Exploring the social and cultural context of sexual health for young people in Mongolia: implications for health promotion

Applying the COM-B behaviour model to understand factors which impact 15-16 year old students' ability to protect themselves against acquirement of Human Papilloma virus (HPV) in Northern Ireland, UK

High-risk strains of Human Papillomavirus (HPV) can lead to the development of a number of cancers including cervical, vulvar, penile, anal and oropharyngeal. HPV vaccination programmes offer the HPV vaccine to males and females 12-13 years old in schools throughout the UK. However, knowledge of HPV remains low in post-primary schools. The aim of this study is to capture 15-16 year old students' perceptions regarding the current provision of HPV education, and whether providing HPV education to 15-16 year olds could influence their intention to be vaccinated and/or future sexual health decisions related to HPV. Between 5th November 2021 and 6th May 2022, seven focus groups were conducted with 34 students in post-primary schools in Northern Ireland, United Kingdom. The data was analysed using the COM-B behaviour model to explore the perceived facilitators and barriers impacting students' ability to protect themselves from acquirement of HPV. Students perceived their knowledge of HPV to be poor and supported the addition of comprehensive mandatory HPV education at 15-16 years old when many of them were becoming sexually active. They identified barriers including lack of parental education, school ethos and religion and insufficient education regarding their legal rights to self-consent to HPV vaccination. Students felt that removal of these barriers would lead to safer sexual practices, increased awareness of the importance of HPV screening and increased HPV vaccination uptake. The recommendations provided by students need to be supported by the Education Authority in conjunction with the Department of Health in order to be successfully implemented into the post-primary school curriculum.

Psychosocial determinants of sexual health in newly married couples: a protocol for a mixed-methods study

BACKGROUND

Regarding psychosocial factors affecting sexual health and in most cultures, healthy and pleasurable sexual relations are valued in the family context, the present study aims to identify the psychosocial determinants of sexual health in newly married couples.

METHODS

The present mixed-methods study will be conducted in three phases. The first phase will be carried out qualitatively based on which psychosocial determinants of the sexual health of newly married couples will be extracted. In the second phase, questionnaire items of psychosocial determinants of sexual health in newly married couples will be compiled, and face validity (quantitative and qualitative), content validity (quantitative and qualitative), and reliability of the questionnaire will be evaluated. In the third phase, which will be the quantitative phase of the study, the construct validity of the questionnaire will be assessed by analyzing the main items. Moreover, at this stage, the relationship between the extracted psychosocial determinants and the sexual health of newly married couples will be investigated.

DISCUSSION

By explaining the psychosocial determinants of sexual health in newly married couples, it is possible to identify key variables for designing interventions that improve the sexual health of this group, based on their cultural sensitivities.

Exploring the why: risk factors for HIV and barriers to sexual and reproductive health service access among adolescents in Nigeria

BACKGROUND

Early sexual debut, low educational attainment, history of rape and transactional and intergenerational sex have been associated with HIV infection among Nigerian adolescents, especially females. We sought to understand the "why", and how to mitigate against these determinants and barriers to addressing adolescent sexual and reproductive health (SRH) and HIV prevention needs.

METHODS

This qualitative study generated data from 49 focus group discussions with male and female adolescents living with and without HIV, healthcare workers, members of civil society organizations working with young people, and parents of adolescents living with HIV. Participants were recruited from all six geopolitical zones in Nigeria. Data was analysed with ATLAS.ti software. Hermeneutic units were created, and codes developed from focus group transcripts. Network View Manager was used to create maps of codes, memos and quotations, and relevant quotes were retrieved from transcripts.

RESULTS

Four major themes were identified, relating to individual, parental, community and government roles in reducing the risk of HIV and unplanned pregnancy among adolescents in Nigeria. Individual factors influencing sexual risk behaviours of adolescents include peer pressure, poor risk perception for HIV, and misconceptions about the efficacy of contraceptives and condoms. Respondents entrusted State responsibilities such as facilitation of HIV-affected adolescents' access to education, rather, to individuals, parents and the community; and placed the blame for rape on rape survivors. Findings also highlighted the inadequacy of health systems to address adolescents' needs for treatment of sexually transmitted infections and to provide appropriate education on secondary HIV prevention for those living with HIV.

CONCLUSION

Rigorous studies are needed to understand dynamics between adolescents' risk behavior, HIV risk perception, parental roles in mitigating HIV risk in adolescents, and the role of communities and government in HIV prevention and treatment for adolescents in Nigeria.

