|
Shally Awasthi
Vinod Kumar Pande
From the Department of Pediatrics and Institute of Clinical Epidemiology, King George's Medical College, Lucknow, India.
Reprint requests: Dr. Shally Awasthi, C-4, Officer's Colony, Niralanagar,
Lucknow (U.P.) 226 020, India.
Manuscript received: October 29,1997; Initial review completed: January 9, 1998;
Revision accepted: July 8, 1998
It has been estimated that India would have the largest number of cases of Human
Immunodeficiency Virus (HIV) infection in the world by the turn of century(1). Adolescents would be at greatest risk of such
infection(2-4). To prevent the spread of HIV and sexually transmitted diseases (STD), reproductive health counseling was started in the developed countries, by and large, through school based programs(5,6). In India almost half the boys drop out after primary school(7). Therefore, reproductive health counseling programs here have to operate both through the schools and directly through community based initiatives. Together, the basic information to start a community based reproductive educational health program, the aim of this study was to assess, among under- privileged 15 to 21 years old boys, sexual behavior patterns and knowledge of STD.
Subjects and Methods
The study was conducted in the Integrated Child Development Scheme (ICDS) centers of urban Lucknow, North India. Of 203 registered Anganwadi centers in urban Lucknow,
35 centers where research projects on under five's were going on
were included in this study. Questions pertaining to the sexual behavior patterns of adolescent boys were made on the basis of western literature(2-4,8). The questions were culturally and linguistically modified for our boys. The questions were field tested for understandability prior to use.
Eligible for the study were boys between the age of 15 to 21 years who were registered with the ICDS anganwadi worker. Two interviews were conducted, 10 to 15 days apart. Prior verbal consent was taken from the boys. In the first inter- view, the educational, socio-economic and marital status of the boys was determined. Questions were asked about their health concerns, substance abuse, sex (local term being "sambhog"),
condom use, number of sex partners till date and the following
symptoms suggestive of sexually transmitted disease: pus discharge, burning during
micturition, increased frequency, urgency or ulcerative genitallesions(9). After 10-15 days a "key informant" interview with in- depth questioning on issues related to sex was conducted on a subset of boys by male project officers. Basic assessment of know- ledge of STD was done on two aspects: symptoms and prevention.
Univariate distribution of age, marital,
socio-economic status and substance abuse was assessed. The proportion of unmarried boys less than and greater than 18 years of age, with its 95% confidence interval (CI), who have had sex was compared using Chi-square test. Crude odd's ratio (OR) with its 95% CI was calculated to assess the association between cigarette smoking and alcohol consumption with sex in the
unmarried boys. In "key informant" inter- view, the proportion similar responders to various questions was assessed.
Results
The survey was done in 35 anganwadi centers and 221 boys were interviewed. Mean number of boys interviewed per slum was 6.3 (SD 2.52). The mean age was 17.4 years (SD 2.13) and 29.8% of the boys were illiterate. Fifteen (7.4%) boys were married. Mean age of the boy at marriage was 16.2 years (SD 4.7), while that of their spouse was 15.6 years (SD 2.6). The point prevalence. of one or more symptoms of STD was 1.8% (95% CI: 0.6-4.3).
The boys cited chronic medical condition as the main reason for physician visit
as compared to causes related to the reproductive organ/ system, where nocturnal ejaculation was the commonest. One third [34.4% (95% CI.: 28.3-40.8)] of the boys were smokers and the mean age of initiation was 12.3 years (SD 5.3). A total of 13.1% (95% CI 9.1-18.1) of the boys took alcohol and the age of initiation was 14.8 years (SD 1.6). Two boys took opium.
derivatives and two had marijuana.
Of the 221 boys, 206' were unmarried and the prevalence of premarial sex in boys; 18 years and> 18 years was 7.9% (11 out of 140) and 7.6% (5 out of 66), respectively. Among the unmarried boys, cigarette smokers, alcohol drinkers and those who had both had a crude OR of 5.1 (95% CI: 0.87-8.66; p=0.049), 2.72 (95% CI: 1044-17.7; p=0.008) and 4.9 (95% CI: 1.09-14.84; p=0.03), respectively, for having sex. The source of knowledge about sex was friends (n=59, 26.6%), no one (n=118, 53.2%), television (n=26, 11.7%), magazines and books
(n=12, 5.3%) and siblings (n=7,
3.2%).
