Vol. 2 1 , No. 5
International Journal of Epidemiology © International EpkfemJotogical Association 1992
Printed in Great Britain
Contraception and Prevalence of Sexually Transmitted Diseases among Adolescents and Young Adults in Uganda WILLIAM K A AGYEI,* ELSBETH J EPEMA** AND MARGARET LUBEGAt
some that publicizing condom use may affect adolescents' and young adults' morals, it is evident from the results of this study that these young respondents are already sexually active. Sexually transmitted diseases are a serious problem in Uganda.1 Moreover, STD, especially genital ulcers, have been documented as important risk factors for the transmission of the human immunodeficiency virus (HIV). Many young people are not aware of the effects STD can have on their future lives. The majority of the respondents have poor information and misconceptions about sexuality, reproductive health and subsequently, STD. Although many of these young people do not contract STD the first time they indulge in sexual activity, nevertheless, age at first sexual intercourse is an important indicator of their exposure to the risk of contracting these diseases. Accordingly, this paper is aimed at (i) exploring knowledge and attitudes of adolescents and young adults towards sex and contraception and (ii) determining their level of knowledge and attitudes towards STD as well as the prevalence of the latter among the respondents. The Adolescent Fertility Survey carried out in six districts (Jinja, Kampala, Masaka, Kabale, Hoima and Mbale) of Uganda between 1988 and 1990 investigated adolescents and young adults aged 15-24
Sexually transmitted diseases (STD) are a major medical and social problem among adolescents and young adults in Uganda. Premarital and to some extent extra-marital sexual activities are very prevalent among Ugandan adolescents and young adults. The majority of the respondents have had sexual intercourse at the time of the survey and most had indulged in sexual activity at quite an early age. Many have several sexual partners. Their knowledge of condoms as a modern contraceptive method is high, but the use is relatively low. Although these young males and females are knowledgeable about STD this knowledge is not adequately utilized for prevention of these diseases. Unsafe sex (penetrative sexual intercourse without condom use) increases the chances of the spread of infection from one individual to the other, and also carries with it the risk of pregnancy. Although it is felt by • Institute of Statistics and Applied Economics, Makerere University, Kampala, Uganda •* Population Branch, DAD/DTCD, United Nations, New York, NY 10017, USA t School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205, USA J The views expressed in this paper are those of the authors and not necessarily those of the United Nations or any of its agencies.
981
Downloaded from http://ije.oxfordjournals.org/ at RMIT University Library on July 20, 2015
Agyei W K A (Institute of Statistics and Applied Economics, Makerere University, Kampala, Uganda), Epema E J and Lubega M. Contraception and prevalence of sexually transmitted diseases among adolescents and young adults in Uganda. International Journal of Epidemiology 1992; 21: 981-988. The study is aimed at (i) exploring the knowledge and attitudes of adolescents (15-19 years old) and young adults (20-24 years old) towards sex and contraception (condoms) and (ii) determining their level of knowledge and attitudes towards sexually transmitted diseases (STD) as well as the prevalence of the latter among the sexually active adolescents and young adults. A sample of 4510 respondents (1545 males and 2965 females) aged 15-24 years from urban and rural areas were interviewed. The majority of adolescents and young adults surveyed have a negative attitude towards the use of condoms although most of them agreed that they prevent STD. Over 95% of the respondents have heard about STD and their level of knowledge is relatively high; slightly higher for urban residents and for young males. Approximately 2 1 % of the male and 8% of the female respondents admitted having ever contracted STD. The gap between contraceptive knowledge and practice is rather wide. Only a small proportion of the respondents were using condoms at the time of the survey.
982
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
years. The 20-24 year age group was also included because there was need to study the behaviour of those who had recently been through adolescence.2 The data set for five districts of the Adolescent Fertility Survey is used for this paper as the data for the sixth district (Mbale) are not yet available.
