraceptive use: 28.2% vs. 16.4%, p = 0.157). Urban boys reported an earlier age at sexual debut than urban girls (mean ± SD: 12.4 ± 2.3 vs. 14.6 ± 1.4 years), although this difference was not statistically significant. In rural settings, boys reported a significantly earlier sexual debut than girls (13.6 ± 2.5 vs. 15.5 ± 2 years; p = 0.03). Risky sexual behaviours were more frequently reported by boys, particularly in rural settings (17.9% vs 3.3%; p = 0.012). Overall, 29% (n = 88) reported having engaged in sexual intercourse, among them 31 (35.2%) reported risky sexual behaviours, and 18 (58,1%) of them stated not using condoms during sexual intercourse in the past six months. Only 69 adolescents (18.1%) reported having used any contraceptive method, while only 38 (9.9%) reported consistent condom use during sexual intercourse, with higher prevalence in urban than rural areas (11.3% vs 6.0%; p = 1.80). Disparities were also evident in menstrual health, 73.8% (n = 165) reported missing school, sports, or social activities due to menstruation, with significantly higher prevalence in rural compared with urban areas (80.3% vs. 63.5%; p < 0.001). Beyond sexual behaviours and contraceptive practices, exposure to sexual and GBV emerged as a major pattern among adolescents and affected 45.8% (n = 175) with boys disproportionately affected (69.8% vs 32.2%; p < 0.001). Reports were more frequent in rural than urban settings (52.0% vs 43.6%), although this difference was not statistically significant (p = 0.184). Approximately one in four adolescents reported inappropriate touching before age 10, and forced sexual acts were significantly more common among boys in both urban (17.0% vs. 8.8%; p = 0.040) and rural areas (28.2% vs. 9.8%; p = 0.017). Overall exposure remained high across subgroups, particularly among rural boys (61.5%) and urban girls (50%). Specific forms of violence are detailed in Table 2 . Table 1 Sexual and reproductive health indicators by sex and place of residence among adolescents aged 11–17 years in Benguela Province, Angola Indicator Urban Rural Women (N = 182) Men (N = 100) p value Women (N = 61) Men (N = 39) p value Age at first sexual intercourse (mean ± SD, years) 14.58 ± 1.44 12.36 ± 2.26 0.13 15.50 ± 1.99 13.65 ± 2.52 0.033 Adequate SRH knowledge 182 (100%) 99 (99%) 0.18 58 (95.1%) 38 (97.4%) 0.558 Use of contraceptive methods 14 (7.7%) 34 (34%) < 0.001 10 (16.4%) 11 (28.2%) 0.157 Has had sexual intercourse 12 (10.4%) 45 (45%) < 0.001 14 (28.6%) 17 (43.6%) 0.143 Risky sexual behaviours 1 (0.5%) 8 (8%) < 0.001 2 (3.3%) 7 (17.9%) 0.012 Menstrual barriers (girls only) 115 (63.5%) NA – 49 (80,3%) NA – Unwanted pregnancy 4 (2.2%) 4 (4%) 0.38 1 (2.6%) 0 (0%) 0.209 Abortion 3 (1.7%) 3 (3%) – 0 (0%) 0 (0%) – Has experienced violence 50 (50%) 73 (40.1%) 0.11 28 (45.9%) 24 (61.5%) 0.127 Footnotes Values are presented as number (percentage) or mean ± standard deviation, unless otherwise specified. Percentages for menstrual-related barriers are calculated among female participants only. NA: not applicable. “–”: statistical comparison not performed due to absence of events or insufficient data. Table 2 Prevalence of reported experiences of sexual and GBV among adolescents aged 11–17 years, by sex and place of residence in Benguela Province, Angola Indicator Urban Rural Girls (N = 182) Boys (N = 100) p value Girls (N = 61) Boys (N = 39) p value Inappropriate or uncomfortable touching before age 10 years 42 (23.1%) 27 (27%) 0.463 14 (23%) 9 (23%) 0.99 Unwanted sexual touching at any age 30 (16.5%) 22 (22%) 0.253 17 (27.9%) 11 (28.2%) 0.97 Forced sexual acts 16 (8.8%) 17 (17%) 0.040 6 (9.8%) 11 (28.2%) 0.02 Heard about inappropriate sexual acts at home 28 (15.4%) 20 (20%) 0.324 12 (19.7%) 5 (12.8%) 0.38 Family member or acquaintance tried to have sex with them 23 (12.6%) 24 (24%) 0.140 15 (24.6%) 15 (38.5%) 0.14 Attempted or completed penetration without consent 9 (4.9%) 7 (7%) 0.475 6 (9.8%) 7 (17.9%) 0.24 Forced to perform sexual acts through physical violence 7 (3.8%) 9 (9%) 0.073 7 (11.5%) 4 (10.3%) 0.85 Sexual acts under the influence of alcohol or drugs (no capacity to consent) 3 (1.6%) 2 (2%) 0.830 2 (3.3%) 1 (2.6%) 0.84 Footnotes: Values are presented as number (percentage). All indicators refer to self-reported experiences occurring at any time during childhood or adolescence. p-values represent comparisons by sex within each place of residence. 3. DISCUSSION This study provides one of the few available assessments of SRH knowledge, attitudes, and lived experiences among adolescents aged 11–17 in Angola, a population that remains largely under-represented in the literature. One of the most concerning findings of this study is the widespread exposure to sexual and GBV, which helps explain why high levels of SRH knowledge do not translate into safer sexual practices in this population. Nearly half of all adolescents reported at least one form of violence, with particularly high prevalence among rural boys and urban girls. These levels are consistent with evidence from other SSA contexts reporting alarmingly high exposure to sexual violence during childhood and early adolescence (37–39). Importantly, this study contributes to a growing body of evidence showing that boys’ experiences of violence are both prevalent and under-recognised (38,40). While much of the existing literature has focused on girls’ victimisation, the high prevalence of forced sexual acts reported by boys in this study underscores the need for more inclusive prevention strategies. Recognising boys solely as potential perpetrators risks obscuring their exposure to violence and the harmful gender norms that shape their experiences (41). Evidence suggests that effective violence-prevention interventions are multilevel and gender-transformative, combining life skills education, family and community engagement and social norms change (42,43). Positive parenting and household stability further act as key protective factors (44), while school-based and empowerment-focused programmes show promise in promoting respectful relationships and reducing violence (45,46). Addressing violence among adolescents therefore requires moving beyond individual risk factors toward systemic, community-based approaches that engage both girls and boys (47–49). The findings reveal a marked disconnect between near-universal SRH knowledge and limited adoption of protective behaviours, underscoring the role of structural and gendered constraints in shaping adolescents’ capacity to exercise their SRR. These findings should be interpreted in light of the wide age range included in the study, which spans early to late adolescence; although analyses were conducted for the sample as a whole, variations in autonomy and decision-making capacity across developmental stages are likely to shape how SRH knowledge translates into behaviour. Despite almost all participants demonstrating adequate SRH knowledge, contraceptive use remained low, particularly among girls. This finding reinforces growing evidence from SSA challenging the assumption that information alone is sufficient to produce behavioural change during adolescence (23,24). Qualitative and review studies consistently show that fear of stigma, unequal power relations, restricted autonomy and limited access to youth-friendly services constrain adolescents’ ability to act on the information they possess(25–27) In this context, the knowledge–practice gap observed in Benguela reflects systemic failures rather than individual shortcomings. Gender disparities in contraceptive use were particularly pronounced in urban settings, where girls reported extremely low use compared with boys. This pattern likely reflects persistent gender norms that place responsibility for contraception on males while simultaneously limiting girls’ decision-making power and access to services (28,29). Similar dynamics have been documented across SSA, where girls’ reproductive agency is constrained by social expectations, partner control and fear of judgement within health services (8,30). By contrast, boys reported earlier sexual initiation and higher engagement in risky sexual behaviours, aligning with dominant constructions of masculinity that valorise early and unprotected sexual activity (31,32) The pronounced gender differences in age at sexual debut observed in this young population warrant particular attention. Early sexual initiation among boys has been associated with adverse relationship dynamics and increased vulnerability to coercion and violence in SSA settings (31). Given the high prevalence of reported violence in this study, early sexual experiences among boys may not always reflect agency or choice but could also occur within contexts of coercion, violence and normative pressures that remain largely under-recognised in SRH research. Conversely, girls’ later sexual debut may reflect restrictive forms of social control rather than empowerment (32,33). These findings highlight the need