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Condom use at first and most recent sex among unmarried people aged
15 to 24 in Uganda: A case of Kabale and Mukono districts
Tumwesigye, NMIngham, RHolmes, D
A presentation in a seminar organized by the Centre for AIDS Research (CAR) University of Southampton on 20th April 2005
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Outline of presentation
• Introduction
• Background
• Objectives
• Previous work
• Methods
• Results
• Discussion and conclusion
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Introduction• Condoms offer best protection against HIV/STD
and unplanned pregnancies for those that can’t abstain
• Consistent and correct use of condoms can prevent 90-95% of HIV infections
• There are claims and counter claims for their role HIV reduction in Uganda - Singh et al. 2003 that all Abstinence, being faithful, and condom (ABC) were equally important Vs Green et al. 2002 for AB and Wawer 2005 for C
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Introduction cont’d• But few consistently use condoms: In field trial,
Rakai- Uganda 4.4% (Ahmed, 2001), Bar and hotel workers, Tanzania 14% (Ao et al. 2003).
• Current condom use among young unmarried women is 41% and men 58% (UDHS 2000/1) higher than Kenya (men: 43%) and Ghana (Men: 38%)
• Little is known about consistency and changes in condom use from first to most recent sex among young people
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Why young people?
• 56% of population is less than 18 years• 20% of the population is aged 15-24 years• Of those aged 15-24, 64% are unmarried • Median age at first marriage is 18.1 for
females and 22.8 for males [UDHS2000/1]• Two thirds of women get pregnant by age 18• HIV prevalence is 4.9% among ANC clients
aged 15-24 [MOH]
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Why first and most recent event? Why Kabale and Mukono?
• Most easily remembered events• Strong link between first use and life time
use: 20 fold increase in life time and 10 fold increase in current use if condom was used at first sex (Miller 1998)
• Kabale and Mukono represent differences in urbanisation, economic level, health facilities. Mukono has better indicators
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Map of Uganda showing Mukono and Kabale districts
Kabale
Mukono
Kampala
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Objectives• Establish level of condom use at first and
most recent sex
• Identify factors associated with condom use at each of the two events
• Compare influence of the factors at the two events
• Determine predictors of consistent condom use for combined events
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Literature: Condom use at First sex
• Level of condom use: A third in Lesotho (FHI et al. 2002)• More likely to be reported by women (FHI et al. 2002)• Increases with age, lower with alcohol (Grunseit,1999)• Higher with more education (Abma &Sonenstein, 2001)• Higher with casual than regular partners (Manlove, 2001)• More likely in urban areas and among those who attend
religious services and more communication with parents (Abma &sonenstein 2001, Karim et al.2003)
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Literature: Condom use at most recent sex
• Level of use: 41% women and 58% men (UDHS,01)• Men more likely to report use & increases with age
(Fadiora et al. 2003)• increases with education level (Karim et al.2003)• lower with alcohol consumption (Hall et al. 1990)• More use with casual than regular partners (Sheeran &
Abraham 1994)• higher with parental support, in urban areas, attending
religious services (Meekers&Klein 2003 Hingson, 1990; Najjumba at al. 2003, Mensch,, 1999)
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Literature: Consistent condom use
• 15 % among STD patients in a hospital, Uganda (Nuwaha et al. 1999)
• 2% among traditional healers in Uganda (Ssali et al. 2002)
• 14% among urban male workers in Zimbabwe (Meekers 2003)
• Consistent use is higher with age at first sex (Tavares, 2004) alcohol consumption (Ray, 1998), casual partnership (Catania et al. 1998)
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Gap in Literature
• Most studies reviewed were from USA, Europe, Australia. Few in Africa like one in Lesotho, Ghana, South Africa, Zimbabwe.
• The studies are mostly on selected risk groups like patients/FP clinic clients, students
• Few are specific to condom use and young people• Nothing seen yet on condom use at first sex in
Uganda
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Methods• Primary data-Survey in Mukono and Kabale
districts: Questions from UDHS, WHO & modified with Pilot –May 2004
• Sample size was 786 but only 445 ever had sex• Sampling: cluster by village and systematic for
household in 94 villages• Analysis: binomial & multinomial Logistic
Regression Models. • Consistency measured by condom use at first and
most recent sex• Model building: Backward & forward
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Description of the sampleVariable Kabale
% of 184
Mukono
% of 261
All
% of 445
Uganda1
% Women 51.1 44.4 47.2 52.8
Age: 15-19 63.6 65.5 64.7 55.5
Urban 28.8 29.1 29.0 16.4
in school 58.2 45.2 50.6 33.3
Sec.education 58.7 64.4 62.0 26.8
Religion
Catholic 42.9 34.1 37.8 41.9
Protestant 53.3 36.0 43.2 35.9
Muslim 1.6 21.8 13.5 12.1
Other 2.2 8.1 5.6 4.61 Source: 2002 Census Denominator = all aged 15-24 except for religion
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Level of condom use at first and most recent sex
First event Most recent sex
Kabale N % N %
Women 94 31.9 90 43.3
men 90 31.1 89 33.7
Mukono
Women 114 81.6 112 64.3
Men 145 50.3 139 71.9
All
Women 208 59.1 202 55.0
Men 235 43.0 228 57.0
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Condom use at first and most recent sex
