Sexual behaviour among study participants
All (100.0%,
n = 471) study participants had prior sexual encounter within the past 12 months, with 86.8% (
n = 409) reporting sexual encounter within the last 3 months preceding the survey (Table
2). More than a third of participants (37.2%,
n = 175) experienced sexual encounter before reaching 18 years of age. There was an almost equal distribution between women who used a condom at the last sexual encounter (49.7%,
n = 234) versus those who did not use it (50.3%,
n = 237) in the past 12 months.
Table 2
Sexual behaviour of participants (condom use at last sex)
Number of male sexual partners (past 3 months) |
0 | 25 | 54,3% | 21 | 45,7% | 46 |
1 | 190 | 50,4% | 187 | 49,6% | 377 |
More than 1 | 16 | 50,0% | 16 | 50,0% | 32 |
Total | 231 | | 224 | | 455 |
Partner employed |
No | 40 | 50,0% | 40 | 50,0% | 80 |
Yes | 172 | 50,9% | 166 | 49,1% | 338 |
Total | 212 | | 206 | | 418 |
Ever Diagnosed with HIV |
No | 172 | 54,4% | 144 | 45,6% | 316 |
Yes | 49 | 40,2% | 73 | 59,8% | 122 |
Total | 221 | | 217 | | 438 |
HIV status of sexual partner |
Negative | 145 | 53,1% | 128 | 46,9% | 273 |
Positive | 31 | 43,7% | 40 | 56,3% | 71 |
Do not know | 35 | 47,9% | 38 | 52,1% | 73 |
Total | 211 | | 206 | | 417 |
Sometimes hitting/slapping with partner |
Agree | 31 | 63,3% | 18 | 36,7% | 49 |
Neutral | 7 | 63,6% | 4 | 36,4% | 11 |
Disagree | 166 | 49,3% | 171 | 50,7% | 337 |
Total | 204 | | 193 | | 397 |
A lot of trust between you and him |
Agree | 138 | 50,2% | 137 | 49,8% | 275 |
Neutral | 30 | 58,8% | 21 | 41,2% | 51 |
Disagree | 32 | 50,0% | 32 | 50,0% | 64 |
Total | 200 | | 190 | | 390 |
Partner has control over sex |
Agree | 49 | 58,3% | 35 | 41,7% | 84 |
Neutral | 91 | 51,1% | 87 | 48,9% | 178 |
Disagree | 60 | 44,8% | 74 | 55,2% | 134 |
Total | 200 | | 196 | | 396 |
Partner has control over condom use |
Agree | 38 | 55,9% | 30 | 44,1% | 68 |
Neutral | 86 | 50,3% | 85 | 49,7% | 171 |
Disagree | 78 | 49,1% | 81 | 50,9% | 159 |
Total | 202 | | 196 | | 398 |
Diagnosed with STI (past 12 months) |
No | 199 | 49,6% | 202 | 50,4% | 401 |
Yes | 29 | 53,7% | 25 | 46,3% | 54 |
Total | 228 | | 227 | | 455 |
Sex under influence of alcohol (past 3 months) |
No | 211 | 50,0% | 211 | 50,0% | 422 |
Yes | 16 | 48,5% | 17 | 51,5% | 33 |
Total | 227 | | 228 | | 455 |
Talked about condoms with partner (past 12 months) |
No | 68 | 75,6% | 22 | 24,4% | 90 |
Yes | 153 | 43,5% | 199 | 56,5% | 352 |
Total | 221 | | 221 | | 442 |
Age at first sex |
12–17 years | 104 | 59,4% | 71 | 40,6% | 175 |
18–24 years | 117 | 45,0% | 143 | 55,0% | 260 |
Total | 221 | | 214 | | 435 |
Age group |
18–24 years | 132 | 54,1% | 112 | 45,9% | 244 |
25–34 years | 89 | 51,7% | 83 | 48,3% | 172 |
35–49 years | 16 | 29,6% | 38 | 70,4% | 54 |
Total | 237 | | 233 | | 470 |
More than a quarter of participants (25.9%, n = 122) had been diagnosed with HIV positive status in the course of their lives and 40.2% (n = 49) of them reported to have not used a condom at their last sex encounter. More than one in six of the participants (15.1%, n = 71) were aware of their sexual partners’ HIV positive status. Despite this awareness, more than half of these (56.3%, n = 40) used a condom at their last sexual encounter. Only 11.5% (n = 54) of participants reported to have been diagnosed with an STI in the past 12 months preceding the study. Of these, 53.7% (n = 29) did not use a condom at their last sexual encounter. The majority of participants (89.6%, n = 422) did not have sex under the influence of alcohol in the past 3 months.
