Skip to content

Advertisement

  • Research
  • Open Access
  • Open Peer Review

Condom use at last sex by young men in Ethiopia: the effect of descriptive and injunctive norms

Reproductive Health201815:164

https://doi.org/10.1186/s12978-018-0607-3

  • Received: 23 February 2018
  • Accepted: 18 September 2018
  • Published:
Open Peer Review reports

Abstract

Background

Condoms are an important prevention method in the transmission of HIV and sexually transmitted infections as well as unintended pregnancy. Individual-level factors associated with condom use include family support and connection, strong relationships with teachers and other students, discussions about sexuality with friends and peers, higher perceived economic status, and higher levels of education. Little, however, is known about the influence of social norms on condom use among young men in Ethiopia. This study examines the effect of descriptive and injunctive norms on condoms use at last sex using the theory of normative social behavior.

Methods

A cross-sectional survey was implemented with 15-24 year old male youth in five Ethiopian regions in 2016. The analytic sample was limited to sexually active single young men (n = 260). Descriptive statistics, bivariate and multivariate logistic regressions were conducted. An interaction term was included in the multivariate model to assess whether injunctive norms moderate the relationship between descriptive norms and condom use.

Results

The descriptive norm of knowing a friend who had ever used condoms significantly increased respondents’ likelihood of using condoms at last sex. The injunctive norm of being worried about what people would think if they learned that the respondent needed condoms significantly decreased their likelihood to use condoms. The injunctive norm did not moderate the relationship between descriptive norms and condom use. Young men who lived closer to a youth friendly service (YFS) site were significantly more likely to have used condoms at last sex compared to those who lived further away from a YFS site.

Conclusions

Social norms play an important role in decision-making to use condoms among single young men in Ethiopia. The interplay between injunctive and descriptive norms is less straightforward and likely varies by individual. Interventions need to focus on shifting community-level norms to be more accepting of sexually active, single young men’s use of condoms and need to be a part of a larger effort to delay sexual debut, decrease sexual violence, and increase gender equity in relationships.

Keywords

  • Social norms
  • Condom use
  • Theory of normative social behavior
  • Young men
  • Ethiopia

Plain English summary

Condoms are an important tool to prevent the spread of HIV, sexually transmitted infections, and unwanted pregnancies. Research conducted in Ethiopia and elsewhere has shown various factors that influence young men’s use of condoms. One important but understudied factor is the effect of social norms on condom use. This study assessed how social norms influenced whether young men in Ethiopia used condoms the last time they had sex by applying the theory of social normative behavior. Results showed that social norms do affect condom use: young men who knew of friends who had used condoms were more likely to have used condoms at last sex, and young men who were not worried about what people would think of them if they found out they needed condoms were more likely to have used condoms as well. Interventions should look to change community norms by increasing the acceptance of condom use among young men who are sexually active and not married, and this should be a part of a larger effort to delay the age of first sex, reduce sexual violence, and promote health masculinities and gender equity.

Background

Eastern and Southern Africa have the highest HIV prevalence rates among young people aged 15–24 in the world with 3.4% of young women and 1.6% of young men living with HIV in 2016 [1]. Though Ethiopia has a relatively low HIV prevalence rate for this region, at 0.4% of young women and 0.5% of young men (UNAIDS 2017) [1], it has the second-highest population in Africa (after Nigeria) at 105 million people in mid-2017 [2]. This large population translates to a high burden of people living with HIV across Ethiopia: in 2016, there were 87,000 young people living with HIV and 8700 new cases among young people across the country [1].

In 2015, the World Health Organization, UNAIDS, and UNFPA issued a position statement encouraging the promotion of condoms to young people, among other populations, as a critical intervention for preventing the spread of HIV, sexually transmitted infections (STIs), and unintended pregnancies [3]. Condom use is also an important indicator for assessing never-married young men’s access to family planning and reproductive health (FP/RH) services. Among Ethiopian men aged 25–49, the median age at first marriage is 23.7 and the median age at first sex is 21.2, 2.5 years before marriage [4]. Furthermore, of the 13.8% of never-married men have who had sexual intercourse in the past 12 months with a person who was neither their wife nor a partner who lived with them, only slightly more than half (53.9%) reported using a condom during last sex with such a partner [4].

