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Sexual-risk behaviour among sexually active firstyear students at the University of the Western Cape, South Africa a
Melissa D Abels & Renette J Blignaut
a
a
Department of Statistics , University of the Western Cape , Private Bag X17, Bellville, 7535, Cape Town, South Africa Published online: 13 Oct 2011.
To cite this article: Melissa D Abels & Renette J Blignaut (2011) Sexual-risk behaviour among sexually active first-year students at the University of the Western Cape, South Africa, African Journal of AIDS Research, 10:3, 255-261, DOI: 10.2989/16085906.2011.626295 To link to this article: http://dx.doi.org/10.2989/16085906.2011.626295
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ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.626295
Sexual-risk behaviour among sexually active first-year students at the University of the Western Cape, South Africa Melissa D Abels* and Renette J Blignaut
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University of the Western Cape, Department of Statistics, Private Bag X17, Bellville 7535, Cape Town, South Africa *Corresponding author, e-mail: [email protected] In South Africa, new HIV infections are concentrated among persons aged 15–24 years. The university population falls within this age group and are prone to higher-risk behaviours that place them at risk of acquiring HIV. In a study to assess this risk among sexually active students, we classified higher-risk sexual behaviours as not using condoms at every instance of sex, having had more than one sexual partner during the preceding 12 months, a relatively young age at first sexual intercourse (7–16 years), and experience of sexual violence and/or transactional sex. In total, 796 first-year students at the University of the Western Cape in Cape Town, South Africa, completed a self-administered questionnaire in 2006. The sample included 263 sexually active, unmarried students, aged 16 to 24 years. The responses showed that 62% did not use a condom for every instance of sex, 39% had two or more sexual partners in the previous 12 months, 53% had initiated sexual intercourse at a younger age (7–16 years), and 2% had ever exchanged money or gifts for sexual intercourse. Eight percent of the respondents said they did not give their consent or permission at initiation of first sexual intercourse. One in every 10 respondents claimed that they had ever been forced to have sexual intercourse, and 4% said that they had ever forced someone to have sexual intercourse. The sexually active students who reported an earlier age of initiation of sexual intercourse and having only one sexual partner during the last year were more likely to not use a condom every time, whereas the sexually active students that had experienced initiation of sexual intercourse while in an older age group (17–24 years) and who had two or more sexual partners in the last year were more likely to use a condom every time. Sexually active university students are in need of particular HIV-prevention interventions given their tendencies for poor condom usage and having multiple sexual partners. Keywords: condoms, HIV/AIDS, risk assessment, risk factors, self-reporting, sexual debut, youths
Introduction In South Africa, the estimated 2009 national HIV prevalence among persons aged 15 to 24 years was 13.6% for females and 4.5% for males (UNAIDS, 2010). Our study refers to persons aged 15 to 24 years as youths. UNAIDS (2006) stated that the future course of the HIV epidemic hinges on the higher-risk behaviour that youths adapt or maintain. HIV-risk behaviours are not using condoms every time, having multiple sexual partners, young age at first sex, experience of sexual violence and/or transactional sex. Not using a condom when having sexual intercourse is a main contributor to new HIV infections, especially in Africa where HIV transmission is overwhelmingly heterosexual (Nattrass, 2004). A 1997 study among undergraduate university students in Hong Kong showed that 22% of the students never used condoms (Abdullah, Fielding & Hedley, 2003). A 1997 study at a college in the United States found that 34% of the sexually active students never used condoms (Eisenberg, 2001). Maswanya, Moji, Horiguchi, Nagata, Aoyagi, Honda & Takemoto (1999) reported that 30% of the sexually active respondents from 12 secondary schools and four colleges in Tanzania did not always use condoms. Young women especially are pressured to not use condoms by their older sexual partners, even despite
previous intentions to always use condoms. Sexual insecurity can cause young women to avoid discussions of condom use in order to prevent confrontation (Roberts & Kennedy, 2006). Females in abusive relationships may fear threats of violence, which prevents them from insisting on condom use, increasing their risk of HIV infection (MacPhail & Campbell, 2001). Moreover, sexual violence increases the risk of HIV infection in the victim because injuries and abrasions can facilitate the entry of HIV into the body (Barnett & Whiteside, 2002). A 2003 South African national survey reported that among 7 692 sexually active youths, 6% claimed that they had ever been forced to have sexual intercourse and 13% stated that they were unwilling at their first instance of sexual intercourse (Pettifor, Rees, Steffenson, Hlongwa-Madikizela, MacPhail, Vermaak & Kleinschmidt, 2004). Similarly, a 2003 study in the United States showed that 9% of the high school students claimed having ever been forced to have sexual intercourse (Basile, Black, Simon, Arias, Brener & Saltzman, 2006). Aside from condom non-use, another influential higherrisk sexual behaviour is having more than one sexual partner (Nattrass, 2004; Pettifor et al., 2004; Richter, Panday, Emmett, Makiwane, Du Toit, Brookes et al., 2005; Shisana, Rehle, Simbayi, Parker, Zuma, Bhana et al., 2005). A 2005 national survey in South Africa reported
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higher HIV prevalence among those persons aged 15 years and older who had had more than one sexual partner (21% HIV prevalence) than those who had had only one sexual partner (16% HIV prevalence) (Shisana et al., 2005). In a previous survey at the University of the Western Cape (UWC) (Vergnani, Blignaut & Jacobs, 2005), among 357 sexually active fulltime first-year students, 37% respondents reported having more than one sexual partner during the preceding year. A practice that encourages multiple sexual partners is the exchange of sexual partners within a small group of friends (such at university); these exchanges are usually short-term experiences, with the sexual partners reverting to their original partners thereafter (Seloilwe, 2005). Seloilwe (2005) surveyed 1 327 students at the University of Botswana in the academic year 1999/2000 to investigate factors influencing the spread of HIV. The study revealed that some students changed partners three to four times in a year; the respondents reported that they sometimes changed partners to acquire material gain, such as money, gifts, clothing and cellphones. Exchanging sexual intercourse for money, gifts, favours, or other material or non-material items is termed transactional sex (Kaufman & Stavrou, 2002). MacPhail & Campbell (2001) found that transactional sex among South African youths from a mining town was an exception. Many of the youths stated that they expected gifts in the course of their relationship and claimed their relationships were not a source of income per se. Hence, gift-giving may be viewed as commonplace among same-age adolescents, a part of courtship, and a means with which to establish a relationship and intimacy (Kaufman & Stavrou, 2002). A younger age at first sexual intercourse places youths at greater risk of contracting HIV (Flisher, Ziervogel, Chalton, Leger & Robertson, 1993; Reisen & Poppen, 1995; Maswanya et al., 1999; Kaufman & Stavrou, 2002; Pettifor et al., 2004; Shisana et al., 2005; Richter et al., 2005; Basile et al., 2006; Maharaj & Cleland, 2006). A 2002 South African survey found that 14.4% of the sexually active youths claimed to have had their first sexual encounter at age 13 years or younger (Reddy, Panday, Swart, Jinabhai, Amosun, James et al., 2003). A 2005 study in Nigeria reported that the median age of sexual debut among sexually active high-school students was 15 years (Oladokun, Morhason-Bello, Enakpene, Owonikoko, Akinyemi & Obisesan, 2007). Peer pressure, coercion from a sexual partner and being intoxicated are common reasons for premature and unwanted first experience of sexual intercourse (Skinner, Smith, Fenwick, Fyfe & Hendriks, 2008). Premature or young age at first sexual intercourse is a poor indicator of acquiring HIV because youths that experience their first sexual intercourse at age 15 years or younger are more likely to not have sexual intercourse again for a year or two (Brooks-Gunn & Furstenberg, 1989; Flisher & Chalton, 2001). Especially, a female youth who has sexual intercourse after abstaining for a few years or who experiences her first sexual intercourse at a relatively older age is more likely to use contraception (Flisher & Chalton, 2001) — since sexual activity is still a relatively new experience, she may elicit greater caution (Reisen & Poppen, 1995).
