Behavioral Medicine

ISSN: 0896-4289 (Print) 1940-4026 (Online) Journal homepage: http://www.tandfonline.com/loi/vbmd20

Sub-Saharan African University Students' Beliefs about Abstinence, Condom Use, and Limiting the Number of Sexual Partners Jingwen Zhang, John B. Jemmott III & G. Anita Heeren To cite this article: Jingwen Zhang, John B. Jemmott III & G. Anita Heeren (2015): Sub-Saharan African University Students' Beliefs about Abstinence, Condom Use, and Limiting the Number of Sexual Partners, Behavioral Medicine, DOI: 10.1080/08964289.2015.1028321 To link to this article: http://dx.doi.org/10.1080/08964289.2015.1028321

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Date: 05 November 2015, At: 18:40

BEHAVIORAL MEDICINE, 0: 1–12, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print / 1940-4026 online DOI: 10.1080/08964289.2015.1028321

Sub-Saharan African University Students’ Beliefs about Abstinence, Condom Use, and Limiting the Number of Sexual Partners Jingwen Zhang Annenberg School for Communication, University of Pennsylvania

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John B. Jemmott III Annenberg School for Communication and Perelman School of Medicine, University of Pennsylvania

G. Anita Heeren Perelman School of Medicine, University of Pennsylvania

Given the high risk of HIV infection among university students in sub-Saharan Africa, there is a need for culturally appropriate risk-reduction interventions specifically targeting this population. Efforts to reduce the risk require an understanding of the modifiable antecedents of sexual-risk behaviors. We report the results of a semi-structured elicitation survey based on the reasoned action approach to identify behavioral, normative, and control beliefs regarding abstinence, condom use, and limiting sexual partners. Two coders classified into 64 belief categories the written responses of 96 sub-Saharan African university students. Most students believed each behavior could reduce risk of HIV infection. The students reported that peer pressure and being in a risky environment made it harder to practice abstinence. Good communication made it easier to use condoms and to limit partners; however, unstable relationships made practicing these protective behaviors harder. The identified beliefs help to inform the development of theory-based HIV risk-reduction interventions.

Keywords: human immunodeficiency virus, sexual behavior, sub-Saharan Africa, survey, university students INTRODUCTION Sub-Saharan Africa, home to nearly 80% of the young people ages 15 to 24 years living with HIV worldwide, remains the region most heavily affected by HIV.1 Heterosexual exposure (ie, heterosexual sexual behavior) is the main mode of HIV transmission in sub-Saharan Africa,2 making behavior changes such as increasing sexual abstinence (ie, not having sexual intercourse), increasing the use of condoms, and limiting the number of sexual partners important Correspondence should be addressed to Dr. John B. Jemmott III, University of Pennsylvania, Perelman School of Medicine, Department of Psychiatry, 3535 Market Street, Suite 520, Philadelphia, PA 19104-3309. E-mail: [email protected]

to efforts to decrease the number of new infections. In South Africa, which has more people living with HIV (estimated 5.6 million) than any other country,2 the HIV prevalence among university students was 3.4%, with even higher prevalence among female (4.7%) and Black African (5.6%) students.3 Main factors affecting HIV infection include sexual risk behaviors and contextual risks such as alcohol and drug abuse.3 In addition, an important challenge in South Africa is that sexual networks with a large percentage of HIV infected individuals may increase the likelihood of individuals’ HIV exposure, even individuals in such networks who are not engaging in any more sexual risk behaviors than individuals in less HIV-saturated sexual networks.4,5 Unprotected intercourse, sex without a latex condom, increases the risk of HIV; reducing the frequency

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of intercourse or increasing the frequency of condom use, theoretically, would reduce unprotected intercourse. Accordingly, in South Africa efforts should be put into designing behavior change interventions that target all three protective behaviors, namely, sexual abstinence, condom use, and limiting sexual partners, to curb the spread of HIV. Despite the high risk of HIV infection among university students in South Africa, only one randomized controlled trial has tested the efficacy of an HIV risk-reduction intervention for this population.6 Hence, there is a need for culturally appropriate HIV risk-reduction interventions specifically targeting university students. Such interventions are likely to be most effective if they influence the modifiable antecedents of sexual-risk behaviors. The reasoned action approach7,8 is a theoretical framework that can be employed to identify modifiable antecedents pertinent in diverse cultural and social contexts. The Theory of Reasoned Action9 and its extension, the Theory of Planned Behavior,10 collectively have been labeled the reasoned action approach.8 Although it might be argued that the approach would be inapplicable to sexual behavior that is often believed to be not “reasoned,” the approach has been applied successfully to explain sexual behavior and to design effective risk-reduction interventions,11,12 including interventions in sub-Saharan Africa.13–15 According to the theory, behavior is primarily determined by intention, which is a function of attitude toward the behavior, subjective norm regarding important others’ approval of the behavior, and perceived self-control to perform the behavior. The approach highlights behavioral beliefs about the consequences of engaging in a behavior that form attitude, normative beliefs about important referents’ approval or disapproval of the behavior that form subjective norm, and control beliefs about factors that may facilitate or inhibit engaging in the behavior that form perceived self-control. Through qualitative and formative research, including elicitation surveys, the salient beliefs in a target population can be identified to inform the development of culturally appropriate HIV risk-reduction interventions.13,16 Interventions that address these identified beliefs will be more likely to influence the target population’s attitude, subjective norm, and perceived self-control, which may lead to behavioral intention and subsequent behavior change. Qualitative studies conducted in South Africa have mainly focused on young adolescents and used interviews and focus group discussions to elicit beliefs.17–20 For instance, previously identified beliefs that could lead to protective behaviors include: abstinence avoids diseases and helps gain independence and personal control in relationships17; condoms are good for preventing infection and carrying condoms indicates taking care of oneself18; and remaining faithful to one’s partner could prevent infection.20 Also, beliefs that could lead to sexual risk behaviors have been discussed, such as: physical urge and curiosity about sex lead to sexual initiation and experimentation21,22;

