DOI 10.1515/ijamh-2013-0322 Int J Adolesc Med Health 2014; 26(3): 403–410
Trang H.T. Do, Linh C. Le, John A. Burgess and Dinh S. Bui*
Determinants of condom use at sexual debut among young Vietnamese Abstract Background and aims: Condom use at sexual debut is associated with subsequent condom use and with decreased risk of sexually transmitted infections. There is a dearth of data on determinants of condom use at first sexual intercourse. We aimed to determine factors associated with condom use at first sexual intercourse before marriage among Vietnamese adolescents and youths. Methods: The study involved the analysis of data from the Survey Assessment of Vietnamese Youth, 2003, the first nationally representative survey of young people in Vietnam. The survey included 7584 adolescents and youths aged 14–25 years. In this study, data of 605 adolescents and youths who had engaged in premarital sex were analyzed for factors associated with condom use using descriptive analyses, and regression techniques, allowing for sampling weights, clustering and stratification. Results: Of 605 adolescents and youths who had engaged in premarital sex, 28.6% reported condom use at first sexual intercourse. Condom use at sexual debut was less common in females than males [odds ratio (OR) = 0.15; 95% confidence interval (95% CI) = 0.07–0.30] and less common in those who experienced peer pressure to engage in social higher risk behaviors (OR = 0.57; 95% CI = 0.32–0.99). Condom use was more common if a friend/ acquaintance or a stranger/sex worker was the first sexual partner (OR = 2.20; 95% CI = 1.16–4.17 and OR = 17.90; 95% CI = 6.88–46.54) respectively, each compared with fiancé/ boyfriend/girlfriend as first sexual partner. Conclusions: These data suggest that approximately one in three unmarried Vietnamese youths used a condom at first sexual intercourse. Gender, peer pressure and the nature of the relationship to the first sexual partner were independently associated with condom use. These results can inform programs directed at preventing HIV and other sexually transmitted infections among young Vietnamese. Keywords: adolescents; condom; first intercourse; sex; sexual debut; Vietnam; youths. *Corresponding author: Dinh S. Bui, Hanoi University of Pharmacy, 13-15 Le Thanh Tong Street, Hoan Kiem, Hanoi, Vietnam, Phone: +84-438241110, Fax: +84-438264464, E-mail: [email protected]; [email protected]
Trang H.T. Do and Linh C. Le: Hanoi School of Public Health, Hanoi, Vietnam John A. Burgess: School of Public Health, University of Melbourne, Melbourne, Australia
Introduction In the past, cultural influences have mitigated against premarital sex in young Vietnamese, but recently the prevalence of premarital sex in this cohort has been increasing (1, 2). This places young individuals at increasing sexual and reproductive health risks. The HIV incidence and prevalence is now increasing in the Vietnamese population and 60% of the documented cases belong to those between 13 and 29 years (3). Moreover, it is estimated that there are approximately 1 million new cases of STIs reported annually in the country (4). Unplanned pregnancy is increasing among young Vietnamese, and as a result Vietnam is among the countries that have the highest rates of abortion in the world, with adolescent abortions contributing to at least one-third of these events (5). Premarital sex among Vietnamese adolescents and youths carries a high risk of sexual and reproductive health consequences (6). This is partly because young people often have multiple partners (1). Moreover, many premarital sexual encounters involve HIV high-risk groups such as commercial sex workers (1). Inconsistent condom use, especially at first sexual intercourse is an additional risk factor (7). Young people’s first sexual intercourse (FSI) is considered a significant life event. Behaviors in the first sexual experience may be associated with “the establishment of behavioral patterns through life” [(8), p. 2], and studies have shown that condom use at FSI is strongly associated with the use of condom in subsequent sexual intercourse and with decreased risk of STIs (9–12). As a result, an understanding of factors that influence condom use at FSI could play an important role in minimizing young people’s vulnerability to STIs. Although there have been some studies on determinants of condom use in Vietnam, the majority (13–15) have focused only on traditional high-risk groups including commercial sex workers and injecting drug users. Little is
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404 Do et al.: Determinants of condom use among young Vietnamese known about factors influencing condom use among adolescents and youths in the general population. There is one study about condom use among never married youth in Vietnam (7), but it was conducted in a selected suburb of Hanoi, the capital city, limiting the external validity of the findings. Using data from the Survey Assessment of Vietnamese Youth, the present study sought to determine factors associated with condom use at sexual debut before marriage.