for gender-sensitive SRH programmes that address harmful norms affecting both girls and boys, including norms that normalise male risk-taking and silence male vulnerability (34–36). Menstrual barriers were also highly prevalent, especially in rural settings, where more than 80% of girls reported refraining from school or daily activities during menstruation. This mirrors findings from SSA showing that lack of sanitary products, inadequate water, sanitation and hygiene (WASH) facilities, and menstrual stigma contribute to absenteeism, discomfort, and psychosocial distress (50–52). The magnitude of menstrual barriers observed in this study indicates that menstrual health should be integrated into SRH programming not only through education, but also through the provision of materials and improvements in school infrastructure. Reports of unintended pregnancy and abortion were relatively infrequent in this young adolescent population. However, the concentration of reported abortions in urban settings may reflect differential access to information and services, or greater social visibility of such events in urban areas. In the Angolan context, where abortion remains legally restricted, these findings underscore the importance of ensuring access to accurate information and confidential, youth-friendly SRH services from early adolescence. Previous evidence from Benguela suggests that unintended pregnancy and unmet contraceptive need increase substantially later in adolescence, highlighting the importance of early preventive interventions (53). Although grounded in the Angolan context, these findings reflect broader challenges observed across SSA, where early adolescence remains under-researched despite being a critical window for preventive SRH interventions. Limitations This study has several limitations. Its cross-sectional design precludes causal inference between SRH knowledge, behaviours and experiences of violence. Self-reported data may underestimate sensitive experiences despite confidentiality measures, and social desirability bias may have influenced reporting. Analyses were conducted at the individual level and did not account for clustering by school. Finally, the study included only school-going adolescents, limiting generalisability to out-of-school youth, who may experience even greater vulnerability. CONCLUSIONS This study demonstrates that adolescents aged 11–17 years in Benguela Province possess high levels of SRH knowledge but face substantial barriers to translating this knowledge into protective behaviours. The findings highlight a persistent knowledge–practice gap shaped by gender norms, limited autonomy, restricted access to youth-friendly services, menstrual health constraints and widespread exposure to sexual and GBV. Girls’ particularly low contraceptive use, despite high levels of knowledge, reflects enduring gendered power imbalances that constrain decision-making and access to care from early adolescence. At the same time, boys’ earlier sexual initiation, higher engagement in risky behaviours and high exposure to forced sexual acts reveal distinct and often overlooked vulnerabilities. Together, these patterns challenge simplified narratives that frame boys solely as risk-takers or perpetrators and girls solely as victims, underscoring the need for more nuanced, gender-responsive approaches. The high prevalence of sexual and GBV across all subgroups, affecting nearly half of participants, emerges as a central finding of this study. Violence appears not as an isolated experience but as a systemic determinant shaping adolescents’ SRH trajectories, limiting agency, normalising coercion and undermining the effectiveness of information-based interventions. These findings suggest that addressing adolescent SRH without explicitly confronting violence, particularly violence affecting boys, risks reproducing the very knowledge–practice gap that education-only interventions seek to close. Menstrual health barriers were also highly prevalent, particularly in rural settings, where they contributed to school absenteeism and reduced participation in daily activities. These findings reinforce the need to recognise menstrual health as a core component of adolescent SRH and educational equity, requiring structural interventions beyond health education alone. Overall, these results indicate that improving adolescent SRH in Angola requires moving beyond information-focused strategies toward integrated, gender-transformative public health approaches. Such approaches should combine comprehensive sexuality education with accessible, confidential and youth-friendly SRH services; systematic violence-prevention and response mechanisms; and menstrual health support, including the provision of sanitary materials and improvements in school infrastructure. Investing in early adolescence is critical to interrupting cycles of vulnerability and to advancing sexual and reproductive rights in under-resourced and under-researched contexts. Declarations Acknowledgements The authors thank all participating adolescents, as well as teachers, school principals, and educational authorities in Lobito and Cubal, for facilitating data collection. This study was conducted within the CHANCE project (NDICI HR INTPA/2023/450-200), funded by the European Union. We especially acknowledge the valuable contributions of the Child Abuse Unit and the Sexually Transmitted Infections Unit of Vall d’Hebron University Hospital (Barcelona, Spain) for reviewing the questionnaire to ensure ethical soundness and child sensitivity. The contributions of the local partner organisations (OIC, AJS, ISPJPB, CAJ) and the fieldwork teams in Lobito and Cubal were essential to this research. This work forms part of the PhD Programme in Medicine at the Universitat Autònoma de Barcelona (UAB). Conflict of Interest The authors declare that they have no competing interests. Funding The study was funded by the European Union through the CHANCE project (NDICI HR INTPA/2023/450-200). No funding was received for the preparation or publication of this manuscript. The funder had no role in study design, data collection, analysis, interpretation or manuscript writing. Ethical statement The study followed the Declaration of Helsinki and Good Clinical Practice guidelines, and was approved by the Ethics Committee of the Ministry of Health of Angola (MINSA, n.º 25/CEMS/2024). Written parental informed consent and adolescent assent were obtained prior to participation. Availability of data and materials De-identified data are available from the corresponding author upon reasonable request. Author Contributions Conceptualization: E.E., I.M., M.L.A. Methodology: E.E., I.M., M.L.A. Investigation: I.A.L.A., C.C.F.V., F.T.M., F.Z., C.P., J.C. Data curation: E.E., I.A.L.A., C.C.F.V. Formal analysis: E.E. Writing – original draft: E.E. Writing – review & editing: E.E, I.O., J.M., P.R.O., M.L.A., I.M. Supervision: I.M., M.L.A. Project administration: I.A.L.A., C.P. Funding acquisition: I.M., M.L.A. 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Hennegan J, Shannon AK, Rubli J, Schwab KJ, Melendez-Torres GJ. Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis. PLoS Med. 2019 May 16;16(5):e1002803. Phillips-Howard PA, Caruso B, Torondel B, Zulaika G, Sahin M, Sommer M. Menstrual hygiene management among adolescent schoolgirls in low- and middle-income countries: research priorities. Glob Health Action. 2016 Dec 1;9(1):33032. Sommer M SM. Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls. Am J Public Health. 2013;103(9):1556–9. UNFPA. State of World Population Report. 2022; Instituto Nacional de Estatística de Angola. Inquérito de Indicadores Múltiplos e de Saúde de Angola (IIMS 2023–2024). 2024; https://www.projectochance.ao/. CHANCE project (Strategies to Improve the Knowledge and Attitudes of Young Angolans Regarding Sexual and Reproductive Health) . Aixut S, Esteban E, Martínez-Campreciós J, Oliveira PR, Gómez-Martínez F, Martín-García D, et al. Sexual and reproductive health knowledge and behaviors and prevalence of sexually transmitted infections among adolescents and young adults from Angola. J Public Health (Bangkok). 2025 Aug 29;47(3):e318–28. Chandra-Mouli V PMAE et al. Adolescent sexual and reproductive health and rights: a stock-taking and call-to-action on the 25th anniversary of the International Conference on Population and Development. Reproductive Health Matters, . 2017;25(1):119-124. Bankole A SSHR. Unwanted pregnancy and induced abortion in Nigeria: causes and consequences. Guttmacher Institute. 2008; Dávila F, Cala-Vitery F, Gómez LT. Determinants of Access to Sexual and Reproductive Health for Adolescent Girls in Vulnerable Situations in Latin America. Int J Environ Res Public Health. 2025 Feb 10;22(2):248. Sidamo NB, Kerbo AA, Gidebo KD, Wado YD. Socio-Ecological Analysis of Barriers to Access and Utilization of Adolescent Sexual and Reproductive Health Services in Sub-Saharan Africa: A Qualitative Systematic Review. Open Access J Contracept. 