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Factors associated with condom use among youth aged 15–24 years in Brazil in 2003

Calazans, Gabrielaa,d; Araujo, Teo Wa; Venturi, Gustavob,d; França, Ivan Juniorc,d

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From the aCentro de Referência e Treinamento DST/AIDS

bCriterium Assessoria em Pesquisas

cFaculdade de Saúde Pública da Universidade de São Paulo

dNúcleo de Estudos para a Prevenção da Aids da Universidade de São Paulo, Nepaids/USP, São Paulo, Brazil.

Correspondence to Gabriela Calazans, Coordenação Estadual de DST/AIDS – SP, Rua Santa Cruz, 81, 04121-000 São Paulo, SP, Brasil. Tel: +55 11 5087 9904; fax: +55 11 5084 0777; e-mail: gcalazans@crt.saude.sp.gov.br

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Objective: To analyse factors associated with the lack of condom use among young people at last sexual intercourse with a steady or casual partner.

Design: A cross-sectional study involving 1170 household interviews and designed to build a representative sample of the population of young Brazilian residents aged 15–24 years (2003).

Methods: In the multivariate analysis of data, non-conditional logistic regression modelling was applied to assess the determinants of condom use at last sexual intercourse among young people with steady or casual partners.

Results: The overall level of condom use at last sexual intercourse was high (60%), although it was significantly more common in casual sexual partnership. Cohabitation was associated with a lack of condom use in both casual and steady partner encounters. In addition, being female, having less schooling, having no work history, and per capita family income above the minimum wage were factors related to not using condoms in the group of young people who had their last sexual encounter with steady partners. Among young people with casual partners, such factors included a positive history of alcohol use, first sex at 9–16 years of age, inadequate knowledge of AIDS treatability and bereavement related to violence.

Conclusion: This study confirmed that the determinants of condom use among youth during last sexual intercourse vary according to whether the partner was casual or steady. Prevention campaigns should develop specific messages for each of these contexts.

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Literature on AIDS prevention research has indicated that young people are an important target population because of an increased risk of sexually transmitted disease (STD)/HIV infection and the fact that behavioural patterns established in youth may persist throughout life [1–3]. Historically in Brazil, young people present higher percentages of condom use compared with all other age groups [4–6].

Condom use varies significantly, among young people as well as among adults, according to the type of sexual relationship, defined as either ‘casual’ or ‘steady’ [4,5,7–13]. When studying types of partnership, condom use has been found to be significantly less frequent and less consistent in steady than in casual relationships [11,13].

There have been few specific national studies involving youth and focusing on condom use, such as those conducted in Ghana [14] and in Mexico [15]. Most studies are restricted to high school students. Studies examining the differences in patterns of condom use according to sexual partners among young adults are rare [16]. In addition, studies rarely examine factors associated with condom use.

In a recent review of successful HIV/AIDS control programmes, it was noted that the strategy of promoting condom use is effective in contexts in which transmission occurs in commercial sex settings and in male–male relationships, but not in contexts of a high prevalence of heterosexual transmission [2]. One of the focuses of the Brazilian HIV/AIDS programme has been the promotion of condom use [4].

In this study, we aimed to evaluate condom use at last sexual intercourse, and analyse factors associated with condom use among young people according to whether sexual partners were steady or casual.

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In November–December of 2003, a national cross-sectional study, involving youth aged 15–24 years, was carried out in Brazil. The study, which included both sexes and all social strata, was designed to build a representative sample of the population of young Brazilians. This population, estimated at 34.1 million, represents 20% of the total population [17].

The data used in this article for a condom use analysis were originally collected in a broader study that investigated relevant topics for creating a sociocultural profile of Brazilian youth based on 3501 interviews [18]. The sample was divided into three subsamples comprising a common set of 57 questions and a set of specific questions. In the present study, we analysed the data from subsample B, which included information related to last sexual intercourse and drug use, as well as values and attitudes with regard to experiences with violence and sex relations.