Methods Study population and data collection This study used data from the Survey Assessment of Vietnamese Youth (SAVY) (16), the first nationwide baseline survey of youth ever undertaken in Vietnam, conducted by the National General Statistic Office in 2003–2004. It included a nationally representative sample of 7584 participants aged 14–25 years from 42 provinces. Sampling design of SAVY was based on the probability selection, multi-stage, clustered sampling and stratified both by provinces in the country’s eight region and by urban and rural area. The response rate was 77.1%. Our study sample includes 605 adolescents and youths who reported having engaged in premarital sex and answered the questions about condom use at FSI. The SAVY protocol and procedures were approved by the Ethics Committee of Medical Research (Vietnam Ministry of Health). The survey was conducted according to the principles expressed in the World Medical Association Declaration of Helsinki (http://www. wma.net, accessed 15 December, 2012).
Definition of variables Dependent variable The dependent variable was “condom use at FSI”. Information about condom use at FSI was derived from the questions “Did you or/and your partner use any contraceptive method at your first sexual intercourse? If yes, what did you use?”
Independent variables Socio-demographic and family background variables We measured four socio-demographic characteristics including gender, educational attainment, whether the participant lived in rural or urban area and socio-economic status. Educational attainment was measured as a binary variable by asking whether the participant had ever attended school. Socio-economic status was developed by using principal component analysis on the presence or absence of 11 items from a list including household’s assets, household’s sources of energy and household’s sources of drinking water. Respondents were then
categorized into three groups (lowest, middle and highest strata of socio-economic status). Family connection This variable was developed by each respondent’s answer (“agree” or “disagree”) to a series of eight items used to measure the level of connection to family (family members help one another at difficult times, family members know other members’ close friends, family members treat one another equally, family members share responsibility, family members feel more comfortable sharing difficulties with non-family members, family members go his/her own way, family members’ opinions are respected). Each young person received a score ranging from 0 to 8, with 0 indicating no family connection and 8 indicating highest level of family connection. Other individual characteristics These variables involve participants’ knowledge about HIV, whether the participants believe that condoms can prevent pregnancy, whether they believe that condoms can prevent sexually transmitted diseases, age at FSI, history of alcohol consumption and history of being drunk. To measure knowledge about HIV, each participant was asked to respond to the question: According to you, can the following prevent HIV: 1. Using condom when having sexual intercourse, 2. Have only one sexual partner, 3. Avoid having sex with strangers, 4. Avoid having sex, 5. Avoid buying or selling sex, 6. Avoid sharing needles, and 7. Avoid blood transfusion. The participant then chose only one response for each statement from the three options: “yes”, “no”, “don’t know”. A new dichotomized variable was created and coded as 1 if “yes” was chosen for all seven statements, and 0 for other response combinations. Two variables “belief in that condom can prevent pregnancy” and “belief in that condom can prevent sexually transmitted diseases” are binary variables. Age at FSI was recorded in years. The variable was then dichotomized into 1 for 14–19 years and 2 for 20–25 years. History of alcohol consumption and history of being drunk are binary variables, measured by asking whether the participant had ever finished a glass of beer of a cup of liquor or not and whether the participant had ever been drunk or not. Peer and partner variables Nature of relationship with partner at FSI included three categories, reflecting decreasing levels of intimacy of the relationship (fiancé/boyfriend/girlfriend, friend/acquaintance and stranger/sex worker). Peer influence was measured by asking the participant whether (s)he has ever been asked or coerced to engage in the following social higher risk behaviors by his/her friend(s): smoking, drinking, using club drugs, watching pornography, having premarital sex, using other drugs or participating in a gang. Community level variables Each participant was asked whether (s)he is a member of any mass organization (such as the Youth Union) or clubs in his/her community.
Statistical methods Descriptive statistics were used to estimate the prevalence of condom use at FSI. Weighted percentages were reported. To identify factors associated with condom use at FSI, bivariate logistic regression was first employed to test whether condom use differed by individual and family characteristics, peer and partner characteristics and community participation. Then multivariate logistic regression was used to test the association between all independent variables with a p-value ≤ 0.2 in univariate analyses and condom use, controlling for potential confounding factors (gender, education, socio-economic status, history of
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Do et al.: Determinants of condom use among young Vietnamese 405
alcohol consumption, nature of relationship with partner, belief that condoms can prevent STIs, history of being drunk and peer influence). All analyses were weighted and the “svy” command set in STATA was used to control for the complex sampling design in the SAVY survey. The final model was determined by retaining those variables with a p-value from an adjusted Wald test ≤ 0.3. Goodness-of-fit of the model was tested that a variable with a p-value > 0.3 was retained in the model if excluding it showed strong evidence of lack of fit (17).