it is fashionable to be sexually active and those who do not engage in sex may be ridiculed and ostracized by peers; men derive status from having multiple sexual partners.19 Furthermore, gender power imbalances and socioeconomic barriers may play a role in shaping young people’s response efficacy in behavioral decisions.23 For instance, violence and coercion are believed to lead women to unwillingly engage in sex. Condom unavailability in local communities is often cited as a reason for unprotected sex that is out of young people’s control.18 Although these studies provided information on a variety of behavioral beliefs, they did not focus on university students, important normative and control beliefs based on behavior change theories, or whether beliefs differed by sociodemographic variables. We report a semi-structured elicitation survey employing the thought-listing technique to identify behavioral beliefs, normative beliefs, and control beliefs regarding three important sexual risk-reduction behaviors, abstinence, condom use, and limiting the number of sexual partners, among students at a university in South Africa. The primary aim is to identify the students’ behavioral beliefs in order to guide the design of HIV risk-reduction interventions for this population. The student body at the university included not only South Africans, but also a substantial number of students from other sub-Saharan African countries. Beliefs may vary from population to population7; therefore, a secondary purpose of the study is to explore whether beliefs vary by not only students’ nationality, but also students’ sex, age, and self-reported sexual experience.

METHODS Recruitment and Sample Institutional Review Board #8 of the University of Pennsylvania and the Ethical Committee of the University of Fort Hare approved the study. The study was announced in lecture halls and public places at a university in Eastern Cape Province, South Africa, where about 95% of the students were black. Students who were currently registered at the university and at least 18 years of age were eligible to participate and signed an informed consent form before enrollment. Participants self-selected into the study so the sample is a convenience sample. We did not have a list of all students and their information in the university, thus we did not have data to compare the characteristics of the students who enrolled in the study and the students who did not enroll in the study. Procedure and Measure Participants completed a pen-and-paper questionnaire in English that had two sections. The first section asked nine

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COLLEGE STUDENTS’ BELIEFS ON HIV-REDUCTION BEHAVIORS

questions, concerning sociodemographic characteristics (ie, sex, age, nationality, and marital status) and sexual behaviors, including report of ever having sexual intercourse, sexual intercourse in the past three months, multiple sexual partners in the past three months, using a condom at last sexual intercourse, and the sex of sexual partners (see Table 1). The second section was a semi-structured elicitation survey24 employing the thought-listing technique.25 The survey questionnaire contained open-ended questions to elicit participants’ personal behavioral beliefs, normative beliefs, and control beliefs regarding abstinence, condom use, and limiting the number of sexual partners. Thought-listing technique is a method for measuring and categorizing individuals’ immediate thoughts in response to a presented stimulus, in this case, a survey question.25 For each behavior, to elicit behavioral beliefs, we asked participants to list the good things and bad things that would happen if they engaged in the behavior of interest (eg, “Please list the good things that would happen if you practice abstinence”; “Please list the bad things that would happen if you practice abstinence”). To elicit normative beliefs, we asked participants to list the referents who would approve or disapprove of their engaging in the behavior (eg, “Please list those people or groups who think you should always use condoms if you have sexual intercourse”; “Please list those people or groups who think you should not use condoms if you have sexual intercourse”), except in the case of limiting partners where the question about disapproving the behavior was unintentionally

omitted and the question about approving the behavior was unintentionally repeated. To elicit control beliefs, we asked participants to list factors that would facilitate or inhibit their ability to perform the behavior (eg, “Please list the things that would make it easy for you to limit the number of people with whom you have sexual intercourse”; “Please list the things that would make it hard for you to limit the number of people with whom you have sexual intercourse”). Because the study concerned three behavioral determinants (two questions for each) for three protective behaviors, the second section of the questionnaire included a total of 18 open-ended questions. We asked the participants to reflect on their own personal experiences and thoughts when answering the questions. Data Analysis The quantitative demographic and sexual behavior data and written responses were double entered into a database independently by two researchers (the first author and a research assistant) with 100% verification. All written responses were first analyzed by conventional content analysis through the systematic classification process of coding and identifying themes.26 The first and the second authors read through all responses to classify similar ones into broader categories and generated corresponding codes for the categories. Because the elicitation survey responses were shorter list-type of text rather than longer narration-type of text, the codes were straightforward. The English responses from the participants were straightforward and did not

TABLE 1 Descriptive Statistics for Sociodemographic Information and Sexual Behaviors Reported by South African University Students

Variable Mean age, mean (SD) Nationality South African Other Marital status Never married Married Widowed Ever had sexual intercourse Sexual intercourse in the past 3 months Had multiple sexual partners in the past 3 months * Used a condom at last sexual intercourse Had sexual intercourse with Both sex Only same sex

All

Female

Male

Students

Students

Students

(N D 96)

(N D 53)

(N D 43)

Test

n (%)

n (%)

n (%)

Statistics

22.2 (2.3) 62 (64.6) 34 (35.4)

22.0 (2.4) 31 (58.5) 22 (41.5)

22.4 (2.1)

p

a

0.80 1.92b

0.43 0.17

2.51b

0.29

3.44b 0.80b 4.34b 0.06b 1.01b

0.06 0.67 0.04 0.80 0.60

31 (72.1) 12 (27.9)

93 (96.9) 2 (2.1) 1 (1.0) 76 (79.2) 55 (57.3) 16 (16.7) 62 (81.6)

50 (94.3) 2 (3.8) 1 (1.9) 38 (71.7) 30 (56.6) 5 (9.4) 31 (58.5)

43 (100) 0 0 38 (88.4) 25 (58.1) 11(25.6) 31 (72.1)

2 (2.1) 1(1.0)

1 (1.9) 1 (1.9)

1 (2.3) 0

Notes. Unless specified as mean (SD), the cell represents n (%). *The percentage of students using a condom at last sexual intercourse was calculated based on the number of students who ever had sexual intercourse. a Test statistic is t statistic. b Test statistic is x2 statistic.

