Revista de Saúde Pública
I SSN 0034- 8910 versão im pressa
Rev Saúde Pública 2003; 37(5)
Contraceptive use among adolescents at public schools in Braz il
Mar ia da Conceição Chagas de Alm eidaa, Est ela Maria Leão de Aquinoa, Lynne Gaffikinb and Robert J Magnanic
a
Program a de Est udos em Gênero e Saúde do I nst it ut o de Saúde Colet iv ada Universidade Federal da Bahia ( MUSA) . Salvador, BA, Brasil. bJHPI EGO Corporat ion.Balt im ore, MD, EUA. cDepar t am ent of
I nt ernat ional Healt h & Developm ent . School of Public Healt h & Tropical Medicine. Tulane Universit y Healt h Sciences Cent er . New Or leans, EUA
ABSTRACT
Objective
Ther e has been a gr ow ing int er est in pat t er ns of cont r acept iv e use am ong adolescent s, due, in par t icular , t o t he social r elev ance at t ached t o pr egnancy in t his age gr oup. Ther efor e, t he obj ect iv e of t he st udy w as t o inv est igat e fact or s associat ed w it h t he use of cont r acept iv e m et hods am ong fem ale and m ale adolescent st udent s.
M et h od
consist ent use. Logist ic r egr ession w as car r ied out for sim ult aneous analy sis of fact or s associat ed w it h t he use of cont r acept iv e m et hods and in or der t o calculat e adj ust ed m easur es.
Results
Am ong t he 1664 st udent s w ho r epor t ed being sex ually act iv e, t he fact or s posit iv ely associat ed w it h t he consist ent use of cont r acept iv e m et hods am ong m ale st udent s included a) post poning t heir fir st ex per ience of sex ual int er cour se and int er act ion w it h a st able part ner, b) t he fam ily as a pot ent ial supplier of cont r acept iv e m et hods, and c) access t o healt h ser v ices. On t he ot her hand, am ong fem ale st udent s fact or s posit iv ely associat ed w it h t he consist ent use of cont r acept iv e m et hods included a) r ecent sex ual init iat ion, and b) having a fat her as t heir source of inform at ion regarding sexualit y, cont r acept ion and STD/ Aids pr ev ent ion. Pr egnancy w as r epor t ed by 6.4% of t he boy s and 18.1% of t he gir ls, it s absence w as associat ed w it h t he consist ent use of cont r a cept ives by t hem ( t he girls) ( Odds Rat io= 3.83; 2.06- 7.15)
Conclusions
These result s confirm t he com plexit y of det erm ining cont racept ive behavior am ong adolescent s and t her efor e r einfor ce t he need t o include m ult i- dim ensional aspect s of t his t hem e in order t o ensur e t he efficacy of sex educat ion pr ogr am s.
Keywords
Kow ledge, at t it udes, pr act ice. Cont r acept ion. Sex ualit y . Cont r acept ion behav ior . Teen healt h. Gender and healt h.
I N TRODUCTION
During t he last t w o decades, innum er ous st udies hav e been under t ak en w hich hav e focused on adolescence as a r esult of t he t r ansfor m at ions in t he social appr aisal of t his gr oup.
The World Healt h Organizat ion1 4 defines adolescent s as people r anging fr om 10 t o 19 year s of age, a definit ion w hich has been adopt ed in Br azil by t he “ Pr ogr am a de Saúde do Adolescent e” ( Adolescent Healt h Program ) of t he “ Minist ério da Saúde” .
I nt er est r egar ding t he cont r acept iv e behav ior of Br azilian adolescent s has incr eased du e t o t h e fact t hat , since 1980, w it hin all r egions of t he count r y , t he r at e of fecundit y has been decr easing in all ot her age gr oups ex cept for adolescent s.5 Thus, alt hough pr egnancy in adolescence is not a r ecent phenom enon, it s r elat iv e significance has incr eased, j ust ify ing fur t her inv est igat ion of cont r acept ion during t his phase of t he life course.
A com parat ive st udy based on dat a from t he Dem ography and Healt h Survey ( DHS)3 undert aken in 37 count ries in developm ent , including Brazil, verified t hat , alm ost all adolescent s sur v ey ed st at ed t hey k new of at least one cont r acept iv e m et hod. Nonet heless, it has becom e clear t hat , w it hin t his age gr oup in par t icular , t he use of cont r acept ion is sm all in m agnit ude. These conclusions ar e consist ent w it h n at ional out com es, 2 indicat ing t hat cont r acept iv e use is not necessar ily dir ect ly r elat ed t o k now ledge am ong adolescent s and t hat ot her det er m inant s of use m ust be t ak en int o consider at ion.
I n t he beginning of t he ninet ies, a crit ical revision of t he int erna t ional lit er at ur e concer ning fact or s associat ed t o t h e lack of con t r acept iv e u se am on g adolescen t s4 r ev ealed t hat y out h w er e not w ell-infor m ed w it h r espect t o m at t er s r elat ed t o concept ion and cont r acept ion. I t also disclosed t hat t hey held som e erroneous beliefs, such as t he idea t hat pr egnancy nev er occur s befor e t he fir st m enst r ual cy cle and t hat one m ust be older in or der t o conceiv e.
One of t he aspect s st r essed by pr ogr am s dir ect ed t ow ar ds adolescent s, accor ding t o t he lit er at ur e, h as been access t o appropriat e inform at ion. However, ot her issues, sucha as t he role of t he fam ily in decisions r egar ding sex ual behav ior and cont r acept iv e choices am ong adolescent s hav e r eceiv ed lit t le at t ent ion, bot h in t he st udies and in int er v ent ions t ar get ed t ow ar ds t his group.
I n Bahia, t he “ Secr et ar ia da Saúde” and “ Secr et ar ia da Educação” ( Depar t m ent s of Healt h and Educat ion) launched a program w it hin t he public schools 1996 ent it led, “ Sexual and Reproduct ive Healt h dur ing Adolescence” . The lat t er sought t o int egr at e ed ucat ional act iv it ies concer ning sex ualit y and r epr oduct ion w it h t he supply of specialized adolescent healt h car e.
