Sexual Health Behaviours: HIV/STI Risk Perception among Namibian University Students

Background: The attitude of young people towards the use of contraceptives differs and it is linked with their sexuality. One of the most frequent assertions for the lack of use of the condoms as contraceptive is that boys did not like using them because it reduces the feeling and pleasure during intercourse and some of the young mothers’ belief that putting on condom just prior to intercourse did interrupt the spontaneous feelings during sexual intimacy Methods: Data was collected using self completed questionnaires for quantitative cross-sectional survey among students in classes selected through simple random sampling in each stratum (University Campus). Relationship between independent variables (method of contraception, misconceptions about the role of contraceptives in preventing STIs/HIV, transactional sex, HIV/STIs Risk perception of young people) and dependents variable (multiple sexual partners) was measured using multivariate model of logistic regression analysis. Results: Among sexually active students, condom use was 88.7%, abstinences 10.1% and did not use anything 1.3%. In thirty days under study about 20.0% have had sex at least twice, 8.2% more than four times and 37.4% did not have vaginal sex. Other forms of intercourse observed among the respondents are oral and anal sex which recorded 11.5% and 2.0% respectively. Only 13.9% have had transactional sex within the last 12 months. Conclusion: Some risky sexual practices such as multiple sexual partners, anal and oral sex and having unprotected vaginal intercourse were noted among the students, despite regular campaigns in media. However, it is a general belief that, the use of contraceptive like condom may interrupt spontaneous arousal feeling and pleasure during intercourse against the backdrop of likelihood of HIV/STDs infection and unwanted pregnancy. Therefore, more rigorous campaign from government at all levels is recommended.


Introduction
Ability to delay pregnancy or prevent unwanted pregnancy as well as prevention of STIs has a direct impact on young peoples' health and well being. This ability depends on the level of contraceptive use among the young people. Contraception (the use of various devices, drugs, agents, sexual practices, or surgical procedures to prevent conception or impregnation) plays a vital role in the eradication of extreme poverty; hence it is considered as one of the key initiatives to pursuing the millennium development goals [1]. While the primary aim of contraception is to prevent unplanned pregnancies, two barrier contraceptives methods i.e. male and female condoms can also prevent Sexually Transmitted Infections (STIs), HIV inclusive [2,3].
According to Davis [4], "monetarily speaking, condoms are the least expensive form of birth control and more easily obtained, no medical examination is required. Yet, many of the girls reported that their boyfriends did not like using them because it reduces the feeling and pleasure during intercourse. This was one of the most frequent reasons stated for the lack of use of the condoms as contraceptive. Additionally, some of the young mothers stated that putting on the condom just prior to intercourse did interrupt the spontaneous feelings during sexual intimacy. Some of the reasons so many teenagers are becoming pregnant is that many do not want to assume any responsibility for birth control. Others are simply ignorant about the whole process of reproduction, and do not associate sex with pregnancy and STIs. Some girls are seeking love, and naively believe a baby can give them the affection they seek".
Early workers in other places reported that, there are increased risks of acquiring/transmitting HIV among women and their partners and, it has been associated with injectable hormonal contraceptives. Also having multiple sexual partners has been proven to be associated with contraceptive use [5][6][7][8][9]. In view of increasing incidence of HIV infection among young people, it is important to understand the perception of contraceptive use among youth and the consequential effects of their risky sexual behaviours.
Namibia is one of the Southern African countries located at the South-Western Africa, with 37% of the population are under 15 years of age [10]. Namibia is a middle income country but considering the disparities in per capita income of the population, it has one of the most skewed incomes per capital in the world. Two thirds of Namibian population live in the rural areas and constitute 70% of the poor population. With the existing data on HIV infection among Namibian  [10]. It therefore, becomes imperative to determine the sexuality pattern and HIV/STI risk perception among Namibian University students. Perhaps, there could be a correlation between contraceptive use, frequency of intercourse and having multiple sexual partners, which is a risk factor in acquiring HIV infection. In Namibia, contraceptive use among University age students and frequency of intercourse in relation to number of sexual partners has not been documented. It is also expected that data provided from this study will be used to improve quality and services of family planning programme in the country.