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Much previous research has investigated the relationship between higher-risk sexual behaviour and not using condoms (as a response variable) (e.g. Maswanya et al., 1999; Flisher & Charlton, 2001; Champion, Foley, DuRant, Hensberry, Altman & Wolfson, 2004; Anderson, Santelli & Morrow, 2006; Kaiser Family Foundation, 2007; Takakura, Wake & Kobayashi, 2007). Takakura et al. (2007) reported that condom use was associated with age at initiation of sexual intercourse and having multiple sexual partners. Champion et al. (2004) reported an association between sexual violence and not using condoms. In the present study, we assessed the higher-risk sexual behaviour of the sexually active fulltime first-year students who registered at UWC for the first time in 2006. The second objective was to profile the relationship between condom usage, number of sexual partners, sexual violence, age at initiation of sexual intercourse, and experience of transactional sexual intercourse with condom usage as the response variable. We constructed frequency distributions, bivariate associations and a logistic regression to present the results. Methods Fulltime first-year students who registered at UWC for the first time in 2006 attended an orientation programme before the commencement of classes (at the end of January 2006). All the students were divided into small groups of 15 to 20 students each, according to their faculty. The students were asked to stay in their respective groups for the entire orientation week. Each peer facilitator was responsible for his/her group. The peer facilitator helped members of their group with registration procedures and introduced them to the campus by taking them to different lectures and presentations, which included one two-hour workshop about HIV/AIDS. Specially trained peer educators presented the workshop to the students in a small group situation. The content of the workshop included having the students identify and discuss the prevention and negotiation of higher-risk sexual behaviour. In these small group workshops, peer educators focused on imparting key facts about HIV and AIDS, ensuring that the students knew where to access relevant services (for example, condoms and free HIV testing on campus), and encouraging the students to know their HIV status (see Vergnani et al., 2005). Every precaution was taken to respect the privacy of the respondents, to maintain the confidentiality of personal information, and to safeguard the students’ health and human rights. No names or student numbers were used, thereby making it impossible to identify individual respondents. The peer educators requested each student present at the HIV/AIDS workshop to complete a consent form and self-administered anonymous questionnaire prior to the workshop. Completion of the questionnaire was voluntary and the respondents could choose not to complete it if they felt uncomfortable with any of the questions; however, all 796 students present at the workshop completed a questionnaire. The respondents placed their completed consent forms and questionnaires into different envelopes, and the envelopes were sealed. One member of the research team
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African Journal of AIDS Research 2011, 10(3): 255–261
was available during the administration of the questionnaire to respond to any queries. The questionnaire included the following variables as determinants of higher-risk sexual behaviour: • not using condoms at every instance of sex; • number of sexual partners in the year preceding the survey; • young age at first sex; • experience of sexual violence; and • experience of transactional sex. This study reports only on the higher-risk sexual behaviour among the sexually active respondents. We decided that respondents aged 25 years or older or married would have sexual practices not comparable to unmarried or younger respondents. Also, to reduce overreporting of drug use, a fictitious drug (derbisol) was mentioned in the questionnaire. As a result, 63 (8%) of the respondents were excluded because they were married, aged 25 years or older, or replied ‘yes’ to the question, ‘Are you currently using derbisol?’ Another South African study reported that sexually active respondents were inconsistent in their reporting of lifetime sexual intercourse, as nearly 40% of the respondents reported being virgins despite reporting experience of sexual activity in an earlier assessment (Palen, Smith, Caldwell, Flisher, Wegner & Vergnani, 2008). As the current study assessed respondents’ sexual behaviour, one option for each question pertaining to sexual behaviour was ‘Never had sex.’ The respondents that answered positively to ever having had vaginal, oral or anal sexual intercourse while also selecting ‘Never had sex’ in response to any of the questions about sexual behaviour were defined as inconsistent and excluded from the study. Table 1 lists combinations of inconsistent answers. A total of 132 questionnaires (17%) showed inconsistent answers and were excluded. The final number of questionnaires that could be utilised was 664, of which only 263 students reported being sexually active and thus were included in the research reported here. The data were captured using Microsoft Excel and read into the Statistical Analysis System (SAS) version 9. SAS was used to clean the data and to do the analyses. Frequency distributions were used to table the respondents’ demographic characteristics and information on higherrisk sexual behaviour. Tests for bivariate independence were computed using chi-square and Fisher exact tests to identify the relationship between the students’ reported condom usage, number of sexual partners, experience of sexual violence, age at initiation of sexual intercourse, and experience of transactional sex with condom usage as the response variable. Variables significant at p < 0.25 and having contingency cell values 5 were entered into the logistic regression analyses. Hosmer & Lemeshow (2000) recommend that the 0.25 level of significance be used as a screening criterion for variable selection. Results Descriptive statistics for the sample This study gathered data from 263 sexually active, fulltime first-year students registered at UWC in 2006; these were
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individuals who reported ever having had vaginal, oral and/ or anal sex. Table 2 lists their demographic characteristics. More than half the respondents were females (55%), and large proportions were either coloured (58%) or black Table 1: Possible combinations of inconsistent answers to the questionnaire Variables Respondents who reported that they never had vaginal, oral or anal sexual intercourse, and who also reported an age of initiation of vaginal, oral and/or anal sexual intercourse, but reported that they had never been forced to have sexual intercourse. Respondents who reported that they never had vaginal, oral or anal sexual intercourse in one question, but who reported in another question that they did not use a condom the last time they had vaginal, oral and/or anal sexual intercourse (i.e. in the latter question, respondents had an option to indicate ‘Never had sex’). Respondents who reported that they never had vaginal, oral or anal sexual intercourse in one question, but who reported in another question that they had used condoms (i.e. in the latter question, they had an option to indicate ‘Never had sex’).