THE RESEARCH INSTRUMENT A mainly precoded questionnaire was used to facilitate data processing. The questionnaire had been constructed and pretested in January 1988. The first part of the general questionnaire gathered background information on members of the household, including age, sex, place of residence, number of eligible respondents and household amenities. In the second part, the individual questions covered personal characteristics of the adolescents and young adults being interviewed, e.g. education, marital status, religion, occupation, sexual behaviour and attitudes to and knowledge and practice of contraception and reproductive health. Those respondents who were sexually active were asked questions regarding age at first sexual intercourse (experience), the frequency of sexual intercourse, the number of sexual partners within a specified time period etc. Further, questions regarding problems directly consequent of sexual activity, such as pregnancy, abortion and STD were also asked. The responses to some of these questions formed the basis for the analysis reported in this paper. RESULTS The background characteristics of the male and female respondents are given in Table 1. The level of education of urban adolescents is relatively higher than that of their rural counterparts. This is not very surprising * Political and social groupings similar to city wards for purposes of administration, representation or voting.
Sexual Experience In both rural and urban areas, male respondents experience sexual intercourse at an earlier age than their female counterparts. This is shown in Tables 2A and 2B. This may be due to the fact that virginity at marriage among women is highly prized in many parts of Uganda although the influence of Westernization is making it less important. Also, some young males tend to regard sex as a sign of bravado and prestige among their peers and such males are, therefore, more likely to have early sexual experience and possibly even exaggerate what they report. Table 3 shows that approximately 18% of the male and 20% of the female respondents had not had any sexual partners by the time of the survey and that males have had more sexual partners than females. Two-thirds of the males had had more than one sexual partner and of these, more than half had four or more sexual partners. The majority of the females had only one sexual partner and only one-third of them had multiple sexual partners. Of the latter, less than half had more than two partners. All sexually active respondents were asked to state the numbers of times they had had sexual intercourse in the month preceding the survey. The data revealed that 39% of the male and approximately 25% of the female respondents had not had sexual intercourse in that period and slightly less than one-third of the total had sex once or twice a week. Female respondents were more sexually active than male respondents and a higher percentage of rural respondents had sexual intercourse very frequently. Although women had more sexual intercourse, they had fewer partners.
Downloaded from http://ije.oxfordjournals.org/ at RMIT University Library on July 20, 2015
THE SAMPLE The Adolescent Fertility Survey utilized the same sampling frame as that of the Uganda Demographic and Health Survey (UDHS) which consisted of Resistance Councils (RC1)* in urban areas and subparishes in the rural areas. Details of the sample design have been reported elsewhere.2-3 The selection of households within each sub-parish or RC1 was a stratified probability sample and respondents were selected from the households based on age (15-24 years old). The sample was proportional to size of rural and urban areas. It is made up of 4510 male and female respondents, regardless of their marital status: 2907 lived in urban areas (951 males and 1956 females) and 1603 lived in rural areas (594 males and 1009 females).
since the urban areas have relatively more and better schools. Only one-fifth of the rural male respondents attained an education up to secondary school level. The proportion of males attaining secondary or higher education is higher than for females. This is because females tend to drop out of school for many reasons. In the rural areas some parents still believe that in circumstances where there is little money for school fees, it should be the boy and not the girl who continues with schooling. Teenage pregnancy has also forced many girls to drop out of school prematurely. Table 1 also shows that the distribution of the respondents by religious affiliation is similar in both rural and urban areas but more male and female urban respondents were in school or working than those in the rural areas. Approximately 36% of urban and 63% of rural female respondents were neither in school or working. A higher proportion of the female respondents were married or cohabiting in both the rural and urban areas.
983
CONTRACEPTION AND SEXUALLY TRANSMITTED DISEASE TABLE 1 Percentage distribution of selected sododemographic
characteristics of the respondents: Uganda, 1988 and 1989
Rural
Urban Characteristic (No.)
Total
Males
Females
Males
Females
Males
Females
951
1956
594
1009
1545
2965
3.5 36.6 53.4 4.2 2.3 100.0
6.1 44.3 44.8 2.6 2.2 100.0
11.3 67.8 18.0 1.6 1.4 100.1
19.5 66.3 13.2 0.8 0.2 100.0
6.5 48.6 39.8 3.2 1.9 100.0
10.6 51.8 34.1 2.0 1.5 100.0
0.2 44.5 39.4 14.2 0.5 1.2 100.0
0.3 41.9 41.3 15.4 0.3 0.8 100.0
0.3 36.5 48.0 14.0 0.3 0.9 100.0
39.9 39.8 19.2 0.3 0.7 99.9
0.3 41.4 42.7 14.1 0.5 1.0 100.0
0.2 41.3 40.8 16.7 0.3 0.8 100.1
48.8 30.4 11.4 9.4 100.0
28.9 20.3 35.5 15.3 100.0
19.7 21.4 26.1 32.8 100.0
10.6 7.2 62.9 19.2 99.9
37.6 26.9 17.0 18.5 100.0
22.7 15.9 44.8 16.7 100.1
87.4 5.6 6.2 0.6 0.2 100.0
62.6 21.4 11.9 3.4 0.7 100.0
69.5 20.7 6.6 2.7 0.5 100.0
39.1 45.7 10.1 4.7 0.4 100.0
80.5 11.4 6.3 1.4 0.4 100.0
54.6 29.7 11.3 3.8 0.6 100.0
Education None Primary" Secondary* Higher" Other Total
None Protestant Roman Catholic Muslim Traditional Other Total Current activity In school Working Neither No response Total Marital status Single Married Cohabiting Formerly married No response Total
* Completed and uncompleted.