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involve any cultural slangs or idioms. For example, for behavioral beliefs regarding good things about abstinence, responses such as “I would be free from the risk of getting HIV”; “You will not have high chances of getting HIV/ AIDS”; “Safe from getting viruses and diseases” (ie, HIV, STDs, etc.) were coded as “reduce risks of HIV/AIDS and STDs”. Table 2 provides a complete list of participants’ responses for a code to further illustrate this coding method. Several iterations of the classification process were taken until no more new codes could be generated. The first and the second authors agreed upon the codes. The second author and the third author validated the codes. The second author has experience conducting HIV research in subSaharan African for more than 10 years and the third author lived in South Africa for over 12 years. This procedure yielded 64 codes representing distinctive behavioral, normative, and control beliefs for each of the three protective behaviors. The number of codes in the study is comparable to previous studies employing the same method.24,27,28 Following Middlestadt and colleagues’ recommendation,24 we used participants’ own words as the codes. According to the thought-listing technique,29 mentioning a belief in response to the question indicates that belief is salient to the participant. Thus, to map the cognitive structure of each participant, we then coded each participant’s responses for each belief as a binary variable indicating whether the participant mentioned that specific belief (1) or not (0). The first author coded all participants’ responses according to the 64 codes first and trained a research assistant to code the dataset again independently. Comparing the coding results, we reached a satisfactory level of agreement, with the Cohen’s Kappa ranging from 0.70 to 1.00. A simple frequency analysis was applied to summarize the frequency of codes in each belief category, namely behavioral, normative, and control. The frequency of coded beliefs mentioned by participants varied to a great extent, ranging from 1 (1%) to 94 (97.9%) of participants, meaning some coded beliefs were mentioned by only 1% of all

TABLE 2 List of Participants’ Responses Coded as “Harm Romantic Relationship” as a Behavioral Belief about Abstinence 1 “Loving someone who has experience of sex and criticizing you. Your romantic relationship threatened because of you lacking experience.” 2 “Abstinence would deprive the pleasure of being in a sexual, romantic relationship.” 3 “Disagreement between me and my partner if one wants to have sex. Bitterness which will lead to break-ups.” 4 “Being screwed up with girls.” 5 “You might end up having no boyfriend if you had one.” 6 “You might not get a boyfriend because you don’t have experience.” 7 “Losing chances of a relationship.” 8 “Could lose your sexual partner.” 9 “If your partner is into sex you’ll lose him/her.” 10 “My girlfriend would probably leave me.”

participants whereas some others were mentioned by almost all participants. In this article, we report only common beliefs that were based on codes with relative high frequencies (above 8%) within each belief category. The 8% criteria was purposefully set because we wanted to present at least two important beliefs for each question. To map participants’ belief structure, we used Chi-square to explore whether sex (female or male), age (more than 22 years or 22 years or less; 22 was the mean and also the median age), nationality (South Africans or non-South Africans), and self-reported sexual experience (had sexual experience or had no sexual experience) were associated with whether participants listed each belief. Fisher’s exact tests were applied to correct the Chi-square significance levels when certain beliefs were mentioned too few times. In addition, we conducted logistic regression analysis, with each belief as the outcome and sex, age, nationality, and self-reported sexual experience as the predictors. Chi-square and logistic regression analysis were performed using STATA (Stata Statistical Software v12, StataCorp. 2011).

RESULTS The participants were 96 self-identified Black students, of whom 55.2% were female. As shown in Table 1, 64.6% were South Africans and 35.4% were citizens of other subSaharan African countries. Participants ranged in age from 18 to 29 years (mean D 22), and 41.7% were more than 22 years of age. About 79.2% reported ever having sexual intercourse, 57.3% reported having sex in the past three months, and 16.7% reported having multiple sexual partners in the past three months. Only two participants reported having sex with both men and women. About 81.6% of sexually experienced participants reported using a condom at last sex. More men than women reported having multiple partners in the past three months. More South Africans (87.1%) than other nationals (66.7%) reported sexual experience (p D .02), and more South Africans (88.9%) than other nationals (66.7%) reported using a condom at last sex (p D .02). Abstinence Table 3 presents 28 common beliefs identified regarding abstinence and the significance levels for the Chi-square tests on the associations between sex, age, nationality, and self-reported sexual experience and the abstinence-related behavioral, normative, and control beliefs. Behavioral Beliefs Participants believed abstinence reduced the risks of pregnancy and contracting HIV/AIDS and other STDs, promoted good health, and reduced stress. Although a plurality

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COLLEGE STUDENTS’ BELIEFS ON HIV-REDUCTION BEHAVIORS TABLE 3 Beliefs about Abstinence Reported by South African University Students N D 96 Female

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Beliefs about abstinence Good things about abstinence Reduce risks of HIV/AIDS and STDs Avoid pregnancy Promote good health Feel less stress Bad things about abstinence Nothing Get pregnancy, HIV/AIDS, and STDs Suffer from peer pressure Harm romantic relationship Generate sex craving Lack sex knowledge and experience Who thinks you should abstain Parents Religious leaders Teens Friends Other family members Teachers, doctors, nurses, health workers Who thinks you should not abstain Friends Girlfriend/boyfriend What makes it easy to practice abstinence Receive education Manage peer pressure Go to church Avoid risky environment Being single Have life goal, self-control and confidence What makes it hard to practice abstinence Peer pressure Being in risky environment Being afraid of losing one’s partner Good relationship or cohabitation

N (%)

Male

Old

N D 53 N D 43

p

Young

N D 40 N D 56

SA p

Non-SA

N D 62 N D 34

Sex p

No-Sex

N D 76 N D 20

p

90(93.8) 53(55.2) 18(18.8) 17(17.7)

50(94.3) 37(69.8) 4(7.6) 4(7.6)

40(93.0) 16(37.2) 14(32.6) 13(30.2)

0.99 0.002 0.003 0.006

37(92.5) 20(50.0) 10(25.0) 10(25.0)

53(94.6) 33(58.9) 8(14.3) 7(12.5)

0.691 0.412 0.198 0.174

59(95.2) 35(56.5) 12(19.4) 10(16.1)

31(91.2) 18(52.9) 6(17.7) 7(20.6)

0.662 0.831 0.99 0.588

72(94.7) 43(56.6) 16(21.1) 14(18.4)

18(90.0) 10(50.0) 2(10.0) 3(15.0)

0.601 0.622 0.347 0.99

26(27.1) 19(19.8) 12(12.5) 10(10.4) 10(10.4) 10(10.4)

18(34.0) 13(24.5) 5(9.4) 6(11.3) 4(7.6) 5(9.4)

8(18.6) 6(14.0) 7(16.3) 4(9.3) 6(14.0) 5(11.6)

0.110 0.303 0.363 0.99 0.335 0.749

14(35.0) 9(22.5) 3(7.5) 1(2.5) 5(12.5) 1(2.5)