Substance use and related risk behaviors among junior high school students in Nakhon Pathom province, Thailand

Purpose

The spread of drug use has been consistently increasing in Asia, posing a serious public health problem, especially among new addicts. In Thailand, the problem has persisted for decades leading to a consistent decline in the age of drug use initiation, making drug use an important social problem, especially among youngsters. This study aimed to examine the factors related to substance abuse risk behaviors among lower secondary school students.

Design/methodology/approach

A cross-sectional survey was conducted using a self-administered questionnaire to collect the data from a sample of 624 students aged 12 through 18 years. Data analysis was performed using descriptive statistics and multiple linear regression to identify factors related to substance use risk behaviors.

Findings

Factors associated with drug use risk behavior were access to drugs (0.882; <0.001), which had the highest predictive power, family relationships (−0.555; <0.001), self-esteem (−0.516; <0.001) and awareness about drugs (−0.412; <0.005).

Originality/value

Prevention interventions that incorporate reducing access to drugs, strengthening family ties, boosting adolescents' self-esteem and increasing their awareness about drugs should be tailored to target homes, schools and communities. As the problem appears to be multidimensional, the full participation of all relevant stakeholders such as teachers, parents, religious and community leaders in the intervention programs is as essential as the interventions themselves.

What are the situational and behavioral factors associated with condomless anal sex without pre-exposure prophylaxis in MSM?

OBJECTIVE

This study aimed to identify situational and behavioral factors associated with condomless anal sex without on-demand PrEP in the open-label extension (OLE) study of the ANRS-IPERGAY trial.

METHODS

Univariable and multivariable modified Poisson regressions with a generalized estimating equation (GEE) were used. The attributable risk percentage for each explanatory variable and for condomless anal sex without PrEP was calculated.

RESULTS

In the OLE, 19% of anal intercourses were unprotected (i.e. no PrEP or condom). Of these, 85% were attributable to sexual intercourse with main partners and 47% with HIV-negative partners. The following factors were positively associated with condomless anal sex without PrEP: a depressive episode in the previous 12 months [aR (95% CI), P-value: 1.49 (1.02--2.17), 0.039], a higher number of sexual intercourses during the previous 4 weeks [1.01 [1.002--1.02], 0.014], and sexual intercourses under the influence of alcohol [1.45 (1.10--1.92), 0.008]. By contrast, condomless anal sex without PrEP was less frequent during sexual intercourses with known casual, unknown casual and multiple partners [0.20 (0.14--0.30), <0.001; 0.10 (0.05--0.20), <0.001; 0.11 (0.05--0.29), <0.001, respectively], as well as with HIV+ partners with an undetectable viral load and HIV+ partners with a detectable/unknown viral load or unknown serology status [0.57 (0.38--0.86), 0.007; 0.52 (0.32--0.87), 0.012, respectively].

CONCLUSION

Choosing to have condomless anal sex without PrEP depends primarily on the sexual partner's characteristics (level of intimacy, serological status). This reflects a form of rationality in HIV risk management. However, our results raise questions about the true efficacy of managing HIV risk using this approach.

Prevalence and incidence of HIV-1 infection in a community-based men who have sex with men (MSM) cohort in Ulaanbaatar, Mongolia

The number of HIV-1-infected men who have sex with men (MSM) Mongolian patients started to increase steeply just before 2011. We started collaborative work with community-based organizations that promote safer sex and HIV testing for MSM since mid-2010. Since early 2013, the Mongolian Government has implemented the treat-all strategy for MSM. To determine the efficacy of these countermeasures, we established an MSM cohort in the capital of Mongolia, Ulaanbaatar, in December 2013. HIV antibody was examined at every visit by rapid test. Syphilis was also examined to monitor their sexual behavior. Clients positive for either rapid test were referred to the National Center for Communicable Diseases, Ulaanbaatar, to confirm the results and treatment. Since safer sex promotion is one of the purposes of this cohort, HIV-positive clients were also eligible to participate. A total of 849 MSM were registered and 2,409 HIV/syphilis tests were conducted until December 2017. During this period, 499 (58.8%) clients visited the testing sites repeatedly. Among the 849 clients, HIV-1 infection was confirmed in 83 at registration (prevalence of HIV- 1: 9.8%). One HIV-1 seroconverter was identified (from negative to positive), resulting in incidence of HIV-1 of 0.10/100 person-years (PY). Syphilis was positive in 144 cases at registration (syphilis prevalence: 17.0%), and 53 new syphilis infection cases were diagnosed during the same period, with an incidence of 5.66/100 PY. Despite the high prevalence of HIV-1, the incidence was very low. The results suggest that countermeasures for HIV-1 prevention seem effective in this cohort, however, we still need further strategies for syphilis control.