Several studies have assessed individual-level factors associated with condom use among young men in Ethiopia. Factors that have shown to support the use of condoms include family support and connection, strong relationships with teachers and other students, discussions about sexuality with friends and peers, higher perceived economic status, and higher levels of education [57]. Risk factors associated with non-use of condoms or other risky sexual behaviors include low involvement in religious activities, high levels of alcohol consumption, and poor knowledge of HIV/AIDS [5, 8]. Thus, there is a need to focus on increasing use of condoms among young men, for the prevention of HIV, STIs, and unintended pregnancy. There is also a need for interventions to focus on the contextual factors surrounding pre-marital sex by addressing violence in early sexual encounters, and gender equity.

Evidence on the role of social norms in young men’s decision making to use condoms is mixed. A study of young adults in rural Ethiopia found that social norms influenced intention to use condoms but not reported use of condoms [9]. In four studies in South Africa, Tanzania, Uganda and Swaziland, where norms were measured by different statements, social norms were shown to influence male and female adolescents’ use of condoms [1013]. However, a study of adolescents in rural Tanzania that examined the role of social norms through statements including the following: “I agree with the opinion of my friends that I should use condoms when having sex” found that norms did not directly predict condom use [14]. These results are inconclusive and do not capture the full range of social norms that can influence behavior.

Theory of normative social behavior

The theory of normative social behavior (TNSB) [15] is a framework used to explain how social norms influence behavior. TNSB distinguishes between two types of social norms: descriptive norms, which are individuals’ perceptions about the prevalence of a behavior [16], and injunctive norms, which are perceived social pressures to conform [17, 18]. Injunctive norms influence behavior because failure to conform carries the threat of social sanctions [15]. TNSB holds that both descriptive and injunctive norms directly affect behavior, but that the relationship between descriptive norms and behavior is moderated by injunctive norms, among other factors [15]. This theory has been tested for various health behaviors, including contraceptive use [19], alcohol consumption [20], handwashing [21], and physical activity [22].

The purpose of this study is to explore the role of social norms, both descriptive and injunctive, on condoms use at last sex, and to determine whether injunctive norms moderate the relationship between descriptive norms and condom use among young men in Ethiopia.

Methods

Data

A cross-sectional household survey of 15–24-year-old males living in rural and peri-urban Ethiopia was conducted in Amhara, Benishangul-Gumuz, Oromia, Southern Nations, Nationalities, and Peoples’ Region (SNNP), and Tigray regions from January to July 2016. The sampling strategy was designed to measure the effect of distance to a youth friendly service (YFS) health center on utilization of a range of health services. Of 247 eligible YFS sites identified in these regions by the Regional Health Bureaus, 5% were randomly selected for inclusion and the number of sites in each region was determined by probability proportional to size. A total of 14 YFS sites were selected from five regions. One non-YFS health center was randomly selected from each region for comparison.

A stratified, two-stage cluster design was employed where enumeration areas (EAs) were the sampling unit for stage one and selected within 5 km of YFS site, within 5 km of a non-YFS site, and within 5-10 km of a YFS site. Households comprised the second stage and approximately 37 households with eligible respondents were randomly selected per EA, and one respondent per household was selected using a Kish grid [23]. A more detailed description of the sampling strategy is available in the study report [24]. The total number of males interviewed was 1244.

The questionnaires included modules on background characteristics; household characteristics; social cohesion and autonomy; puberty, family planning, and sexual activity; and facility visits for condoms, sexually transmitted infections, HIV, and basic health services. The questionnaires were translated into Amharic, Afan Oromo, and Tigrigna.

Sample population

The sample was limited to 15–24 year old never-married young men who had ever had sexual intercourse. Young men who were married/in-union were excluded from the analysis because they reported low condom use at last sex (1.3%) because they were trying to get pregnant, were in a steady/committed relationship, or because of religious prohibition.

Measures

The dependent variable is condom use at last sex measured by responses to the question “Did you use a condom the last time you had sexual intercourse?”. Though this measure does not capture consistent condom use, it is advantageous as it minimizes recall bias by only asking about one recent incidence of sex [25]. Respondents who used a condom at last sex were coded as 1 and those who did not use a condom were coded as 0.

Descriptive norms were measured by asking respondents whether they knew of any friend who had ever used a condom. Respondents who knew of a friend who had ever used condoms were coded as 1 and those who did not know of a friend or were unsure were coded as 0.

Injunctive norms were measured by the following attitudinal statement: “I would be worried about what people in my community would say about me if they found out I needed condoms.” This statement was measured on a four-point Likert scale ranging from strongly agree to strongly disagree. The responses were combined to form a dichotomized variable of agree or worry coded as 0 and disagree or not worried coded as 1.