The majority of participants (71.5%, n = 337) reported that they were not exposed to violence with a sexual partner (i.e. sometimes hitting or slapping). About half of these (50.7%, n = 171) used a condom at their last sexual encounter. More than a third (36.3%, n = 171) of participants were neutral on whether or not the sexual partner has control over condom use, with 50.1% (n = 86) of these not having used a condom at the last sex encounter. Close to a quarter (21.2%, n = 84) of participants reported that the sexual partner has control over their sexual activities. The majority of participants (74.7%, n = 352) had talked about condoms with their partners during the preceding 12 months leading to the study, and 56.5% (n = 199) of these used a condom at last sex.
Factors associated with condom use at last sex encounter in univariate and multivariate analysis
Condom use among women in Umlazi Township showed a significant association with four factors in univariate analysis, and these were: ever diagnosed with HIV (OR 1.78, 95% CI: 1.16–2.72), having talked about condoms with partner during the preceding 12 months (OR 4.02, 95% CI: 2.38–6.80), women’s delayed sexual debut, 18–24 years (OR 1.79, 95% CI: 1.21–2.64) and women’s older age category, 35–49 years (OR 2.80, 95% CI: 1.48–5.29). In multivariate analysis, only two variables were significantly associated with condom use at last sex among women in Umlazi Township. Participants who had talked about condoms with their partner during the preceding 12 months to the study were significantly more likely to have used a condom in their last sex encounter. For example, condom use at last sex was 3.74 times (OR 3.74, 95% CI: 2.01–6.98) more likely in women who had talked about condoms with their partner during the preceding 12 months compared to those who had not. Older women (35–49 years) were significantly more likely to use a condom at last sex compared to their younger counterparts (OR 2.70, 95% CI: 1.07–6.81), suggesting that early sex debut is a risk factor to non-condom usage.
Interestingly, women who reported to have ever been diagnosed with HIV (
p = 0.466), those whose sexual partners had been diagnosed HIV positive (
p = 0.847), and those who had been diagnosed with an STI in the past 12 months leading to the study (
p = 0.139) did not influence condom use at last sex encounter. Women who were exposed to partner violence (i.e. sometimes hitting or slapping with a partner) was not associated with condom use at last sex (
p = 0.968). Detailed univariate and multivariate analyses results are shown in Table
3.
Table 3
Factors associated with condom use at last sex in univariate and multivariate analysis
Number of male sexual partners (past 3 months) |
0 (ref) |
1 | 1.17 | 0.613 | 0.63 2.17 | | | |
More than 1 | 1.19 | 0.705 | 0.48 2.94 | | | |
Partner employed | 1.00 | 0.9 | 0.61 1.63 | | | |
No (ref) |
Yes | 0.97 | 0.886 | 0.59 1.57 | | | |
Ever diagnosed with HIV |
No (ref) |
Yes | 1.78 | 0.006 | 1.16 2.72 | 1.33 | 0.466 | 0.62 2.85 |
HIV status of sexual partner | | | | 1.50 | 0.131 | 0.89 2.53 |
Do not know (ref) |
Negative | 0.81 | 0.433 | 0.48 1.36 | 1.10 | 0.784 | 0.57 2.12 |
Positive | 1.89 | 0.606 | 0.62 2.29 | 1.10 | 0.847 | 0.44 2.74 |
Sometimes hitting/slapping with partner |
Neutral (ref) |
Agree | 1.02 | 0.982 | 0.26 3.95 | 1.03 | 0.968 | 0.19 5.55 |
Disagree | 1.80 | 0.354 | 0.52 6.27 | 2.05 | 0.360 | 0.44 9.56 |
Lots of trust in the relationship |
(ref) |
Agree | 1.42 | 0.258 | 0.77 2.60 | | | |
Disagree | 1.43 | 0.346 | 0.68 3.00 | | | |
Partner has control over sex |
Neutral (ref) |
Agree | 0.75 | 0.275 | 0.44 1.26 | | | |
Disagree | 1.29 | 0.267 | 0.83 2.02 | | | |
Partner has control over condom use |
Neutral (ref) |
Agree | 0.80 | 0.436 | 0.45 1.41 | | | |
Disagree | 1.05 | 0.822 | 0.68 1.62 | | | |
Ever diagnosed with STI (past 12 months) |
No (ref) |
Yes | 0.85 | 0.574 | 0.48 1.50 | 0.59 | 0.139 | 0.29 1.19 |
Sex under influence of alcohol |
More than 1 (ref) |
Never | 0.84 | 0.626 | 0.42 1.68 | | | |
Talked about condoms with partner in 12 months |
No (ref) |
Yes | 4.02 | 0.000 | 2.38 6.80 | 3.74 | < 0.0001 | 2.01 6.98 |
Age at first sex |
(Ref: 12–17 years) |
18–24 years | 1.79 | 0.003 | 1.21 2.64 | 1.50 | 0.150 | 0.86 2.61 |
Age group |
(Ref: 18–24 years) |
25–34 years | 1.10 | 0.636 | 0.74 1.62 | 0.85 | 0.530 | 0.52 1.40 |
35–49 years | 2.80 | 0.002 | 1.48 5.29 | 2.70 | 0.035 | 1.07 6.81 |
Discussion
This study aimed to investigate risky sexual behaviours and associated factors among women of reproductive age in Umlazi Township in KZN province, South Africa. The main findings of this study indicate that women who talked about condoms with partner during the preceding 12 months were significantly more likely to use condoms when having sex. Older women (35–49 years) were significantly more likely to use a condom at last sex compared to their younger counterparts, suggesting that early sex debut is a risk factor to non-condom usage. Having been diagnosed with HIV or having a sexual partner with a known HIV positive status, did not show any significant association with condom use at last sex among women in Umlazi Township. The sexual behaviour of women who reported to have more than one sexual partner in the past 3 months was risky, given the inconsistent condom use and exposure to STIs. Women who were exposed to partner violence (i.e. sometimes hit or slapped by a partner) was not significantly associated with condom use at last sex. This finding may be supported by the fact that women who are exposed to partner violence may find it difficult to negotiate condom use.