2023 Jun;Volume 14:103–18. Habtu M, Rutayisire E, Nisengwe S, Nikwigize S, Asingizwe D, Dodoo N, et al. Challenges to Accessing and Utilizing Adolescent Sexual and Reproductive Health and Rights Services in Rwanda. J Multidiscip Healthc. 2025 Jul;Volume 18:3951–65. Biddlecom AE, Munthali A, Singh S, Woog V. Adolescents’ views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda. Afr J Reprod Health. 2007 Dec;11(3):99–110. Woog V SSBAPJ. Adolescent women’s need for and use of sexual and reproductive health services in developing countries. . Guttmacher Institute. 2015; Nguyen MC WQ. Impact of early marriage and adolescent pregnancy on education, labor force participation, and earnings. . 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BMJ Glob Health. 2020 Oct 13;5(10):e002997. Gottert A, Pulerwitz J, Weiner R, Okondo C, Werner J, Magni S, et al. Systematic review of reviews on interventions to engage men and boys as clients, partners and agents of change for improved sexual and reproductive health and rights. BMJ Open. 2025 Jan;15(1):e083950. Ruane-McAteer E, Amin A, Hanratty J, Lynn F, Corbijn van Willenswaard K, Reid E, et al. Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews. BMJ Glob Health. 2019 Sep 11;4(5):e001634. Abreu L, Hecker T, Goessmann K, Abioye TO, Olorunlambe W, Hoeffler A. Prevalence and correlates of sexual violence against adolescents: Quantitative evidence from rural and urban communities in South-West Nigeria. PLOS Global Public Health. 2025 Feb 11;5(2):e0004223. Ezenwosu IL, Uzochukwu BSC. Prevalence, risk factors and interventions to prevent violence against adolescents and youths in Sub-Saharan Africa: a scoping review. Reprod Health. 2025 Feb 14;22(1):23. Gwirayi P. The prevalence of child sexual abuse among secondary school pupils in Gweru, Zimbabwe. Journal of Sexual Aggression. 2013 Nov;19(3):253–63. Fry MW, Skinner AC, Wheeler SB. Understanding the Relationship Between Male Gender Socialization and Gender-Based Violence Among Refugees in Sub-Saharan Africa. Trauma Violence Abuse. 2019 Dec 29;20(5):638–52. DeHond A, Brady F, Kalokhe AS. Prevention of Perpetration of Intimate Partner Violence by Men and Boys in Low- and Middle-Income Countries: A Scoping Review of Primary Prevention Interventions. Trauma Violence Abuse. 2023 Oct 5;24(4):2412–28. Leite L, Yates R, Strigelli GC, Han JYC, Chen-Charles J, Rotaru M, et al. Scoping review of social norms interventions to reduce violence and improve SRHR outcomes among adolescents and young people in sub-Saharan Africa. Frontiers in Reproductive Health. 2025 May 15;7. Edwards KM, Kumar M, Waterman EA, Mullet N, Madeghe B, Musindo O. Programs to Prevent Violence Against Children in Sub-Saharan Africa: A Systematic Review. Trauma Violence Abuse. 2024 Jan 25;25(1):593–612. Cluver LD, Rudgard WE, Toska E, Zhou S, Campeau L, Shenderovich Y, et al. Violence prevention accelerators for children and adolescents in South Africa: A path analysis using two pooled cohorts. PLoS Med. 2020 Nov 9;17(11):e1003383. Kågesten AE, Oware PM, Ntinyari W, Langat N, Mboya B, Ekström AM. Young People’s Experiences With an Empowerment-Based Behavior Change Intervention to Prevent Sexual Violence in Nairobi Informal Settlements: A Qualitative Study. Glob Health Sci Pract. 2021 Sep 30;9(3):508–22. Cahill H, Dadvand B, Suryani A, Farrelly A. A Student-Centric Evaluation of a Program Addressing Prevention of Gender-Based Violence in Three African Countries. Int J Environ Res Public Health. 2023 Aug 1;20(15):6498. Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. The Lancet. 2015 Apr;385(9977):1580–9. Rizzo AJ, Banyard VL, Edwards KM. Unpacking Adolescent Masculinity: Relations between Boys’ Sexual Harassment Victimization, Perpetration, and Gender Role Beliefs. J Fam Violence. 2021 Oct 1;36(7):825–35. Koris A, Steven S, Akika V, Puls C, Okoro C, Bitrus D, et al. Opportunities and challenges in preventing violence against adolescent girls through gender transformative, whole-family support programming in Northeast Nigeria. Confl Health. 2022 Dec 12;16(1):26. Governo de Angola. Código Penal (Lei n. o 38/20 de 11 de novembro de 2020). . Diário da República. Habitu YA YAAT. Prevalence and associated factors of unintended pregnancy among pregnant women in Gondar town, northwest Ethiopia, 2020: a community-based cross-sectional study. BMC Women’s Health. 2021;21(114). Jewkes R GTWM et al. Why are women still aborting outside designated facilities in metropolitan South Africa? Reproductive Health Matters. 2005;13(26):62–70. Esteban E, Larrea O, Irrazabal MG, Sánchez A, Zacarias F, Oliveira PR, et al. “Unintended pregnancy and attitudes towards sexual and reproductive health among young people in Benguela Province, Angola.” Reprod Health. 2025 Nov 10;22(1):223. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9009395","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606461491,"identity":"14a16cdb-ad4b-446d-8d5e-0b1b76d2fe6f","order_by":0,"name":"Esperanza Esteban 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Vall d’Hebron-Drassanes, Infectious Diseases Department, Vall d’Hebron University Hospital, PROSICS","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Luisa","lastName":"Aznar","suffix":""},{"id":606461502,"identity":"b692653c-ecfa-4845-a021-cba99ac6d697","order_by":11,"name":"Israel Molina","email":"","orcid":"","institution":"International Health Unit Vall d’Hebron-Drassanes, Infectious Diseases Department, Vall d’Hebron University Hospital, PROSICS","correspondingAuthor":false,"prefix":"","firstName":"Israel","middleName":"","lastName":"Molina","suffix":""}],"badges":[],"createdAt":"2026-03-02 11:11:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9009395/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9009395/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109010567,"identity":"1430b980-d151-44f7-837a-2ac23e9f7ca6","added_by":"auto","created_at":"2026-05-11 16:28:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":322523,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9009395/v1/5eb79288-b3bd-426d-874e-d2d545c774b8.pdf"},{"id":104732602,"identity":"232b4805-c65e-4edd-b6bb-057a1b03f7d8","added_by":"auto","created_at":"2026-03-16 14:50:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":57765,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9009395/v1/9b1f39a66ba791da7b6bef12.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond knowledge: violence as a structural determinant of adolescent sexual and reproductive health in Angola","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eAdolescence is a critical stage in identity formation, the development of autonomy, and the beginning of experiences related to sexuality. During this stage, young people navigate decisions related to consent, protection and the exercise of their sexual and reproductive rights (SRR), in ways shaped by intersecting social, cultural and structural factors that may either enable or constrain their autonomy (1,2) Adolescence is not a homogeneous life stage; early adolescence, in particular, is characterised by limited autonomy, high dependence on family and school environments, and distinct vulnerabilities that shape how sexual and reproductive health knowledge is understood and acted upon (3\u0026ndash;5)\u003c/p\u003e \u003cp\u003eAccess to accurate sexual and reproductive health (SRH) information has been shown to improve knowledge, reduce risk behaviours and increase contraceptive use (6,7). Comprehensive sexuality education (CSE) has therefore been promoted as a key strategy for supporting a safe and informed transition to adulthood (2,8).\u003c/p\u003e \u003cp\u003eHowever, growing evidence indicates that improvements in knowledge alone are often insufficient to produce sustained changes in behaviour, particularly in settings characterised by gender inequality, stigma and limited access to youth-friendly SRH services (1,9,10). This persistent knowledge\u0026ndash;practice gap highlights the importance of examining the broader social and structural conditions under which adolescents make SRH-related decisions (11).\u003c/p\u003e \u003cp\u003eAcross sub-Saharan Africa (SSA), adolescents, particularly girls, continue to face multiple, intersecting barriers to the exercise of their SRR(12). Gender inequality, restrictive social norms and limited access to youth-friendly SRH services have been consistently documented as key constraints across the region.\u003c/p\u003e \u003cp\u003eIn parallel, adolescents are widely exposed to sexual and gender-based violence (GBV), which further undermines SRH outcomes by limiting agency, increasing biological risk and normalising coercive relationships. Recent studies in SSA report that between 40% and 70% of adolescents have experienced some form of sexual violence, including coercion, harassment or abuse by peers or adults (13,14). Despite its prevalence, violence is often treated as a parallel outcome rather than as a central structural determinant of adolescent SRH (12). This analytical separation risks underestimating how early exposure to coercion, abuse and forced sexual experiences shapes adolescents\u0026rsquo; sexual trajectories, particularly among boys.