Additional independent variables included in the model were: respondent’s age; education; religion; wealth quintile; ownership of personal savings to assess financial autonomy; living with both parents; chewing khat, drinking alcohol, or smoking cigarettes in the past month; distance living away from a YFS facility to assess physical access and presence of age-appropriate services; age at first sex; and whether the respondent had gone for HIV testing or counseling in the last 6 months.

Analysis

Descriptive statistics were calculated for respondent characteristics, dependent and independent variables. Bivariate analyses of condom use at last sex were conducted using Pearson’s chi-squared tests and t-tests for significance. Multivariate logistic regression models were used and were adjusted by variables that were statistically significant in the bivariate analysis or were theoretically important. Akaike’s Information Criterion (AIC) was employed to compare relative quality and fit of several models, and the model with the lowest AIC was chosen. The final model was run with and without an interaction term to assess the moderating effect of injunctive norms on descriptive norms. The likelihood-ratio test was used to determine if inclusion of the interaction term improved model fit. Lastly, the Hosmer-Lemeshow test was applied to the final model to assess model fit to the data. All analyses were conducted using Stata v15.

Results

Table 1 shows characteristics of sexually active single young men aged 15–24 (n = 260). Three out of five (60%) respondents were aged 20–24 years and the median age at first sex was 17 years. Most respondents were out of school at the time of the survey (70%), were living with both parents (64%), and did not have their own savings (72%). Approximately half were Orthodox Christian (49%) and the remaining half were Muslim (41%) or Protestant (10%). Over one-third (37%) of respondents lived within 5 km of a YFS site while 38% lived within 5-10 km, and the remaining quarter (25%) lived within 5 km of a non-YFS site. Respondents were of all wealth quintiles, though the greatest proportion was in the lowest wealth quintile (27%).
Table 1

Respondent Characteristics (n = 260)

 

Percent

Number

Age

 15–19

40.8

106

 20–24

59.2

154

Age at first sex (median, range)

17.0

(10–23)

School status

 In school

30.4

79

 Out of school

69.6

181

Educationa

 Never attended school

4.6

12

 Primary

55.0

143

 Secondary/technical/vocational/higher

40.0

104

Living with both mother and father

 No

35.8

93

 Yes

64.2

167

Has own savings

 No

71.5

186

 Yes

28.5

74

Religion

 Muslim

41.2

107

 Orthodox Christian

48.8

127

 Protestant

10.0

26

Region

 SNNP

24.2

63

 Tigray

21.2

55

 Amhara/Benishangul-Gumuz

17.3

45

 Oromia

37.3

97

Proximity to health facility/YFS

  < 5 km from YFS

36.5

95

 5-10 km from YFS

38.5

100

  < 5 km from non-YFS

25.0

65

Wealth quintile

 Lowest

26.5

69

 Lower

14.2

37

 Middle

19.2

50

 Higher

20.4

53

 Highest

19.6

51

Chewed khat, drank alcohol, smoked cigarettes in past month

 Did not do any behavior

49.2

128

 Did one or more behaviors

50.8

132

Has ever heard of HIV

 No

0.4

1

 Yes

99.6

259

Knows HIV can be transmitted via unprotected sexa

 No

3.5

9

 Yes

96.2

250

Has gone for HIV testing or counseling in last 6 months

 No

89.2

232

 Yes

10.8

28

Descriptive norm: Knows a friend who has ever used condoms

 No/don’t know

43.5

113

 Yes

56.5

147

Injunctive norm: “I would be worried about what people in my community would say if they found out I needed condoms”

 Disagree

37.3

97

 Agree

62.7

163

Ever used of condoms

 No

33.8

88

 Yes

66.2

172

Condom use at last sex

 No

44.2

115

 Yes

55.8

145

aPercent and number do not add to 100% or 260 due to missing values

Slightly more than half of the sample had either chewed khat, drank alcohol, and/or smoked cigarettes (51%) in the past month. Most respondents had not gone for HIV testing or counseling in the last 6 months (90%), while virtually all respondents knew of HIV (99.6%) and knew that HIV can be transmitted by unprotected sex (96%). Fifty-seven percent of respondents knew of a friend who had ever used a condom (descriptive norm) and 63% agreed that they would be worried about what people in their community would say if they found out the respondent needed condoms (injunctive norm). Two-thirds (66%) of the respondents had ever used condoms and 56% of the sample used a condom at last sex.