The cur r ent st udy ensues fr om a pr oj ect designed t o evaluat e t he im pact of t his int egr at ed pr ogr am in t he acquisit ion of k now ledge as w ell as on changes in at t it udes and behav ior am ong adolescent s inv olv ed in it .7 I t s obj ect iv e w as t o ident ify fact or s associat ed w it h t he use of cont r acept ion dur ing t he phase preceding int ervent ion.
M ETHODS
Th is is a cr oss- sect ional st udy, undert aken in 1997, inv olv ing st udent s aged 11 t o 19 r egist er ed at 12 Bahia St at e public schools, eight of w hich w er e locat ed in t he st at e capit al ( Salv ador ) and four in t he int er ior of t he st at e ( w it hin t he m unicipalit ies of I t abuna and Sant o Ant onio de Jesus) .
The sam ple w as con st r u ct ed t o at t en d t o t h e obj ect iv es of t h e ev alu at ion of t h e “ Sex u al an d Reproduct ive Healt h during Adolescence” program m ent ioned above. The schools w ere select ed according t o t he following crit eria: geographic proxim it y ( wit hin a radius of 5 km ) t o one of t he healt h car e cent er s par t icipat ing in t he pr oj ect ; num ber of r egist er ed st udent s ( at least 200 st udent s in each t arget grade) ; level of previous cooperat ion wit h t he program on t he part of school adm inist rat ors and t each er s.
Dat a pr oduct ion cont em plat ed t he applicat ion of a self - applied quest ionnaire com posed of set s of quest ions on general inform at ion, know ledge concer ning sex ualit y , concept ion, cont r acept ion, and STD/ AI DS, at t it udes t ow ar ds pr egnancy and STD/ AI DS and issues r elat ed t o sexual init iat ion. The quest ionnaires w ere applied in 50 m inut es at m ost , w hich corresponds t o t he period of t im e of one class. Teach er s were asked t o leave t he classroom while t he quest ionnaire was being applied. Dat a w as collect ed sim ult aneously in all classes and gr ades w it hin t he sam ple dur ing each school per iod, so as t o guar ant ee t hat t hose r esponding w ould not be aw ar e of t he cont ent s of t he quest ionnair e befor ehand.
The 6.0 v er sion of Epi I nfo soft w ar e w as ut ilized in t he const r uct ion of t he dat a bank , w it h double digit at ion by dist inct pr ofessionals. St at ist ical analy sis w as under t ak en ut ilizing STATA 7 soft w ar e.
Th e u se of con t racept iv es w as chosen as t he dependent v ar iable com pr ehending t hr ee indicat or s: t he fir st and last t im e t he individual engaged in sexual int er cour se and t he consist ent use of cont r acept iv es on bot h occasions. For analy t ical pur poses, not k now ing or not r ecalling whet her or not cont r acept iv es w er e used on t hese occasions w as consider ed as equiv alent t o not hav ing used t hem . Socio- dem ogr aphic char act er ist ics, k now ledge concer ning fer t ilit y concept ion and cont r acept ion; sex ual and r epr oduct iv e ev ent s, as w ell as t hose r efer r ing t o social and fam ily suppor t w er e select ed as independent variables.
Tw o indicat or s of k now ledge w er e cr eat ed: 1) one is r elat ed t o cont r acept ion and cor r esponds t o t he sum of known cont racept ive m et hods, varying from zero t o six. This indicat or w as dichot om ized aft er w ar ds, and t he m edian w as ut ilized as t he cut - off point ( know ledge of up t o t hree m et hods and of four t o six m et hods) ; 2) t he second r efer s t o fer t ilit y and concept ion, cor r esponding t o t he sum of cor r ect answ er s t o t he quest ions on t his t hem e, t he scor e var ying fr om zer o t o six. This scor e w as also dichot om ized aft er w ar ds ( up t o t w o cor r ect answ er s and t hr ee t o six cor r ect r eplies) .
Part nership w hen sexual int ercourse occurred for t he first t im e w as considered st able w hen it involved a boyfriend or girlfriend, a fiancé or a spouse; all ot her sit uat ions were considered unst able part nerships ( a friend, a neighbor, a st ranger) . The num ber of part ners during t he last six m ont hs w as cat egor ized in t hr ee lev els: no par t ner s, one part ner and m ult iple part ners ( t wo or m ore part ners in sim ult aneous or sequent ial relat ionships) .
As a m easur e of occur r ence, r at es of pr ev alence of cont r acept iv e use w er e calculat ed and as a m easur e of associat ion, odds r at io w as ut ilized w it h t he r espect iv e confidence int er v al at 95% . Logist ic r egr ession w as ut ilized for sim ult aneous analysis of t he var iables of int er est , calculat ing adj ust ed m easur es.
The pr oj ect w as appr ov ed by t he Com m it t ee on Et hics in Resear ch of t he “ Univ er sidade Feder al da Bahia” . Confident ialit y of t he infor m at ion obt ained w as assur ed by t he fact t hat quest ionnair es w er e self - applied, being ident ified exclusively by an ident ificat ion num ber, wit hout any nom inal reference t o t he per son w ho filled it out . The r ight t o r efuse t o par t ic ipat e in t he st udy w as guar ant eed t o t he v olunt ar y par t icipant s and t hose r esponsible for t hem by m eans of a let t er elabor at ed by t he r esear ch coor dinat or s and sent t o st udent s by t he school pr incipals, solicit ing t he par ent ( s) ’ agr eem ent ( s) . Wit h in t h e classr oom , befor e t he quest ionnair e w as applied, all et hical aspect s of t he st udy w er e r eit er at ed, confer r ing st udent s w it h anot her chance t o w it hdr aw fr om t he inv est igat ion or t o st op filling out t he quest ionnaire at any point in t im e.