Impact of HIV risk perception on both pre-exposure prophylaxis and condom use

Risk perception is one of the several important factors impacting sexual health behaviours. This study investigated the evolution of HIV risk perception on pre-exposure prophylaxis adherence and condom use in men who have sex with men at high risk of HIV and associated factors. Group-based trajectory modelling helped in identifying patterns of risk perception, pre-exposure prophylaxis adherence and condom use over time. The association between the former and the latter two dimensions was then investigated. An estimated 61 per cent (p < 0.001) of participants perceiving low risk and 100 per cent (p < 0.001) of those perceiving high risk had systematic pre-exposure prophylaxis adherence, while an estimated 49 per cent (p < 0.001) and 99.8 per cent (p < 0.001), respectively, reported low-level condom use.

Perceptions of sexual violence among men who have sex with men and individuals on the trans-feminine spectrum in Mongolia

With the growing realisation that sexual violence poses pressing health and human rights concerns for men who have sex with men (MSM) and individuals on the trans-feminine spectrum, research has focused on the context in which sexual violence takes place. Rape myths and other perceptions of sexual violence affect the prevalence of perpetration and the availability of services and support for survivors. Little research has been conducted on rape myths among sexual and gender minority groups, especially in low- and middle-income countries. Two focus groups and 30 in-depth interviews were conducted with MSM and individuals on the trans-feminine spectrum in Ulaanbaatar, Mongolia. A number of rape myths previously noted to be prevalent among Western, heterosexual men, and women were expressed by participants, including the myth that males are never raped, rape as a cause of homosexuality or transgenderism, conceptualisations of prototypical rape as requiring overwhelming force, and victim blaming. However, many of these perceptions appeared to have different origins and effects in these populations. This study illustrates interesting similarities and differences compared to rape myths explored in Western, heterosexual male samples, and draws attention to the need to address community perceptions of sexual violence in sexual health and violence intervention programming.

Evolving understanding of the epidemiology of HIV and prevention needs among men who have sex with men in Ulaanbaatar, Mongolia

This study describes HIV and syphilis bio-behavioral survey conducted among 200 men who have sex with men (MSM) recruited via respondent-driven sampling (RDS) between January 4 and February 1, 2012 in Ulaanbaatar, Mongolia. Participants were administered a structured questionnaire and data were analyzed with RDS-network program in STATA. Of 196 participants who agreed to be tested for HIV and syphilis, 21 (10.7 %; weighted 7.5; 95 % CI: 4.9, 11.4) and 8 (4.1 %; weighted 3.4; 95 % CI: 1.7, 6.7) were positive for HIV and syphilis, respectively. Exposure to HIV prevention programs in the last 12 months was reported by 51.8 % (weighted 33.6; 95 % CI: 27.6, 40.1) of participants. This study found high HIV prevalence and limited uptake of HIV prevention services among MSM in Mongolia. Given the concentrated HIV epidemic among MSM in Mongolia, HIV prevention, treatment and care services should focus on MSM as the population group most affected by HIV.

Gendered discourses of youth sexualities--an exploration of PubMed articles on prevention of sexually transmissible infections

OBJECTIVE

To explore how gender is addressed in medical articles on the prevention of sexually transmissible infections (STI) among adolescents.

METHODS

Sixtyone articles were retrieved from a PubMed search and scrutinized by qualitative content analysis.

RESULTS

Most articles were affiliated with North American research institutions, but there were also reports from Europe, Africa, South America, and Asia. Gender turned up in the following four recurrent discourses: Gendered Receptiveness for Information, Stereotyped Heterosexual Expectations, Power Imbalance in Sexual Relations, and Gendered Prevention Approaches. Young women were described as knowledgeable, communicative, and responsible, but at risk because of feminine ideals and a lack of negotiating power. Men were described as less informed, more reluctant to discuss, and more risk taking due to masculine ideals and power dominance. Prevention approaches concerned how to postpone sex and/or tailor gender-sensitive programs for specific groups of young women and men.

CONCLUSION

Researchers' own gender expectations might have a substantial impact on how sex and sexual health is considered in prevention research. To avoid reconstruction of current inequalities and stereotypes regarding sexual practices of young women and men, the impact of gender, the power structures in intimate relations, and the cultural context should be considered. Medical research on STI prevention could benefit from including a wider array of gender perspectives.