Table 2 presents the results of the bivariate analyses for condom use at last sex. Young men who had attended secondary education or higher were significantly more likely to report condom use at last sex (65%) than those had never attended or only attended primary school (49%). Young men who lived < 5 km from a YFS site were significantly more likely to have used a condom at last sex (65%) compared to those who lived < 5 km from a non-YFS (55%) and those who lived 5-10 km away from a YFS site (47%). Young men living in higher wealth quintiles were more likely than those in lower wealth quintiles to report condom use at last sex, with a range from 67% in the highest wealth quintile to 41% in the lowest.
Table 2

Bivariate analysis of condom use at last sex (n = 260)

 

Condom use at last sex (%)

Age

 15–19

59.4

 20–24

53.2

School status

 In school

60.8

 Out of school

53.6

Education

 Never attended school/Primary

49.0

 Secondary/technical/vocational/higher

65.4*

Living with both mother and father

 No

58.1

 Yes

54.5

Has own savings

 No

52.2

 Yes

64.9

Religion

 Orthodox

50.4

 Muslim

61.7

 Protestant

57.7

Region

 Oromia

53.6

 Tigray

50.9

 Amhara/Benishangul-Gumuz

53.3

 SNNP

65.1

Proximity to health facility/YFS

  < 5 km from YFS

65.3*

 5-10 km from YFS

47.0

  < 5 km from non-YFS

55.4

Wealth quintile

 Lowest

40.6

 Lower

54.1

 Middle

52.0

 Higher

69.8

 Highest

66.7**

Chewed khat, drank alcohol, smoked cigarettes in past month

 Did not do any behavior

58.6

 Did one or more behaviors

53.0

Has gone for HIV testing or counseling in last 6 months

 No

54.7

 Yes

64.3

Descriptive norm: Knows a friend who has ever used condoms

 No/don’t know

40.7

 Yes

67.3**

Injunctive norm: “I would be worried about what people in my community would say if they found out I needed condoms”

 Disagree

64.9

 Agree

50.3*

* p-value ≤0.05; ** p-value ≤0.01

In terms of norms, condom use at last sex was significantly associated with both descriptive and injunctive norms. Among those who knew of a friend who had ever used a condom (descriptive norm), 67% used a condom at last sex, compared to 41% of those who did not know of a friend who had used condoms. Condom use at last sex was significantly higher among young men who disagreed with the measure of injunctive norm: those who disagreed (that is, would not worried about what people would say if they found out the respondent needed condoms) were significantly more likely to have used condoms at last sex (65%) than those who agreed (50%).

A t-test was conducted to determine if mean age at first sex differed for those who used condoms at last sex and those who did not. The mean age was 17.2 for both populations, and the difference was not significant (data not shown). Since nearly all respondents reported HIV awareness and knowledge that unprotected sex can transmit HIV, these two measures were excluded from bivariate and multivariate analysis.

Table 3 presents the adjusted odds ratios (AORs) of the effect of descriptive and injunctive norms on condom use at last sex, adjusting for respondent characteristics, distance to a YFS facility, and use of khat, alcohol, or cigarettes. Though theoretically relevant and shown elsewhere as significant predictors to condom use at last sex, we removed five variables from the multivariate model because these measures were not significant in the bivariate analysis, and to ensure a stronger fit of the data: age at first sex, school status, living with mother and father, has own savings, and used HIV testing or counseling in the past 6 months.
Table 3

Adjusted odds ratios of condom use at last sex (n = 260)

 

AOR

95% CI

Age

 15–19

ref

 

 20–24

0.61

(0.33–1.12)

Education

 Never attended school/Primary

ref

 

 Secondary/technical/vocational/higher

1.84

(0.99–3.42)

Religion

 Orthodox Christian

ref

 

 Muslim

2.07

(0.96–4.45)

 Protestant

1.63

(0.51–5.23)

Region

 Oromia

ref

 

 Tigray

1.12

(0.46–2.71)

 Amhara/Benshangul-Gumuz

1.07

(0.44–2.63)

 SNNP

1.67

(0.72–3.87)

Proximity to health facility/YFS

  < 5 km from YFS

ref

 

 5-10 km from YFS

0.46*

(0.23–0.92)

  < 5 km from non-YFS

0.47

(0.22–1.05)

Wealth quintile

 Lowest

ref

 

 Lower

2.31

(0.87–6.14)

 Middle

1.64

(0.70–3.85)