0
10
20
30
40
50
60
70
In Out Primary Sec. Drank Didn't Steady Casual Once <15 15-19 20-24
Schooling Education Alcohol Partner Age1st sex
Variables
Percent
First Recent
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Logistic Reg. Models for condom use at first and latest sex
Factor First sex Latest
District (Mukono vs Kabale) 17.42 (7.16-42.39)*** 3.51 (1.61-7.66)***
Sex (Male Vs Female) 2.06 (0.59-7.26) 2.77 (1.30-5.89)**
Male*District-Mukono 0.30 (0.10-0.93)*
Age at first sex (base <=14)
15-19 3.97 (2.23-7.09)*** 0.85 (0.47-1.54)
20-24 8.86 (3.59-21.86)*** 0.33 (0.13-0.81)*
In school (Base =No) 3.07 (1.85-5.10) *** 5.59 (2.44-12.81)***
In school*Male 0.34 (0.12-0.99)*
School foundation (base=public)
Religious 0.51 (0.27-0.99)* 0.87 (0.45-1.67)
Private 0.58 (0.31-1.08) 1.46 (0.77-2.78)
Listening to radio 2.48 (1.21-5.12)*
Type of partner (base=steady)
Casual (Known) 0.23 (0.11-0.46)*** 0.45 (0.17-1.18)
One time partner 0.39 (0.17-0.88)* 0.40 (0.16-1.00)*
Condom use at first sex (base=No) ------------------- 14.34 (5.91-34.77)***
*** p<0.001 ** p<0.01 * p<0.05
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Consistency of condom use
• Used
condom at latest sex
Used
condom at first sex
Consistency
of condom use
Gender
Males Female % %
All
%
N
Yes Yes Consistent (No risk) 36.0 45.0 40.2 172
Yes No Inconsistent (Risky) 21.1 9.5 15.7 67
No Yes Inconsistent ( Risky) 7.5 14.5 10.8 46
No No Non use (Very risky) 35.5 31.0 33.4 143
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Multinomial model predicted probabilities of condom use Variable Males Female
Consistent Inconsistent Never used Consistent Inconsistent Never used
District
Kabale 21.5 22.7 55.7 30.0 16.7 53.3
Mukono 45.3*** 32.9** 21.9 57.3*** 30.0** 12.7
Alcohol
No 42.9 28.6 28.6 47.3 20.7 32.0
Yes 24.7 29.4 45.9 38.0 34.0** 28.0
In school
No 32.1 30.2 32.7 27.9 32.7 37.4
Yes 39.5 27.7 32.8 63.5** 14.6 21.9
Age at first sex
<15 17.7 35.3 47.1 35.4 18.5 46.2
15-19 45.0*** 27.5 27.5 50.8 24.2 25.0
20-24 40.5** 21.5 37.8 40.0 24.0 31.0
*** p<0.001 ** p<0.01
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Discussion• Condom use at first sex is higher than in other
countries in Africa like Ghana (18% men , 27% women) and Lesotho (34% men)
• Condom use at most recent sex higher than the country average in Mukono but lower in Kabale
• Women more likely to use condom at first sex than men. Similar results in Karim et al 2003, FHI et al. 2002
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Discussion cont’d
• Condom use at first sex is higher in Mukono district, among women (Mukono), in steady relationship, among those in school, among those attending public schools and with higher age at first sex
– Age at first sex, being in school, women cited in other studies (Karim et al.2003 Grunseit, 1999)
– Condom use in steady relationship differs from Manlove et al. 2001
– Attending public schools- not surprising
– Women are more likely to use condom because their partners are older (16 Vs 20 years) are in steady relationship
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Discussion cont’d• Condom use at most recent event is higher in
Mukono district, among males, with lower age at first sex, among those in school, among those who listen to radio, among those who use condoms at first sex, in steady relationship– Higher condom use at lower age at first sex different
from several studies including Abma et al 2001 and Benefo 2004. Probably, getting to trust their partners
– Similar effect of radio, condom use at first sex cited in many studies including Yoder at al 1997 in Zambia, Abma et al. 2001,
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Discussion cont’d
• Reduced influence by most recent sex– Age at first sex– School foundation– Type of partner
• Increased influence by most recent sex– Gender. – Radio
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Discussion cont’d
• Consistent use is higher – in Mukono, probably due to accessibility– among those in school (women only), probably
due to influence of condom use at first sex where among men alcohol is less influencial
– with higher age at first sex same in Tavares, 2004
– among non-alcohol consumers same as Ray, 1998
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Conclusions and implications• Less condom use in Kabale and probably similar
upcountry districts calls for more sensitization• First relationships for young men tend to be casual or
one time partnership. Important in HIV/STD sensitization
• Less condom use in mission and private schools. Design of ways to reach young people in the schools
• Keeping young people in school is protective against risky sex, hence support for Universal Primary Education (UPE) and proposed universal Secondary Education (USE)
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Conclusions and implications• Increase in condom use with age at first sex
renders support for campaigns for delayed first sex (primary abstinence)
• Less condom use in mission and private schools calls for ways of reaching young people in the schools
• Communication through radios continue to be effective
• Evidence of effect of alcohol on risky sex is important for health education messages
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Constraints
• Cross-sectional design: Attributes at latest event may not be the same with first event. E.g taking alcohol and listening to radio.
• Possible memory lapse for events at first sex especially if not consensual
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Work in progress
• Multi-level effects –village & parish• Qualitative data to answer why
– Religious and private school less likely to use
– Being in school is protective
– Alcohol consumption
• Differences by district
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