\u003c/p\u003e \u003cp\u003eMenstrual health represents another critical yet frequently neglected dimension of adolescent SRH. Across SSA, menstruation remains surrounded by stigma and inadequate resources and many girls miss school or experience shame and social isolation during menstruation due to pain, lack of sanitary materials or restrictive cultural norms (15\u0026ndash;17). These barriers reinforce gendered educational and health inequalities from early adolescence.\u003c/p\u003e \u003cp\u003eIn Angola, deep social inequalities, cultural barriers, and limited investment in adolescent health exacerbate these challenges. Despite increasing awareness of SRH, structural barriers continue to hinder the translation of knowledge into practice (6,10,18). National assessments, including the 2022 UNFPA evaluation (19) and the 2023\u0026ndash;2024 IIMS survey (20) reported persistently high adolescent fertility rates and low use of modern contraceptives, particularly in rural areas.\u003c/p\u003e \u003cp\u003eAlthough studies across SSA have examined aspects of SRH knowledge and behaviour, most have been conducted in anglophone countries and focus on older adolescents or specific issues such as human immunodeficiency virus (HIV) or contraception (1,7,9). Evidence from Portuguese-speaking African countries, particularly Angola, remains extremely limited, and very little is known about how younger adolescents understand SRH, negotiate sexual relationships or experience violence and structural constraints within school settings.\u003c/p\u003e \u003cp\u003eThis study is framed within the CHANCE project (\u003cem\u003eStrategies to Improve the Knowledge and Attitudes of Young Angolans Regarding Sexual and Reproductive Health\u003c/em\u003e) (21), funded by the European Union. The project aims to strengthen Sexual and Reproductive Health (SRH) among young people in Cubal and Lobito, with particular attention to girls and socially vulnerable groups.\u003c/p\u003e \u003cp\u003eThis baseline study aimed to describe SRH knowledge, behaviours and structural vulnerabilities among adolescents aged 11\u0026ndash;17 years in Benguela Province, Angola. By examining the intersection of knowledge, gender, violence and menstrual health, the study explicitly positions sexual and GBV as a core structural factor influencing adolescents\u0026rsquo; sexual and reproductive health trajectories.\u003c/p\u003e"},{"header":"2. MATERIAL AND METHODS","content":"\u003cp\u003e \u003cb\u003eStudy design and setting\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis cross-sectional descriptive study was conducted in Benguela Province, Angola, within the framework of the CHANCE project (NDICI HR INTPA/2023/450\u0026thinsp;\u0026minus;\u0026thinsp;200). Data collection took place in October 2024 in two municipalities representing contrasting socioeconomic and service-access contexts. Lobito is a predominantly urban and peri-urban municipality with higher population density, greater school enrolment and comparatively better access to SRH services. Cubal represents a largely rural context characterised by greater socioeconomic vulnerability and more limited availability of youth-friendly health services.\u003c/p\u003e \u003cp\u003eThe study design allows for the simultaneous assessment of knowledge, behaviours, and structural vulnerabilities among adolescents, providing a comprehensive snapshot of SRH outcomes in different context.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePopulation and sampling\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe target population comprised 65,507 adolescents aged 11 to 17 years enrolled in lower and upper secondary education in the municipalities of Lobito (n\u0026thinsp;=\u0026thinsp;55,799) and Cubal (n\u0026thinsp;=\u0026thinsp;9,708). A representative sample of 382 adolescents was calculated using the Raosoft\u0026reg; statistical calculator, with a 95% confidence level and a 5% margin of error.\u003c/p\u003e \u003cp\u003eAlthough initial proportional allocation was 85% for Lobito and 15% for Cubal, the final sample (282 urban; 100 rural) was adjusted to reduce sampling error in the rural site and enable comparisons. Rural schools were therefore intentionally oversampled to enable urban\u0026ndash;rural comparisons; analyses were not population-weighted.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSampling strategy\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSystematic random sampling was used. In each municipality, schools were selected in coordination with local educational authorities. Within selected schools, specific classes (turmas) were chosen based on scheduling feasibility and coordination with school staff and students were selected from class attendance lists using a fixed interval (every 5th student), with replacement when absent.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData collection instrument\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA structured questionnaire was developed by the research team, drawing on validated instruments from previous studies on SRH (22) and adapted to the Angolan context. To ensure the ethical formulation of sensitive questions and the appropriateness of language for adolescents, the questionnaire underwent a comprehensive expert review by the Child Abuse Unit and the STIs Unit of Vall d\u0026rsquo;Hebron University Hospital (Barcelona, Spain), with particular attention to items addressing sexuality, pregnancy, and experiences of violence. Local project partners also evaluated the tool for cultural relevance.\u003c/p\u003e \u003cp\u003eA pilot test was conducted with 38 adolescents (approximately 10% of the intended sample) in both urban and rural areas. Based on this feedback, the final questionnaire included 89 items across nine thematic sections: sociodemographic variables, pregnancy and abortion, SRH knowledge, sexual behaviour, GBV, menstruation, contraceptive use, sexual orientation and gender equality. The full questionnaire is provided as online supplemental material (Supplementary file 1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eOperational definitions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSRH knowledge was measured through statements on sexuality, pregnancy, menstruation, puberty, STIs, contraception, and fertility risks. Correct answers were scored as one and incorrect or \u0026ldquo;don\u0026rsquo;t know\u0026rdquo; as zero (maximum score: 14), with scores\u0026thinsp;\u0026ge;\u0026thinsp;7 indicating adequate knowledge. Conceptually, knowledge was treated as a necessary but insufficient condition for protective practices and was therefore analysed in conjunction with behavioural and structural indicators rather than as a primary outcome.\u003c/p\u003e \u003cp\u003eContraceptive use was defined as self-reported use of any pregnancy prevention method. Practices were assessed using a composite score (preventive behaviours\u0026thinsp;=\u0026thinsp;1; risk behaviours\u0026thinsp;=\u0026thinsp;0). Barriers were measured with a yes/no item, and attitudes toward contraception with Likert-scale items, where higher scores indicated more favourable views toward universal access.\u003c/p\u003e \u003cp\u003eRisky sexual behaviour was defined as self-reported behaviours associated with increased biological risk of sexually transmitted infections or unintended pregnancy,: including sex with an STI-positive partner, multiple concurrent partners, sex under the influence of alcohol or drugs, sex under threat or coercion, transactional sex, or lack of condom use in casual encounters.\u003c/p\u003e \u003cp\u003eMenstrual health barriers were assessed through four yes/no items asking whether menstruation had ever caused girls to miss school, miss work, avoid leaving home or other daily activities.\u003c/p\u003e \u003cp\u003ePregnancy and abortion were assessed by asking whether respondents or their partners had ever experienced an unintended pregnancy and, if so, whether abortion had been used. Two binary variables were created: history of unintended pregnancy and history of abortion, with abortion analysed only among those reporting an unintended pregnancy.\u003c/p\u003e \u003cp\u003eExperiences of sexual and GBV were defined as reporting any of the following in childhood: inappropriate touching, forced sexual acts, exposure to sexual acts at home, sexual advances by adults, attempted or completed penetration, forced participation in sexual activity, or inability to consent due to intoxication. These experiences were analysed independently from sexual risk behaviours to avoid conflation of distinct constructs.