12(21.4) 10(17.9) 9(16.1) 9(16.1) 5(8.9) 9(16.1)

0.166 0.611 0.348 0.042 0.737 0.042

14(22.6) 14(22.6) 8(12.9) 7(11.3) 7(11.3) 8(12.9)

12(35.3) 5(14.7) 4(11.8) 3(8.8) 3(8.8) 2(5.9)

0.231 0.430 0.99 0.99 0.99 0.486

23(30.3) 16(21.1) 10(13.2) 6(7.9) 10(13.2) 6(7.9)

3(15.0) 3(15.0) 2(10.0) 4(20.0) 0(0.0) 4(20.0)

0.259 0.755 0.99 0.209 0.115 0.209

33(34.4) 27(28.1) 24(25.0) 14(14.6) 12(12.5) 12(12.5)

20(37.7) 19(35.9) 10(18.9) 12(22.6) 11(20.8) 5(9.4)

13(30.2) 8(18.6) 14(32.6) 2(4.7) 1(2.3) 7(16.3)

0.519 0.071 0.157 0.018 0.010 0.363

12(30.0) 11(27.5) 9(22.5) 6(15.0) 4(10.0) 3(7.5)

21(37.5) 16(28.6) 15(26.8) 8(14.3) 8(14.3) 9(16.1)

0.517 0.99 0.811 0.99 0.756 0.348

22(35.5) 15(24.2) 16(25.8) 8(12.9) 8(12.9) 7(11.3)

11(32.4) 12(35.3) 8(23.5) 6(17.7) 4(11.8) 5(14.7)

0.825 0.343 0.99 0.556 0.99 0.749

28(36.8) 22(29.0) 16(21.1) 10(13.2) 9(11.8) 9(11.8)

5(25.0) 5(25.0) 8(40.0) 4(20.0) 3(15.0) 3(15.0)

0.430 0.99 0.091 0.481 0.710 0.710

38(39.6) 24(45.3) 14(32.6) 0.217 15(37.5) 23(41.1) 0.833 24(38.7) 14(41.2) 0.830 33(43.4) 5(25.0) 0.199 8(8.3) 7(13.2) 1(2.3) 0.071 2(5.0) 6(10.7) 0.462 5(8.1) 3(8.8) 0.99 7(9.2) 1(5.0) 0.99 21(21.9) 21(21.9) 21(21.9) 18(18.8) 14(14.6) 13(13.5)

11(20.8) 15(28.3) 9(17.0) 11(20.8) 6(11.3) 10(18.9)

10(23.3 6(14.0) 12(27.9) 7(16.3) 8(18.6) 3(7.0)

0.808 0.136 0.223 0.611 0.388 0.134

8(20.0) 9(22.5) 12(30.0) 5(12.5) 6(15.0) 8(20.0)

13(23.2) 12(21.4) 9(16.1) 13(23.2) 8(14.3) 5(8.9)

0.805 0.99 0.134 0.289 0.99 0.139

9(14.5) 13(21.0) 13(21.0) 9(14.5) 12(19.4) 6(9.7)

12(35.3) 8(23.5) 8(23.5) 9(26.5) 2(5.9) 7(20.6)

0.037 0.800 0.800 0.177 0.128 0.211

15(19.7) 16(21.1) 17(22.4) 13(17.1) 13(17.1) 9(11.8)

6(30.0) 5(25.0) 4(20.0) 5(25.0) 1(5.0) 4(20.0)

0.366 0.763 0.99 0.520 0.288 0.461

34(35.4) 22(22.9) 15(15.6) 14(14.6)

20(37.7) 11(20.8) 12(22.6) 4(7.6)

14(32.6) 11(25.6) 3(7.0) 10(23.3)

0.670 0.630 0.048 0.042

15(37.5) 12(30.0) 5(12.5) 5(12.5)

19(33.9) 10(17.9) 10(17.9) 9(16.1)

0.829 0.219 0.575 0.772

20(32.3) 9(14.5) 12(19.4) 11(17.7)

14(41.2) 13(38.2) 3(8.8) 3(8.8)

0.504 0.011 0.243 0.366

29(38.2) 14(18.4) 12(15.8) 13(17.1)

5(25.0) 8(40.0) 3(15.0) 1(5.0)

0.308 0.069 0.99 0.288

Notes. The cell represents n (%). Numbers in bold are p-values < 0.05. All p values are based on x2 statistics of Fisher-Exact Test. Female refers to female students, Male refers to male students; Old refers to students who are older than 22, Young refers to students who are 22 or younger; SA refers to South African, Non-SA refers to non-South African; Sex refers to students who ever had sexual intercourse, No-Sex refers to students who never had sexual intercourse.

of participants indicated there was nothing bad about abstinence (27.1%), almost one fifth indicated abstinence could cause pregnancy and infection with HIV/AIDS and other STDs, 12.5% indicated practicing abstinence would make them suffer from peer pressure, and about 10% indicated it harmed romantic relationships, generated sex cravings, and led to a lack of sex knowledge and experience. Women more frequently mentioned avoiding pregnancy (OR D 4.56; 95% CI, 1.83–11.37) but less frequently mentioned promoting good health (OR D 0.19; 95% CI, 0.05– 0.63) and stress reduction (OR D 0.18; 95% CI, 0.05–0.64) as the benefits of abstinence than did men. Compared with younger participants, those who were more than 22 years of age less frequently mentioned that abstinence harmed

romantic relationships (OR D 0.10; 95% CI, 0.01–0.99). Participants who reported sexual experience mentioned less frequently that abstinence led to a lack of sex knowledge (OR D 0.16; 95% CI, 0.03–0.92) compared with their counterparts who reported no sexual experience. Normative Beliefs Many students indicated parents (34.4%) and religious leaders (28.1%) as referents approving of them practicing abstinence and friends (39.6%) as referents discouraging abstinence. Interestingly, women more frequently identified friends (OR D 5.80; 95% CI, 1.19–28.24) and family members (OR D 11.54; 95% CI, 1.39–96.03) as referents who

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would approve of their practicing abstinence than did men. Participants who reported sexual experience mentioned less frequently that teens thought the participants should abstain (OR D 0.26; 95% CI, 0.08–0.87) compared with their counterparts who reported no sexual experience.