One
boy responded both siblings and friends. Some of the self-reported sexual bahavior patterns are given in
Table 1.
Out of 221 boys, 47 boys were contacted for the "key informant" interview and the responses are shown in Table II. At this interview, 93.8% responded that the symptoms of STD were similar in males and females, 91.7% said that it was not easy to cure STD. The proportion of boys who said that a particular method was appropriate for protection against STD was as follows: washing before. and after sex with anti" septic solution (48.9%), not ejaculating in- side (12.8%) and. taking antibiotics after sex (38.3%). None of these three methods will provide a complete protection against STD.
Table I
Self Reported Sexual Behavior Pattern in Adolescents
(n=221)
|
Behavior |
n |
% |
| 1.
Condom use (ever) |
| Yes |
6 |
2.7 |
| No |
153 |
69.2 |
| No
reply |
18 |
8.1 |
|
Don't know "condom" |
44 |
19.9 |
| 2.
Engaged in sex |
| Yes |
18 |
8.1 |
| No |
175 |
79.2 |
| No
reply |
28 |
12.7 |
| 3. Sex with
commercial sex worker |
|
|
| Yes |
3 |
1.4 |
| No |
186 |
84.2 |
| No
reply |
32 |
14.5 |
| 4.
Number of sexual partners till date |
| 0- |
180 |
81.4 |
| 1- |
15 |
6.8 |
| 2- |
19 |
8.6 |
| 3- |
4 |
1.8 |
| 4-7- |
3 |
1.5 |
| 5.
Condom use in last three months |
|
All times |
0 |
0 |
|
Sometimes |
8 |
3.6 |
|
Never |
213 |
96.6 |
Discussion
The current cross-sectional survey revealed that 7.9% and 7.6% of unmarried adolescent boys
≤ and > 18 years, respectively, living in the urban slums of Lucknow, North India are sexually active. These boys are also engaged in high risk sexual behavior, like man to man sex and visits to CSW, and had poor knowledge of STD symptoms and prevention. Thus, these boys are at risk to acquire STD. Since cases of STD are at an increased risk of acquiring
HIV infection(10), further studies are needed to develop educational strategies to increase the knowledge of adolescent boys about STD.
All the boys contacted by us were eager to participate in the
study. The survey revealed that less than one-tenths of the boys are sexually active, as compared to more than three quarters of same age counterparts in the West(5,11) and African countries(12). Point prevalence of STD was 1.8%. Even though this is a crude estimate based on self reported symptoms, it is less than the community based incidence
reported from the USA(13). There was a wide discrepancy in the proportion of boys wh9 had reportedly had
sex or sexual partners as compared to those who had used a condom, the former being 3 to 9 times greater than the latter. They also had poor knowledge about STD prevention. This places the boys at risk for STD and HIV.
TABLE II
Responses on Interview of 47 Key Informant Boys for Sexual Behavior Pattern.
| 1.
Reported sex in 4 boys of the same age |
| 0:
78.7% |
1-2:
2.1% |
3-4: 19.1% |
| 2.
Relation to the person with whom the first sexual contact
took place |
|
Relative: 0% |
Girl
friend: 6.3% |
Commercial sex worker (CSW): 0% |
| 3. Estimated age of first sexual contact in boys in Lucknow slums |
|
Mean, SD: |
16.9 years, 1.3 |
|
|
Range: |
14 to 20 years |
|
| 4.
First sex partner: |
| Wife:
|
39.6% |
|
| Girl
friend:
|
60.4% |
|
| 5. Whether they are aware of boys visiting a CSW: |
| Yes:
|
14.9% |
|
| 6.
Sex with males/boys in this place is (4.2% boys did not
reply): |
| Not
known: 36.2% |
Uncommon: 34% |
|
|
Common: 21.3% |
Very common: 4.3% |
|
| 7.