Study design
Quantitative methodology was used in the conduct of this study, the research was a cross-sectional survey, with an aim to determine contraceptive use among Namibian University students' and establish the correlation between contraceptive use and the likelihood of having more frequent intercourse and multiple sexual partners. The dependent variable (dVs) was having multiple sexual partners; while independent variables (idVs) were contraceptive use, method of contraception and frequency of intercourse.

Sample size, frame and population
The population studied consists of undergraduate students in three campuses of the only University in Namibia (University of Namibia (UNAM)) in Oshana Region, Northern part of Namibia.
Four hundred and twenty two subjects (422) respondents were contacted for the study. The sample size was calculated using confidence level=95%, and the prevalence of contraceptive use among sexually active young women in Namibia which is 52% from earlier records. Sample size was calculated using Aday and Cornelius method [11] and considered 10% attrition. Stratified and simple random sampling was used by dividing the sample size into strata based on the campuses in Oshana Region. A contact session with the lecturers and students was arranged to give the details of the study. Then, each student in the randomly selected classes was given a combined participant information sheet and questionnaires. Those who consented to participate in the study answered the questionnaires while others returned theirs.
Ethical approval was obtained from the University of Liverpool Research Ethics Committee and the Biomedical Research Ethics Committee (BREC) in the Ministry of Health and Social Services, Namibia.

Participants
The inclusion criteria for participation were 19-25 years old students of the University of Namibia campuses in Oshana Region. Students above 25 year or below 19 year of age were excluded from the study.
Most students at the University fall within the age group of 19-25 years. It was expected that good percentage of students in this age group will be sexually active [12].

Procedures
The data collection tool (questionnaires) was adapted from the ACHA-NCHA questionnaires on sexual behaviour, perceptions, and contraception with alpha scores for sex-related behaviours=0.67 [13]. A pilot study was carried out on 12 students of University of Namibia, Oshana Region and slight adjustments was made on alternatives/ possible answers based on the need during analysis prior to data collection. Data was collected over 3 weeks from October 29 to November 16, 2012.

Data analysis
IBM-SPSS (Statistical Package for Social Science) version 20 was used for the analysis. Descriptive statistics and cross tabulations were calculated to display the socio-demographic distribution of the participants and characterize sexual behaviour.

Results
The frequency of vaginal sex which is a prime route of transmission of HIV/STI is shown in Figure 1. About 37.4% have not had vaginal sex in the last 30 days, 20.0% have had sex at least twice in the last 30 days, 8.2% had sex more than four times in the last 30 days, while 38.3% never. Among sexually active students, the most common contraceptive methods used by respondent or their partners to prevent pregnancy in the most recent vaginal sex was condom use 293/328 (88.7%), abstinences 33/328 (10.1%) and nothing (did not use anything) 14/328(1.2%). About 31.1% (67/215) have had 2 or more sexual partners in the last 12 months. Other forms of intercourse observed among the respondents are oral and anal sex which recorded 34/296(11.5%) and 6/289 (2.0%) respectively. And 45/323(13.9%) have had transactional sex within the last 12 months (Table 1). Did this 1 or more times 34 11.5

(ii) Frequency of anal sex within past 30 days (N = 289)
Never did this sexual activity 246 85.1 Have not done this activityduring the last 30 37 12.8 Did this 1 or more times 6 2.0

(iii) Transactional sex within past 12 months (N =323)
Never did this sexual activity 263 81.4 Have not done this activityduring the last 12 15 4.6 Did this 1 or more times 45 13.9