Table 2: Demographic characteristics of the sexually active fulltime, first-year students answering a questionnaire at the University of the Western Cape, South Africa, 2006 (n = 263) Variable Gender:
Female Male Missing data Age group (years): 15–19 20–24 Missing data Home language: Xhosa English Afrikaans Zulu Other Missing data Racial group: Black Coloured White Indian/Asian Missing data Province: Western Cape Eastern Cape Northern Cape Gauteng Other Missing data Residence at Home with relatives university: University hostel Rent accommodation with friends Rent a room alone Missing data Religion: Christian Muslim Traditional Other Missing data
n 145 118 0 202 57 4 85 96 63 8 9 2 96 151 7 5 4 201 39 6 5 10 2 188 59 8 6 2 230 21 5 5 2
% 55 45 78 22 33 37 24 3 3 37 58 3 2 77 15 2 2 4 72 23 3 2 88 8 2 2
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African (37%). The median age of the respondents was 18 years. The respondents’ home languages were English (37%), Xhosa (33%), Afrikaans (24%), Zulu (3%), and ‘Other’ (3%). Most had finished high school in the Western Cape Province (77%), while 14% were from the Eastern Cape Province. While at university, most reported they were living at home with relatives (72%), and 23% said they were living in a university hostel. Regarding religious orientation, 88% indicated that they were Christians and 8% that they were Muslims. At the time of the study, 62% of the respondents indicated that they did not use a condom every time they had sexual intercourse, 53% had experienced their first sexual intercourse at age 7 to 16 years, and 61% had had one sexual partner in the previous 12 months before the survey (Table 3). The students’ median ages at initiation of vaginal sexual intercourse, oral sexual intercourse, and anal sexual intercourse were ages 17, 17 and 16 years, respectively. Bivariate associations Table 4 shows the bivariate associations between using a condom every time and higher-risk sexual behaviour. The variables included in the logistic regression model were those statistically significant at the 0.25 level and have a contingency cell value 5. Thus, the variables included in the logistic regression were the number of sexual partners within the year preceding the survey, and the age group at initiation of sexual intercourse. Logistic regression In the logistic regression, the resulting model included the response variable ‘not using condoms every time’ and the explanatory variables were the number of sexual partners within the year preceding the survey and age at initiation of sexual intercourse. In total, the SAS program read 263 observations denoting ‘sexually active,’ but 21 observations were deleted due to missing values. Of the 242 observations used for the logistic regression, 152 respondents had said they did not always use condoms and 90 said they used condoms every time. Table 5 shows the maximum likelihood estimates and the odds ratio estimates, with ‘using a condom every time’ as the dependent variable. Equation 1 is a formulation of the maximum likelihood estimates (see Table 5): ො p
(no) = P(Y = 1) exp[0.4481 + 0.3082(no.of sex partners) í 0.3907(age at initiation of sex)] 1 + exp[0.4481 + 0.3082(no.of sex partners) í 0.3907(age at initiation of sex)]
=
The response variable modelled the probability that the respondents did not use a condom every time they had sexual intercourse. The independent variable (i.e. the number of sexual partners in the preceding year) was classified as ‘One sexual partner’ = 1, and ‘Two or more sexual partners’ = –1; the independent variable (i.e. age at initiation of sexual intercourse) was classified as ‘7 to 16 years’ = –1, and ‘17 to 24 years’ = 1. By substituting category values which are 1 and –1 into Equation 1, the relationship between not always using condoms, the number of sexual partners during the past year, and the
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respondent’s age group for initiation of sexual intercourse was calculated. The probability of not using a condom every time given that they had only one sexual partner during the year preceding the survey and had experienced their first sexual intercourse at age 7 to 16 years is calculated as: ො p
exp[0.4481 + 0.3082(1) í 0.3907(í1)] (no) = P(Y = 1) = 1 + exp[0.4481 + 0.3082(1) í 0.3907(í1)] = 0.7590
The probability of not using a condom every time given they had two or more sexual partners during the preceding year and had experienced their first sexual intercourse at age 7 to 16 years is calculated as: ො p
exp[0.4481 + 0.3082(í1) í 0.3907(í1)] (no) = P(Y = 1) = 1 + exp[0.4481 + 0.3082(í1) í 0.3907(í1)] = 0.6296
The probability of not using a condom every time given they had only one sexual partner during the year prior to the survey and had experienced their first sexual intercourse at age 17 to 24 years is calculated as: ො p
exp[0.4481 + 0.3082(1) í 0.3907(1)] (no) = P(Y = 1) = 1 + exp[0.4481 + 0.3082(1) í 0.3907(1)] = 0.5904
The probability of not using a condom every time given they had two or more sexual partners during the year prior to the survey and had experienced their first sexual intercourse at age 17 to 24 years is calculated as: ො p
exp[0.4481 + 0.3082(í1) í 0.3907(1)] (no) = P(Y = 1) = 1 + exp[0.4481 + 0.3082(í1) í 0.3907(1)] = 0.4376
In summary, the probability of not having used a condom every time they had sexual intercourse was highest among those who had experienced sexual intercourse at a younger age and who had only one sexual partner in the preceding 12 months. Whereas the probability of having used a condom every time they had sexual intercourse was highest among those who had experienced their first sexual intercourse at an older age and who had two or more sexual partners in the preceding 12 months. The Hosmer and Lemeshow goodness-of-fit test had a p-value of 0.7824 at 2 degrees of freedom. As a result, the null hypothesis — that the model provides a good fit — is not rejected. The classification table evaluates the predictive accuracy of the multivariate logistic regression model. The overall rate of correct classification was estimated at the 0.5 level, with 91.4% of those reporting that they did not use a condom every time being correctly classified. Discussion and conclusions Implications of the study The study investigated sexual-risk behaviour among sexually active, fulltime first-year students registered at UWC in 2006. The results show that age at initiation of sexual intercourse and the number of sexual partners
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Table 3: Estimates of sexual behaviour among the sexually active respondents (n = 263 university students) Variable Use a condom at every instance of sex:
Age at initiation of sexual intercourse:
Gave consent/permission at time of first sexual intercourse:
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Ever forced someone to have sexual intercourse:
Have ever been forced to have sexual intercourse:
Ever received money or gifts in exchange for sexual intercourse:
Number of sexual partners in the last 12 months:
n 163 100 0 139 121 3 19 210 34 252 10 1 233 29 1 253 6 4 150 95 18
‘No’ ‘Yes’ Missing data 7–16 years 17–24 years Missing data ‘No’ ‘Yes’ Missing data ‘No’ ‘Yes’ Missing data ‘No’ ‘Yes’ Missing data ‘No’ ‘Yes’ Missing data One Two or more Missing data
% 62 38 53 47 8 92 96 4 89 11 98 2 61 39
Table 4: Bivariate associations among the data for the sexually active respondents Use a condom every time ‘No’ ‘Yes’ n (%) n (%)
Variable Age at initiation of sexual intercourse: 7–16 years 17–24 years Gave consent/permission at first sexual intercourse: ‘No’ ‘Yes’ Ever forced someone to have sexual intercourse: ‘No’ ‘Yes’ Have ever been forced to have sexual intercourse: ‘No’ ‘Yes’ Ever received money or gifts in exchange for sexual intercourse: ‘No’ ‘Yes’ Number of sexual partners in the last 12 months: One Two or more
p-value
93 (67) 68 (56)
46 (33) 53 (44)
0.0761*
15 (79) 125 (60)
4 (21) 85 (40)
0.1393
154 (61) 9 (90)
98 (39) 1 (10)
0.0951
142 (61) 20 (69)
91 (39) 9 (31)
0.4017
157 (62) 4 (67)
96 (38) 2 (33)
1.0000
99 (66) 55 (58)
51 (34) 40 (42)
0.2008*
*Statistically significant at the 0.25 level and the contingency cell value is 5
within the year preceding the survey significantly contributed to the modelled probability of condom use. Takakura et al. (2007) reported findings consistent with these. In this study, not using a condom every time was more likely among those sexually active students that had only one sexual partner in the year preceding the survey and who had experienced their first sexual intercourse at a younger age (7–16 years). Research shows that in long-term
relationships there is more concern about pregnancy than HIV infection. If contraceptives (for example, oral contraceptives) are not used, then the sexually active youth is more likely to use condoms; however, if contraceptives are used, then inconsistent condom use is more likely (Maharaj & Cleland, 2006). Public health efforts should continue promoting condom use among youths. Addressing the implications made above
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Table 5: Logistic regression model using data from only the sexually active respondents (with ‘Use a condom every time’ as the dependent variable)
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Maximum likelihood estimates Parameter Intercept Number of sexual partners in the last 12 months: One Two or more Age at initiation of sexual intercourse: 17–24 years 7–16 years
Odds ratio estimates Odds ratio 95% confidence interval
Estimate 0.4481
Chi-square 10.5154
p-value 0.0012
0.3082
4.4293
0.0353
1.852 1.000
1.043–3.289
–0.3907
7.3562
0.0067
0.458 1.000
0.260–0.805
will help create an environment that promotes wise decisionmaking about sexual behaviour in regard to HIV-risk. Limitations of the study The data were not representative of all UWC students, nor are the findings generalisable to other university student populations. Only sexually active, fulltime first-year students who registered at UWC in 2006 and who also attended the orientation programme could be included in the study. In total, 796 students attended the programme and completed the research questionnaire. Sixty-three respondents were excluded because they were married, aged 25 years or older, and replied ‘Yes’ to using a fictitious drug; another 132 questionnaires showed inconsistent answers (see Table 1) and were also excluded. The final number of questionnaires that could be utilised was 664; of these, 263 respondents indicated they were sexually active and thus were included in the study. Any attempt to generalise from these findings to other populations must be made with caution. An approximation of validity stems from two sources: 1) underreporting, arising from apprehension about possible exposure, embarrassment, or possible legal consequences; and 2) overreporting (cf. Flisher et al., 1993; Flisher, Reddy, Muller & Lombard, 2003). The questionnaire used in the study had no items to measure underreporting. Overreporting occurs when respondents are tempted to provide answers that they believe are expected of them although incorrect. Considering the subject matter (sexual activity, drug use, etc.) and the fact that the measuring instrument was a self-administered questionnaire, the possibility of response ‘dishonesty’ remains. To reduce overreporting of drug use, an item concerning the use of a fictitious drug (derbisol) was inserted into the questionnaire. However, the researchers must assume that the strict anonymity and confidentiality of the study encouraged the students to respond honestly. As a cross-sectional survey, this study avoids making any definitive causal claims about the direction of the relationship between higher-risk sexual behaviour and other risk behaviour. Recommendation Future research concerning higher-risk sexual behaviour among university students should examine factors such as the environment (e.g. attendance at bars, parties, on campus residences) that induce these risk behaviours.
Different higher-risk sexual behaviours coexist and should be examined so that appropriate interventions can be designed to prevent and reduce HIV-risk among young adults. Also, male and female youths engage in different higher-risk sexual behaviours, hence future research should investigate these risk behaviours among males and females separately. Acknowledgments — We would like to thank Professor Tania Vergnani, director of the HIV/AIDS programme at the University of the Western Cape, for making the data available. The authors — Renette Blignaut (MSc, PhD) has worked as a biostatistician and statistician at the Medical Research Council (South Africa) and at Rupert International, respectively. Currently, she is an associate professor in the Department of Statistics at the University of the Western Cape and has acted as chairperson of the department since 2005. She has conducted research in the fields of biostatistics, data mining and science education. Melissa Abels completed a BSc degree in mathematics and statistics, and an MSc degree in statistics at the University of the Western Cape; she was appointed lecturer in statistics in 2007. Her special field of interest is SAS programming.