The first stages of the sampling procedure for each of the subsamples were probabilistic (proportional to the size selection of cities, census tracts and household), combined with sex and age quotas for the selection of individuals (final stage). Given this procedure of quota control, refusals were immediately replaced in the same household by individuals of the same sex and age profile, and were not counted. In subsample B, 1170 interviews, carried out in 198 municipalities, were stratified by geographical location (capital and countryside, urban and rural) and by size (small, medium-sized and large), encompassing 25 of the 27 Brazilian states. In nine metropolitan regions and in the Federal District of Brasília, the sample was expanded as follows: the proportion of interviews in those areas was increased from 29.73% (which corresponded to its original weight) to 34.27%, in order to reach 1200 from the 3501 interviews. For the national results, those interviews were multiplied by a correction factor (0.86) in order to reduce them to its original proportionality.

The inclusion criterion for this condom use analysis was being sexually active in the past 12 months. A total of 316 (27%) and 173 (15%) young people were excluded from the sample, respectively, because they were not sexually active or because they reported that their last sexual encounter had occurred more than a year before the interview. Therefore, the final sample consisted of 681 young people who had been sexually active within the preceding year.

The household survey instrument was a 90-question structured questionnaire. An informed consent form was read to individuals before the interview and stated the following: (i) complete anonymity of the interviewee was guaranteed; (ii) the interviewee had the option of declining to answer any question; (iii) questions were designed to elicit opinions, and there were no right or wrong answers. The interviewers were instructed to interview the young people individually and in private.

An analysis of the correlates of a lack of condom use among young people at last sexual intercourse was carried out after subdividing the study population into two groups: those whose last sexual encounter was with a steady partner and those whose last sexual encounter was with a casual partner. Participant-driven definitions of the type of partner were used.

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The young people were divided according to age groups: 15–17, 18–20 and 21–24 years. They were also categorized according to their marital status: (i) widow/er or divorced; (ii) single; or (iii) cohabiting (whether married or not).

Skin colour-related data was self-reported based on the options: black, mulatto, white, Asian and indigenous [19]. Data were grouped into two categories: black (black and mulatto) and non-black (Asian, indigenous and white).

We created three employment categories: never worked (and were not seeking a job); working; and seeking a job. We also created four categories of religion: protestant or evangelical; spiritism, Umbanda or Candomblé; catholic; and other. The youths’ educational background was grouped into four categories: 0–4; 5–8; 9–11; and 12 or more years of schooling.

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Sexual and reproductive life

Data collected concerning the last sexual intercourse were: condom use and whether the partner was steady or casual. In addition, they were asked about the age of first sexual intercourse and their sexual orientation, as well as about parenthood. In addition, the adequacy of their knowledge about AIDS treatability (whether it is curable, incurable but treatable, or fatal) was assessed.

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Other life experiences

Participants were queried about their previous use of alcohol, marijuana or cocaine. In order to evaluate sex-related values, interviewees were also asked to express agreement or disagreement with seven statements about gender roles.

During the interview, the young people were asked if they had ever experienced psychological violence (perceived humiliation, disrespect or discrimination) or abuse (from an immediate family member or relative). In addition, they were asked whether they had experienced bereavement associated with violence or the loss of someone close to them (a relative or a friend) through accident, homicide, suicide, etc., and whether they had ever personally witnessed the body of someone who had had a violent death.

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Differences in proportions were assessed using the chi-squared test, with a 5% level of significance. Non-conditional, weighted logistic regression modelling was performed. When a given variable attained a value of P < 0.15 in the univariate analysis, it was selected by a forward stepwise selection procedure to identify significant predictors of condom use. Associated P values of 5% or less were considered statistically significant. The database was originally compiled using the SPSS package (SPSS Inc., Chicago, Illinois, USA), and data analysis was carried out with Stata 8.0 (STATA Corp., College Station, Texas, USA).