Contraceptive Knowledge and Attitudes Contraceptive knowledge was investigated by asking the respondents to mention any method that they had heard about that could be used to prevent pregnancy. It should be borne in mind that only respondents using condoms protect themselves from contracting STD and therefore, in this paper emphasis is placed on the use of the condom. Table 4 shows that 78% of males and approximately 57% of females have heard about the condom, but they were more likely to be urban residents. Table 4 also shows that although knowledge of condoms is high their use is relatively low. Approximately 13% of males who had knowledge of condoms were using them and over 80% of them reported non-
use of contraception. More male than female respondents were using condoms particularly in urban areas. A number of statements were used to explore attitudes towards sex and contraception, and respondents were asked to indicate whether they agreed, agreed strongly, disagreed or disagreed strongly, with the statements. The results are presented in Tables 5A and 5B for urban and rural respondents respectively. Table 5A shows that approximately 58% and 59% of the urban male and female respondents agreed or agreed strongly that sexually active young adults find it difficult to obtain contraceptives. Among the rural respondents, 64% of males and 73% of females agreed or agreed strongly with the same statement (Table
Downloaded from http://ije.oxfordjournals.org/ at RMIT University Library on July 20, 2015
Religion
984 TABLE 2A
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Percentage distribution of urban respondents by age at first sexual intercourse and current age: Uganda 1988 and 1989
Females
Males Current age (years)
International Journal of Epidemiology © International EpkfemJotogical Association 1992
Printed in Great Britain
Contraception and Prevalence of Sexually Transmitted Diseases among Adolescents and Young Adults in Uganda WILLIAM K A AGYEI,* ELSBETH J EPEMA** AND MARGARET LUBEGAt
some that publicizing condom use may affect adolescents' and young adults' morals, it is evident from the results of this study that these young respondents are already sexually active. Sexually transmitted diseases are a serious problem in Uganda.1 Moreover, STD, especially genital ulcers, have been documented as important risk factors for the transmission of the human immunodeficiency virus (HIV). Many young people are not aware of the effects STD can have on their future lives. The majority of the respondents have poor information and misconceptions about sexuality, reproductive health and subsequently, STD. Although many of these young people do not contract STD the first time they indulge in sexual activity, nevertheless, age at first sexual intercourse is an important indicator of their exposure to the risk of contracting these diseases. Accordingly, this paper is aimed at (i) exploring knowledge and attitudes of adolescents and young adults towards sex and contraception and (ii) determining their level of knowledge and attitudes towards STD as well as the prevalence of the latter among the respondents. The Adolescent Fertility Survey carried out in six districts (Jinja, Kampala, Masaka, Kabale, Hoima and Mbale) of Uganda between 1988 and 1990 investigated adolescents and young adults aged 15-24
Sexually transmitted diseases (STD) are a major medical and social problem among adolescents and young adults in Uganda. Premarital and to some extent extra-marital sexual activities are very prevalent among Ugandan adolescents and young adults. The majority of the respondents have had sexual intercourse at the time of the survey and most had indulged in sexual activity at quite an early age. Many have several sexual partners. Their knowledge of condoms as a modern contraceptive method is high, but the use is relatively low. Although these young males and females are knowledgeable about STD this knowledge is not adequately utilized for prevention of these diseases. Unsafe sex (penetrative sexual intercourse without condom use) increases the chances of the spread of infection from one individual to the other, and also carries with it the risk of pregnancy. Although it is felt by • Institute of Statistics and Applied Economics, Makerere University, Kampala, Uganda •* Population Branch, DAD/DTCD, United Nations, New York, NY 10017, USA t School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205, USA J The views expressed in this paper are those of the authors and not necessarily those of the United Nations or any of its agencies.