 Higher

3.10*

(1.24–7.73)

 Highest

1.99

(0.79–4.99)

Chewed khat, drank alcohol, smoked cigarettes in past month

 Did not do any behavior

ref

 

 Did one or more behaviors

0.88

(0.45–1.70)

Descriptive Norm: Knows a friend who has ever used condoms

 Yes

4.74**

(2.26–9.95)

Injunctive norm: “I would be worried about what people in my community would say if they found out I needed condoms”

 Disagree

3.39**

(1.38–8.35)

Descriptive norm × Injunctive norm

 Descriptive Norm: Yes × Injunctive Norm: Disagree

0.37

(0.12–1.19)

* p-value ≤0.05; ** p-value ≤0.01

The likelihood-ratio test was used to test the difference between the model with the interaction term of injunctive and descriptive norms and the model without the interaction. The test was borderline significant with a p-value of 0.0952. The final model presented in Table 3 includes the interaction term.

Among respondents who agreed with the injunctive norm statement (would be worried about what people in their community would say if they found out they needed condoms), those who knew of a friend who had ever used condoms were 4.7 times (95% CI: 2.26–9.95) more likely to use condoms at last sex than those who did not have a friend who had used condoms. Furthermore, among respondents who did not know of a friend who had ever used a condom, those who disagreed with the injunctive norm statement (or would not be worried) were 3.4 times (95% CI: 1.38–8.35) more likely to have used a condom at last sex compared to those who agreed with the statement. The interaction term of descriptive norm × injunctive norm was not statistically significant, and no synergistic effect of condom use at last sex was observed.

Respondents who lived 5-10 km away from a YFS facility were significantly less likely to have used a condom at last sex compared to those who lived within 5 km of a YFS site (AOR = 0.46, 95% CI: 0.23–0.92). There was no significant difference in the odds of condom use at last sex for those who lived within 5 km from a non-YFS site compared to those who lived within 5 km from a YFS site. No significant difference was observed among those who lived 5-10 km from YFS to those who lived < 5 km from non-YFS in condom use at last sex (data not shown). Those who lived in the higher wealth quintile were significantly more likely to have used a condom at last sex than those in the lowest quintile (AOR = 3.10, 95% CI: 1.24–7.73).

The Hosmer-Lemeshow goodness-of-fit test demonstrated that the model fits the data reasonably well (p = 0.601).

Discussion

The purpose of this study was to assess the role of social norms in condom use at last sex among sexually active single young men in Ethiopia. Using the TNSB, the study looked at how perceptions of friends’ use of condoms (descriptive norm) and worry of what community members would say if they learned that the respondent needed condoms (injunctive norm) influenced condom use at last sex. This study also explored whether the injunctive norm moderated the relationship between the descriptive norm and condom use. The results show that, in the context of never-married, sexually active young men in Ethiopia, while descriptive and injunctive norms individually influence condom use at last sex, injunctive norms do not moderate the relationship between descriptive norms and condom use.

A study of contraceptive use using the TNSB framework in India also found that injunctive norms do not have a strong moderating effect on the relationship between descriptive norms and behavior [19]. Condom use, like contraceptive use, is a semi-private behavior in that it generally occurs between partners with limited public knowledge of the behavior. The lack of moderation may have occurred because private behaviors are not observed by others and are thus not subjected to the same levels of public scrutiny or stigma as public behaviors. In addition, the lack of moderation on condom use suggests that descriptive and injunctive norms may function differently for individuals and their interaction is more complex.

The study results are important for the Ethiopian government to reach its ambitious goals related to HIV knowledge, condom use and HIV testing and counseling by 2020 [26]. Different programmatic strategies with young men need to be tested and evaluated. For instance, the Ethiopian government is exploring the inclusion of FP/RH and HIV education in school-based programming [26]. In our sample, the vast majority (95%) had attended at least primary school, though only 40% went on to secondary school. Using primary schools as a space where age-appropriate information can be shared about FP/RH and HIV at earlier ages may provide young men with the knowledge and tools that they need to make better and safer decisions around condom use in the future.

The study results also showed that respondents who are worried and concerned about how they would be perceived if others in their community learned that they needed condoms suggest that even in a place like Ethiopia, where condoms are relatively ubiquitous, fear of how one who uses condoms is perceived can weigh heavily on adopting protective behaviors. As has been shown with programs to delay girls’ marriage [27, 28], the Ethiopian government may consider holding community conversations to engage young men and their parents to begin addressing social norms that restrict adolescents from using condoms, especially in rural areas where traditional notions forbidding pre-marital sex exist.