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Control Beliefs On control beliefs, as factors that would make it easier to practice abstinence, participants mentioned receiving education (21.9%), managing peer pressure (21.9%), and going to church (21.9%) most frequently, followed by avoiding risky environments (18.8%), being single (14.6%), and having life goals and self-control (13.5%). Peer pressure (35.4%) was mentioned by a plurality of participants as a factor inhibiting abstinence, followed by being in risky environments (22.9%), being afraid of losing their partners (15.6%), and having a good relationship or cohabiting with a partner (14.6%). Female participants more frequently cited being afraid of losing their partners as a control belief inhibiting abstinence (OR D 4.73; 95% CI, 1.18–18.96) than did male

participants. Compared with younger participants, those who were more than 22 years of age less frequently listed avoiding risky environments facilitated abstinence (OR D 0.23; 95% CI, 0.06–0.92). South Africans less frequently mentioned receiving education (OR D 0.17; 95% CI, 0.05– 0.64) and avoiding risky environments (OR D 0.25; 95% CI, 0.07–0.94) as factors that facilitated their ability to practice abstinence than did other nationals. Condom Use As shown in Table 4, we identified 19 beliefs regarding condom use. Behavioral Beliefs A large majority of participants listed the benefits of using condoms in preventing HIV/AIDS and other STDs and unwanted pregnancy. A plurality of participants listed there was nothing bad about using condoms (28.1%), but about one-fifth of the participants listed using condoms would cause HIV/AIDS and other STDs, about 15% listed

TABLE 4 Beliefs about Condom Use Reported by South African University Students

Beliefs about condom use Good things about condom use Reduce risks of HIV/AIDS and STDs Prevent unplanned pregnancy Bad things about condom use Nothing Get HIV/AIDS and STDs Condoms are not 100% safe Get unwanted pregnancy Reduce the joy of sex Who thinks you should use condoms Friends Family members Health workers Who thinks you should not use condoms No one Friends and bad peers What makes it easy to use condoms Good communication Availability of good quality condoms Being educated Being conscientious What makes it hard to use condoms Lack of agreement Unavailability of condoms Get drunk and use drugs

N D 96

Female

Male

N (%)

N D 53

N D 43

Old p

Young

N D 40 N D 56

SA p

Non-SA

N D 62 N D 34

Sex p

No-Sex

N D 76 N D 20

p

94(97.9) 53(100.0) 41(95.4) 0.198 39(97.5) 55(98.2) 0.99 60(96.8) 34(100) 0.538 74(97.4) 20(100) 0.99 83(86.5) 48(90.6) 35(81.4) 0.237 34(85.0) 49(87.5) 0.768 53(85.5) 30(88.2) 0.99 68(89.5) 15(75.0) 0.136 0.178 17(42.5) 10(17.9) 0.011 16(25.8) 0.138 7(17.5) 13(23.2) 0.613 14(22.6) 0.149 5(12.5) 9(16.1) 0.772 5(8.1) 0.388 4(10.0) 10(17.9) 0.383 13(21.0) 0.335 4(10.0) 6(10.7) 0.99 6(9.7)

27(28.1) 18(34.0) 20(20.8) 8(15.1) 14(14.6) 5(9.4) 14(14.6) 6(11.3) 10(10.4) 4(7.6)

9(20.9) 12(27.9) 9(20.9) 8(18.6) 6(14.0)

11(32.4) 6(17.7) 9(26.5) 1(2.9) 4(11.8)

0.636 0.612 0.031 0.017 0.739

22(29.0) 5(25.0) 0.99 13(17.1) 7(35.0) 0.119 10(13.2) 4(20.0) 0.481 11(14.5) 3(15.0) 0.99 8(10.5) 2(10.0) 0.99

35(36.5) 20(37.7) 32(33.3) 23(43.4) 21(21.9) 12(22.6)

15(34.9) 0.833 17(42.5) 18(32.1) 0.390 23(37.1) 12(35.3) 0.99 27(35.5) 9(20.9) 0.029 11(27.5) 21(37.5) 0.382 23(37.1) 9(26.5) 0.367 27(35.5) 9(20.9) 0.990 9(22.5) 12(21.4) 0.99 10(16.1) 11(32.4) 0.076 17(22.4)

8(40.0) 0.796 5(25.0) 0.435 4(20.0) 0.99

28(29.2) 15(28.3) 17(17.7) 11(20.8)

13(30.2) 0.99 14(35.0) 14(25.0) 0.363 16(25.8) 12(35.3) 0.355 20(26.3) 6(14.0) 0.432 2(5.0) 15(26.8) 0.006 12(19.4) 5(14.7) 0.781 13(17.1)

8(40.0) 0.273 4(20.0) 0.749

30(31.3) 20(37.7) 24(25.0) 13(24.5) 18(18.8) 10(18.9) 10(10.4) 3(5.7)

10(23.3) 11(25.6) 8(18.6) 7(16.3)

9(45.0) 3(15.0) 4(20.0) 1(5.0)

27(28.1) 16(30.2) 14(14.6) 8(15.1) 10(10.4) 6(11.3)

11(25.6) 0.655 10(25.0) 17(30.4) 0.648 21(33.9) 6(14.0) 0.99 3(7.5) 11(19.6) 0.143 9(14.5) 4(9.3) 0.99 7(17.5) 3(5.4) 0.088 4(6.5)

0.184 14(35.0) 16(28.6) 0.513 16(25.8) 14(41.2) 0.167 21(27.6) 0.99 11(27.5) 13(23.2) 0.641 11(17.7) 13(38.2) 0.047 21(27.6) 0.99 8(20.0) 10(17.9) 0.797 8(12.9) 10(29.4) 0.059 14(18.4) 0.106 3(7.5) 7(12.5) 0.514 8(12.9) 2(5.9) 0.486 9(11.8) 6(17.7) 0.103 22(29.0) 5(14.7) 0.99 11(14.5) 6(17.7) 0.159 7(9.2)

0.176 0.384 0.99 0.682

5(25.0) 0.99 3(15.0) 0.99 3(15.0) 0.430

Notes. The cell represents n (%). Numbers in bold are p-values < 0.05. All p values are based on x2 statistics of Fisher-Exact Test. Female refers to female students, Male refers to male students; Old refers to students who are older than 22, Young refers to students who are 22 or younger; SA refers to South African, Non-SA refers to non-South African; Sex refers to students who ever had sexual intercourse, No-Sex refers to students who never had sexual intercourse.