\u003c/p\u003e \u003cp\u003eAlthough items on sexual orientation and gender equality were included in the questionnaire, they were excluded from the analysis due to ethical and developmental considerations related to participants\u0026rsquo; age (11\u0026ndash;17 years).\u003c/p\u003e \u003cp\u003e \u003cb\u003eData collection procedures\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBefore the study began, approval was obtained from the National Directorate of Public Health of Angola and communicated to the municipal education authorities in Lobito and Cubal, who authorised the selected schools to participate. Community activists then met with school principals to explain the study procedures, and school administrators coordinated the collection of parental informed consent for participating students.\u003c/p\u003e \u003cp\u003eFieldwork took place in October 2024. In Cubal, surveys were conducted from 8\u0026ndash;11 October; in Lobito, from 22\u0026ndash;26 October. Teams included 14 data collectors in Cubal and 40 in Lobito, working in pairs under supervision. Each interview lasted approximately 35 minutes and was conducted in a private setting within school premises to ensure confidentiality. The questionnaire was administered with individual assistance from trained community activists experienced in working with children and sensitised to sexual and reproductive health topics. To safeguard participants\u0026rsquo; wellbeing, the instrument followed a progressive structure, so that children were not exposed to more sensitive sections unless necessary. All data were collected in a confidential environment and in a language familiar to the participants.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData Management and Statistical Analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCategorical variables were described using absolute frequencies and percentages. Continuous variables were presented as means and standard deviations or medians and interquartile ranges, depending on the distribution. Normality was assessed using the Shapiro\u0026ndash;Wilk test.\u003c/p\u003e \u003cp\u003eFor bivariate analysis, Chi-square or Fisher\u0026rsquo;s exact test was used to compare categorical variables, and Student\u0026rsquo;s t-test or Mann\u0026ndash;Whitney U test was applied to compare continuous variables, depending on their distribution. A \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003eData were entered into a secure database and analysed using IBM SPSS Statistics v.26 (IBM Corp., Armonk, NY, USA). There were no missing data for the main study variables, as non-responding students were replaced during data collection to achieve the target sample size. Replacement was conducted using the same sampling interval to preserve randomness.\u003c/p\u003e \u003cp\u003e This study is reported in accordance with the STROBE guidelines for cross-sectional studies.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatient and Public Involvement\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCommunity stakeholders and adolescents contributed to the design and conduct of this study. The questionnaire was culturally adapted in partnership with local organisations and community activists with expertise in adolescent health to enhance contextual relevance, comprehension, and acceptability of sensitive measures. A pilot conducted with adolescents from urban and rural settings informed the refinement of the data collection tool.\u003c/p\u003e \u003cp\u003eCommunity activists facilitated data collection within schools, supporting ethically grounded and context-sensitive research practices. Adolescents were not involved in data analysis or interpretation. Findings will be disseminated to participating schools and local partners to promote community engagement and inform adolescent sexual and reproductive health programming.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical considerations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The study protocol was approved by the relevant ethical and educational authorities in Angola (MINSA, n.\u0026ordm; 25/CEMS/2024). Parental consent and student assent were obtained prior to participation. Participation was voluntary, and anonymity and data confidentiality were ensured throughout the process. Interviewers received specific training in child safeguarding and the ethical management of sensitive disclosures. A predefined referral pathway was in place to ensure that any disclosure of abuse, violence or immediate risk was managed confidentially and referred to appropriate local health or social protection services in accordance with national child protection protocols. The questionnaire included sensitive items on violence; the full instrument is available as supplementary material.\u003c/p\u003e"},{"header":"2. RESULTS","content":"\u003cp\u003eSeventeen schools were included in total (ten in Lobito and seven in Cubal), with a total of 382 adolescents aged 11 to 17 years (mean 14.3 SD\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8). Most participants resided in urban areas 73.8%, (n\u0026thinsp;=\u0026thinsp;282), while 26.2% (n\u0026thinsp;=\u0026thinsp;100) lived in rural settings. SRH knowledge was high overall, with 98.7% (n\u0026thinsp;=\u0026thinsp;377) demonstrating adequate knowledge.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents SRH indicators stratified by sex and place of residence.\u003c/p\u003e \u003cp\u003eIn urban settings, boys were significantly more likely than girls to report having initiated sexual intercourse (45.0% vs 10.4%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and contraceptive use (34.0% vs. 7.7%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A similar pattern was observed in rural areas, although differences did not reach statistical significance (43.6% vs 28.6%; p\u0026thinsp;=\u0026thinsp;0.143); contraceptive use: 28.2% vs. 16.4%, p\u0026thinsp;=\u0026thinsp;0.157). Urban boys reported an earlier age at sexual debut than urban girls (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 vs. 14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 years), although this difference was not statistically significant. In rural settings, boys reported a significantly earlier sexual debut than girls (13.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 vs. 15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2 years; p\u0026thinsp;=\u0026thinsp;0.03). Risky sexual behaviours were more frequently reported by boys, particularly in rural settings (17.9% vs 3.3%; p\u0026thinsp;=\u0026thinsp;0.012).\u003c/p\u003e \u003cp\u003eOverall, 29% (n\u0026thinsp;=\u0026thinsp;88) reported having engaged in sexual intercourse, among them 31 (35.2%) reported risky sexual behaviours, and 18 (58,1%) of them stated not using condoms during sexual intercourse in the past six months. Only 69 adolescents (18.1%) reported having used any contraceptive method, while only 38 (9.9%) reported consistent condom use during sexual intercourse, with higher prevalence in urban than rural areas (11.3% vs 6.0%; p\u0026thinsp;=\u0026thinsp;1.80).\u003c/p\u003e \u003cp\u003eDisparities were also evident in menstrual health, 73.8% (n\u0026thinsp;=\u0026thinsp;165) reported missing school, sports, or social activities due to menstruation, with significantly higher prevalence in rural compared with urban areas (80.3% vs. 63.5%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eBeyond sexual behaviours and contraceptive practices, exposure to sexual and GBV emerged as a major pattern among adolescents and affected 45.8% (n\u0026thinsp;=\u0026thinsp;175) with boys disproportionately affected (69.8% vs 32.2%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Reports were more frequent in rural than urban settings (52.0% vs 43.6%), although this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.184). Approximately one in four adolescents reported inappropriate touching before age 10, and forced sexual acts were significantly more common among boys in both urban (17.0% vs. 8.8%; p\u0026thinsp;=\u0026thinsp;0.040) and rural areas (28.2% vs. 9.8%; p\u0026thinsp;=\u0026thinsp;0.017). Overall exposure remained high across subgroups, particularly among rural boys (61.5%) and urban girls (50%). Specific forms of violence are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSexual and reproductive health indicators by sex and place of residence among adolescents aged 11\u0026ndash;17 years in Benguela Province, Angola\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen (N\u0026thinsp;=\u0026thinsp;182)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen (N\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen (N\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMen (N\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at first sexual intercourse (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.36\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate SRH knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 (99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58 (95.