The study showed that unmarried young men who know of a friend who has used condoms are more likely to use condoms themselves suggests that communication and sharing of information within social and peer networks is important in changing behaviors. Condom use is by and large a private behavior that is not explicitly known or seen by others. Knowledge of a friend’s use of condoms would likely occur in discussions and so if young men brag to their friends about sex [29, 30], then perhaps the narrative around sexual discourse has changed to also include condom use. A study in Ethiopia showed that discussions about sexuality with friends had a positive association with condom use, though “discussions of sexuality” was not well defined [6]. Condom use may be also considered a sign of autonomy or increased status, where young men can obtain condoms without shame. The government may consider creating young mens’ groups to engage unmarried young men in a range of health and relationship issues, including the importance of condoms use, and to provide referrals to facilities for HIV counseling and testing.

The study also showed that respondents who lived closer to a YFS facility were significantly more likely to use condoms at last sex compared to those who lived further away from a YFS facility, and marginally more likely than those who lived close to a non-YFS facility. This finding suggests that proximity to a facility, especially one that has received programmatic interventions to increase its youth friendliness, is important to young men’s use of condoms at last sex. Ethiopia is scaling YFS sites across the country, and this may additionally contribute to increased condom use among young men. The results of this study suggest that increasing YFS, however, is not sufficient to increase condom use - social norms also must be addressed.

Interventions aimed at increasing condom use and addressing social norms should also focus on greater contextual factors in Ethiopia. Because early sexual encounters in Ethiopia are often in the context of force or coercion [6, 31, 32], interventions should consider the role of gender-based violence and inequitable gender norms in condom use. For young women and girls in Ethiopia, the formation of girls’ groups and community conversations about child marriage were shown to be effective not only in raising the age at marriage [27, 28], but also in increasing FP/RH knowledge and voluntary contraceptive use [27]. Adaptations of these interventions may include forming young men’s groups and convening community conversations to engage young men, their parents, and community leaders to begin shifting social norms that inhibit condom use and address gender norms, raise the age of sexual debut, and decrease gender-based violence among young people in Ethiopia.

Further research is necessary especially on positive deviants, that is the young men who did use condoms at last sex, to understand the pathways that lead to them to this decision including where they first heard about condoms, how they learned to use them or where to get them, negotiating with their partner, among many other issues.

Examining the factors associated with condom use at last sex among young males is paramount, as there is evidence to suggest that decision-making on condom use rests predominantly with males [6]. Efforts to examine and increase condom use must therefore include and target boys and young men, as the present study has, and empower them to access and use condoms. However, social change is also critical to enable inclusion of girls and young women in the discourse around condoms, so that condom decision-making becomes more equitable between partners.

Study limitation

A limitation of this study is the lack of temporality. Because this is a cross-sectional survey, it is not certain that knowledge of friend’s use of condoms influenced condom use at last sex or whether use of condoms at last sex influenced the respondent to discuss condoms with their friends. Either way, communication around condom use with friends and peers appears to be important.

Conclusions

This study examined condom use at last sex among single young men in rural Ethiopia through the theory of normative social behavior to assess the relationship of descriptive and injunctive norms on behavior. More than half of single young men used condoms at last sex. Those who knew of a friend who had used condoms (descriptive norm), and who were not worried about what members of their community would say if they found out they needed condoms (injunctive norms) were more likely to use condoms at last sex, though there was no moderating effect of injunctive norms. Young men who lived close to a YFS site were also more likely to use condoms at last sex. The results of this study suggest that social change is needed to improve access to and use of condoms at last sex in Ethiopia.

Abbreviations

AIC: 

Akaike’s information criterion

AIDS: 

Acquired immune deficiency syndrome

AOR: 

Adjusted odds ratio

CI: 

Confidence interval

FP/RH: 

Family planning and reproductive health

HIV: 

Human immunodeficiency virus

SNNP: 

Southern Nations, Nationalities, and Peoples’ Region

STI: 

Sexually transmitted infection

TNSB: 

Theory of normative social behavior

UNAIDS: 

Joint United Nations Programme on HIV and AIDS

UNFPA: 

United Nations Population Fund

USAID: 

United States Agency for International Development

WHO: 

World Health Organization

YFS: 

Youth friendly services

Declarations

Acknowledgements

We thank Lemi Negeri who served as a research coordinaor during this study. We also thank the research assistants and drivers who collected the data in Ethiopia. We sincerely thank our colleagues Mihira Karra, Erika Martin, and Erika Houghtaling of USAID for their feedback on the manuscript. The manuscript benefitted from feedback received at the IUSSP conference held in Cape Town, South Africa, in November 2017, where it was presented as an oral presentation. Finally, we are grateful to the youth who participated in the study and shared their time and experiences.