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Profile of the young adults in this study

A significant percentage (60%) reported condom use at last sexual intercourse, and there was a significant difference in condom use according to the type of partner: 80% used condoms with casual partners, compared with 49% when partners were steady. These sexually active young people were predominantly single men, aged 21–24 years, black and catholic. Moreover, they had 9–11 years of schooling, and were seeking a job. Two-thirds of the young people had their last sexual encounter with a steady partner (Table 1). Only 3% reported homosexual orientation.

Table 1
Table 1
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Differences in condom use at last sexual intercourse according to type of partner

The two groups (those with steady or casual sex partners) differed in terms of sex, age, marital status, condom and alcohol use. There were more men (78%) and singles (96%) in the casual partner group. In contrast, young people in the steady partner group were, on average, slightly older (means 20.4 versus 19.1 years in the casual group, a significant difference of 1.3 years). Moreover, the steady partner group presented higher proportions of women and of cohabiting individuals. There were no significant differences in other social demographic variables across the two groups studied. There were five individuals that besides cohabiting had their last sexual intercourse with a casual partner (Table 1).

We found that those in the steady partner group started their sexual life much later, that is, 35% were over 17 years, compared with 17% among those in the casual partner group. More individuals in the steady partner group had children. With regard to their opinions on sex role statements, casual partner group members were more likely to believe that men should have the last word within the couple, and were less likely to believe that politics would improve if there were more women in important positions. Alcohol use was more common among the casual partner group (84%).

There were no significant differences between the two groups in terms of sexual orientation, life experiences regarding violence, marijuana or cocaine use and knowledge on AIDS treatability.

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Correlates of lack of condom use during last intercourse when the partner was ‘steady’

In univariate analysis (Table 2), cohabitation, not having children, being a woman and never having worked were associated with a lack of condom use.

Table 2
Table 2
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Those youths in the sample with less schooling (0–4 or 5–8 years), as well as those in the older age group (21–24 years), also reported lower condom use at last sexual intercourse.

Bereavement associated with violence was associated with less condom use at last sexual intercourse, as were inadequate knowledge about AIDS treatment and having the opinion that men must be more sexually experienced than women. In contrast, no significant differences in condom use were found with regard to life experiences involving violence or alcohol, cocaine or marijuana use.

In multivariate analysis, cohabitation, being a woman, having less than 4 years of schooling and never having worked were factors independently associated with a lack of condom use at last sexual intercourse. Reporting a per capita family income above the minimum wage also emerged as an independent factor for the lack of condom use, although this stratum did not show any association in univariate analysis (Table 2).

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Correlates of lack of condom use at last sexual intercourse when the partner was ‘casual’

In both univariate and multivariate analyses (Table 3), condom use was found to be lower among those who were cohabiting (whether married or not), compared with single respondents. Similarly, both bereavement associated with violence and an inadequate understanding of AIDS treatability were associated with a lack of condom use in both univariate and multivariate models. Age of first sex (from 9 to 16 years old) and alcohol use emerged as being associated only in the multivariate model. In contrast, having experienced psychological abuse was not retained in the multivariate analysis. Cocaine and marijuana use was not associated with a lack of condom use.

Table 3
Table 3
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In this study, we identified fairly high condom use at last sexual intercourse within the past 12 months among Brazilian youth. The 60% level of condom use presented herein is higher than the 40% reported by Pimenta et al. [6] in a study assessing condom use by young people in Brazil and conducted in the second half of the 1990s, although using different methodologies.

Findings from previous national studies involving the general population indicated a higher use by youth than by adults [4,5]. One has to take into account that methodological diversity may explain these differences. The CEBRAP study assessed consistency in condom use in conjunction with condom use within the past 12 months [5], and Paiva et al. [4] evaluated only consistency in use.