981
Downloaded from http://ije.oxfordjournals.org/ at RMIT University Library on July 20, 2015
Agyei W K A (Institute of Statistics and Applied Economics, Makerere University, Kampala, Uganda), Epema E J and Lubega M. Contraception and prevalence of sexually transmitted diseases among adolescents and young adults in Uganda. International Journal of Epidemiology 1992; 21: 981-988. The study is aimed at (i) exploring the knowledge and attitudes of adolescents (15-19 years old) and young adults (20-24 years old) towards sex and contraception (condoms) and (ii) determining their level of knowledge and attitudes towards sexually transmitted diseases (STD) as well as the prevalence of the latter among the sexually active adolescents and young adults. A sample of 4510 respondents (1545 males and 2965 females) aged 15-24 years from urban and rural areas were interviewed. The majority of adolescents and young adults surveyed have a negative attitude towards the use of condoms although most of them agreed that they prevent STD. Over 95% of the respondents have heard about STD and their level of knowledge is relatively high; slightly higher for urban residents and for young males. Approximately 2 1 % of the male and 8% of the female respondents admitted having ever contracted STD. The gap between contraceptive knowledge and practice is rather wide. Only a small proportion of the respondents were using condoms at the time of the survey.
982
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
years. The 20-24 year age group was also included because there was need to study the behaviour of those who had recently been through adolescence.2 The data set for five districts of the Adolescent Fertility Survey is used for this paper as the data for the sixth district (Mbale) are not yet available.
THE RESEARCH INSTRUMENT A mainly precoded questionnaire was used to facilitate data processing. The questionnaire had been constructed and pretested in January 1988. The first part of the general questionnaire gathered background information on members of the household, including age, sex, place of residence, number of eligible respondents and household amenities. In the second part, the individual questions covered personal characteristics of the adolescents and young adults being interviewed, e.g. education, marital status, religion, occupation, sexual behaviour and attitudes to and knowledge and practice of contraception and reproductive health. Those respondents who were sexually active were asked questions regarding age at first sexual intercourse (experience), the frequency of sexual intercourse, the number of sexual partners within a specified time period etc. Further, questions regarding problems directly consequent of sexual activity, such as pregnancy, abortion and STD were also asked. The responses to some of these questions formed the basis for the analysis reported in this paper. RESULTS The background characteristics of the male and female respondents are given in Table 1. The level of education of urban adolescents is relatively higher than that of their rural counterparts. This is not very surprising * Political and social groupings similar to city wards for purposes of administration, representation or voting.
Sexual Experience In both rural and urban areas, male respondents experience sexual intercourse at an earlier age than their female counterparts. This is shown in Tables 2A and 2B. This may be due to the fact that virginity at marriage among women is highly prized in many parts of Uganda although the influence of Westernization is making it less important. Also, some young males tend to regard sex as a sign of bravado and prestige among their peers and such males are, therefore, more likely to have early sexual experience and possibly even exaggerate what they report. Table 3 shows that approximately 18% of the male and 20% of the female respondents had not had any sexual partners by the time of the survey and that males have had more sexual partners than females. Two-thirds of the males had had more than one sexual partner and of these, more than half had four or more sexual partners. The majority of the females had only one sexual partner and only one-third of them had multiple sexual partners. Of the latter, less than half had more than two partners. All sexually active respondents were asked to state the numbers of times they had had sexual intercourse in the month preceding the survey. The data revealed that 39% of the male and approximately 25% of the female respondents had not had sexual intercourse in that period and slightly less than one-third of the total had sex once or twice a week. Female respondents were more sexually active than male respondents and a higher percentage of rural respondents had sexual intercourse very frequently. Although women had more sexual intercourse, they had fewer partners.