RESULT S
t his st udy. Am ong t he 4,774 st udent s int er view ed, 1,664 ( 34.8% ) st at ed t hey had pr ev iously engaged in sex ual int er cour se and w er e consider ed as t he st udy populat ion. Those st udent s w ho st at ed t hey “ did not k now ” w het her t heir par t ner had ut ilized a cont r acept iv e m et hod in t heir fir st and/ or m ost recent experience of sexual int er cour se cor r esponded t o 14.0% of t he st udy populat ion and 93.1% of t he lat t er w er e m en. The r esult s obt ained w hen t hese st udent s w er e ex cluded fr om t he st udy w er e com par ed t o t hose obt ained w hen t hey w er e included am ong t he gr oup w ho st at ed t hey had not used cont r acept iv e m et hods on t hese t w o occasions. The last alt er nat iv e w as adopt ed t hr oughout t he analy sis for it did not change t he dir ect ion of associat ions and incr eased t he pr ecision of t he r esult s.
The pr opor t ion of y oung m en and w om en t hat st at ed t hey had previously engaged in sexual int er cour se w as quit e dist inct , being equivalent , r espect ively, t o 62.2% and 15.0% . Consequent ly, t he m aj orit y of t he populat ion st udied is com posed of m ale st udent s ( 74.3% ) . The young m en were a lit t le bit y ounger t han t he y oung w om en, w it h a m edian of 15 and 16 y ear s of age, r espect iv ely . ( Table 1)
Ta ble 1 – Char act er ist ics of adolescent s accor ding t o sex .
Sex Male (N= 1237)
Fem ale (N= 427)
P-value Ch ar act er ist ics
% % (χ2)
Age group
11- 14 37.5 13.8 0.000
15- 19 62.5 86.2
( Median) ( 15 yrs of
age)
( 16 yrs of age)
Skin color*
Light and dark m orena/ black wom an
89.6 87.9 0.345
Wh it e 10.4 12.1
Schooling
6th grade 57.6 37.2 0.000
8th grade 42.4 62.8
Current ly working
Yes 23.0 11.9 0.000
No 77. 0 88.1
Sex ual and Repr oduct iv e ev ent s Age at sexual init iat ion
11- 14 77.4 32.3 0.000
15- 19 22.6 67.7
( Median) ( 13 yrs of
age)
( 15 yrs of age)
Type of part nership during t he first experience of sexual int er cour se.
St able* * 44.7 93.7 0.000
Not st able* * * 55.3 6.3 Part nership during t he last 6 m ont hs
Wit hout a par t ner 24.1 7.7 0.000 Single part nership 29.3 70.5
Mult iple
par t ner ship* * * *
Tim e expired since sexual init iat ion
Up t o 2 years 64.0 89.2 0.000
3 years or m ore 36. 0 10.8 Pr ev alence of
pr egn an cy * * * * *
6. 4 18.1 0.000
* N( m ale) = 1208; N( fem ale) = 413.
* * I ncluding boyfriends or girlfriends, fiancés and spouses.
* * * I ncI uding friend and ot her person.
* * * * I n sim ult aneous or sequent ial relat ionship.
* * * * * N( m ale) = 1059; N( fem ale)= 414.
The m aj orit y of t he young wom en int erviewed were in t he eight h grade ( 62.8% ) , while only 42.4% of t he young m en w er e in t he sam e gr ade. A high per cent age of adolescent s of bot h sexes classified t hem selves as light / dark m or en os [ dark - com plexi oned] or black ( 89.0% ) .
The young m en st at ed t heir sexual init iat ion occur r ed sooner t han t he young w om en, w it h m edians of 13 and15 y ear s of age r espect iv ely . While t he gr eat m aj or it y of gir ls st at ed t hat t he fir st t im e t hey engaged in sex ual int er cour se this occurred wit h a st able part ner ( 93.7% ) , only 44.7% of t he boys st at ed t hey had t his t y pe of par t ner at t he t im e. Analy sis of t he num ber of par t ner s in t he last six m ont hs reveals t hat single part nership was prevalent am ong t he young wom en ( 70.5% ) ; whereas t h e young m en st at ed t hey had no part ners ( 24.1% ) , or t hat t hey had m ult iple sim ult aneous or sequent ial part nerships ( 46.6% ) . I t is int erest ing t o not e t hat 18.1% of t he young w om en referred t o at least one pr egnancy w her eas only 6. 4% st at ed t hey had im pregnat ed a part ner ( Table 1) .
The adolescent s pr esent ed lit t le k now ledge of issues r elat ed t o fer t ilit y and concept ion. The y oung w om en had a gr eat er pr opor t ion of cor r ect r eplies t o quest ions on t hese issues w hen com par ed t o t he young m en, wit h st at ist ically significant differ ences bet w een t hem ( Table 2) . The y oung m en w er e par t icular ly unfam iliar w it h quest ions r elat ed t o t he m enst r ual cycle, but bot h sexes, in t he absolut e m aj or it y of cases, t hought t hat it w as not possible t o becom e pr egnant befor e t he onset of m enst ruat ion and a large port ion of t hem believed t hat , during t he first t im e t hey have int ercourse, pr egnancy does not occur .
Ta ble 2 – Know ledge concer ning cont r acept ion, fer t ilit y and concept ion, use and m ot iv e for not using con t r acept iv es m et hods, accor ding t o sex .
Sex Male ( N= 1237)
Fem ale ( N= 427)
P-v alu e Know ledge/ use
% % (χ2)
Know ledge concer ning fer t ilit y and concept ion* High index ( 3 t o 6 cor r ect
answers)
22.0 45.0 0.00
Mean dur at ion of a cy cle 17.4 49.9 0.00 0
Fert ile period 18.9 31.4 0.00
0 Risk of becom ing pregnant before
t he fir st m enst r uat ion
20.6 21.8 0.61
0 Risk of becom ing pregnant t he
first t im e one has sexual int er cour se
49.7 64.6 0.00
0
Risk of becom ing pregnant during t he fir st m enst r uat ion
31.3 41.0 0.00
0 Risk of becom ing pregnant when
ej aculat ion occur s out side of t he v agina.