Results Characteristics of the participants Overall, 605 participants [152 (25.1%) females] were included in the analysis (Table 1). The mean age (years)
of participants was 22 ± 0.2 (females 21 ± 0.1; males 22 ± 0.1; p = 0.007). The majority (71%) of participants came from rural areas, with 63% being in the middle or high strata of socio-economic status. More females (52.6%) than males (31.4%; p
Trang H.T. Do, Linh C. Le, John A. Burgess and Dinh S. Bui*
Determinants of condom use at sexual debut among young Vietnamese Abstract Background and aims: Condom use at sexual debut is associated with subsequent condom use and with decreased risk of sexually transmitted infections. There is a dearth of data on determinants of condom use at first sexual intercourse. We aimed to determine factors associated with condom use at first sexual intercourse before marriage among Vietnamese adolescents and youths. Methods: The study involved the analysis of data from the Survey Assessment of Vietnamese Youth, 2003, the first nationally representative survey of young people in Vietnam. The survey included 7584 adolescents and youths aged 14–25 years. In this study, data of 605 adolescents and youths who had engaged in premarital sex were analyzed for factors associated with condom use using descriptive analyses, and regression techniques, allowing for sampling weights, clustering and stratification. Results: Of 605 adolescents and youths who had engaged in premarital sex, 28.6% reported condom use at first sexual intercourse. Condom use at sexual debut was less common in females than males [odds ratio (OR) = 0.15; 95% confidence interval (95% CI) = 0.07–0.30] and less common in those who experienced peer pressure to engage in social higher risk behaviors (OR = 0.57; 95% CI = 0.32–0.99). Condom use was more common if a friend/ acquaintance or a stranger/sex worker was the first sexual partner (OR = 2.20; 95% CI = 1.16–4.17 and OR = 17.90; 95% CI = 6.88–46.54) respectively, each compared with fiancé/ boyfriend/girlfriend as first sexual partner. Conclusions: These data suggest that approximately one in three unmarried Vietnamese youths used a condom at first sexual intercourse. Gender, peer pressure and the nature of the relationship to the first sexual partner were independently associated with condom use. These results can inform programs directed at preventing HIV and other sexually transmitted infections among young Vietnamese. Keywords: adolescents; condom; first intercourse; sex; sexual debut; Vietnam; youths. *Corresponding author: Dinh S. Bui, Hanoi University of Pharmacy, 13-15 Le Thanh Tong Street, Hoan Kiem, Hanoi, Vietnam, Phone: +84-438241110, Fax: +84-438264464, E-mail: [email protected]; [email protected]
Trang H.T. Do and Linh C. Le: Hanoi School of Public Health, Hanoi, Vietnam John A. Burgess: School of Public Health, University of Melbourne, Melbourne, Australia
Introduction In the past, cultural influences have mitigated against premarital sex in young Vietnamese, but recently the prevalence of premarital sex in this cohort has been increasing (1, 2). This places young individuals at increasing sexual and reproductive health risks. The HIV incidence and prevalence is now increasing in the Vietnamese population and 60% of the documented cases belong to those between 13 and 29 years (3). Moreover, it is estimated that there are approximately 1 million new cases of STIs reported annually in the country (4). Unplanned pregnancy is increasing among young Vietnamese, and as a result Vietnam is among the countries that have the highest rates of abortion in the world, with adolescent abortions contributing to at least one-third of these events (5). Premarital sex among Vietnamese adolescents and youths carries a high risk of sexual and reproductive health consequences (6). This is partly because young people often have multiple partners (1). Moreover, many premarital sexual encounters involve HIV high-risk groups such as commercial sex workers (1). Inconsistent condom use, especially at first sexual intercourse is an additional risk factor (7). Young people’s first sexual intercourse (FSI) is considered a significant life event. Behaviors in the first sexual experience may be associated with “the establishment of behavioral patterns through life” [(8), p. 2], and studies have shown that condom use at FSI is strongly associated with the use of condom in subsequent sexual intercourse and with decreased risk of STIs (9–12). As a result, an understanding of factors that influence condom use at FSI could play an important role in minimizing young people’s vulnerability to STIs. Although there have been some studies on determinants of condom use in Vietnam, the majority (13–15) have focused only on traditional high-risk groups including commercial sex workers and injecting drug users. Little is
Brought to you by | University of Connecticut Authenticated Download Date | 6/7/15 3:26 AM
404 Do et al.: Determinants of condom use among young Vietnamese known about factors influencing condom use among adolescents and youths in the general population. There is one study about condom use among never married youth in Vietnam (7), but it was conducted in a selected suburb of Hanoi, the capital city, limiting the external validity of the findings. Using data from the Survey Assessment of Vietnamese Youth, the present study sought to determine factors associated with condom use at sexual debut before marriage.