Percentage of boys having sex with males: |
| 0: 27.1 % |
2:6.3% |
5: 25% |
10:29.2% |
15:12.5% |
| 8. Who usually has sex with young boys:
|
|
Men: |
18.8%
|
Females: |
10.4% |
Animals: |
18.8% |
| No
one: |
47.9% |
Not known: 4.2% |
|
We have also found that those who smoke or consume alcohol or do both were more likely to be sexually active before marriage. Substance abuse has been associated
with irregular condom use(3, 14-16) and also with STD(3).
Therefore, targeted counseling for smokers can be considered since
33.9% (n = 70) of the unmarried boys smoke here. The
cost-effectiveness of targeted counseling versus mass counselling
has to be studied before making any policy decisions.
The key informant interview validated the findings of the initial interview. It also provided valuable additional information about awareness of the presence of man to man sex and visits to CSW among adolescent boys in the community. However, the exact prevalence of man to man sex has not been determined in this study.
We conclude that since adolescent un- married boys are sexually active, indulge in high risk sex behaviors and substance abuse and have poor knowledge of STD, there is an urgent need for initiating reproductive health counseling programs after developing appropriate educational package.
Acknowledgment
This study was funded by the International Clinical Epidemiological Network (INCLEN), Philadelphia, USA through its reproductive health initiative. Prof. Mark Nichter of University of Arizona, Tucson, helped in designing the study.
|
1.
Jain MK, John TJ, Keusch GT. A review of immunodeficiency virus infection in India.
J
Acquir Immune Defic Syndr 1994; 7: 1185-1194.
2.
Donovan C. Adolescent sexuality. BMJ 1990; 300; 1026-1027.
3.
Kirby D. Sex and HIV / AIDS education in schools. BMJ 1995; 311: 403.
4.
MacDonald NE, Walls GA, Fisher WA, Warren WK, King MA, Doherty JA, Bowie WR. High risk STD /HIV behavior among college students. JAMA 1990; 263: 3155-3159.
5.
Mellanby AR, Phelps FA, Crichton NJ, Tripp JH. School sex education: An experimental program with educational and medical benefit. BMJ 1995; 311: 414-417.
6.
Willing K, Wadsworth J, Johnson AM, Field J, Whitaker L, Field B. Provision of sex education and early sexual experience: The relation examined. BMJ 1995; 311: 417-420.
7.
National Family Health Survey (MCH and Family Planning) Uttar Pradesh 1992-93. Population Research Center. Lucknow
University and International Institute of Population Science, Mumbai, 1994.
8.
Sugerman ST, Hergenroeder AC. Chacko MR, Parcel GS. Acquired immunodeficiency syndrome and adolescents. Knowledge,
attitudes, and behaviors of runaway and homeless youths. Amer
J
Dis Child 1991; 145: 431-436.
9.
Neinstein LS. Overview of sexually transmitted diseases. In: Adolescent Health Care: A Practical Guide. Ed. Neinstein LS. Baltimore, Williams and Wilkins, 1996; pp 853-874.
10.
Rodriques H, Mehendale SM, Shepherd ME, Divakar AD, Gangakhedhar RR, Quinn TC, et al. Risk factors for HIV among people attending clinics for sexually transmitted disease in India. BMJ 1995; 29: 283-286.
11.
DiClemente RJ, Lodico M, Grinstead OA, Harper G, Rickman.RL, Evans PE, Coates TJ. African-American adolescents residing
in high risk urban environments do use condoms: Correlates and
predictors of condom use among adolescents in public housing. Pediatrics 1996; 98: 269-278.
12.
Mosha F, Nicoll A, Boronool Bonodorff M, Newell J, Senkoro K, et al. A population based study of syphilis and sexually transmitted disease syndromes in north- western Tanzania: I. Prevalence and incidence. Genitourin Med 1993; 69: 415-420.
13.
Braveman PK, Strasburger VC. Sexually transmitted diseases. Clin Pediatr 1994; 33: 26-27.
14.
Joffe A. Adolescents and condom use. Am
J
Dis Child 1993; 147: 746-754.
15.
Hingson RW, Strumm L, Berlin BM, Heiren T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am
J
Public Health 1990; 80: 295-299.
16.
Lowry R, Holtzman D, Truman BI, Kann L, Collins JL, Kolbe LJ. Substance use and HIV-related sexual behaviors among US high school students: Are they related? Am
J
Public Health 1994; 84: 1116-1120.
|