23.5 29.5 0.01
4
Know ledge of cont r acept iv e m et hods by t y pe High r at e ( 4 t o 6 cont r acept iv e
m et hods)
43.3 52.5 0.00
0
Masculine preservat ives 92.8 95.3 0.07
1
The pill 71.4 93. 7 0.00
0
I UD 42.1 74.9 0.00
0
I nj ect ion 33.1 72.8 0.00
0
I nt er r upt ed coit us 55.5 62.5 0.01
2
Table 23.9 52.9 0.00
0 Use of con t r acept iv es
During t he first sexual relat ionship ( Pr ev alence)
38.6 50.8 0.00
0 Masculine pr eser v at iv es 90.1 73.5 0.00
0
I nt er r upt ed coit us 5. 6 6. 5 0.64
0
Pill 2. 6 14.9 0.00
0
Tab le* * 0. 0 1. 4 0.01
0
Ot hers 1.73 3.73 0.11
1 During t he last t im e t hey had sex
( Pr ev alence)
66.3 74.0 0.00
3 Masculine pr eser vat ive or
Condom
60.3 43.2 0.00
0
I nt er r upt ed coit us 15.9 26.5 0.00
0
Pills 7. 5 14.6 0.00
0
Rhyt hm 2. 4 2. 9 0.58
Ot hers 1. 2 2. 6 0.05 3 During t he first and last t im e t hey
had sex ( Pr ev alence)
36.6 46.4 0.00
0 During t he last 6 m ont hs
( Pr ev alence)
41.0 56.1 0.00
0 Mot iv es for not using cont r acept iv es dur ing t he last 6 m ont hs* * * I w asn’t ex pect ing t o hav e sex 59.1 65.8 0.12
9 I t hink t hat cont r acept ion get s in
t h e w ay
31.5 18.0 0.00
1 I nev er t hought about t his 14.6 6. 2 0.00
5 Did not k now w her e t o get access
to it
10.6 11.2 0.85
0 Did not know how t o avoid
pr egnancy
10.2 9. 3 0.73
8 I w ant ed t o becom e pregnant 6. 0 14.9 0.00
0 My religion doesn’t perm it t his 2. 1 2. 5 0.76
6
*Percentage of correct replies.
**Despite the fact that p-value was calculated, values smaller than 5 were expected.
***Those that did not have sex during this period were excluded. N(males)= 479; N(females)= 161.
Alm ost all adolescent s, bot h m ale and fem ale, said t hey were fam iliar wit h som e kind of cont racept ive ( 97.4% ) , being t hat t he m ale condom was t he m et hod m ost frequent ly m ent ioned ( approxim at ely 95.0% ) . How ever, am ong t he young w om en, t he percent age w ho w ere know ledgeable about a w ide var iet y of cont r acept ive m et hods w as consider ably higher t han am ong t he young m en, w it h st at ist ically significant differ ences, ex cept for male condom s ( Table 2) .
The fem ale adolescent s st at ed m or e fr equent ly t hat t hey or t heir par t ner s used som e for m of cont r acept ion t he fir st and last t im e t hey had sex ual int er cour se ( 50.8% on t he fir st t im e and 74% on t he last t im e t hey had sex ) . The y oung w om en also pr esent ed a m or e consist ent use of cont r acept iv es ( 46.4% ) ( Table 2) . Am ong t he boy s w ho ut ilized cont r acept iv es t he fir st t im e t hey had int er cour se, alm ost all m ent ioned t hey preferred t he condom ( 90.1% ) , a preference which was also not ed am ong t he young wom en, but t o a lesser degree ( 73.5% ) . Am ong t he lat t er, preference was divided, being t he pill t he second opt ion ( 14.9% ) . The last t im e t hey had sex, t he m ale condom was st ill t he m aj or inform ed choice for bot h sexes ( 60.3% of t he young m en and 43.2% of t he young wom en) , alt hough ot her m et hods em er ged as alt er nat ives, par t icular ly int er r upt ed coit us ( Table 2) .
Fact or s associat ed w it h t he use of cont r acept iv es am ong t he boy s on t he fir st t im e t hey had sex , w er e t heir age at pr esent , r anging fr om 15 t o 19 y ear s old, higher lev el of educat ion, t he fact t hat t hey could count on t he fam ily as a pot ent ial supplier of cont r acept iv e m et hods, a m or e adv anced age and a st able part nership at t he t im e of sexual init iat ion, as w ell as having init iat ed sexual int ercourse m ore r ecent ly. The num ber of par t ner s w it hin t he last six m ont hs pr esent ed a gr adient of posit ive associat ion wit h m ult iple part nerships and single part nerships, not ably associat ed wit h t he use of cont r acept ion ( Table 3 ) .
Ta b le 3 – Associat ion bet w een use of cont r acept ion dur ing t he fir st t im e t hey had sex ual int er cour se and select ed var iable accor ding t o sex.
Sex
Male ( N= 1059* ) Fem ale ( N= 414* ) Variable
OR CI 95% OR CI 95% Age Group ( 15- 19/ 11 - 14 y r s of age) 1.45 1.03 –
2.03
1.62 0.78 – 3.35
Grade ( 8t h / 6th) 1.42 1.05 –
1.94
0.76 0.47 – 1.22 Age at sex ual init iat ion ( 15- 19/ 11- 14 yrs of age) 1.61 1.14 –
2. 27
0.83 0.48 – 1.43 Ty pe of par t ner ship ( st able/ not st able) 1.74 1.33 –
2.29
1.11 0.43 – 2.86 Tim e elapsed since sexual init iat ion ( up t o 2 yrs/
3 yrs or m ore)
2.60 1.90 – 3.54
2.29 1.08 – 4.87 Part nership during t he last 6 m ont hs
Single part ner/ no part ner 1.70 1.16 – 2.49
1.36 0.58 – 3.22 Mult iple part nership/ no part ners 1.99 1.39 –
2.84
1.66 0.66 – 4.13
Pr egnacy ( no/ y es) 1.09 0.63 –
1.87
3.26 1.81 – 5.87 Know ledge on cont r acept ive m et hods( fr om 4 t o
6/ up t o 3 m et hods)
1.08 0.81 – 1.43
1.44 0.85 – 2.43 Know ledge on fert ilit y and concept ion( from 3 t o
6/ up t o 2 correct replies)
1.15 0.83 – 1.57
0.93 0.61 – 1.43 Access t o healt h ser v ices w it hin t he last y ear
( y es/ no)
1.31 0.96 – 1.78
1.28 0.81 – 2.03 Mot her as t heir source of inform at ion* * ( yes/ no) 1.17 0.85 –
1.61
1.46 0.91 – 2.33 Fat her as t heir sour ce of infor m at ion* * ( y es/ no) 0.98 0.71 –
1.34
3.38 1.09 – 10.51 Fam ily as pot ent ial sour ce of cont r acept iv e
m et hds ( yes/ no)
1.69 1.21 – 2.37
0.56 0.29 – 1.08 Feels com for t able about speaking t o m ot her
about sexual life( yes/ no)
1.08 0.79 – 1.48
1.60 0.95 – 2.68
* Those t hat m ent ioned t hey did not k now about a pr egnancy w er e ex cluded.