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Reddy, S.P., Panday, S., Swart, D., Jinabhai, C.C., Amosun, S.L., James, S., Monyeki, K.D., Stevens, G., Morejele, N., Kambaran, N.S., Omardien, R.G. & Van den Borne, H.W. (2003) Umthente Uhlaba Usamila — The 1st South African National Youth Risk Behaviour Survey 2002. November 2003. Cape Town, South Africa, South African Medical Research Council. Reisen, C.A. & Poppen, P.J. (1995) College women and condom use: importance of partner relationship. Journal of Applied Social Psychology 25(17), pp. 1485–1498. Richter, L., Panday, S., Emmett, T., Makiwane, M., Du Toit, R., Brookes, H., Potgieter, C., Altman, M. & Mukhara, M. (2005) The Status of Youth Report 2003: Young People in South Africa. November 2005. Commissioned by the Umsobomvu Youth Fund. Cape Town, South Africa, HSRC Press. Roberts, S.T. & Kennedy, B.L., (2006) Why are young college women not using condoms? Their perceived risk, drug use, and developmental vulnerability may provide important clues to sexual risk. Archives of Psychiatric Nursing 20(1), pp. 32–40. Seloilwe, E.S. (2005) Factors that influence the spread of HIV among students of the University of Botswana. Journal of the Association of Nurses in AIDS Care 16(3), pp. 3–10. Shisana, O., Rehle, T., Simbayi, L.C., Parker, W., Zuma, K., Connolly, C., Jooste, S., Pillay, V., Bhana, A. et al. (2005) South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2005. Cape Town, South Africa, HSRC Press. Skinner, S.R., Smith, J., Fenwick, J., Fyfe, S. & Hendriks, J. (2008) Perceptions and experiences of first sexual intercourse in Australian adolescent females. Journal of Adolescent Health 43(6), pp. 593–599. Takakura, M., Wake, N. & Kobayashi, M. (2007) Relationship of condom use with other sexual risk behaviors among selected Japanese adolescents. Journal of Adolescent Health 40(1), pp. 85–88. UNAIDS (2006) 2006 Report on the Global AIDS Epidemic: Executive Summary. Geneva, UNAIDS. UNAIDS (2010) UNAIDS Report on the Global AIDS Epidemic 2010. Geneva, UNAIDS. Vergnani, T., Blignaut, R.J. & Jacobs, J.J. (2005) HIV/AIDS-related knowledge, attitudes and sexual behaviour of first-time entering students at the University of the Western Cape. Technical Report, University of the Western Cape, Bellville, South Africa.
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Sexual-risk behaviour among sexually active firstyear students at the University of the Western Cape, South Africa a
Melissa D Abels & Renette J Blignaut
a
a
Department of Statistics , University of the Western Cape , Private Bag X17, Bellville, 7535, Cape Town, South Africa Published online: 13 Oct 2011.
To cite this article: Melissa D Abels & Renette J Blignaut (2011) Sexual-risk behaviour among sexually active first-year students at the University of the Western Cape, South Africa, African Journal of AIDS Research, 10:3, 255-261, DOI: 10.2989/16085906.2011.626295 To link to this article: http://dx.doi.org/10.2989/16085906.2011.626295
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ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.626295
Sexual-risk behaviour among sexually active first-year students at the University of the Western Cape, South Africa Melissa D Abels* and Renette J Blignaut
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University of the Western Cape, Department of Statistics, Private Bag X17, Bellville 7535, Cape Town, South Africa *Corresponding author, e-mail: [email protected] In South Africa, new HIV infections are concentrated among persons aged 15–24 years. The university population falls within this age group and are prone to higher-risk behaviours that place them at risk of acquiring HIV. In a study to assess this risk among sexually active students, we classified higher-risk sexual behaviours as not using condoms at every instance of sex, having had more than one sexual partner during the preceding 12 months, a relatively young age at first sexual intercourse (7–16 years), and experience of sexual violence and/or transactional sex. In total, 796 first-year students at the University of the Western Cape in Cape Town, South Africa, completed a self-administered questionnaire in 2006. The sample included 263 sexually active, unmarried students, aged 16 to 24 years. The responses showed that 62% did not use a condom for every instance of sex, 39% had two or more sexual partners in the previous 12 months, 53% had initiated sexual intercourse at a younger age (7–16 years), and 2% had ever exchanged money or gifts for sexual intercourse. Eight percent of the respondents said they did not give their consent or permission at initiation of first sexual intercourse. One in every 10 respondents claimed that they had ever been forced to have sexual intercourse, and 4% said that they had ever forced someone to have sexual intercourse. The sexually active students who reported an earlier age of initiation of sexual intercourse and having only one sexual partner during the last year were more likely to not use a condom every time, whereas the sexually active students that had experienced initiation of sexual intercourse while in an older age group (17–24 years) and who had two or more sexual partners in the last year were more likely to use a condom every time. Sexually active university students are in need of particular HIV-prevention interventions given their tendencies for poor condom usage and having multiple sexual partners. Keywords: condoms, HIV/AIDS, risk assessment, risk factors, self-reporting, sexual debut, youths
Introduction In South Africa, the estimated 2009 national HIV prevalence among persons aged 15 to 24 years was 13.6% for females and 4.5% for males (UNAIDS, 2010). Our study refers to persons aged 15 to 24 years as youths. UNAIDS (2006) stated that the future course of the HIV epidemic hinges on the higher-risk behaviour that youths adapt or maintain. HIV-risk behaviours are not using condoms every time, having multiple sexual partners, young age at first sex, experience of sexual violence and/or transactional sex. Not using a condom when having sexual intercourse is a main contributor to new HIV infections, especially in Africa where HIV transmission is overwhelmingly heterosexual (Nattrass, 2004). A 1997 study among undergraduate university students in Hong Kong showed that 22% of the students never used condoms (Abdullah, Fielding & Hedley, 2003). A 1997 study at a college in the United States found that 34% of the sexually active students never used condoms (Eisenberg, 2001). Maswanya, Moji, Horiguchi, Nagata, Aoyagi, Honda & Takemoto (1999) reported that 30% of the sexually active respondents from 12 secondary schools and four colleges in Tanzania did not always use condoms. Young women especially are pressured to not use condoms by their older sexual partners, even despite
previous intentions to always use condoms. Sexual insecurity can cause young women to avoid discussions of condom use in order to prevent confrontation (Roberts & Kennedy, 2006). Females in abusive relationships may fear threats of violence, which prevents them from insisting on condom use, increasing their risk of HIV infection (MacPhail & Campbell, 2001). Moreover, sexual violence increases the risk of HIV infection in the victim because injuries and abrasions can facilitate the entry of HIV into the body (Barnett & Whiteside, 2002). A 2003 South African national survey reported that among 7 692 sexually active youths, 6% claimed that they had ever been forced to have sexual intercourse and 13% stated that they were unwilling at their first instance of sexual intercourse (Pettifor, Rees, Steffenson, Hlongwa-Madikizela, MacPhail, Vermaak & Kleinschmidt, 2004). Similarly, a 2003 study in the United States showed that 9% of the high school students claimed having ever been forced to have sexual intercourse (Basile, Black, Simon, Arias, Brener & Saltzman, 2006). Aside from condom non-use, another influential higherrisk sexual behaviour is having more than one sexual partner (Nattrass, 2004; Pettifor et al., 2004; Richter, Panday, Emmett, Makiwane, Du Toit, Brookes et al., 2005; Shisana, Rehle, Simbayi, Parker, Zuma, Bhana et al., 2005). A 2005 national survey in South Africa reported
