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African Population Studies/Etude de la Population Africaine, Vol. 18, No. 1, April 2003, pp. 67-80 Risk Perception And Condom Use In Uganda Najjumba Mulindwa Innocent, Ntozi James, Ahimbisibwe E. Fred, Odwee Jonathan, Ayiga Natal Department of Population Studies, Institute of Statistics and Applied Economics, Makerere University, Kampala Uganda Code Number: ep03005 Abstract The paper examines the risk perception and condom use in Uganda, based on 600 respondents drawn from Kabale, Kampala and Lira districts. The majority of the respondents were aged 35 and above, were married and engaged in subsistence farming. HIV risk perception was found to be associated with condom use, religion, educational attainment, marital status, residence, number of sexual partners and having contracted an STD. Predictors of high HIV risk perception were non use of condoms, rural residence, having ever engaged in sex for gain and ever discussed sex. Mistrust of partners, past social history, having many sexual partners, and having undergone blood transfusion are the main reasons why people consider themselves at risk of contracting HIV. Ever use of condoms was at 46% among males and 27% among females. Respondents who do not consider themselves at risk of contracting HIV and those who have never contracted STDs are less likely to use condoms. Respondents who had ever engaged in gainful sex were more likely to use condoms than those who engage in sex for pleasure. Post-primary education and urban residence are strong contributors to condom use. Résumé Cet article examine la perception du risque et l'utilisation du condom en Ouganda à partir de données obtenues auprès de 600 répondants choisis dans les districts de Kabala, Kampala et Lira. La plupart des répondants sont âgés de plus de 35 ans, sont mariés et pratiquent une agriculture de subsistance. Les résultats ont montré que les risques de contamination du VIH sont associés à la non utilisation du condom, la résidence rurale, la pratique de rapports sexuels à des fins commerciales, l'absence de discussions autour des rapports sexuels. Les principales raisons pour lesquelles les personnes se considèrent en risque de contamination du VIH/SIDA sont le manque de confiance entre partenaires, l'histoire sociale passée, la pratique de rapports sexuels avec plusieurs partenaires ainsi que la transfusion sanguine. 46 % des hommes ont jamais utilisé les condoms alors seules 27 % des femmes l'utilisent. Les répondants qui ne se considèrent pas en situation de risque de contamination du VIH et ceux qui n'ont jamais eu de MST sont ceux qui peu probablement utiliseront les condoms. Les répondants qui ont jamais pratiqué des rapports sexuels à des fins commerciales étaient ceux qui avaient plus certainement utilisés les condoms que ceux qui pratiquaient des rapports sexuels par simple plaisir. L'enseignement post-primaire ainsi que la résidence urbaine contribuent pour beaucoup à l'utilisation du condom. Background Uganda is one of the countries most hit by HIV/AIDS. The first HIV/AIDS case was identified in Rakai district in 1982, after which the virus spread widely and severely affected Uganda (Konde-Lule, 1995). Estimates indicate that there were 1,438,000 and 1,107,644 adults and children living with AIDS as of December 1999 and 2000 respectively. The cumulative deaths due to AIDS were reported at 848,492 by December 2000 (MoH, 1999 and 2000). Uganda, whose HIV prevalence rate peaked at 18.5% in 1995 was the first country in sub-Saharan Africa to reverse its own epidemic. The rate dropped to 16.3% in 1996, 14.7% in 1998. By 1999, this had been halved to 8.3%. The steady decline has been attributed to strong preventive measures including condom use, public awareness raising campaigns and behaviour change messages. Other factors include behaviour change in sexual patterns, control of sexually transmitted infections and fear of death (Ntozi and Ahimbisibwe, 1999). Risk factors for HIV transmission are mainly sexual intercourse, having multiple sexual partners, non-use of condoms especially with casual sexual relations, blood transfusion, and intra-venous injections. Knowledge about these among the Uganda population is high and almost universal. Given such knowledge, one would want to assess people's perceptions of the risks they have for contracting HIV. In the 1995 Uganda Demographic and Health Survey, 65% of women and 84% of men who had heard of AIDS said they had little or no chances of being infected. Women were more likely than men to report that their chances of getting HIV were great (13% against 6%). The proportion who said they had no chances of getting HIV was higher among the younger men and women, the never married, those who had no sexual partners other than their spouses in the preceding 12 months, the rural and those in Northern Uganda. Condom Use Condom use is central to the prevention of STDs, including HIV among sexually active populations. As such, condom use is dramatically increasing despite the fact that men in particular do not like using them. For example, in a longitudinal study carried out in Kasangati - Uganda among 1990 respondents over a 7 year period (1987-1994), results showed a 7.3 fold increase in condom use over the study period. Ever use of condoms rose from 28% in 1987 to 26% in 1992 and to 41% in 1994 (Konde-Lule et al, 1997). Social marketing campaigns have played a vital role in this together with the increased awareness about AIDS (Finger, 1998). A number of studies on condom use in Africa have been carried out to particularly assess condom acceptance and use among different populations. In a Nigerian study among unmarried female trade apprentices, sex risk behaviors were identified and these include low levels of condom use during the first and last sexual intercourse, lack of prompt treatment of sexually transmitted diseases and