The findings of this study are consistent with the findings of similar studies conducted in comparable settings [
21,
22]. The fact that women who talked about condoms with their partner during the preceding 12 months were more likely to use condoms during their sexual encounter suggests that being in a relationship where women are confident to have discussions related to sexual practices with their partners, is important for improving women’s confidence to negotiate for condom use. Similar findings were shown in a study conducted in Tanzania [
21]. Women’s capacity to speak about condoms with their sexual partners provides opportunities for improved sexual behavior and protection against STIs, as well as unintended pregnancies [
21], while the opposite may be true for women who are unable to negotiate for condom use.
Despite some similar findings to a study conducted in Tanzania, some aspects are contradictory, in as far as the associations between condom use and multiple sexual partners among women are concerned [
21]. However, in Ethiopia, participants who were on antiretroviral therapy (ART) and had multiple sexual partners were more likely to engage in risky sexual behaviour [
22], and this pattern was observed in both males and females alike. In this study, we found no evidence to suggest that HIV positive status of women had any significant influence on condom use in multivariate analysis. This supports the importance of strengthening HIV education among women and their sexual partners, given the risks of HIV infection. It has been shown that condom use is effective in preventing the spread of HIV by more than 90% [
23].
In a study conducted in South Africa [
18], the researchers revealed that factors previously found to be significantly associated with contraceptive use, such as being HIV positive, having been diagnosed with STI in the past 12 months, having concurrent sexual partners and early sexual debut, showed stronger negative associations with contraceptive use among women. Although this study did not precisely focus on contraceptive use, linking these behavioural changing patterns among women is important, given the concerns they are raising. Similar to this study, risky sexual behaviours among participants whose partners were HIV positive was also shown in Ethiopia [
22]. There is less chances of condom use at sexual debut among youth [
3,
24], suggesting the importance of delaying sexual debut among women until they are able to make the informed and/or guided decisions with full considerations of the exposure to HIV infection [
25]. Interventions aimed at encouraging women to delay sexual debut and intentional condom use at first sexual encounter are imperative.
While this study provides an important contribution in the field of sexual and reproductive health, it has notable limitations. Given that the sampling frame for this study was limited to women seeking healthcare services in public health clinics in Umlazi Township, women who do not use public healthcare services or use them less frequently were excluded and/or under-represented in the sample. However, the participants of this study represented all the 10 public health clinics in Umlazi Township. Therefore, the insights gained from the participants will likely be relevant to other public health clinics in similar settings in South Africa. This study sought self-reported sexual health information from participants, thereby making the findings vulnerable to social desirability bias. Furthermore, information deemed to have the potential for leading to judgements may have been withheld by the participants. Some participants may have been unable to recall whether or not a condom was used at last the sexual encounter, leading to incorrect information provided. Information on whether or not HIV positive status was reported among participant’s monogamous partner, was not sought. In addition, the data collection instrument did not capture information on ART use among HIV positive women. Older participants may have been unable to recall the age at which they had sexual debut. This may have contributed to reporting bias. Given the cross-sectional nature of the study design, it is not possible to establish a cause-and-effect relationship between study variables.
The findings of this study raise concerns over women’s exposures to new HIV infections, amid risky sexual behaviours. Therefore, we aim to expand this research project to include a qualitative component towards understanding women’s perceptions and experiences regarding risky sexual behaviours and HIV prevention in Umlazi Township. Conducting longitudinal studies on this topic is important to understand women’s sexual behavioural changes, exposures and patterns over time.
The findings of this study make a case for the importance of implementing and/or strengthening evidence-based educational programmes, aimed at improving women’s sexual behaviours and HIV prevention strategies. We further recommend that such programmes may be integrated into school-health programmes to reach younger women, but also include men.