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that condoms were not 100% safe and could result in unwanted pregnancy, and about 10% listed that condom use would reduce the joy of sex. Women less frequently mentioned that condom use would cause HIV infection (OR D 0.32; 95% CI, 0.10– 0.99) and condoms were not 100% safe (OR D 0.13; 95% CI, 0.03–0.69) than did men. Participants who were more than 22 years of age more frequently mentioned nothing was bad about condom use (OR D 4.35; 95% CI, 1.50– 12.59) and less frequently mentioned condoms were not 100% safe (OR D 0.12; 95% CI, 0.02–0.77), than did younger participants. South Africans more frequently mentioned condoms would cause unwanted pregnancy (OR D 10.43; 95% CI, 1.08–101.19), but less frequently mentioned condoms were not 100% safe (OR D 0.05; 95% CI, 0.01–0.36), than did other nationals. Participants reporting sexual experience more frequently mentioned using condoms could prevent unwanted pregnancy (OR D 5.10; 95% CI, 1.14– 22.88) but less frequently mentioned that condom would cause HIV infection (OR D 0.21; 95% CI, 0.06–0.79) compared with their counterparts with no sexual experience. Normative Beliefs Participants thought friends (36.5%), family members (33.3%), and health workers (21.9%) were referents approving condom use, whereas friends and some bad peers (17.7%) would disapprove it. Women more frequently cited family members (OR D 3.58; 95% CI, 1.36–9.48) as people who wanted them to use condoms than did men. Other nationals more frequently mentioned health workers as encouraging condom use (OR D 3.45; 95% CI, 1.04–11.11) than did South Africans. Younger participants more frequently mentioned friends and bad peers as discouraging condom use (OR D 8.33; 95% CI, 1.54–50) than did participants who were more than 22 years of age. Control Beliefs A plurality of participants expressed the positive control belief that good communication could facilitate condom use (31.3%). Large percentages also listed the availability of good quality condoms (25.0%) and being educated about using condoms (18.8%) as facilitators of condom use. Participants indicated that the primary obstacle to condom use was a lack of agreement between partners (28.1%), followed by condom unavailability (14.6%), and alcohol and drug use (10.4%). South Africans less frequently mentioned condom availability (OR D 0.21; 95% CI, 0.06–0.70) and being educated (OR D 0.26; 95% CI, 0.07–0.94) as factors making condom use easier than did other nationals. Limiting the Number of Sexual Partners We identified 17 beliefs regarding limiting sexual partners, as shown in Table 5.

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Behavioral Beliefs The most frequently identified good consequence of limiting partners was that it lowered the risks of contracting HIV/AIDS and other STDs. Participants also listed that limiting partners lowered chances of unwanted pregnancy, reduced stress, and led to a good relationship and marriage. A plurality of participants listed there was nothing bad about limiting the number of sexual partners, but 15.6% listed limiting the number of partners would increase infections with HIV/AIDS and other STDs. South African participants less frequently mentioned limiting partners reduced risks of contracting HIV/AIDS and other STDs (OR D 0.18; 95% CI, 0.04–0.77) and limiting partners reduced stress (OR D 0.17; 95% CI, 0.04–0.71), than did other nationals. Normative Beliefs Participants listed a diverse group of people who would approve of their limiting partners, including parents, friends, health workers, other family members, and church people. South Africans less frequently listed church people as encouraging limiting partners (OR D 0.07; 95% CI, 0.01–0.42) than did other nationals. Control Beliefs Having a committed relationship and good communication was the primary control belief facilitating students’ ability to limit partners, mentioned by 27.1% of the participants, whereas 16.7% listed a long distance or unstable relationship inhibited limiting sexual partners. Participants also listed that management of peer pressure and receiving education were important in facilitating limiting partners. South Africans less frequently mentioned having commitment and good communication as facilitating limiting partners (OR D 0.17; 95% CI, 0.05–0.59) than did other nationals. Sex, age, and self-reported sexual experience were not associated with any beliefs about limiting partners.

DISCUSSION This study revealed salient behavioral beliefs, normative beliefs, and control beliefs about abstinence, condom use, and limiting the number of sexual partners among subSaharan African university students. The primary behavioral belief about these behaviors concerned reducing the risk of HIV, other STDs, and pregnancy, which other studies have termed “prevention beliefs.”30–32 A variety of behavioral beliefs indicating negative consequences of each behavior were also identified, but a plurality of participants believed there were no negative consequences. The perceived negative consequences of abstaining included peer pressure to have sex, harm to the relationship,

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ZHANG ET AL. TABLE 5 Beliefs about Limiting the Number of Partners Reported by South African University Students N D 96 Female

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Beliefs about limiting partners Good things about limiting partners Reduce risks of HIV/AIDS and STDs Lower chances of unwanted pregnancy Reduce stress Have a good relationship and marriage Bad things about limiting partners Nothing Increase infections with HIV/AIDS and STDs Who thinks you should limit partners Parents Friends Health workers Other family members Church people What makes it easy to limit partners Have a committed relationship and good communication Avoid negative peer pressure Being educated What makes it hard to limit partners In a long distance or unstable relationship Have peer pressure Nothing

N (%)

75(78.1) 17(17.7) 16(16.7) 15(15.6)

Male

Old

N D 53 N D 43

40(75.5) 11(20.8) 7(13.2) 6(11.3)

35(81.4) 6(14.0) 9(20.9) 9(20.9)

p

0.621 0.432 0.411 0.261

Young

N D 40 N D 56

33(82.5) 5(12.5) 7(17.5) 6(15.0)

42(75.0) 12(21.4) 9(16.1) 9(16.1)

SA p

0.458 0.292 0.99 0.99

Non-SA

N D 62 N D 34

44(71.0) 12(19.4) 7(11.3) 11(17.7)

31(91.2) 5(14.7) 9(26.5) 4(11.8)

Sex p

0.023 0.781 0.084 0.563

No-Sex

N D 76 N D 20

60(79.0) 14(18.7) 14(18.4) 11(14.5)