Methods Study population and data collection This study used data from the Survey Assessment of Vietnamese Youth (SAVY) (16), the first nationwide baseline survey of youth ever undertaken in Vietnam, conducted by the National General Statistic Office in 2003–2004. It included a nationally representative sample of 7584 participants aged 14–25 years from 42 provinces. Sampling design of SAVY was based on the probability selection, multi-stage, clustered sampling and stratified both by provinces in the country’s eight region and by urban and rural area. The response rate was 77.1%. Our study sample includes 605 adolescents and youths who reported having engaged in premarital sex and answered the questions about condom use at FSI. The SAVY protocol and procedures were approved by the Ethics Committee of Medical Research (Vietnam Ministry of Health). The survey was conducted according to the principles expressed in the World Medical Association Declaration of Helsinki (http://www. wma.net, accessed 15 December, 2012).
Definition of variables Dependent variable The dependent variable was “condom use at FSI”. Information about condom use at FSI was derived from the questions “Did you or/and your partner use any contraceptive method at your first sexual intercourse? If yes, what did you use?”
Independent variables Socio-demographic and family background variables We measured four socio-demographic characteristics including gender, educational attainment, whether the participant lived in rural or urban area and socio-economic status. Educational attainment was measured as a binary variable by asking whether the participant had ever attended school. Socio-economic status was developed by using principal component analysis on the presence or absence of 11 items from a list including household’s assets, household’s sources of energy and household’s sources of drinking water. Respondents were then
categorized into three groups (lowest, middle and highest strata of socio-economic status). Family connection This variable was developed by each respondent’s answer (“agree” or “disagree”) to a series of eight items used to measure the level of connection to family (family members help one another at difficult times, family members know other members’ close friends, family members treat one another equally, family members share responsibility, family members feel more comfortable sharing difficulties with non-family members, family members go his/her own way, family members’ opinions are respected). Each young person received a score ranging from 0 to 8, with 0 indicating no family connection and 8 indicating highest level of family connection. Other individual characteristics These variables involve participants’ knowledge about HIV, whether the participants believe that condoms can prevent pregnancy, whether they believe that condoms can prevent sexually transmitted diseases, age at FSI, history of alcohol consumption and history of being drunk. To measure knowledge about HIV, each participant was asked to respond to the question: According to you, can the following prevent HIV: 1. Using condom when having sexual intercourse, 2. Have only one sexual partner, 3. Avoid having sex with strangers, 4. Avoid having sex, 5. Avoid buying or selling sex, 6. Avoid sharing needles, and 7. Avoid blood transfusion. The participant then chose only one response for each statement from the three options: “yes”, “no”, “don’t know”. A new dichotomized variable was created and coded as 1 if “yes” was chosen for all seven statements, and 0 for other response combinations. Two variables “belief in that condom can prevent pregnancy” and “belief in that condom can prevent sexually transmitted diseases” are binary variables. Age at FSI was recorded in years. The variable was then dichotomized into 1 for 14–19 years and 2 for 20–25 years. History of alcohol consumption and history of being drunk are binary variables, measured by asking whether the participant had ever finished a glass of beer of a cup of liquor or not and whether the participant had ever been drunk or not. Peer and partner variables Nature of relationship with partner at FSI included three categories, reflecting decreasing levels of intimacy of the relationship (fiancé/boyfriend/girlfriend, friend/acquaintance and stranger/sex worker). Peer influence was measured by asking the participant whether (s)he has ever been asked or coerced to engage in the following social higher risk behaviors by his/her friend(s): smoking, drinking, using club drugs, watching pornography, having premarital sex, using other drugs or participating in a gang. Community level variables Each participant was asked whether (s)he is a member of any mass organization (such as the Youth Union) or clubs in his/her community.
Statistical methods Descriptive statistics were used to estimate the prevalence of condom use at FSI. Weighted percentages were reported. To identify factors associated with condom use at FSI, bivariate logistic regression was first employed to test whether condom use differed by individual and family characteristics, peer and partner characteristics and community participation. Then multivariate logistic regression was used to test the association between all independent variables with a p-value ≤ 0.2 in univariate analyses and condom use, controlling for potential confounding factors (gender, education, socio-economic status, history of
Brought to you by | University of Connecticut Authenticated Download Date | 6/7/15 3:26 AM
Do et al.: Determinants of condom use among young Vietnamese 405
alcohol consumption, nature of relationship with partner, belief that condoms can prevent STIs, history of being drunk and peer influence). All analyses were weighted and the “svy” command set in STATA was used to control for the complex sampling design in the SAVY survey. The final model was determined by retaining those variables with a p-value from an adjusted Wald test ≤ 0.3. Goodness-of-fit of the model was tested that a variable with a p-value > 0.3 was retained in the model if excluding it showed strong evidence of lack of fit (17).
Results Characteristics of the participants Overall, 605 participants [152 (25.1%) females] were included in the analysis (Table 1). The mean age (years)
of participants was 22 ± 0.2 (females 21 ± 0.1; males 22 ± 0.1; p = 0.007). The majority (71%) of participants came from rural areas, with 63% being in the middle or high strata of socio-economic status. More females (52.6%) than males (31.4%; p