The level of condom use identified in our study is comparable with that described in studies involving young people in developed countries, and is higher than indicated in studies conducted in other developing countries [1,11,13,20]. These high percentages can be explained by the fact that this generation initiated their sexual life under the aegis of AIDS awareness programmes, which is consistent with previous studies [21,22]. This seems to be particularly relevant in view of studies indicating that condom use during sexual initiation is correlated with their subsequent use [1]. However, it should be noted that, among studies carried out in developed countries, we found none that involved representative samples of the general population of youth, only students.

The promotion of condom use is central to the Brazilian programme to counter the HIV/AIDS epidemic [4,23,24], and young people assessed in the present study represent a priority population for this programme [25–28]. Therefore, our results support a trend towards increased condom use by young people, consistent with other studies [13,29]. However, only periodical national studies may confirm this hypothesis.

Although the results of several studies have indicated the need to examine condom use in relation to the type of sex partner, a standardized approach has yet to be developed for this purpose [1,11–13,30,31]. In the present study, we decided to employ self-reported categorization, and, unlike other national studies [4,5], we established no specific parameters for the definition of steady and casual relationships. The purpose was to highlight the role of personal views about partners in defining condom use patterns. These methodological differences, in conjunction with the distinction between the two approaches utilized in measuring condom use (at last sexual intercourse versus consistent use over a certain period of time), constitute significant limitations when comparing surveys. There is, however, some comparability because condom use at last sexual intercourse has been considered a reliable proxy in prospective studies [20,30,32].

The assessment of condom use is complex. The fact that the data in the present survey refer to the last sexual encounter might be viewed as a limitation. Some authors suggest the need to assess consistent condom use rather than simply determining condom use at last sexual intercourse [33,34]. Other authors have reported retrospective narrative accounts of last sexual intercourse as a proxy of future condom use [30,32].

The differences found among young people based on the type of relationship (more women and higher mean age among those in steady relationships; more men among those in casual relationships) are consistent with the findings of Paiva et al. [4]. Data obtained by these authors differ from those collected in the present study in terms of the level of education. In our study, we identified no significant differences in years of schooling between the steady and the casual partner groups, whereas Paiva et al. [4] found that those in steady relationships tended to have lower levels of education than did those in casual relationships. This discrepancy might be associated with the fact that we only studied the young population, which presents higher and more homogeneous levels of education than do other age groups in Brazil [35].

We identified a significant difference in condom use among young people according to the type of partnership at last sexual intercourse, being more frequent with casual partners than with steady partners. The results of some national studies have indicated significant differences in condom use according to whether the sexual partner is steady or casual [4,5]. Differences in condom use in relation to the type of partner expressed as odds ratios (OR), were identified in a study involving army recruits, being more frequent with commercial partners, paid (OR 1.7) or paying (OR 1.4), and with casual partners (OR 1.3) than with steady partners. In a study involving the sexually active Brazilian population [4], condom use during sexual intercourse with casual partners was found to be four times more frequent than its use with steady partners.

The differences between the two sex partner groups (steady and casual) regarding factors associated with the lack of condom use at last intercourse seem to be coincident with some aspects of vulnerability to AIDS previously identified in Brazil and in other developing countries. In such contexts, where a pattern of heterosexual transmission and a trend towards the feminization of the AIDS epidemic are emerging [36,37], the population of poorly educated or unemployed women who have few sexual partners during their lives plays an important role in the epidemiological profile, as a result of their economic dependency on their sexual partners and lack of power in negotiating condom use. However, this study also showed that a per capita family income above one minimum wage posed an independent risk when schooling had been taken into account, suggesting that schooling and income play separate and diverging roles in this model, rather than converging in a more traditional construct of social class.