lack of assertiveness skills. In addition, they had limited knowledge about the benefits of condom use for prevention of HIV. Girls were fearful of unwanted pregnancy and sexually transmitted diseases including AIDS, and expressed problems with using condoms (Dada et al, 1998). Focus group discussions and in-depth interviews conducted in Ghana - Cape Coast revealed that condom use was rare and associated with infidelity. Men perceive condoms as reducing sexual sensitivity and they are unlikely to remain with a partner who insists on condom use (Ankomah, 1998). Agha (1998), in a study carried out in Lusaka - Zambia revealed that Zambian women are limited in their ability to negotiate condom use in sexual relationships. In the same study, it was found that men's age and education were significant predictors of condom use for men. In addition, condom use was significantly associated with non-marital sexual activity. A number of studies on condom use have also been carried out in some districts of Uganda. In a study carried out in Lira and Soroti districts on a sample of 1358 and 1464 residents respectively, it was revealed that around 6% of the respondents in each district had ever used condoms. Condom use during the last sexual intercourse was greater with non-regular partners than with spouses or regular partners. The main reason for non-use of condoms was unavailability of the same followed by objection by partner and personal dislike of condoms. The same study confirmed the great shortage of condoms in the areas surveyed. Regarding other attributes, men were more likely to report condom use than females. People also believed that sex with a non-regular partner was more risky than with a regular partner (Opio et al, 1997). Another study was also carried out in Kampala on a sample of 301 men. Forty-six per cent of them reported having used a condom at the last sexual encounter and 31% reported always using a condom with casual partners. Correlates of condom use included higher condom self efficacy, lower embarrassment around condoms, knowing where to buy a condom, knowing how to use a condom and increasing number of casual sex partners (Kamya et al, 1997). Recent studies on condom use have also focused on the efficacy, tolerance, and acceptability of the female condom. In Kenya and Brazil, for example, sampled women in both countries praised the female condom for its protection from pregnancy and disease, lack of interference with sexual pleasure, comfort relative to the male condom, and an opportunity for couples to stay together longer after ejaculation (Ankrah and Ettika, 1997). Similarly, the majority of commercial sex workers in Zimbabwe liked the female condom very much or fairly well (Ray and Maposhere, 1997). Methodology The paper is based on data generated from a survey on 'resistance to sexual behaviour change in the African AIDS epidemic', conducted in Uganda in 1999, with an aim of establishing factors responsible for continued risky sexual practices amidst the HIV/AIDS epidemic. The survey was conducted in the districts of Kabale, Kampala and Lira. Three methods of data collection were used in the study and these were; focus group discussions, in-depth interviews with key informants, and quantitative data collection using structured questionnaires. The paper is based on responses from the structured questionnaire, which sought data from 600 respondents. Purposive and random sampling procedures were used in the survey. In order to select the respondents, two sub-counties with the highest HIV/AIDS prevalence rates were selected from each district and it can be noted that the sub-counties selected in all districts were either urban or peri-urban. Two parishes per sub-county were then randomly selected from which, two villages per parish were selected and 20 households systematically selected per village, from which adult males and females were interviewed. These had to be either, household heads, spouses or adult married children living with parents. A total of 600 respondents were probed in the three districts of whom 192 were from Lira, 210 from Kabale and 198 from Kampala. The Chi-square has been used to establish differentials in risk perception and condom use for the various categories of respondents, while the Logistic Regression analysis was employed to establish determinants of risk-perception to HIV and condom use in the sample. Characteristics of Respondents Table 1 presents the background characteristics of respondents by sex. The data show that the majority (53%) of the male respondents in the sample were 35 yeras and over, and only 8% were youths. For the females, the proportion aged 35 years and over was 38% and the youths comprised 29% of the female sample. Nineteen per cent of the female respondents had never attended school compared to only 6% of the males. Fifty-seven per cent of the males had also attained at least secondary education, while the corresponding fraction for females is 41%. Most of the respondents belonged to the Catholic denomination. The majority were married and in monogamous unions (65males and 54% females). Forty-three per cent of the females were subsistence farmers and 21% were engaged in business or trade. For the males, 28% were engaged in business activities while policy makers and casual labourers contributed around 23% in each category. The proportion not employed is 8% and 3% for the female and male respondents respectively. Risk Perception of HIV The data in Table 2 show the risk perception of HIV by different attributes of respondents. Considering male respondents, the proportion that perceives themselves at risk of contracting HIV is highest among the 25-34 (73%) followed by the youths (70%). Data for the females show no wide differentials across age groups. Religion, education and marital status are significantly associated with perception of risk to HIV among women. The proportion