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38 (97.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of contraceptive methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (16.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas had sexual intercourse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (43.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisky sexual behaviours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (17.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenstrual barriers (girls only)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (63.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49 (80,3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnwanted pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbortion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas experienced violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (40.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (45.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFootnotes\u003c/strong\u003e \u003cp\u003e \u003cem\u003eValues are presented as number (percentage) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, unless otherwise specified.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003ePercentages for menstrual-related barriers are calculated among female participants only.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNA: not applicable.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026ndash;\u0026rdquo;: statistical comparison not performed due to absence of events or insufficient data.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of reported experiences of sexual and GBV among adolescents aged 11\u0026ndash;17 years, by sex and place of residence in Benguela Province, Angola\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGirls (N\u0026thinsp;=\u0026thinsp;182)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBoys (N\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGirls (N\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBoys (N\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInappropriate or uncomfortable touching before age 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.463\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnwanted sexual touching at any age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (16.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (27.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForced sexual acts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeard about inappropriate sexual acts at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (12.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily member or acquaintance tried to have sex with them\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (12.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (24.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttempted or completed penetration without consent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (17.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForced to perform sexual acts through physical violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (10.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual acts under the influence of alcohol or drugs (no capacity to consent)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.830\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eFootnotes: Values are presented as number (percentage).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eAll indicators refer to self-reported experiences occurring at any time during childhood or adolescence.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003ep-values represent comparisons by sex within each place of residence.\u003c/em\u003e \u003c/p\u003e"},{"header":"3. DISCUSSION","content":"\u003cp\u003eThis study provides one of the few available assessments of SRH knowledge, attitudes, and lived experiences among adolescents aged 11\u0026ndash;17 in Angola, a population that remains largely under-represented in the literature.\u003c/p\u003e \u003cp\u003eOne of the most concerning findings of this study is the widespread exposure to sexual and GBV, which helps explain why high levels of SRH knowledge do not translate into safer sexual practices in this population. Nearly half of all adolescents reported at least one form of violence, with particularly high prevalence among rural boys and urban girls. These levels are consistent with evidence from other SSA contexts reporting alarmingly high exposure to sexual violence during childhood and early adolescence (37\u0026ndash;39). Importantly, this study contributes to a growing body of evidence showing that boys\u0026rsquo; experiences of violence are both prevalent and under-recognised (38,40).\u003c/p\u003e \u003cp\u003eWhile much of the existing literature has focused on girls\u0026rsquo; victimisation, the high prevalence of forced sexual acts reported by boys in this study underscores the need for more inclusive prevention strategies. Recognising boys solely as potential perpetrators risks obscuring their exposure to violence and the harmful gender norms that shape their experiences (41). Evidence suggests that effective violence-prevention interventions are multilevel and gender-transformative, combining life skills education, family and community engagement and social norms change (42,43). Positive parenting and household stability further act as key protective factors (44), while school-based and empowerment-focused programmes show promise in promoting respectful relationships and reducing violence (45,46). Addressing violence among adolescents therefore requires moving beyond individual risk factors toward systemic, community-based approaches that engage both girls and boys (47\u0026ndash;49).\u003c/p\u003e \u003cp\u003eThe findings reveal a marked disconnect between near-universal SRH knowledge and limited adoption of protective behaviours, underscoring the role of structural and gendered constraints in shaping adolescents\u0026rsquo; capacity to exercise their SRR.\u003c/p\u003e \u003cp\u003eThese findings should be interpreted in light of the wide age range included in the study, which spans early to late adolescence; although analyses were conducted for the sample as a whole, variations in autonomy and decision-making capacity across developmental stages are likely to shape how SRH knowledge translates into behaviour.\u003c/p\u003e \u003cp\u003eDespite almost all participants demonstrating adequate SRH knowledge, contraceptive use remained low, particularly among girls. This finding reinforces growing evidence from SSA challenging the assumption that information alone is sufficient to produce behavioural change during adolescence (23,24). Qualitative and review studies consistently show that fear of stigma, unequal power relations, restricted autonomy and limited access to youth-friendly services constrain adolescents\u0026rsquo; ability to act on the information they possess(25\u0026ndash;27) In this context, the knowledge\u0026ndash;practice gap observed in Benguela reflects systemic failures rather than individual shortcomings.\u003c/p\u003e \u003cp\u003eGender disparities in contraceptive use were particularly pronounced in urban settings, where girls reported extremely low use compared with boys. This pattern likely reflects persistent gender norms that place responsibility for contraception on males while simultaneously limiting girls\u0026rsquo; decision-making power and access to services (28,29). Similar dynamics have been documented across SSA, where girls\u0026rsquo; reproductive agency is constrained by social expectations, partner control and fear of judgement within health services (8,30).\u003c/p\u003e \u003cp\u003eBy contrast, boys reported earlier sexual initiation and higher engagement in risky sexual behaviours, aligning with dominant constructions of masculinity that valorise early and unprotected sexual activity (31,32)\u003c/p\u003e \u003cp\u003eThe pronounced gender differences in age at sexual debut observed in this young population warrant particular attention. Early sexual initiation among boys has been associated with adverse relationship dynamics and increased vulnerability to coercion and violence in SSA settings (31). Given the high prevalence of reported violence in this study, early sexual experiences among boys may not always reflect agency or choice but could also occur within contexts of coercion, violence and normative pressures that remain largely under-recognised in SRH research. Conversely, girls\u0026rsquo; later sexual debut may reflect restrictive forms of social control rather than empowerment (32,33). These findings highlight the need for gender-sensitive SRH programmes that address harmful norms affecting both girls and boys, including norms that normalise male risk-taking and silence male vulnerability (34\u0026ndash;36).