As for t he y oung w om en, t he use of cont r acept iv es during t he first t im e t hey had sexual int ercourse w as posit ively associat ed w it h sexual init iat ion occur r ing m or e r ecent ly and w it h t heir fat her being t heir source of inform at ion on sexualit y, prevent ion of STD/ AI DS and concept ion. The young w om en w ho had not y et becom e pr egnant had 3.36 t im es m or e chances of hav ing ut ilized a cont r acept iv e m et hod dur ing t he fir st t im e t hey had sex ( Table 3) .
The use of cont racept ives by young m en during t he last t im e t hey had sexual int ercourse rem ained associat ed t o t h e f ollow ing var iables: pr esent age – ranging from 15 t o 19 years old – t o a lar ger ex t ent t han age on occasion of t he fir st t im e t hey had sex ; st able par t ner ship w hen t hey had sex for t he fir st t im e and t he fact t hat t his occur r ed m or e r ecent ly ; single par t ner s hip and a m ult iple par t ner ship dur ing t he last six m ont hs. As t o t he w om en, besides being highly associat ed t o prot ect ion from pregnancy, single part nership during t he last six m ont hs seem s t o be a relevant fact or ( Table 4) .
Ta ble 4 – Associat ion bet w een t he use of cont r acept ion in t he m ost r ecent ex per ience of sex ual int er cour se and select ed v ar iables accor ding t o sex .
Sex Male ( N= 1059* )
Fem ale ( N= 414* ) Variable
OR CI 95% OR CI 95% Age group ( 15- 19/ 11- 14 yrs old) 2. 2
9
1.63 – 3.20
1.4 2
0.64 – 3.18
Gr ade ( 8t h/ 6t h) 1. 1
5
0.83 – 1.59
1.0 4
0.61 – 1.76 Age at sexual init iat ion ( 15 - 19/ 11- 14 yrs old) 1. 0
9
0.74 – 1.62
0.7 2
0.39 – 1.33 Ty pe of par t ner ship ( st able/ not st able) 1. 9
5
1.45 – 2.61
0.7 0
0.23 – 2.17 Period of t im e since sexual init iat ion ( up t o 2 yrs/ 3
yrs and m ore)
1. 4 0
1.03 – 1.90
1.7 0
0.81 – 3.56 Part nerships during t he last 6 m ont hs
Single part ners / no part ner 1. 7
5
1.21 – 2.52
2.8 3
1.17 – 6.83 Mult iple part nerships / no part ner 2. 3
7
1.69 – 3.34
2.5 1
0.97 – 6.50
Pr egnancy ( no/ y es) 0 . 7
7
0.41 – 1.45
2.9 1
1.63 – 5.19 Know ledge concer ning cont r acept ive m et hods ( fr om
4 t o 6/ up t o 3)
1. 1 8
0.87 – 1.60
0.9 4
0.51 – 1.72 Know ledge concerning fert ilit y and concept ion ( from
3 t o 6/ up t o 2 cor r ect r eplies)
0. 8 8
0.63 – 1.23
0.7 9
0.49 – 1.28 Access t o healt h ser v ices dur ing t he last y ear
( y es/ no)
1. 3 3
0.96 – 1.86
1.5 4
0.89 – 2.65 Mot her as a source of inform at ion* * ( yes/ no) 0. 9
2
0.65 – 1.29
1.2 3
0.72 – 2.13 Fat her as a source of inform at ion* * ( yes/ no) 1. 4
1
0.99 – 2.00
3.3 9
0.70 – 16.45 Family as a pot en t ial sou r ce of con t r acept iv e
m et hods ( yes/ no)
1. 4 0
1.03 – 1.90
0.6 6
0.33 – 1.34 Feels com fort able about speaking t o m ot her about
sexual life ( yes/ no)
0. 9 9
0.71 – 1.37
1.5 6
* Those t hat m ent ioned t hey did not k now about a pr egnanc y w ere excluded.
* * I nfor m at ion on sex ualit y , STD/ Aids and cont r acept ion.
Consist ent use of cont r acept ion by y oung m en w as posit iv ely associat ed w it h age at pr esent , r anging fr om 15 t o 19 y ear s old, t o a higher lev el of for m al educat ion, t o a st able par t ner ship on occasion of t heir sex ual init iat ion and t o t he fact t hat t his occur r ed m or e r ecent ly , t o single and m ult iple par t ner ships dur ing t he last six m ont hs, and t o access t o healt h ser v ices w it hin t he last y ear . Am ong t he y oung w om en consist ent use of c ont r acept ion w as posit iv ely associat ed w it h hav ing init iat ed sexual int er cour se w it hin t he last t w o year s, w it h t heir fat her being t heir sour ce of infor m at ion on sexualit y, pr event ion of STD/ AI DS and concept ion; feeling com for t able about discussing t heir sex life w it h t heir m ot her , as w ell as being pr ot ect ed fr om a pr egnancy ( Table 5) .
Ta ble 5 – Associat ion bet w een t he use of cont r acept ion dur ing t he fir st and last ex per ience of sex ual int er cour se and select ed v ar iables accor ding t o sex .