15(75.0) 3(17.7) 2(10.0) 4(20.0)

p

0.763 0.99 0.510 0.508

44(45.8) 26(49.1) 18(41.9) 0.540 20(50.0) 24(42.9) 0.537 23(37.1) 21(61.8) 0.032 32(42.1) 12(60.0) 0.208 15(15.6) 11(20.8) 4(9.3) 0.162 6(15.0) 9(16.1) 0.99 11(17.7) 4(11.8) 0.563 11(14.5) 4(20.0) 0.508

24(25.0) 23(24.0) 16(16.7) 15(15.6) 11(11.5)

12(22.6) 16(30.2) 7(13.2) 11(20.8) 8(15.1)

12(27.9) 7(16.3) 9(20.9) 4(9.3) 3(7.0)

0.638 0.150 0.411 0.162 0.335

10(25.0) 12(30.0) 9(22.5) 5(12.5) 6(15.0)

14(25.0) 11(19.6) 7(12.5) 10(17.9) 5(8.9)

0.99 0.332 0.267 0.575 0.517

15(24.2) 13(21.0) 8(12.9) 9(14.5) 2(3.2)

9(26.5) 10(29.4) 8(23.5) 6(17.7) 9(26.5)

0.810 0.454 0.252 0.771 0.001

21(27.6) 19(25.0) 14(18.4) 13(17.1) 9(11.8)

3(15.0) 4(20.0) 2(10.0) 2(10.0) 2(10.0)

0.384 0.774 0.510 0.730 0.99

26(27.1) 14(26.4) 12(27.9) 0.99 10(25.0) 16(28.6) 0.817 12(19.4) 14(41.2) 0.030 21(27.6) 5(25.0) 0.99 14(14.6) 10(18.9) 4(9.3) 0.249 5(12.5) 9(16.1) 0.772 8(12.9) 6(17.7) 0.556 12(15.8) 2(10.0) 0.727 13(13.5) 7(13.2) 6(14.0) 0.99 7(17.5) 6(10.7) 0.376 5(8.1) 8(23.5) 0.058 9(11.8) 4(20.0) 0.461 16(16.7) 12(22.6) 4(9.3) 0.102 5(12.5) 11(19.6) 0.415 11(17.7) 5(14.7) 0.782 14(18.4) 2(10.0) 0.510 11(11.5) 9(17.0) 2(4.7) 0.104 5(12.5) 6(10.7) 0.99 4(6.5) 7(20.6) 0.049 9(11.8) 2(10.0) 0.99 11(11.5) 4(7.6) 7(16.3) 0.211 6(15.0) 5(8.9) 0.517 9(14.5) 2(5.9) 0.318 10(13.2) 1(5.0) 0.449

Notes. The cell represents n (%). Numbers in bold are p-values < 0.05. All p values are based on x2 statistics of Fisher-Exact Test. Female refers to female students, Male refers to male students; Old refers to students who are older than 22, Young refers to students who are 22 or younger; SA refers to South African, Non-SA refers to non-South African; Sex refers to students who ever had sexual intercourse, No-Sex refers to students who never had sexual intercourse.

unrequited cravings for sex, and missed opportunities for sexual knowledge and experience. A perceived negative consequence of condom use was reduced sexual enjoyment, which dovetails with the “hedonistic beliefs” examined in previous research.30,33–36 Curiously, some students mentioned that an increased probability of unwanted pregnancy and infection with HIV and other STDs were negative consequences of abstinence, condom use, and limiting partners. Many of the students who held these beliefs concurrently held the belief that the behaviors reduce sexual risks: for instance, all 19 students who mentioned increased risk of pregnancy, HIV/AIDS, and STDs was a consequence of abstinence also mentioned that abstinence reduced the risks of HIV/AIDS and STDs and 15 mentioned it avoided pregnancy. Similarly, 18 of the 20 students who mentioned that getting HIV/AIDS and STDs was a consequence of condom use also mentioned that condom use reduced the risks of HIV/AIDS and STDs, and 11 of the 14 who mentioned that getting pregnant was a consequence of condom use also mentioned that condom use prevented unplanned pregnancy. Finally, 12 of the 15 who mentioned that increased risk of HIV/AIDS and STDs was a consequence of limiting partners also mentioned that

limiting partners reduced the risks of HIV/AIDS and STDs. We do not fully understand how these students might have been reasoning. It is possible that these student simply misunderstood the questions, held misperceptions,37 or they might have reasoned that each protective behavior had a failure rate and was not always 100% effective in different situations. Future research must examine these questions in more depth to understand students’ reasoning processes that lead to behavior decisions. This study also highlighted normative beliefs. Although parents and other family members were consistently mentioned as referents approving each of the behaviors, some normative beliefs differed for abstinence compared to the other behaviors. Health workers and friends were seen as approving of condom use and limiting partners, but health workers were not mentioned as approving abstinence and friends were seen as disapproving of abstinence. Also evident was the influence of religion, with religious leaders seen as approving abstinence and church people seen as approving limiting sexual partners. Interestingly, participants did not mention their sexual partners in response to the normative belief question about limiting sexual partners. This may be due to the fact that students seldom