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higher HIV prevalence among those persons aged 15 years and older who had had more than one sexual partner (21% HIV prevalence) than those who had had only one sexual partner (16% HIV prevalence) (Shisana et al., 2005). In a previous survey at the University of the Western Cape (UWC) (Vergnani, Blignaut & Jacobs, 2005), among 357 sexually active fulltime first-year students, 37% respondents reported having more than one sexual partner during the preceding year. A practice that encourages multiple sexual partners is the exchange of sexual partners within a small group of friends (such at university); these exchanges are usually short-term experiences, with the sexual partners reverting to their original partners thereafter (Seloilwe, 2005). Seloilwe (2005) surveyed 1 327 students at the University of Botswana in the academic year 1999/2000 to investigate factors influencing the spread of HIV. The study revealed that some students changed partners three to four times in a year; the respondents reported that they sometimes changed partners to acquire material gain, such as money, gifts, clothing and cellphones. Exchanging sexual intercourse for money, gifts, favours, or other material or non-material items is termed transactional sex (Kaufman & Stavrou, 2002). MacPhail & Campbell (2001) found that transactional sex among South African youths from a mining town was an exception. Many of the youths stated that they expected gifts in the course of their relationship and claimed their relationships were not a source of income per se. Hence, gift-giving may be viewed as commonplace among same-age adolescents, a part of courtship, and a means with which to establish a relationship and intimacy (Kaufman & Stavrou, 2002). A younger age at first sexual intercourse places youths at greater risk of contracting HIV (Flisher, Ziervogel, Chalton, Leger & Robertson, 1993; Reisen & Poppen, 1995; Maswanya et al., 1999; Kaufman & Stavrou, 2002; Pettifor et al., 2004; Shisana et al., 2005; Richter et al., 2005; Basile et al., 2006; Maharaj & Cleland, 2006). A 2002 South African survey found that 14.4% of the sexually active youths claimed to have had their first sexual encounter at age 13 years or younger (Reddy, Panday, Swart, Jinabhai, Amosun, James et al., 2003). A 2005 study in Nigeria reported that the median age of sexual debut among sexually active high-school students was 15 years (Oladokun, Morhason-Bello, Enakpene, Owonikoko, Akinyemi & Obisesan, 2007). Peer pressure, coercion from a sexual partner and being intoxicated are common reasons for premature and unwanted first experience of sexual intercourse (Skinner, Smith, Fenwick, Fyfe & Hendriks, 2008). Premature or young age at first sexual intercourse is a poor indicator of acquiring HIV because youths that experience their first sexual intercourse at age 15 years or younger are more likely to not have sexual intercourse again for a year or two (Brooks-Gunn & Furstenberg, 1989; Flisher & Chalton, 2001). Especially, a female youth who has sexual intercourse after abstaining for a few years or who experiences her first sexual intercourse at a relatively older age is more likely to use contraception (Flisher & Chalton, 2001) — since sexual activity is still a relatively new experience, she may elicit greater caution (Reisen & Poppen, 1995).
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Much previous research has investigated the relationship between higher-risk sexual behaviour and not using condoms (as a response variable) (e.g. Maswanya et al., 1999; Flisher & Charlton, 2001; Champion, Foley, DuRant, Hensberry, Altman & Wolfson, 2004; Anderson, Santelli & Morrow, 2006; Kaiser Family Foundation, 2007; Takakura, Wake & Kobayashi, 2007). Takakura et al. (2007) reported that condom use was associated with age at initiation of sexual intercourse and having multiple sexual partners. Champion et al. (2004) reported an association between sexual violence and not using condoms. In the present study, we assessed the higher-risk sexual behaviour of the sexually active fulltime first-year students who registered at UWC for the first time in 2006. The second objective was to profile the relationship between condom usage, number of sexual partners, sexual violence, age at initiation of sexual intercourse, and experience of transactional sexual intercourse with condom usage as the response variable. We constructed frequency distributions, bivariate associations and a logistic regression to present the results. Methods Fulltime first-year students who registered at UWC for the first time in 2006 attended an orientation programme before the commencement of classes (at the end of January 2006). All the students were divided into small groups of 15 to 20 students each, according to their faculty. The students were asked to stay in their respective groups for the entire orientation week. Each peer facilitator was responsible for his/her group. The peer facilitator helped members of their group with registration procedures and introduced them to the campus by taking them to different lectures and presentations, which included one two-hour workshop about HIV/AIDS. Specially trained peer educators presented the workshop to the students in a small group situation. The content of the workshop included having the students identify and discuss the prevention and negotiation of higher-risk sexual behaviour. In these small group workshops, peer educators focused on imparting key facts about HIV and AIDS, ensuring that the students knew where to access relevant services (for example, condoms and free HIV testing on campus), and encouraging the students to know their HIV status (see Vergnani et al., 2005). Every precaution was taken to respect the privacy of the respondents, to maintain the confidentiality of personal information, and to safeguard the students’ health and human rights. No names or student numbers were used, thereby making it impossible to identify individual respondents. The peer educators requested each student present at the HIV/AIDS workshop to complete a consent form and self-administered anonymous questionnaire prior to the workshop. Completion of the questionnaire was voluntary and the respondents could choose not to complete it if they felt uncomfortable with any of the questions; however, all 796 students present at the workshop completed a questionnaire. The respondents placed their completed consent forms and questionnaires into different envelopes, and the envelopes were sealed. One member of the research team
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African Journal of AIDS Research 2011, 10(3): 255–261
was available during the administration of the questionnaire to respond to any queries. The questionnaire included the following variables as determinants of higher-risk sexual behaviour: • not using condoms at every instance of sex; • number of sexual partners in the year preceding the survey; • young age at first sex; • experience of sexual violence; and • experience of transactional sex. This study reports only on the higher-risk sexual behaviour among the sexually active respondents. We decided that respondents aged 25 years or older or married would have sexual practices not comparable to unmarried or younger respondents. Also, to reduce overreporting of drug use, a fictitious drug (derbisol) was mentioned in the questionnaire. As a result, 63 (8%) of the respondents were excluded because they were married, aged 25 years or older, or replied ‘yes’ to the question, ‘Are you currently using derbisol?’ Another South African study reported that sexually active respondents were inconsistent in their reporting of lifetime sexual intercourse, as nearly 40% of the respondents reported being virgins despite reporting experience of sexual activity in an earlier assessment (Palen, Smith, Caldwell, Flisher, Wegner & Vergnani, 2008). As the current study assessed respondents’ sexual behaviour, one option for each question pertaining to sexual behaviour was ‘Never had sex.’ The respondents that answered positively to ever having had vaginal, oral or anal sexual intercourse while also selecting ‘Never had sex’ in response to any of the questions about sexual behaviour were defined as inconsistent and excluded from the study. Table 1 lists combinations of inconsistent answers. A total of 132 questionnaires (17%) showed inconsistent answers and were excluded. The final number of questionnaires that could be utilised was 664, of which only 263 students reported being sexually active and thus were included in the research reported here. The data were captured using Microsoft Excel and read into the Statistical Analysis System (SAS) version 9. SAS was used to clean the data and to do the analyses. Frequency distributions were used to table the respondents’ demographic characteristics and information on higherrisk sexual behaviour. Tests for bivariate independence were computed using chi-square and Fisher exact tests to identify the relationship between the students’ reported condom usage, number of sexual partners, experience of sexual violence, age at initiation of sexual intercourse, and experience of transactional sex with condom usage as the response variable. Variables significant at p < 0.25 and having contingency cell values 5 were entered into the logistic regression analyses. Hosmer & Lemeshow (2000) recommend that the 0.25 level of significance be used as a screening criterion for variable selection. Results Descriptive statistics for the sample This study gathered data from 263 sexually active, fulltime first-year students registered at UWC in 2006; these were
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individuals who reported ever having had vaginal, oral and/ or anal sex. Table 2 lists their demographic characteristics. More than half the respondents were females (55%), and large proportions were either coloured (58%) or black Table 1: Possible combinations of inconsistent answers to the questionnaire Variables Respondents who reported that they never had vaginal, oral or anal sexual intercourse, and who also reported an age of initiation of vaginal, oral and/or anal sexual intercourse, but reported that they had never been forced to have sexual intercourse. Respondents who reported that they never had vaginal, oral or anal sexual intercourse in one question, but who reported in another question that they did not use a condom the last time they had vaginal, oral and/or anal sexual intercourse (i.e. in the latter question, respondents had an option to indicate ‘Never had sex’). Respondents who reported that they never had vaginal, oral or anal sexual intercourse in one question, but who reported in another question that they had used condoms (i.e. in the latter question, they had an option to indicate ‘Never had sex’).