at risk is highest for Moslems (76%) and lowest for Catholics (57%). Women in polygamous unions registered the highest percentage of women who consider themselves at risk of contracting HIV (81%) followed by those in cohabiting relationships (78%). Risk perception of HIV significantly increases with number of sexual partners. Respondents who have ever contracted an STD are more likely to consider themselves at risk of contracting HIV than their counterparts who have never contracted any STD. Reasons for perception of risk to HIV are presented in Table 3 and they significantly vary by sex of respondents. It is interesting to note that both sexes reported mistrust of partners as the leading reason for being at risk to HIV, with females expressing more mistrust (73%) than males (50%). It is however, surprising that the respondents down played the reason of many partners (14% of males and 11% of females), perhaps because much of that reason is reflected in the mistrust. Table 3 also shows that a large majority of respondents who considered themselves not at risk of HIV infection attributed it to faithfulness of selves and partners (78% and 68% for males and females respectively). Other reasons given include not sick, currently abstaining from sex, having one sexual partner and being involved in protected sex. Ever Use of Condoms Information on condom use was obtained in the survey by asking respondents whether they had ever used condoms. The findings in Table 4 show that the proportion of females who had ever used condoms was almost three quarters (73%), which is high. The differential in condom use between the sexes is highly significant, with males reporting more condom use (46%) than the females (27%). Of the males who had ever used condoms, the highest proportion used them with casual partners (40%) followed by regular partners (31%) and friends (21%). This implies that on the one hand, the males used condoms for protection against probably pregnancy and STDs. On the other hand, most female condom users used condoms with regular partners (53%) followed by friends (31%), which suggests the mistrust females have for regular partners.This is also an indication of the high risk perception among females and implies that females are less likely to have non-regular partners. Respondents advanced two reasons for their use of condoms (Table 4). Most of the respondents used condoms to avoid STDs including HIV (71% of males and 68% of females). The proportion that uses condoms for contraceptive purposes (avoiding pregnancy) is also substantial for both sexes. Condom Use and Risk Perception The findings on condom use and risk perception (Table 5) indicate a significant association between the two variables. Half of the males at risk of HIV had ever used condoms compared to only 36% who felt they were not at risk. The pattern among females is however surprising, with only 36% of those who were at risk reporting to have ever used condoms. Of importance to note is that for both sexes, the proportion that had never used condoms is highest among those who reported not to be at risk of contracting AIDS (64% and 89% for males and females respectively). When asked with whom respondents had used condoms at their last sexual encounter before the survey, the highest proportion of the males who felt they had higher chances of contracting HIV (43%) used condoms with casual partners, followed by 30% who reported to have used them with prostitutes. This may portray peoples' awareness about the risks associated with casual sex in relation to HIV/AIDS. It is however surprising to note that a sizeable proportion of female respondents used condoms with regular partners (at least 65%) at their last sexual experience before the survey, as opposed to those who reported to have used them on casual partners and prostitutes. Table 5 shows that there is no significant association between the respondents' perception of their chances of contracting AIDS and the reasons for condom use before the survey. Majority of males and females used condoms to avoid getting STDs, particularly HIV. This is an indicator of people's awareness about the protection offered by condoms. It is however important to note that a substantial proportion of female respondents used it for contraceptive purposes (avoid getting pregnant). Respondents were further probed on what they would do if their sexual partners refused to use condoms and responses to this enquiry have been cross tabulated with the risk people had of contracting HIV. It is positive to note that majority of males and females would not have sex if their partners refused to use condoms. However, unexpectedly, a high percentage of females (31%) who reported to be at risk of HIV reported that they would have sex with a partner who refused to use condoms, which would expose them to even higher risks of contracting the disease. Determinants of Condom Use To understand the reasons for condom use among the respondents, a logistic regression model was fitted where, ever use of condom was regressed on whether respondents were at risk of HIV, had consented to sex for a gain and level of education of respondent. Other variables were, place of residence, would have sex if partner refused condom, and if married whether they had other sexual partners. The odds ratios from the regression are shown in Table 6. It is displayed in the table that respondents who were not at risk of HIV were less likely to use condoms than those who were at risk and this was significantly true for both males and females. The results show that respondents perceived use of condoms as a preventive measure against HIV. People who were at risk of contracting HIV used condoms to avoid HIV infection. This probably shows that the fear for HIV/AIDS makes people use condoms as prevention for infection. The respondents who had never contracted STDs were less likely to use condoms