Downloaded from http://ije.oxfordjournals.org/ at RMIT University Library on July 20, 2015
THE SAMPLE The Adolescent Fertility Survey utilized the same sampling frame as that of the Uganda Demographic and Health Survey (UDHS) which consisted of Resistance Councils (RC1)* in urban areas and subparishes in the rural areas. Details of the sample design have been reported elsewhere.2-3 The selection of households within each sub-parish or RC1 was a stratified probability sample and respondents were selected from the households based on age (15-24 years old). The sample was proportional to size of rural and urban areas. It is made up of 4510 male and female respondents, regardless of their marital status: 2907 lived in urban areas (951 males and 1956 females) and 1603 lived in rural areas (594 males and 1009 females).
since the urban areas have relatively more and better schools. Only one-fifth of the rural male respondents attained an education up to secondary school level. The proportion of males attaining secondary or higher education is higher than for females. This is because females tend to drop out of school for many reasons. In the rural areas some parents still believe that in circumstances where there is little money for school fees, it should be the boy and not the girl who continues with schooling. Teenage pregnancy has also forced many girls to drop out of school prematurely. Table 1 also shows that the distribution of the respondents by religious affiliation is similar in both rural and urban areas but more male and female urban respondents were in school or working than those in the rural areas. Approximately 36% of urban and 63% of rural female respondents were neither in school or working. A higher proportion of the female respondents were married or cohabiting in both the rural and urban areas.
983
CONTRACEPTION AND SEXUALLY TRANSMITTED DISEASE TABLE 1 Percentage distribution of selected sododemographic
characteristics of the respondents: Uganda, 1988 and 1989
Rural
Urban Characteristic (No.)
Total
Males
Females
Males
Females
Males
Females
951
1956
594
1009
1545
2965
3.5 36.6 53.4 4.2 2.3 100.0
6.1 44.3 44.8 2.6 2.2 100.0
11.3 67.8 18.0 1.6 1.4 100.1
19.5 66.3 13.2 0.8 0.2 100.0
6.5 48.6 39.8 3.2 1.9 100.0
10.6 51.8 34.1 2.0 1.5 100.0
0.2 44.5 39.4 14.2 0.5 1.2 100.0
0.3 41.9 41.3 15.4 0.3 0.8 100.0
0.3 36.5 48.0 14.0 0.3 0.9 100.0
39.9 39.8 19.2 0.3 0.7 99.9
0.3 41.4 42.7 14.1 0.5 1.0 100.0
0.2 41.3 40.8 16.7 0.3 0.8 100.1
48.8 30.4 11.4 9.4 100.0
28.9 20.3 35.5 15.3 100.0
19.7 21.4 26.1 32.8 100.0
10.6 7.2 62.9 19.2 99.9
37.6 26.9 17.0 18.5 100.0
22.7 15.9 44.8 16.7 100.1
87.4 5.6 6.2 0.6 0.2 100.0
62.6 21.4 11.9 3.4 0.7 100.0
69.5 20.7 6.6 2.7 0.5 100.0
39.1 45.7 10.1 4.7 0.4 100.0
80.5 11.4 6.3 1.4 0.4 100.0
54.6 29.7 11.3 3.8 0.6 100.0
Education None Primary" Secondary* Higher" Other Total
None Protestant Roman Catholic Muslim Traditional Other Total Current activity In school Working Neither No response Total Marital status Single Married Cohabiting Formerly married No response Total
* Completed and uncompleted.
Contraceptive Knowledge and Attitudes Contraceptive knowledge was investigated by asking the respondents to mention any method that they had heard about that could be used to prevent pregnancy. It should be borne in mind that only respondents using condoms protect themselves from contracting STD and therefore, in this paper emphasis is placed on the use of the condom. Table 4 shows that 78% of males and approximately 57% of females have heard about the condom, but they were more likely to be urban residents. Table 4 also shows that although knowledge of condoms is high their use is relatively low. Approximately 13% of males who had knowledge of condoms were using them and over 80% of them reported non-
use of contraception. More male than female respondents were using condoms particularly in urban areas. A number of statements were used to explore attitudes towards sex and contraception, and respondents were asked to indicate whether they agreed, agreed strongly, disagreed or disagreed strongly, with the statements. The results are presented in Tables 5A and 5B for urban and rural respondents respectively. Table 5A shows that approximately 58% and 59% of the urban male and female respondents agreed or agreed strongly that sexually active young adults find it difficult to obtain contraceptives. Among the rural respondents, 64% of males and 73% of females agreed or agreed strongly with the same statement (Table
Downloaded from http://ije.oxfordjournals.org/ at RMIT University Library on July 20, 2015
Religion
984 TABLE 2A
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Percentage distribution of urban respondents by age at first sexual intercourse and current age: Uganda 1988 and 1989
Females
Males Current age (years)