Sex Masculino N= 1059* )
Fem inino ( N= 414* ) Variable
OR I C 95% OR I C 95% Age group ( 15- 19/ 11- 14 yrs old) 1. 5
3
1.09 – 2.16
1. 5 4
0.4 – 3.9
Grades( 8t h/ 6t h) 1. 4
6
1.07 – 1.99
0. 7 7
0.8 – 1.4
Age at sexual init iat ion ( 15- 19/ 11- 14 yrs old) 1. 5 5
1.10 – 2.19
0. 7 3
0.2 – 1.8
Typ e of par t ner ship ( st able/ not st able) 1. 7 4
1.32 – 2.28
1. 1 6
0.5 – 3.1
Period of t im e since sexual init iat ion ( up t o 2 yrs/ 3 yrs and m ore)
2. 6 4
1.92 – 3.61
2. 2 1
1.2 – 4.0
Part nerships during t he last 6 m ont hs
Single part ners / no part ner 1. 6
2
1.10 – 2.39
1. 4 7
0.2 – 3.9
Mult iple part nerships / no part ner 1. 9 9
1.39 – 2.86
1. 6 5
0.6 – 4.4
Pr egnancy ( no/ y es) 0. 9
9
0.57 – 1.70
3. 8 3
2.6 – 7.5
Know ledge concer ning cont r acept iv e m et hods ( fr om 4 t o 6/ up t o 3)
1. 0 3
0.77 – 1.38
1. 2 4
0.3 – 2.1
Know ledge concerning fert ilit y and concept ion ( from 3 t o 6/ up t o 2 cor r ect r eplies)
1. 0 3
0.75 – 1.42
0. 9 3
0.0 – 1.3
Access t o healt h ser v ices dur ing t he last y ear ( yes/ no)
1. 4 0
1.03 – 1.91
1. 3 0
0.2 – 2.7
Mot her as a source of inform at ion* * ( yes/ no) 1. 1 4
0.82 – 1.57
1. 3 9
0.7 – 2.3
Fat her as a sour ce of infor m at ion* * ( y es/ no) 1. 0 3
0.75 – 1.42
3. 8 5
1.5 – 11.8
Fam ily as a pot ent ial sour ce of cont r acept iv e m et hods ( yes/ no)
1. 6 3
1.17 – 2.28
0. 6 8
Feels com for t able about speak ing t o m ot her about sexual life ( y es/ no)
1. 0 8
0.79 – 1.48
1. 6 9
1.01 – 2. 4
OR= Odds rat io adj ust ed by t he rem aining variables.
CI = Confidence I nt erval at 95% .
* Those t hat m ent ioned t hey did not k now about a pr egnancy w er e ex cluded.
* * I nfor m at ion on sex ualit y , STD/ Aids and cont r acept ion.
Fact or s r elat ed t o suppor t fr om t he fam ily and social suppor t , in gener al, pr esent ed associat ions on t he bor der line lev el of st at ist ical significance, w it h t he ex cept ion of access t o healt h ser v ices w it hin t he last y ear , w hich w as posit iv ely associat ed wit h t he use of cont r acept ion by y oung m en on t he fir st and last t im e t hey had sexual int er cour se.
I ndicat or s of k now ledge concer ning cont r acept ion as w ell as on fer t ilit y and concept ion w er e not associat ed t o t he use of cont r acept iv e m et hods by m en and w om en under any cir cum st ances. This w as also v er ified dur ing t he one t o one analy sis of t he v ar iables t hat com pose t his k now ledge ( dat a not pr esent ed) .
D ISCUSSION
Befor e discussing t he cont r ibut ions of t he r esult s, som e m et hodological aspect s m aust be t aken int o consider at ion.
The proport ion of refusals wit hin t he st udy populat ion was negligible ( 0.0% ) and t he num ber of losses, all of w hich w er e due t o absence on t he day t he quest ionnair e w as dist r ibut ed, w as sm all ( 13.3% ) .
Alt hough t he sam ple is not r epr es ent at iv e of t he t ot al st udent populat ion, nor is it r epr esent at iv e of t he adolescent s w ho ar e cur r ent ly out of school, t he st udy populat ion pr esent ed som e char act er ist ics w hich t hey hav e in com m on w it h t hose adolescent s w ho st udy at t he m aj or it y of public schools in t he St at e of Bahia or ev en t he count r y as a w hole. Com ing, in lar ge par t , fr om t he poor est social st r at a, t heir age is, t o a lar ge ex t ent , out of phase w it h r espect t o t he gr ade t hey ar e in, due t o t he innum erous episodes in which t hey are left back ( fail) at t he end of t he school year and/ or dr op out and r et ur n t o school.
The possibilit y t hat pr oblem s hav e ar isen w it h r espect t o self - classificat ion concer ning sexual init iat ion, result ing in som e kind of select ion bias, m ust be t aken int o consid er at ion. I t m ay be, for exam ple, t hat par t icular ly am ong t he m en, a few t hat have not yet engaged in sexual int er cour se w er e included in t he st udy populat ion, but , r esponding t o social ex pect at ions w it h r espect t o sex ual r oles, t hey declar ed t hat t hey alr e ady had sexual int ercourse. I n cont rast , part icularly am ong t he w om en, t he ex act opposit e m ay hav e occur r ed, cont r ibut ing, in t his case, t o t heir being underrepresent ed in t he st udy populat ion.
The m edian age of sexual init iat ion w as, on t he average, t w o years less t han w hat has been found, am ong bot h sexes, in ot her nat ional st udies.2,9 This could speak in favor of t he hypot hesis of m ale ov er- r epr esent at ion, including t hose t hat falsely declar ed t hey had alr eady had sex ual init iat ion. How ever, am ong t he w om en in this st udy sexual init iat ion also occurred at an earlier age t han in t he nat ional st udies, w hich speak s against t heir sub- r epr esent at ion and r elat ivizes t he assum pt ion of er r or s in classificat ion.