Discussion
Multiple sexual partners, oral and unprotected sex was observed among the study group, a practice that is risky and potential route of acquiring HIV/STIs. This is a window that needs to be closed in other to stem down the occurrence of HIV/STIs among the youths in the region. Government at all levels should step up enlightenment campaign to curb the menace. This study intended to establish the association between HIV/STI risk perception and multiple sexual partners among young people. The association might be the effect of multiple sexual partners' perception of HIV/STI risk among individuals. People with multiple sexual partners or those contemplating their partners to be having multiple sexual partners agreed they are at risk but their actions in response to this perception depends on the social conditions of the individuals and other risk perceived. It was observed that there was negative association between multiple sexual partners and perception of HIV/STI risk, above a third of the study population have had multiple sexual partners within the period studied, in spite of the everyday campaigns on media. This finding is in tandem with the reports of Gayet et al. [14] and Ojikutu et al. [15] that in separate reports documented negative association between multiple sexual partners and perception of HIV/STI risk among young people.
This study showed no significant association between the condom use and multiple sexual partners among the students. This finding is in agreement with 1992 NHIS (National Health Interview Survey) in US that showed no relationship between condom use and the number of sexual partners among 12-21 year old from sampled households as reported by Santelli et al. [16] and Ritchter et al. [17] which showed a negative association. Contrary to the reports of Svare et al. [5][6][7]18] which showed positive association between multiple sexual partners and condom use. The variation in report may not be unconnected to the level of awareness, educational background and government involvement in the prevention, control and management of HIV/STIs infections in the communities. However, there was a significant positive association between other methods used and multiple sexual partners among the students after adjusting for important potential confounders (age group, gender, alcohol in 30 days and HIV/STIs Risk perception, though not reported in this paper). This finding is in tandem with the work done in Tanzania by Yeatman et al. [8] that showed positive association between "injectable hormonal" contraceptives and multiple sexual partners among under 25 years antenatal clinic (ANC) attendants. Also associations established in this study cannot be used for determining causality in that it cannot discern which event led to the other, since the first event could not be identified through the study [19].
The survey result may not be generalized for all tertiary school students in Namibia because the study was carried out in the Northern part of the country where the white and the mixed are not well represented although black is the majority in Namibia (black 87.5%, white 6%, mixed 6.5%) according to Indexmundi [20]. It will also be difficult to generalize the result for young people in Namibia since education, an important factor influencing sexual behaviour and contraception was not used in the analysis because the respondents fall within the same level of education. The study is also limited to

Conclusion
There are some risky sexual practices such as multiple sexual partners, oral sex and having unprotected vaginal intercourse, despite regular campaigns in media. The knowledge of contraceptives exists among the study group and level of compliance is relatively low. However, it is a general belief that, the use of contraceptives like condoms may interrupt spontaneous arousal feeling and pleasure during intercourse against the backdrop of likelihood of HIV/STDs infection and unwanted pregnancy, thus, abuse is inevitable.

Limitation and Strength of this Study
Survey is a popular research methodology because it is effective in investigating associations within a short time from a fairly large population of interest at a relative low cost. However, using closeended questions in this study might have encouraged guessing leading to a misrepresentation of the knowledge and practices of the students. Also associations established in this study cannot be used for determining causality in that it cannot discern which event led to the other event since the first event could not be identified through the study.
The survey result may not be generalized for all tertiary school students in Namibia because the study was carried out in the Northern part of the country where the white and the mixed are not well represented although black is the majority in Namibia. It will also be difficult to generalize the result for young people in Namibia since education, an important factor influencing sexual behaviour and contraception use was not applied in the analysis because the respondents fall within the same level of education. The study was also limited to heterosexual students, since the size of gay/lesbian and bisexual groups were too small for analysis. However, combining male and female responses for gender specific contraception like withdrawal, birth control pills and condom use could exacerbate recall bias. Self reporting when dealing with sensitive subjects like the one considered in this study could also lead to information bias. These two forms of bias could have influence the result of this study and affect its validity.