Barriers of modern contraceptive practices among Asian women: a mini literature review

Family planning has been cited as essential to the achievement of Millennium Development Goals (MDG). Family planning has a direct impact on women's health and consequence of each pregnancy. The use of modern contraception among Asian women is less than global average. In Asia a majority of unintended pregnancies are due to using traditional contraceptive or no methods which lead to induced unsafe abortion. Cultural attitudes, lack of knowledge of methods and reproduction, socio demographic factors, and health service barriers are the main obstacles to modern contraceptive practice among Asian women. Culturally sensitive family planning program, reforming health system, and reproductive health education through mass media to create awareness of the benefits of planned parenthood are effective strategies to improve modern contraceptive practice among Asian women.

Health system reform and safe abortion: a case study of Mongolia

Unsafe abortion serves as a marker of global inequity as it is concentrated in the developing world where the poorest and most vulnerable women live. While liberalisation of abortion law is essential to the reduction of unsafe abortion, a number of challenges exist beyond this important step. This paper investigates how popular health system reforms consonant with neoliberal agendas can challenge access to safe abortion. We use Mongolia, a country that has liberalised abortion law, yet, limited access to safe abortion, as a case study. Mongolia embraced market reforms in 1990 and subsequently reformed its health system. We document how common reforms in the areas of finance and regulation can compromise the safety of abortions as they foster challenges that include inconsistencies in service delivery that further foment health inequities, adoption of reproductive health programmes that are incompatible with the local sociocultural context, unregulated growth of the private sector and poor enforcement of standards and technical guidelines for safe abortion. We then discuss how this case study suggests the conversations that reproductive health policy-makers must have with those engineering health sector reform to ensure access to safe abortion in a liberalised environment.

Sexual perceptions and practices of young people in Northern Thailand

This study draws together survey and qualitative data on sexual practices among more than 1,750 young Northern Thai people aged 17-20 years. The survey data indicate that sexually active young people frequently engage in, or are subjected to, risk-taking behaviours that may expose them to sexually transmitted infections and unwanted pregnancies. These include having multiple sexual partners and quite frequent partner turnover. High percentages also engage in unprotected sexual intercourse with various types of sexual partner (steady, casual and paid), and young women especially had often experienced sexual coercion. Qualitative data revealed a mixture of perceptions and practices affecting sexual intercourse among the young, such as having unplanned sex, engaging in sexual relations to display love or cement committed relationships, and having serial relationships, both monogamous and non-monogamous. We conclude that condom use should be a central focus of activities aimed at preventing adverse sexual health outcomes, but that new intervention approaches to encourage use of other contraceptives are also needed. Changes in sexual norms among young people also need to be acknowledged and accepted by older Thai generations in order for programs and interventions to combat negative sexual and reproductive health consequences to be more effective.

Dating and Sex Among Emerging Adults in Nepal

Social and cultural changes in Nepal, including better communication facilities and transport, more urbanization and a rising age at which people marry, have created more opportunities for young people for “dating.” Our qualitative study explores whether the existence of dating cultures influences young people’s sexual behavior in Nepal. Focus group discussions with a total of 75 participants and 31 in-depth individual interviews were conducted among young people in Nepal. Most urban and rural young people liked the dating culture. Although it is a new kind of culture in Nepalese society, it is gaining popularity. The mass media were regarded as encouraging and creating an environment for dating. Most participants believed that dating culture encourages premarital and extramarital sexual behavior. The authors underpin their findings by linking it to the “emerging adulthood” framework. In terms of public health, they recommend that dating practice should be discussed in formal and informal education to promote safer sex.

Everything's better in moderation: young women's gender role attitudes and risky sexual behavior

PURPOSE

This study examines the association between gender role attitudes and risky sexual behavior among young women. Previous studies have posed seemingly contradictory arguments: that either traditional attitudes or egalitarian attitudes are associated with riskier behavior.

METHODS

Data are based on the children of the National Longitudinal Survey of Youth, representing 520 sexually active 18-19-year-old women. Propensity radius matching was used to assess differences in rates of multiple sexual partners and sex outside of a committed relationship.

RESULTS

Relative to moderate gender role attitudes, both egalitarian gender role attitudes and traditional gender role attitudes are associated with higher rates of risky sexual behavior. Both women with egalitarian role attitudes and those with traditional role attitudes have about a 10% higher prevalence of risky behavior compared to women with more moderate gender role attitudes.

CONCLUSION

Existing, seemingly contradictory contentions about the relationship between gender role attitudes and risky sexual behavior may be more coherent than they seem. By shifting focus from risk to protection, the results suggest that moderate gender role attitudes are protective against risky sexual behavior. Future studies should investigate the causal mechanisms and intervention implications of this protective relationship.