I n addit ion, an issue t o be r aised w it h r espect t o t he calculat ion of m edian age at sexual init iat ion concer ns t he fact t hat a lar ge par t of t he sam ple fr om w hich t his st udy populat ion or iginat es had not y et engaged in sex ual int er cour se. I t is k now n t hat t he analy sis of age dist r ibut ion of a life ev ent w hich only t ak es int o consider at ion t hose t hat hav e ex per ienced t his ev ent , w it h t he differ ent ial inclusion of t hose for w hich it occur r ed pr ecociously, r esult s in a sub est im at ion of t he m ean value, par t icular ly if t his gr oup const it ut es a m inor it y .1 3
As t o t h e classificat ion of t he effect in quest ion, t hat is, t he asser t ion t hat t hese adolescent s used cont r acept iv es, it is r elev ant t o not e t hat t his r esear ch w as car r ied out in a school. I n addit ion t o t he fact t hat t he inst r um ent w as self - applied, t his could hav e cont r ibut ed t o t he super- est im at ion of t he effect being m easur ed, since t he adolescent s w ould t end t o answ er w hat t hey t hought w as t he cor r ect or m or e appr opr iat e alt er nat iv e. How ev er , at least am ong t he y oung w om en, t he use of cont r acept iv es w as highly associat ed t o av oiding pr egnancy , w hich indicat es t he v alidit y of t he answers wit hin t his group.
The findings w it h r espect t o pr ev alence of t he use of cont r acept iv es dur ing t he fir st ex per ience of sexual int ercourse w ere sim ilar t o t hose found in a nat ional st udy on t he use of condom s am ong st udent s, 2 but relat ively higher if com pared wit h a nat ional populat ion based survey.1 As t o t h e
pr ev alence of t he use of cont r acept iv es dur ing t he last t im e t hey engaged in sex ual int er cour se, t he v alues w er e also com pat ible w it h ot her nat ional st udies2 , 6 involving schools, alt hough t hey w ere
higher t han t hose obser ved in t he populat ion at lar ge.1 This is also coher ent w it h t he associat ion, descr ibed in t he lit er at ur e, bet w een y ear s of schooling and t he use of cont r acept iv es, part icularly am ong wom en.1
I n t he pr esent st udy , t he m aj or it y of adolescent s of bot h sex es indicat ed t hat t hey w er e k now ledgeable w it h r espect t o at least one cont r acept iv e m et hod, t hus cor r obor at ing t he findings of t he BEMFAM1 inv est igat ion, w hich r ev e als t hat pract ically 100% of Brazilian yout hs ( aged 15 t o 24) were fam iliar w it h at least one m et hod. The condom was t he m ost frequent ly m ent ioned m et hod by m ot h m en and wom en, which m ay be relat ed bot h t o it s ut ilizat ion as a m eans of avoiding pregnancy and t o t he st r ong influence of t he cam paigns for t he pr ev ent ion of STD/ AI DS. How ev er , t he w om en pr esent ed higher per cent ages of know ledge concer ning all t he m et hods included in t his st udy, w hich pr obably r eflect s t he t r adit ion of cont r acept iv e use as an ex c lusively fem ale at t ribut e.
Gender differ ences w er e so im por t ant t hat t he analysis cont em plat ed t he t w o gr oups separ at ely, despit e t he fact t hat t her e w er e consider ably less w om en. As a r esult , m any associat ions w er e not st at ist ically significant , ev en t hough t he r esult s w er e consist ent w it h ot her st udies conduct ed in Br azil, not ably t he BEMFAM1 invest igat ion.
result , 18.1% report ed at least one pregnancy, a proport ion t hree t im es higher t han w as found am ong t he m en.
Prevalence of cont racept ive use was higher am ong young wom en, bot h during sexual init iat ion and during t he last t im e t hey had int er cour se, r esult ing in a higher consist ent use of cont r acept iv es. How ev er , t he low er r efer ence t o cont r acept iv e use am ong y oung m en m ay only r eflect t heir gr eat er ignorance concerning cont racept ive use by t heir part ners, part icularly in unst able rela t ionships. The fact t hat m en r efer less fr equent ly t o t he use of pills and m or e fr equent ly t o int er r upt ing coit us t ends t o sust ain t his hy pot hesis, w hich is also r einfor ced by anot her r esult of t he inv est igat ion, nam ely , t hat an inv er se associat ion bet w een t he use of cont r acept iv es and pr egnancy w as only v er ified am ong t he wom en.
How ev er , despit e t hese differ ences w it h r espect t o gender in r elat ion t o cont r acept iv e choices, t he st rengt h of t he cam paigns st im ulat ing t he use of m ale condom s apparent ly prevails once again, giv en t hat it appear s as t he fir st choice, am ong bot h sex es, bot h in t heir fir st and last ex per ience of sex ual int er cour se.
Am ong adolescent s w ho engaged in sexual int ercourse during t he last six m ont hs and st at ed t hey did not use cont r acept iv es dur ing t his per iod, t he unpr edict able nat ur e of t hese r elat ions w as t he pr incipal m ot ive given, by bot h m en and w om en, for not having used cont r acept ives. Equally im por t ant am ong t he m en, in par t icular , w as t he inconv enience caused by t he m et hod ( pr obably t he m ale condom ) . Fur t her m or e, t he r esult s indicat e t hat 14.9 % of t he y oung w om en w ant ed t o get pr egnant , a per cent age sim ilar t o t hat found in t he BEMFAM 1 invest igat ion – 16.5% - am ong young people
ranging from 15 t o 24 years of age.
Analy zing t he fact or s associat ed w it h t he use of cont r acept iv es, t he fir st r elev ant asser t ion is t he absence of significant st at ist ical associat ions w it h k now ledge concer ning cont r acept ion, concept ion and fer t ilit y . This is consist ent w it h ot her st udies3 w hich r ev eal t hat gr eat er k now ledge w it h r espect t o cont r acept iv e m et hods is not necessar ily r elat ed t o m or e fr equent or cor r ect use of t hese m et hods.
Since exposure and effect w ere st udied sim ult aneously in t his invest igat ion, it is not possible t o affirm t h at t h e k n owledge r ev ealed by t he st udy w as acquir ed befor e t he fir st or ev en t he last ex per ience of sexual int er cour se. How ever , it should be t aken int o consider at ion t hat t he age of t he st udy populat ion and t he short int erval of t im e elapsed since sexual init iat ion dr aw t he event s being invest igat ed closer t o t he m om ent w hen t he quest ionnair e w as applied. Per haps t his explains t he associat ions found bet w een char act er ist ics of sex ual init iat ion – age and t ype of part nership – and t he use of cont r acept iv es dur ing t he most r ecent ex per ience of sex ual int er cour se.