\u003c/p\u003e \u003cp\u003eMenstrual barriers were also highly prevalent, especially in rural settings, where more than 80% of girls reported refraining from school or daily activities during menstruation. This mirrors findings from SSA showing that lack of sanitary products, inadequate water, sanitation and hygiene (WASH) facilities, and menstrual stigma contribute to absenteeism, discomfort, and psychosocial distress (50\u0026ndash;52). The magnitude of menstrual barriers observed in this study indicates that menstrual health should be integrated into SRH programming not only through education, but also through the provision of materials and improvements in school infrastructure.\u003c/p\u003e \u003cp\u003e Reports of unintended pregnancy and abortion were relatively infrequent in this young adolescent population. However, the concentration of reported abortions in urban settings may reflect differential access to information and services, or greater social visibility of such events in urban areas. In the Angolan context, where abortion remains legally restricted, these findings underscore the importance of ensuring access to accurate information and confidential, youth-friendly SRH services from early adolescence. Previous evidence from Benguela suggests that unintended pregnancy and unmet contraceptive need increase substantially later in adolescence, highlighting the importance of early preventive interventions (53). Although grounded in the Angolan context, these findings reflect broader challenges observed across SSA, where early adolescence remains under-researched despite being a critical window for preventive SRH interventions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has several limitations. Its cross-sectional design precludes causal inference between SRH knowledge, behaviours and experiences of violence. Self-reported data may underestimate sensitive experiences despite confidentiality measures, and social desirability bias may have influenced reporting. Analyses were conducted at the individual level and did not account for clustering by school. Finally, the study included only school-going adolescents, limiting generalisability to out-of-school youth, who may experience even greater vulnerability.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study demonstrates that adolescents aged 11\u0026ndash;17 years in Benguela Province possess high levels of SRH knowledge but face substantial barriers to translating this knowledge into protective behaviours. The findings highlight a persistent knowledge\u0026ndash;practice gap shaped by gender norms, limited autonomy, restricted access to youth-friendly services, menstrual health constraints and widespread exposure to sexual and GBV.\u003c/p\u003e \u003cp\u003eGirls\u0026rsquo; particularly low contraceptive use, despite high levels of knowledge, reflects enduring gendered power imbalances that constrain decision-making and access to care from early adolescence. At the same time, boys\u0026rsquo; earlier sexual initiation, higher engagement in risky behaviours and high exposure to forced sexual acts reveal distinct and often overlooked vulnerabilities. Together, these patterns challenge simplified narratives that frame boys solely as risk-takers or perpetrators and girls solely as victims, underscoring the need for more nuanced, gender-responsive approaches.\u003c/p\u003e \u003cp\u003eThe high prevalence of sexual and GBV across all subgroups, affecting nearly half of participants, emerges as a central finding of this study. Violence appears not as an isolated experience but as a systemic determinant shaping adolescents\u0026rsquo; SRH trajectories, limiting agency, normalising coercion and undermining the effectiveness of information-based interventions. These findings suggest that addressing adolescent SRH without explicitly confronting violence, particularly violence affecting boys, risks reproducing the very knowledge\u0026ndash;practice gap that education-only interventions seek to close.\u003c/p\u003e \u003cp\u003eMenstrual health barriers were also highly prevalent, particularly in rural settings, where they contributed to school absenteeism and reduced participation in daily activities. These findings reinforce the need to recognise menstrual health as a core component of adolescent SRH and educational equity, requiring structural interventions beyond health education alone.\u003c/p\u003e \u003cp\u003eOverall, these results indicate that improving adolescent SRH in Angola requires moving beyond information-focused strategies toward integrated, gender-transformative public health approaches. Such approaches should combine comprehensive sexuality education with accessible, confidential and youth-friendly SRH services; systematic violence-prevention and response mechanisms; and menstrual health support, including the provision of sanitary materials and improvements in school infrastructure. Investing in early adolescence is critical to interrupting cycles of vulnerability and to advancing sexual and reproductive rights in under-resourced and under-researched contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participating adolescents, as well as teachers, school principals, and educational authorities in Lobito and Cubal, for facilitating data collection. This study was conducted within the CHANCE project (NDICI HR INTPA/2023/450-200), funded by the European Union.\u003c/p\u003e\n\u003cp\u003eWe especially acknowledge the valuable contributions of the Child Abuse Unit and the Sexually Transmitted Infections Unit of Vall d’Hebron University Hospital (Barcelona, Spain) for reviewing the questionnaire to ensure ethical soundness and child sensitivity. The contributions of the local partner organisations (OIC, AJS, ISPJPB, CAJ) and the fieldwork teams in Lobito and Cubal were essential to this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis work forms part of the PhD Programme in Medicine at the Universitat Autònoma de Barcelona (UAB).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by the European Union through the CHANCE project (NDICI HR INTPA/2023/450-200). No funding was received for the preparation or publication of this manuscript. The funder had no role in study design, data collection, analysis, interpretation or manuscript writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study followed the Declaration of Helsinki and Good Clinical Practice guidelines, and was approved by the Ethics Committee of the Ministry of Health of Angola (MINSA, n.º 25/CEMS/2024). Written parental informed consent and adolescent assent were obtained prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDe-identified data are available from the corresponding author upon reasonable request.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: E.E., I.M., M.L.A.\u003c/p\u003e\n\u003cp\u003eMethodology: E.E., I.M., M.L.A.\u003c/p\u003e\n\u003cp\u003eInvestigation: I.A.L.A., C.C.F.V., F.T.M., F.Z., C.P., J.C.\u003c/p\u003e\n\u003cp\u003eData curation: E.E., I.A.L.A., C.C.F.V.\u003c/p\u003e\n\u003cp\u003eFormal analysis: E.E.\u003c/p\u003e\n\u003cp\u003eWriting – original draft: E.E.\u003c/p\u003e\n\u003cp\u003eWriting – review \u0026amp; editing: E.E, I.O., J.M., P.R.O., M.L.A., I.M.\u003c/p\u003e\n\u003cp\u003eSupervision: I.M., M.L.A.\u003c/p\u003e\n\u003cp\u003eProject administration: I.A.L.A., C.P.\u003c/p\u003e\n\u003cp\u003eFunding acquisition: I.M., M.L.A.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications and contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study highlights major gaps between SRH knowledge and behaviour among adolescents in Angola, emphasising gendered barriers in contraception, menstrual health, and violence. By including younger adolescents and comparing urban–rural contexts, the findings provide evidence to guide more equitable, gender-transformative SRH programmes and inform education and health system responses targeting early adolescence.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eChandra-Mouli V LCWS. What does not work in adolescent sexual and reproductive health: a review of evidence on interventions commonly accepted as best practices. Glob Health Sci Pract. 2015;3(3):333\u0026ndash;40.\u003c/li\u003e\n \u003cli\u003eUNESCO. International Technical Guidance on Sexuality Education. Revised Edition. 2018;\u003c/li\u003e\n \u003cli\u003eVillalobos A, Estrada F, Hubert C, Torres-Ibarra L, Rodr\u0026iacute;guez A, Romero I, et al. Sexual and reproductive health among adolescents in vulnerable contexts in Mexico: Needs, knowledge, and rights. 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Guttmacher Institute. 2015;\u003c/li\u003e\n \u003cli\u003eNguyen MC WQ. Impact of early marriage and adolescent pregnancy on education, labor force participation, and earnings. . The Review of Faith \u0026amp; International Affairs, . 2014;12(3):40\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eSeff I, Steiner JJ, Stark L. Early sexual debut: A multi-country, sex-stratified analysis in sub-Saharan Africa. Glob Public Health. 