Culture-Specific Factors Contributing to HIV Risk Among Jamaican Adolescents

The purpose of this article is to describe the results from an elicitation research study addressing the multisystem-level factors that contribute to HIV risk among Jamaican adolescents. Focus group and survey data were determined from parents, adolescents, and teachers in Kingston, Jamaica, from 2004 and 2005. Guided by an ecological extension of the Theory of Planned Behavior, focus groups and survey questionnaires identified cultural factors at the individual, family, and societal levels that significantly influence Jamaican adolescents' behavioral, normative, and control beliefs related to sexual behaviors that contribute to risk for HIV and other sexually transmitted infections. Although some factors were similar to those reported among adolescents living in the United States, others were culture-specific influences and beliefs that were unique to Jamaica. Results from the current study could contribute to the development of theory-based, culture-specific HIV risk-reduction interventions for use with Jamaican adolescents.

Effectiveness of an HIV prevention program for secondary school students in Mongolia

PURPOSE

To evaluate the effectiveness of a 3-year human immunodeficiency virus (HIV) prevention program for adolescents attending secondary school in Mongolia.

METHODS

Comparisons of knowledge, attitudes, self-efficacy and safe sex practices of grade 10 students from schools with a peer education prevention program to grade 10 students from schools without the intervention. Peer education programs were launched in 2000 across Mongolia. In 2004, survey data was collected among 720 randomly selected students from eight schools with the peer education prevention program and compared with those of 647 students from eight schools without this intervention. Data was collected in Ulaanbaatar and three Mongolian provinces and analyzed using multilevel regression methods.

RESULTS

Students of schools with the program were statistically significantly more knowledgeable, had less traditional attitudes, and had greater awareness of their self-efficacy in regards to HIV and sexual health. Students from schools with the peer education program were more likely to practice safe sex, though the difference was not statistically significant. However, safe sex practice was found to be statistically significantly safer in a subset of schools that had small teams of peer educators.

CONCLUSION

Adolescents in Mongolia are sexually active and at risk for infection with HIV and other STIs. Peer education programs, particularly those that are managed by small teams, appear effective and should be implemented more broadly.

Sexual behaviour in context: a global perspective

Research aimed at investigating sexual behaviour and assessing interventions to improve sexual health has increased in recent decades. The resulting data, despite regional differences in quantity and quality, provide a historically unique opportunity to describe patterns of sexual behaviour and their implications for attempts to protect sexual health at the beginning of the 21st century. In this paper we present original analyses of sexual behaviour data from 59 countries for which they were available. The data show substantial diversity in sexual behaviour by region and sex. No universal trend towards earlier sexual intercourse has occurred, but the shift towards later marriage in most countries has led to an increase in premarital sex, the prevalence of which is generally higher in developed countries than in developing countries, and is higher in men than in women. Monogamy is the dominant pattern everywhere, but having had two or more sexual partners in the past year is more common in men than in women, and reported rates are higher in industrialised than in non-industrialised countries. Condom use has increased in prevalence almost everywhere, but rates remain low in many developing countries. The huge regional variation indicates mainly social and economic determinants of sexual behaviour, which have implications for intervention. Although individual behaviour change is central to improving sexual health, efforts are also needed to address the broader determinants of sexual behaviour, particularly those that relate to the social context. The evidence from behavioural interventions is that no general approach to sexual-health promotion will work everywhere and no single-component intervention will work anywhere. Comprehensive behavioural interventions are needed that take account of the social context in mounting individual-level programmes, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour.

Health sector reform and sexual and reproductive health services in Mongolia

Since its transition to democracy, Mongolia has undergone a series of reforms, both at national level and in the health sector. This paper examines the pace and scope of these reforms, the ways in which they have impacted on sexual and reproductive health services and their implications for the health workforce. Formerly pro-natalist, Mongolia has made significant advances in contraceptive use, women's education and reductions in maternal mortality. However, rising adolescent pregnancy and sexually transmitted infections, and persisting high levels of abortion, remain challenges. The implementation of the National Reproductive Health Programme has targeted skills development, outreach and the provision of resources. Innovative adolescent-friendly health services have engaged urban youth, and the development of family group practices has created incentives to provide primary medical care for marginalised communities, including sexual and reproductive health services. The Health Sector Strategic Masterplan offers a platform for coordinated development in health, but is threatened by a lack of consensus in both government and donor communities, competing health priorities and the politicisation of emerging debates on fertility and abortion. With previous gains in sexual and reproductive health vulnerable to political change, these tensions risk the exacerbation of existing disparities and the development by default of a two-tiered health care system.