The fact t hat an associat ion w as found bet w een a shor t er per iod of sex ual act iv it y and a m or e fr equent use of cont r acept ion m ay, in par t , be explained by an effect of m em or y. How ever , t his m ay also ex pr ess t he r esult of r ecent int ensificat ion of educat ional act iv it ies concer ning sex ualit y and r epr oduct iv e healt h, bot h in t he m edia and in t he school cont ex t .
One of t he fact or s posit iv ely associat ed w it h t he use of cont r acept ion dur ing t he fir st ex per ience of sexual int ercourse was an older age at t he t im e of init iat ion ( 15 t o 19 yrs of age) am ong t he m en. The sam e associat ion w as not found am ong t he w om en , how ever , t he lit er at ur e indicat es t hat adolescent s of bot h sex es t end t o use cont r acept ion less w hen sex ual init iat ion occur s befor e t hey ar e 15 y ear s old.1 0
associat ed w it h t he use of cont r acept iv es w it hin t he t hr ee sit uat ions inv est igat ed. St udies under t ak en in ot her cont ext s, involving yout h in Nor t h Am er ica8 and Sw it zer land,1 0 also indicat e less fr equent use of cont r acept iv es dur ing t he fir st ex per ience of sex ual int er cour se w hen t his occur r ed w it hin a casual relat ionship.
I t is possible t o assum e t hat st abilit y wit hin a relat ionship propit iat es m ore t im e for negot iat ing t he use of cont r acept ion am ong par t ner s. How ever , as is descr ibed in ot her nat ional st udies, it has been obser v ed t hat am ong w om en t her e is a t endency t o use m ale condom s less consist ent ly , w hen t he part ner is well- know n and becom es st able. This decision is m ot iv at ed, abov e all, by t he belief t hat not using condom s w ould be a pr oof of fidelit y . On t he ot her hand, upon est ablishing t his t y pe of par t ner ship, w om en t end t o opt for or al cont r acept ives or ot her m et hods inst ead of m ale condom s.2, 8
Significant associat ions w er e found bet w een t he use of cont r acept ion by m en and being able t o count on t he fam ily as a pot ent ial sour ce of cont r acept ive m et hods ( pr obably t he m ale condom ) . The sam e associat ion w as not ver ified am ong t he w om en. I n a Canadian st udy,1 1 a posit iv e effect of count ing on par ent s as pr ov ider s of m ale condom s w as also obser v ed w it h r espect t o t he int ent t o use cont r acept iv es am ong m ale adolescent s. Am ong Mex ican adolescent s 1 2, it w as ver ified t hat t he gir ls w ho pr esent ed a high pr obabilit y of using a cont r acept iv e m et hod w er e t hose w ho spok e t o t heir m ot hers about sex and boyfriends. I t was also observed t hat t he young m en wit h a lower probabilit y of having im pregnat ed a w om an w ere t hose w hose com m unicat ion w it h t heir m ot hers w as bet t er. I n a st udy undert aken in Rio Grande do Sul 2, t he adolescent w om en int er v iew ed, w hen t hey denied t hat t heir par ent s r ecom m ended t hey use cont r acept iv es suggest ed t hat t his w ould be equiv alent t o consent ing t o t heir engagem ent in sexual relat ionships. Perhaps t his can cont r ibut e t o r eflect ion concer ning one of t he r esult s of t his st udy w hich seem s sur pr ising at fir st , nam ely t he associat ion bet w een t he use of cont r acept iv e m et hods and hav ing t he fat her as t heir sour ce of infor m at ion, a condit ion w hich w as not fr equent in t his gr oup ( 6.6% ) . The r esult s w it h r espect t o t he r ole of t he m ot her w er e not st at ist ically significant and t he dat a available does not m ake it possible t o evaluat e t he qualit y of int er act ion t he adolescent s in t his st udy and t heir par ent s.
The r esult s of t his st udy indicat e t he need for new inv est igat ions w hich w ould m ak e it possible t o obt ain a great er com prehension of t his and ot her aspect s such as t he role of t he fam ily in sexual and r epr oduct iv e behav ior of adolescent s; t he r elat ion bet w een schooling and sex ualit y ; cont r acept iv e choices in differ ent k inds of affect iv e and sex ual r elat ionships and t he r ole play ed by differ ent cont ex t s on gender relat ions.
The com plex it y of det er m ining cont r acept iv e behav ior am ong adolescent s is also confirm ed by t he result s of t his invest igat ion. I t also indicat es t he im port ance of incorporat ing t he m ult iple dim ensions of t his issue in educat ional pr ogr am s if t hese ar e t o be effect iv e.
I t seem s t hat cam paigns for t he prevent ion of AI DS and t he broad dissem inat ion of knowledge concerning t he use of m ale condom s m ay be having an influence on t he prevent ion of pregnancy, alt hough a gr eat deal of sex ual encount er s am ong adolescent s occur w it hout any k ind of pr ot ect ion. I t is r ecom m endable t hat int er vent ion st r at egies dir ect ed t ow ar ds t his populat ion gr oup should int egr at e cont ent s and act iv it ies r elat ed t o t he pr ev ent ion of STD and sex ual and r epr oduct iv e car e.
ACKNOWLEDGMENTS
To Dr. Balbina Lem os of t he Secret aria da Saúde do Est ado da Bahia, Professor Rosa Gaspar of t he Secret aria da Educação do Est ado da Bahia, and I lka Rondelli of t he JHPI EGO Corporat ion for t heir inst it ut ional suppor t .
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Address to correspondence
Maria da Conceição Chagas de Alm eida
I nst it ut o de Saú de Colet iv ada Universidade Federal da Bahia MUSA – Program a de Est udos em Gênero e Saúde
Rua Padre Feij ó, 29 4º andar 40110 - 170 Salvador, BA, Brasil E- m ail: m [email protected]
Support ed by JHPI EGO Corporat ion e pelo Program a FOCUS on Young Adult s Program / Pat hfinder I nt er nat ional. ( Grant s nº P- 6002- I SC- 01 CCP- A- 06- 90002- 02).
Received on11/ 7/ 2002. Reviewed on 31/ 3/ 2003. Approved on 9/ 5/ 2003.
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