2021 Jul 3;16(7):1046\u0026ndash;56.\u003c/li\u003e\n \u003cli\u003eKushal SA, Amin YM, Reza S, Hossain FB, Shawon MSR. Regional and Sex Differences in the Prevalence and Correlates of Early Sexual Initiation Among Adolescents Aged 12\u0026ndash;15 Years in 50 Countries. Journal of Adolescent Health. 2022 Apr;70(4):607\u0026ndash;16.\u003c/li\u003e\n \u003cli\u003ede Graaf H, Schouten F, van Dorsselaer S, K\u0026ouml;ltő A, Ball J, Stevens GWJM, et al. Trends and the Gender Gap in the Reporting of Sexual Initiation Among 15-Year-Olds: A Comparison of 33 European Countries. The Journal of Sex Research. 2025 May 4;62(4):445\u0026ndash;54.\u003c/li\u003e\n \u003cli\u003eRuane-McAteer E, Gillespie K, Amin A, Aventin \u0026Aacute;, Robinson M, Hanratty J, et al. Gender-transformative programming with men and boys to improve sexual and reproductive health and rights: a systematic review of intervention studies. BMJ Glob Health. 2020 Oct 13;5(10):e002997.\u003c/li\u003e\n \u003cli\u003eGottert A, Pulerwitz J, Weiner R, Okondo C, Werner J, Magni S, et al. Systematic review of reviews on interventions to engage men and boys as clients, partners and agents of change for improved sexual and reproductive health and rights. BMJ Open. 2025 Jan;15(1):e083950.\u003c/li\u003e\n \u003cli\u003eRuane-McAteer E, Amin A, Hanratty J, Lynn F, Corbijn van Willenswaard K, Reid E, et al. Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews. BMJ Glob Health. 2019 Sep 11;4(5):e001634.\u003c/li\u003e\n \u003cli\u003eAbreu L, Hecker T, Goessmann K, Abioye TO, Olorunlambe W, Hoeffler A. Prevalence and correlates of sexual violence against adolescents: Quantitative evidence from rural and urban communities in South-West Nigeria. PLOS Global Public Health. 2025 Feb 11;5(2):e0004223.\u003c/li\u003e\n \u003cli\u003eEzenwosu IL, Uzochukwu BSC. Prevalence, risk factors and interventions to prevent violence against adolescents and youths in Sub-Saharan Africa: a scoping review. Reprod Health. 2025 Feb 14;22(1):23.\u003c/li\u003e\n \u003cli\u003eGwirayi P. The prevalence of child sexual abuse among secondary school pupils in Gweru, Zimbabwe. Journal of Sexual Aggression. 2013 Nov;19(3):253\u0026ndash;63.\u003c/li\u003e\n \u003cli\u003eFry MW, Skinner AC, Wheeler SB. 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Trauma Violence Abuse. 2024 Jan 25;25(1):593\u0026ndash;612.\u003c/li\u003e\n \u003cli\u003eCluver LD, Rudgard WE, Toska E, Zhou S, Campeau L, Shenderovich Y, et al. Violence prevention accelerators for children and adolescents in South Africa: A path analysis using two pooled cohorts. PLoS Med. 2020 Nov 9;17(11):e1003383.\u003c/li\u003e\n \u003cli\u003eK\u0026aring;gesten AE, Oware PM, Ntinyari W, Langat N, Mboya B, Ekstr\u0026ouml;m AM. Young People\u0026rsquo;s Experiences With an Empowerment-Based Behavior Change Intervention to Prevent Sexual Violence in Nairobi Informal Settlements: A Qualitative Study. Glob Health Sci Pract. 2021 Sep 30;9(3):508\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eCahill H, Dadvand B, Suryani A, Farrelly A. A Student-Centric Evaluation of a Program Addressing Prevention of Gender-Based Violence in Three African Countries. Int J Environ Res Public Health. 2023 Aug 1;20(15):6498.\u003c/li\u003e\n \u003cli\u003eJewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. The Lancet. 2015 Apr;385(9977):1580\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eRizzo AJ, Banyard VL, Edwards KM. Unpacking Adolescent Masculinity: Relations between Boys\u0026rsquo; Sexual Harassment Victimization, Perpetration, and Gender Role Beliefs. J Fam Violence. 2021 Oct 1;36(7):825\u0026ndash;35.\u003c/li\u003e\n \u003cli\u003eKoris A, Steven S, Akika V, Puls C, Okoro C, Bitrus D, et al. Opportunities and challenges in preventing violence against adolescent girls through gender transformative, whole-family support programming in Northeast Nigeria. Confl Health. 2022 Dec 12;16(1):26.\u003c/li\u003e\n \u003cli\u003eGoverno de Angola. C\u0026oacute;digo Penal (Lei n.\u003csup\u003eo\u003c/sup\u003e 38/20 de 11 de novembro de 2020). . Di\u0026aacute;rio da Rep\u0026uacute;blica.\u003c/li\u003e\n \u003cli\u003eHabitu YA YAAT. Prevalence and associated factors of unintended pregnancy among pregnant women in Gondar town, northwest Ethiopia, 2020: a community-based cross-sectional study. BMC Women\u0026rsquo;s Health. 2021;21(114).\u003c/li\u003e\n \u003cli\u003eJewkes R GTWM et al. Why are women still aborting outside designated facilities in metropolitan South Africa? Reproductive Health Matters. 2005;13(26):62\u0026ndash;70.\u003c/li\u003e\n \u003cli\u003eEsteban E, Larrea O, Irrazabal MG, S\u0026aacute;nchez A, Zacarias F, Oliveira PR, et al. \u0026ldquo;Unintended pregnancy and attitudes towards sexual and reproductive health among young people in Benguela Province, Angola.\u0026rdquo; Reprod Health. 2025 Nov 10;22(1):223.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adolescents / early adolescence, Sexual and reproductive health, Gender-based violence, Menstrual health, Sub-Saharan Africa / Angola, School-based study","lastPublishedDoi":"10.21203/rs.3.rs-9009395/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9009395/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Evidence on adolescent sexual and reproductive health (SRH) in Angola remains scarce, particularly among younger adolescents who are frequently excluded from research. Context-specific data are needed to understand how SRH knowledge translates into behaviours and how structural factors shape adolescents’ ability to act on this knowledge. This study aimed to describe SRH knowledge, behaviours, exposure to violence, and structural vulnerabilities among adolescents aged 11–17 years in Benguela Province, Angola.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We conducted a school-based cross-sectional study in October 2024 among 382 adolescents from urban (n = 282) and rural (n = 100) settings in Benguela Province, selected through systematic random sampling. A culturally adapted questionnaire assessed key SRH domains, including knowledge, sexual behaviours, contraceptive use, menstrual health, pregnancy and abortion, and experiences of sexual and gender-based violence (GBV). Data were analysed using descriptive and bivariate statistics to characterise patterns by sex and residence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eNearly all participants demonstrated adequate SRH knowledge (98.7%). However, only 18.1% reported using any contraceptive method, with pronounced gender disparities, particularly in urban settings (urban boys 34.0% vs. urban girls 7.7%; p \u0026lt; 0.001). Overall, 29.0% reported having engaged in sexual intercourse, and 8.1% reported risky sexual behaviours, including inconsistent condom use during sexual intercourse. Nearly half of adolescents (45.8%) reported experiences of sexual or GBV, with forced sexual acts disproportionately affecting boys, positioning violence as a key constraint on adolescents’ sexual and reproductive agency. Menstrual-related barriers were widespread, affecting 63.5% of urban girls and 80.3% of rural girls, and included missing school or daily activities. Unintended pregnancy was reported by 2.4% of participants, and all reported abortions occurred in urban settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Despite near-universal SRH knowledge, adolescents face substantial barriers to adopting protective practices. Widespread exposure to violence emerges as a central structural determinant, operating alongside restrictive gender norms, limited access to youth-friendly services, and menstrual health challenges to constrain adolescents’ ability to act on existing knowledge. Improving adolescent SRH in Angola will require moving beyond information-based strategies toward integrated, gender-responsive approaches that combine education with accessible services, menstrual health support, and comprehensive violence-prevention efforts.\u003c/p\u003e","manuscriptTitle":"Beyond knowledge: violence as a structural determinant of adolescent sexual and reproductive health in Angola","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-16 14:50:08","doi":"10.21203/rs.3.rs-9009395/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"823ba80e-9da2-4199-9d15-1042b7d0054e","owner":[],"postedDate":"March 16th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-11T16:13:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T08:05:38+00:00","index":29,"fulltext":""},{"type":"reviewerAgreed","content":"161186965452947933459807946941989192672","date":"2026-05-03T07:50:42+00:00","index":28,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T16:27:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-16 14:50:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9009395","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9009395","identity":"rs-9009395","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}