implying that those who used it did so to prevent infection. This was significantly so among females who are known not to dictate condom use over males. Table 6 also shows that though not significant, respondents who were involved in gainful sex were more likely to use condoms than those who engaged in sex for pleasure. This probably shows people's awareness of the risks associated with casual sex, with the gains reaped out of it notwithstanding. The odds ratios were the same for both males and females. The result of females is supported by evidence from Kampala prostitutes who reported practicing safe sex with their partners and reflects positive behaviour for the group, which is known to be desperate to earn money for a living. For meaningful analysis, education was divided into only two categories; not beyond primary and post primary education. The results in Table 7 show that respondents who did not attain post primary education were significantly less likely to use condoms that those of post primary education. This may be due to lack of AIDS awareness among this group of respondents given their low educational levels. As expected, urban respondents were more likely to use condoms than rural ones. However, the odds ratio (4.2) for males was higher than that of females, which is not surprising given the fact that condoms are male based and their use primarily initiated by men. Table 7 also shows that respondents who said that they would not have sex if partners refused condoms were more likely to use condoms than those who said they would go ahead and have sex. This probably reflects the great AIDS awareness among the former, the knowledge they have about the protective mechanism of condoms, and their strong desire to protect themselves against AIDS. The respondents who had other partners besides their wives or husbands were more likely to use condoms than those who did not have such partners. This was most likely to be among females (4.4) than males. This probably portrays the informed knowledge people have about the risks associated with casual sex. This also shows their desire to protect themselves and their regular partners against the associated outcomes of such behaviour. Determinants of Perceptions of Risk to HIV It was also necessary to identify factors which put one at risk of HIV. Table 8 displays the results of logistic regression where being at risk of HIV was regressed on condom use, had ever contracted STDs, education level, place of residence, discussed AIDS and ever consented to sex for gain. As expected, the results show that respondents who had never used condoms were more likely to be at risk of AIDS than those who had used condoms and this was true for both sexes. Similarly those who had ever had STD episodes were more likely to be at risk than those who had never had STDs. Though not significant, respondents with post primary education were more likely to be at risk than those with primary education. For place of residence, the results show that respondents in rural areas were more likely to be at risk of HIV. This was significantly more so for rural women (3.0). However, the rural males were less likely to be at risk than urban males. The results also show that respondents who had never discussed AIDS were more likely to be at risk than those who had ever discussed the disease. Material and economic hardship is a major factor of reckless sex. As expected, respondents who had had sex for gain were significantly more likely to consider themselves at risk of HIV than those who had never involved themselves in sex for gain. The odds ratio for females (2.6) was however, higher than that of males (1.2) since the females were mostly the ones more involved in this kind of activity than the males. Conclusion The findings suggest that the way people perceive themselves either at risk or not at risk of contracting HIV determines their sexual behaviour patterns. High risk perception is associated with condom use particularly with casual sexual partners among men. For the females however, 64% of those who think they can contract HIV use condoms. In addition, a substantial proportion that is risk of HIV reported they would have sex with partners who refused to use condoms. This probably reflects a lesser degree of empowerment among women regarding sexual matters or some degree of recklessness at this age of AIDS or probably lack of awareness about the HIV protection provided by condoms. HIV/AIDS initiatives need to address aspects of condom negotiation among females to reduce their vulnerability to HIV infection. Promotion of the female condom should also be heightened. High levels of condom use were found to also be associated with having ever had an STD, involvement in gainful sex and multiple sexual partners, which show the informed knowledge people have about risky sexual practices. Post primary education and urban residence were also found to be significant predictors of condom use, which implies the need for government and development partners to encourage education beyond primary school; and to also extend service delivery particularly condom distribution to the rural areas of the country. Results further indicate that people in Uganda have more informed knowledge about HIV/AIDS. For example, those who have ever been involved in gainful sex and those who have ever contracted STDs considered themselves at risk of contracting HIV. Rural residents also considered themselves at a higher risk of contracting HIV than their urban counterparts. The major reasons advanced for being at risk was mistrust for both self and partner. References
Copyright 2003 - Union for African Population Studies The following images related to this document are available:Photo images[ep03005t7.jpg] [ep03005t6.jpg] [ep03005t5.jpg] [ep03005t3.jpg] [ep03005t2.jpg] [ep03005t1.jpg] [ep03005t4.jpg] |
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