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COLLEGE STUDENTS’ BELIEFS ON HIV-REDUCTION BEHAVIORS

discussed sexual life histories with their sexual partners38 so they did not know the partners’ opinions. Some control beliefs about the behaviors were similar: education was seen as facilitating the ability to abstain, use condoms, and limit partners; good communication was seen as facilitating using condoms and limiting partners; managing peer pressure was seen as important to practicing abstinence and limiting partners. However, participants listed a large number of other control beliefs regarding abstinence, most of which differed from those regarding the other two behaviors. Avoiding risky situations, a control belief that was an important mediator of the effects of an HIV risk-reduction intervention on sexual intercourse among South African adolescents,15 was mentioned as strengthening the ability to practice abstinence, as were beliefs about church attendance, being single, having life goals and self-control. In contrast, beliefs such as fear of losing a partner and having a good relationship and cohabiting with a partner were mentioned as decreasing the ability to practice abstinence. Alcohol and drug use was mentioned as interfering with practicing abstinence and condom use, which dovetails with research on the relation of alcohol use to condom use39 and infection with HIV.40 Moreover, many participants mentioned that the unavailability of good quality condoms made condom use difficult. A recent study41 suggests an explanation of this observation, finding that students at a South African university perceived the easily accessible public-sector condoms as “ineffective, smelly and even ‘infectious’” and generally lower in status than commercial brands of condoms. The cost of the commercial condoms and the misperceptions associated with the public-sector condoms may together contribute to the perceived barrier in using condoms. Besides qualitatively identifying a large set of beliefs, this study also quantitatively analyzed the relations of the beliefs to sociodemographic variables. Sex, the factor most frequently associated with participants’ beliefs about abstinence in this study, was a less prominent correlate of beliefs about condom use. Although women more frequently mentioned that they were afraid of losing their partners if they insisted on abstinence than did men, women and men were equally likely to mention good communication and agreement to use condoms as facilitating condom use. The latter lack of differences regarding beliefs about using condoms is surprising when juxtaposed with research suggesting that gender-based power inequalities in South Africa render women less capable of controlling their sexual behaviors18,42–45 and increase their risk for unprotected sex and HIV infection.46 In not confirming women’s relative lack of power to use condoms, the present study suggests the larger picture of gender inequality may be very different for university students compared with other youth populations, a difference that may be due to female students’ education and independence received in the university or the characteristics of the subpopulation of women who attend university.

9

There were few important age or nationality differences in regard to participants’ beliefs. Younger participants more frequently mentioned risky environments as an obstacle to abstinence and more frequently mentioned their friends as normative referents disapproving of using condoms. This observation may be explained by previous research showing risk taking and risky decision making decreased with age due to decreased conformity to peer influence.47 The most important observed difference regarding nationality was on beliefs about religion. Non-South African participants frequently listed church people and religious groups in their responses. In addition, non-South African students were also more likely to report receiving education as facilitating their ability to practice abstinence and use condoms than were South African students. Sexual experience has direct influence on experiential beliefs, beliefs in personal and social consequences, beliefs in others’ reactions, and beliefs in perceived self-control.48 Perhaps because of direct experiences, sexually experienced participants were less likely to list certain beliefs, especially potential misperceptions. Sexually experienced participants were less likely to list that abstinence led to lack of sex knowledge, that teens thought the participants should abstain, and that condom use caused HIV infection than were those who reported no sexual experience. In addition, sexually experienced participants were more likely to mention condoms prevented pregnancy. The present findings should be considered in light of the limitations of the study. The students wrote very short responses and did not provide specific reasons that explained their beliefs in depth. For instance, they listed “reduce stress” and “have a good relationship and marriage” as good things about limiting partners, however, they did not provide detailed explanations for making these connections. To address these beliefs in interventions, researchers and facilitators need to probe students’ reasons through interviews or focus group discussions and guide them through the reasoning processes to make sure they fully understand the benefits of safer sex practices. In addition, the convenience sample from a specific university does not generalize to all university students in sub-Saharan Africa. Participants were recruited on a specific campus; thus, the specific campus environment, student culture, or existing health education programs might have preconditioned the beliefs or affected the associations between beliefs and sociodemographic factors that we observed. Given the nature of the convenience sample, there is also the concern about self-selection bias. Without a list of all students and their information in the university, we did not know any specific characteristics or sexual norms that might have discouraged certain students from enrolling into the study. For instance, we did not have data on these students’ HIV status and did not ask this question in the survey questionnaire. The quantitative results should be interpreted only as information that suggests future examination using more robust methodologies and

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ZHANG ET AL.

statistical controls. Because the aim of the research is to explore how students’ beliefs differ by sociodemographic characteristics, we did not use Type 1 error–adjusted significance probabilities for the chi-square and logistic regressions. Lastly, there was a mistake in the questionnaire where the question about disapproving limiting sexual partners was unintentionally omitted and the question about approving the behavior was unintentionally repeated. We did not get beliefs on who would disapprove limiting sexual partners. Notwithstanding these limitations, our explorative results presented in the tables provide valuable insights for formulating more refined hypotheses for future research. Besides the abovementioned methodological limitations, it is also important to acknowledge the limitation of the reasoned action approach. Although this theoretical framework has been successfully employed in guiding the design of several effective HIV risk-reduction interventions in subSaharan Africa,6,14,49 it is still an individual-based approach that focuses on cognitive determinants of behavior. It does not consider the roles of perceived vulnerability, emotions, and subconscious processes50 in driving the behavior51 and it does not consider higher-level structural determinants of HIV risks, such as social networks.52 Because our research focuses on individual students and their protective behaviors, the use of the reasoned action approach and the sets of beliefs identified based on students’ responses should serve as the core evidence for developing culturally appropriate interventions. Future research can build upon this approach and add in evidence-based intervention elements addressing the other important factors.

CONCLUSIONS The findings from this study have important implications for those who would develop HIV risk-reduction interventions for university students in sub-Saharan Africa. The full set of 64 beliefs provides a starting point for designing intervention messages and activities. Especially for developing theory-based interventions, researchers can select beliefs and test their relations to behavioral intentions and outcomes. The fact that we found relatively few differences in beliefs held by different sociodemographic groups suggests the possibility of developing a generic sexual riskreduction intervention that focuses on the identified beliefs in this study, one that would be applicable in a variety of subgroups of sub-Saharan African university students. Such a generic intervention should cover topics related to personal wellbeing, intimate relationships, and peer pressure. Emphasis should be put on enhancing communication and negotiation skills between sexual partners and among friends, changing social norms, and lowering behavioral barriers at the structural and institutional level. This study also informs the development of targeted or tailored interventions that could employ more personally

relevant messages and activities based on the salient beliefs identified in specific subgroups of students. For example, to address the obstacles to practicing abstinence, researchers might craft different messages depending on different perceived normative pressures for male (eg, collective normative pressure from their peers) and female students (eg, specific pressure from their intimate partners). To address the obstacles in limiting the number of partners, researchers may need to have a thorough understanding and acknowledgement of students’ diverse religious backgrounds, recognizing that discussions on religious beliefs and sexual behaviors may be more effective for non-South African students than for South African students. In conclusion, the present study identified a set of beliefs on three important risk-reduction behaviors based on the reasoned action approach. Further research should explore students’ reasoning for holding specific beliefs, which would contribute to explaining some of the findings in this study in more depth. To develop practical education and intervention programs, researchers also need to test these beliefs in their targeted population and refine specific messages and programs accordingly.

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