Funding

The Evidence Project is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of cooperative agreement no. AIDOAA-A-13-00087. The contents of this manuscript are the sole responsibility of the Evidence Project and Population Council and do not necessarily reflect the views of USAID or the United States Government.

Availability of data and materials

The dataset analyzed during the current study will be available at the USAID Development Data Library, https://www.usaid.gov/data.

Authors’ contributions

AJ was the Principal Investigator for the study, conceptualized the article, carried out analyses and contributed to writing of all sections of the manuscript. ET carried out analyses and contributed to writing of all sections. HI was Co-Principal Investigator on the study. HI and AE contributed to study conceptualization and data collection and provided substantive comments to the manuscript. All authors read multiple drafts and approved the final manuscript.

Ethics approval and consent to participate

Informed consent was obtained from all respondents. This study received ethical approval from the Population Council Institutional Review Board and the Ethiopian Public Health Institute.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington DC, 20008, USA
(2)
Population Council, Heritage Plaza, 4th floor, Bole Medhaneialem Road, Addis Ababa, Ethiopia

References

  1. UNAIDS: AIDSinfo. http://aidsinfo.unaids.org (2017). Accessed 26 Oct 2017.
  2. Population Reference Bureau. 2017 World population data sheet. Washington, DC: Population Reference Bureau; 2017.Google Scholar
  3. UNAIDS. UNFPA, WHO and UNAIDS: Position statement on condoms and the prevention of HIV, other sexually transmitted infections and unintended pregnancy.(2015) http://www.unaids.org/en/resources/presscentre/featurestories/2015/july/20150702_condcon_prevention. Accessed 26 Oct 2017.Google Scholar
  4. Central Statistical Agency (CSA) [Ethiopia] and ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland: CSA and ICF; 2016.Google Scholar
  5. Abebe M, Tsion A, Netsanet F. Living with parents and risky sexual behaviors among preparatory school students in Jimma zone, south West Ethiopia. Afr Health Sci. 2013;13(2):498–506.PubMedPubMed CentralGoogle Scholar
  6. Bogale A, Seme A. Premarital sexual practices and its predictors among in-school youths of shendi town, west Gojjam zone, North Western Ethiopia. Reprod Health. 2014;11:49.View ArticlePubMed CentralGoogle Scholar
  7. Maria W. Sexual behaviour, knowledge and awareness of related reproductive health issues among single youth in Ethiopia. Afr J Reprod Health. 2007;11(1):14–21.Google Scholar
  8. Kassa G, Degu G, Yitayew M, Misganaw W, Muche M, Demelash T, Mesele M, Ayehu M. Risky sexual behaviors and associated factors among Jiga high school and preparatory school students, Amhara region, Ethiopia. Int Sch Res Notices. 2016;2016:1–7. https://doi.org/10.1155/2016/4315729.View ArticleGoogle Scholar
  9. Molla M, Nordrehaug Åstrøm A, Brehane Y. Applicability of the theory of planned behavior to intended and self-reported condom use in a rural Ethiopian population. AIDS Care. 2007;19(3):425–31.View ArticlePubMed CentralGoogle Scholar
  10. Bryan A, Kagee A, Broaddus M. Condom use among south African adolescents: developing and testing theoretical models of intentions and behavior. AIDS Behav. 2006;10(4):387–97.View ArticlePubMed CentralGoogle Scholar
  11. Eggers S, Aarø L, Bos A, Mathews C, Kaaya S, Onya H, de Vries H. Sociocognitive predictors of condom use and intentions among adolescents in three sub-Saharan sites. Arch Sex Behav. 2015;45(2):353–65.View ArticlePubMed CentralGoogle Scholar
  12. Sacolo H, Chung M, Chu H, Liao Y, Chen C, Ou K, Chang L, Chou K. High risk sexual behaviors for HIV among the in-school youth in Swaziland: a structural equation modeling approach. PLoS One. 2013;8(7):e67289.View ArticlePubMed CentralGoogle Scholar