Studies carried out in these contexts indicate difficulties in the incorporation of condom use, especially within steady relationships. This occurs because these relationships apparently present a lower perceived infection risk, which may actually reflect reality. However, even when there is a perception of risk, proposing condom use within the context of supposedly monogamous and truly hierarchical relationships may signal a lack of trust between partners, and jeopardizes the relationship to the extent that the social contract of marriage implies in the assumption of fidelity [2,11,31,38]. In addition, several authors have stressed the fact that contraception is the primary concern among individuals, especially women, involved in steady relationships. In such cases, women adopt contraceptive methods that are considered to be more effective, to the detriment of condom use [13]. Moreover, condom use should be discussed in a context of an open and mutual exchange of knowledge about the partners’ serostatus.

Among those in the casual partner group, factors correlated with the lack of condom use were cohabitation, age of first sex at 9–16 years of age, a positive history of alcohol use, inadequate understanding about AIDS treatability, and bereavement associated with violence.

The fact that individuals who used to cohabit report lower condom use in their intercourses with casual partners might be interpreted in two ways. First, these individuals might be generally different from single individuals who have more readily incorporated condom use with casual partners. Second, it might reveal that they are relating to their casual partners using a condom-related norm acceptable with ‘steady’ partners.

Among those in the steady partner group, it is likely that living in contexts of less exposure and, more importantly, cohabitation lead to less incorporation of the habit of condom use because it competes with other contraceptive methods and involves the question of trust and serostatus awareness.

In our study we found an association between the initiation of sexual life at 9–16 years of age and the lack of condom use among those in the casual partner group. Some studies have demonstrated this association between the earlier age of first sex and the lack of condom use [21,22,39,40]. It is possible to consider that at earlier ages, youth found more obstacles to negotiate condom use. This finding supports the importance of early condom use to establish a pattern of condom use forward to subsequent sexual activity [1,21,22,39].

In contrast to the steady partner group, alcohol plays an important role as a determinant of the lack of condom use in the casual partner group. Research has shown an association between alcohol use and risky sexual behaviour in adolescents, such as condom non-use [1,12,20,40–45]. Considering our findings, in conjunction with the Brazilian literature on young people's sexual behaviour and AIDS prevention, it is plausible to think that alcohol has been used as a disinhibition strategy. The literature reports the use of alcohol by young men in dating contexts as a strategy to reduce the inhibition caused by the social pressures on male sexual behaviour [46,47].

This seems to be particularly relevant in view of studies indicating the high prevalence of alcohol use in life by youth in Brazil: 48% among young people aged 12–17 years and 73.2% among young people aged 18–24 years, in a nationwide household survey [48], and 86.8% in two school-based surveys, in two different capitals from the southern region of the country [49,50].

It is important to note, however, that our study measured alcohol use in life; it did not investigate the influence of alcohol use in the last sexual intercourse, nor did it analyse data on the frequency of alcohol use.

With regard to knowledge about AIDS and treatment effectiveness, we found that adequate knowledge increased the levels of condom use. Despite the wide dissemination of information concerning AIDS, it is worthwhile bolstering information programmes in Brazil, highlighting the potentials and limitations of antiretroviral therapy.

In this study, a lack of condom use was associated with bereavement as a result of violence. Living under conditions of impending risks to survival on an everyday basis could represent an obstacle with respect to the adoption of HIV protective practices [51].

In conclusion, this nationwide study provides additional evidence of differences in the determinants of condom use according to whether partners are ‘steady’ or ‘casual’. Prevention policies and programmes should develop strategies responsive to such diverse contexts of sexual partnerships.

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The authors would like to thank the Instituto Cidadania (Citizenship Institute), the coordinators of the Projeto Juventude (Youth Project) and Criterium Assessoria em Pesquisas (Criterium Research Assistance) for having allowed us to utilize data from the ‘Perfil da Juventude Brasileira’ (Brazilian Youth Profile) study in order to produce this article. They would also like to thank Mrs Rita Dias for her effort in explaining the methodological aspects involved on the study design.

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condoms; Latin America; prevention of sexual transmission; risk factors; sexual behaviour

© 2005 Lippincott Williams & Wilkins, Inc.


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