Table 2: Demographic characteristics of the sexually active fulltime, first-year students answering a questionnaire at the University of the Western Cape, South Africa, 2006 (n = 263) Variable Gender:
Female Male Missing data Age group (years): 15–19 20–24 Missing data Home language: Xhosa English Afrikaans Zulu Other Missing data Racial group: Black Coloured White Indian/Asian Missing data Province: Western Cape Eastern Cape Northern Cape Gauteng Other Missing data Residence at Home with relatives university: University hostel Rent accommodation with friends Rent a room alone Missing data Religion: Christian Muslim Traditional Other Missing data
n 145 118 0 202 57 4 85 96 63 8 9 2 96 151 7 5 4 201 39 6 5 10 2 188 59 8 6 2 230 21 5 5 2
% 55 45 78 22 33 37 24 3 3 37 58 3 2 77 15 2 2 4 72 23 3 2 88 8 2 2
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African (37%). The median age of the respondents was 18 years. The respondents’ home languages were English (37%), Xhosa (33%), Afrikaans (24%), Zulu (3%), and ‘Other’ (3%). Most had finished high school in the Western Cape Province (77%), while 14% were from the Eastern Cape Province. While at university, most reported they were living at home with relatives (72%), and 23% said they were living in a university hostel. Regarding religious orientation, 88% indicated that they were Christians and 8% that they were Muslims. At the time of the study, 62% of the respondents indicated that they did not use a condom every time they had sexual intercourse, 53% had experienced their first sexual intercourse at age 7 to 16 years, and 61% had had one sexual partner in the previous 12 months before the survey (Table 3). The students’ median ages at initiation of vaginal sexual intercourse, oral sexual intercourse, and anal sexual intercourse were ages 17, 17 and 16 years, respectively. Bivariate associations Table 4 shows the bivariate associations between using a condom every time and higher-risk sexual behaviour. The variables included in the logistic regression model were those statistically significant at the 0.25 level and have a contingency cell value 5. Thus, the variables included in the logistic regression were the number of sexual partners within the year preceding the survey, and the age group at initiation of sexual intercourse. Logistic regression In the logistic regression, the resulting model included the response variable ‘not using condoms every time’ and the explanatory variables were the number of sexual partners within the year preceding the survey and age at initiation of sexual intercourse. In total, the SAS program read 263 observations denoting ‘sexually active,’ but 21 observations were deleted due to missing values. Of the 242 observations used for the logistic regression, 152 respondents had said they did not always use condoms and 90 said they used condoms every time. Table 5 shows the maximum likelihood estimates and the odds ratio estimates, with ‘using a condom every time’ as the dependent variable. Equation 1 is a formulation of the maximum likelihood estimates (see Table 5): ො p
(no) = P(Y = 1) exp[0.4481 + 0.3082(no.of sex partners) í 0.3907(age at initiation of sex)] 1 + exp[0.4481 + 0.3082(no.of sex partners) í 0.3907(age at initiation of sex)]
=
The response variable modelled the probability that the respondents did not use a condom every time they had sexual intercourse. The independent variable (i.e. the number of sexual partners in the preceding year) was classified as ‘One sexual partner’ = 1, and ‘Two or more sexual partners’ = –1; the independent variable (i.e. age at initiation of sexual intercourse) was classified as ‘7 to 16 years’ = –1, and ‘17 to 24 years’ = 1. By substituting category values which are 1 and –1 into Equation 1, the relationship between not always using condoms, the number of sexual partners during the past year, and the
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respondent’s age group for initiation of sexual intercourse was calculated. The probability of not using a condom every time given that they had only one sexual partner during the year preceding the survey and had experienced their first sexual intercourse at age 7 to 16 years is calculated as: ො p
exp[0.4481 + 0.3082(1) í 0.3907(í1)] (no) = P(Y = 1) = 1 + exp[0.4481 + 0.3082(1) í 0.3907(í1)] = 0.7590
The probability of not using a condom every time given they had two or more sexual partners during the preceding year and had experienced their first sexual intercourse at age 7 to 16 years is calculated as: ො p
exp[0.4481 + 0.3082(í1) í 0.3907(í1)] (no) = P(Y = 1) = 1 + exp[0.4481 + 0.3082(í1) í 0.3907(í1)] = 0.6296
The probability of not using a condom every time given they had only one sexual partner during the year prior to the survey and had experienced their first sexual intercourse at age 17 to 24 years is calculated as: ො p
exp[0.4481 + 0.3082(1) í 0.3907(1)] (no) = P(Y = 1) = 1 + exp[0.4481 + 0.3082(1) í 0.3907(1)] = 0.5904
The probability of not using a condom every time given they had two or more sexual partners during the year prior to the survey and had experienced their first sexual intercourse at age 17 to 24 years is calculated as: ො p
exp[0.4481 + 0.3082(í1) í 0.3907(1)] (no) = P(Y = 1) = 1 + exp[0.4481 + 0.3082(í1) í 0.3907(1)] = 0.4376
In summary, the probability of not having used a condom every time they had sexual intercourse was highest among those who had experienced sexual intercourse at a younger age and who had only one sexual partner in the preceding 12 months. Whereas the probability of having used a condom every time they had sexual intercourse was highest among those who had experienced their first sexual intercourse at an older age and who had two or more sexual partners in the preceding 12 months. The Hosmer and Lemeshow goodness-of-fit test had a p-value of 0.7824 at 2 degrees of freedom. As a result, the null hypothesis — that the model provides a good fit — is not rejected. The classification table evaluates the predictive accuracy of the multivariate logistic regression model. The overall rate of correct classification was estimated at the 0.5 level, with 91.4% of those reporting that they did not use a condom every time being correctly classified. Discussion and conclusions Implications of the study The study investigated sexual-risk behaviour among sexually active, fulltime first-year students registered at UWC in 2006. The results show that age at initiation of sexual intercourse and the number of sexual partners
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Table 3: Estimates of sexual behaviour among the sexually active respondents (n = 263 university students) Variable Use a condom at every instance of sex:
Age at initiation of sexual intercourse:
Gave consent/permission at time of first sexual intercourse:
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Ever forced someone to have sexual intercourse:
Have ever been forced to have sexual intercourse:
Ever received money or gifts in exchange for sexual intercourse:
Number of sexual partners in the last 12 months:
n 163 100 0 139 121 3 19 210 34 252 10 1 233 29 1 253 6 4 150 95 18
‘No’ ‘Yes’ Missing data 7–16 years 17–24 years Missing data ‘No’ ‘Yes’ Missing data ‘No’ ‘Yes’ Missing data ‘No’ ‘Yes’ Missing data ‘No’ ‘Yes’ Missing data One Two or more Missing data
% 62 38 53 47 8 92 96 4 89 11 98 2 61 39
Table 4: Bivariate associations among the data for the sexually active respondents Use a condom every time ‘No’ ‘Yes’ n (%) n (%)
Variable Age at initiation of sexual intercourse: 7–16 years 17–24 years Gave consent/permission at first sexual intercourse: ‘No’ ‘Yes’ Ever forced someone to have sexual intercourse: ‘No’ ‘Yes’ Have ever been forced to have sexual intercourse: ‘No’ ‘Yes’ Ever received money or gifts in exchange for sexual intercourse: ‘No’ ‘Yes’ Number of sexual partners in the last 12 months: One Two or more
p-value
93 (67) 68 (56)
46 (33) 53 (44)
0.0761*
15 (79) 125 (60)
4 (21) 85 (40)
0.1393
154 (61) 9 (90)
98 (39) 1 (10)
0.0951
142 (61) 20 (69)
91 (39) 9 (31)
0.4017
157 (62) 4 (67)
96 (38) 2 (33)
1.0000
99 (66) 55 (58)
51 (34) 40 (42)
0.2008*
*Statistically significant at the 0.25 level and the contingency cell value is 5
within the year preceding the survey significantly contributed to the modelled probability of condom use. Takakura et al. (2007) reported findings consistent with these. In this study, not using a condom every time was more likely among those sexually active students that had only one sexual partner in the year preceding the survey and who had experienced their first sexual intercourse at a younger age (7–16 years). Research shows that in long-term
relationships there is more concern about pregnancy than HIV infection. If contraceptives (for example, oral contraceptives) are not used, then the sexually active youth is more likely to use condoms; however, if contraceptives are used, then inconsistent condom use is more likely (Maharaj & Cleland, 2006). Public health efforts should continue promoting condom use among youths. Addressing the implications made above
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Table 5: Logistic regression model using data from only the sexually active respondents (with ‘Use a condom every time’ as the dependent variable)
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Maximum likelihood estimates Parameter Intercept Number of sexual partners in the last 12 months: One Two or more Age at initiation of sexual intercourse: 17–24 years 7–16 years
Odds ratio estimates Odds ratio 95% confidence interval
Estimate 0.4481
Chi-square 10.5154
p-value 0.0012
0.3082
4.4293
0.0353
1.852 1.000
1.043–3.289
–0.3907
7.3562
0.0067
0.458 1.000
0.260–0.805
will help create an environment that promotes wise decisionmaking about sexual behaviour in regard to HIV-risk. Limitations of the study The data were not representative of all UWC students, nor are the findings generalisable to other university student populations. Only sexually active, fulltime first-year students who registered at UWC in 2006 and who also attended the orientation programme could be included in the study. In total, 796 students attended the programme and completed the research questionnaire. Sixty-three respondents were excluded because they were married, aged 25 years or older, and replied ‘Yes’ to using a fictitious drug; another 132 questionnaires showed inconsistent answers (see Table 1) and were also excluded. The final number of questionnaires that could be utilised was 664; of these, 263 respondents indicated they were sexually active and thus were included in the study. Any attempt to generalise from these findings to other populations must be made with caution. An approximation of validity stems from two sources: 1) underreporting, arising from apprehension about possible exposure, embarrassment, or possible legal consequences; and 2) overreporting (cf. Flisher et al., 1993; Flisher, Reddy, Muller & Lombard, 2003). The questionnaire used in the study had no items to measure underreporting. Overreporting occurs when respondents are tempted to provide answers that they believe are expected of them although incorrect. Considering the subject matter (sexual activity, drug use, etc.) and the fact that the measuring instrument was a self-administered questionnaire, the possibility of response ‘dishonesty’ remains. To reduce overreporting of drug use, an item concerning the use of a fictitious drug (derbisol) was inserted into the questionnaire. However, the researchers must assume that the strict anonymity and confidentiality of the study encouraged the students to respond honestly. As a cross-sectional survey, this study avoids making any definitive causal claims about the direction of the relationship between higher-risk sexual behaviour and other risk behaviour. Recommendation Future research concerning higher-risk sexual behaviour among university students should examine factors such as the environment (e.g. attendance at bars, parties, on campus residences) that induce these risk behaviours.
Different higher-risk sexual behaviours coexist and should be examined so that appropriate interventions can be designed to prevent and reduce HIV-risk among young adults. Also, male and female youths engage in different higher-risk sexual behaviours, hence future research should investigate these risk behaviours among males and females separately. Acknowledgments — We would like to thank Professor Tania Vergnani, director of the HIV/AIDS programme at the University of the Western Cape, for making the data available. The authors — Renette Blignaut (MSc, PhD) has worked as a biostatistician and statistician at the Medical Research Council (South Africa) and at Rupert International, respectively. Currently, she is an associate professor in the Department of Statistics at the University of the Western Cape and has acted as chairperson of the department since 2005. She has conducted research in the fields of biostatistics, data mining and science education. Melissa Abels completed a BSc degree in mathematics and statistics, and an MSc degree in statistics at the University of the Western Cape; she was appointed lecturer in statistics in 2007. Her special field of interest is SAS programming.
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