  13. Rijsdijk L, Bos A, Lie R, Ruiter R, Leerlooijer J, Kok G. Correlates of delayed sexual intercourse and condom use among adolescents in Uganda: a cross-sectional study. BMC Public Health. 2012;12:817.Google Scholar
  14. Kalolo A, Kibusi S. The influence of perceived behaviour control, attitude and empowerment on reported condom use and intention to use condoms among adolescents in rural Tanzania. Reprod Health. 2015;12(1):105.View ArticlePubMed CentralGoogle Scholar
  15. Rimal R, Real K. How behaviors are influenced by perceived norms: a test of the theory of normative social behavior. Commun Res. 2005;32(3):389–414.View ArticleGoogle Scholar
  16. Cialdini R, Reno R, Kallgren C. A focus theory of normative conduct: recycling the concept of norms to reduce littering in public places. J Pers Soc Psychol. 1990;58(6):1015–26.View ArticleGoogle Scholar
  17. Rimal R, Real K. Understanding the influence of perceived norms on behaviors. Commun Theor. 2003;13(2):184–203.View ArticleGoogle Scholar
  18. Lapinski M, Rimal R. An explication of social norms. Commun Theor. 2005;15(2):127–47.View ArticleGoogle Scholar
  19. Rimal R, Sripad P, Speizer I, Calhoun L. Interpersonal communication as an agent of normative influence: a mixed method study among the urban poor in India. Reprod Health. 2015;12:71.View ArticlePubMed CentralGoogle Scholar
  20. Jang S, Rimal R, Cho N. Normative influences and alcohol consumption: the role of drinking refusal self-efficacy. Health Commun. 2013;28(5):443–51.View ArticlePubMed CentralGoogle Scholar
  21. Lapinski M, Anderson J, Shugart A, Todd E. Social influence in child care centers: a test of the theory of normative social behavior. Health Commun. 2014;29(3):219–32.View ArticlePubMed CentralGoogle Scholar
  22. Priebe CS, Spink KS. When in Rome: descriptive norms and physical activity. Psychol Sport Exerc. 2011;12(2):93–8.View ArticleGoogle Scholar
  23. Kish L. A procedure for objective respondent selection within the household. J Am Stat Assoc. 1949;44(247):380–7.View ArticleGoogle Scholar
  24. Jain A, Ismail H, Tobey E, Erulkar A. Understanding adolescent and youth sexual and reproductive health-seeking behaviors in Ethiopia: implications for youth friendly service programming. Washington, DC: Population Council; 2017.Google Scholar
  25. MEASURE Evaluation. Condom use at last high-risk sex. In: Family planning and reproductive health indicators database; 2017. https://www.measureevaluation.org/prh/rh_indicators/womens-health/stis-hiv-aids/condom-use-at-last-high-risk-sex. Accessed 26 Oct. 2017.Google Scholar
  26. Ministry of Health of Ethiopia. National adolescent and youth health strategy (2016–2020). Addis Ababa: Federal Democratic Republic of Ethiopia; 2017.Google Scholar
  27. Erulkar A, Muthengi E. Evaluation of Berhane Hewan: a program to delay child marriage in rural Ethiopia. Int Perspect Sex Reprod Health. 2009;35(1):6–14.View ArticlePubMed CentralGoogle Scholar
  28. Erulkar A, Medhin G, Weissman E. The impact and cost of child marriage prevention in three African settings. Addis Ababa. New York: Population Council; 2017.Google Scholar
  29. Selikow T, Ahmed N, Flisher A, Mathews C, Mukoma W. I am not “umqwayito”: a qualitative study of peer pressure and sexual risk behavior among young adolescents in Cape Town, South Africa. Scand J Public Healt. 2009;37(Suppl 2):107–12.View ArticleGoogle Scholar
  30. Izugbara C. Notions of sex, sexuality and relationships among adolescent boys in rural southeastern Nigeria. Sex Educ. 2004;4(1):63–79.View ArticleGoogle Scholar
  31. Annabel Erulkar, Abebaw Ferede, (2009) Social Exclusion and Early or Unwanted Sexual Initiation Among Poor Urban Females in Ethiopia. International Perspectives on Sexual and Reproductive Health. 35(04):186–93.View ArticlePubMed CentralGoogle Scholar
  32. Lelissa G, Yusuf L. A Cross Sectional Study on Prevalence of Gender Based Violence in Three High Schools, Addis Ababa, Ethiopia. Ethiop J Reprod Health.Google Scholar

Copyright

© The Author(s). 2018

Advertisement