Consistent Condom Use and Associated Factors among sexually active Military Personnel in Eastern Ethiopia: Cross-Sectional Study Design

Introduction

Globally, it has been demonstrated that both male and female latex condoms are highly effective and efficient in reducing HIV and other sexually transmitted infections. Male condoms, by far the most common, are made of a disposable one-time-use tube-shaped piece of thin latex rubber or lambskin.¹ In addition, other barrier prevention methods, such as a latex barrier or a dental dam, a thin, flexible piece of latex that prevents direct mouth-to-genital or mouth-to-anus contact during oral sex are pivotal in reducing the risk of sexually transmitted infections (STIs) while still allowing for clitoral or anal stimulation.^2,3

Although condoms are very important, their use is one of the most important issues to address when designing prevention programs and People’s failure to use condoms regularly can exacerbate the HIV/AIDS infection epidemic and lead to re-infection with new drug-resistant viral strains.⁴ However, when used correctly and consistently, male and female condoms are effective barrier methods against HIV, STIs, and unintended pregnancies.⁵

Sub-Saharan Africa bears the greatest burden of HIV/AIDS, accounting for an estimated 71% of the global total. In Ethiopia, an estimated715404people were infected with HIV in 2015, rising to722248in 2017.⁶ Ethiopia remains one of the hardest-hit areas by the HIV/AIDS pandemic, with the Harari regional state (Eastern Ethiopia) having the third-highest (3.5%) HIV prevalence.⁶

Studies pointed out that the prevalence of HIV among military personnel differs across the globe. For instance, the prevalence of HIV among the personnel was Congo,⁷ Cameroonian Armed Force,⁸ Sierra Leone Armed Forces.⁹ Military members are more likely to be male, younger, and to travel away from their primary sexual partners than the general population in low- and middle-income countries, all of which may increase their risk of contracting HIV.⁸ Risky sexual behaviors such as unprotected sex, multiple partnerships, no or inconsistent condom use, and drug abuse are extremely detrimental to adolescents’ health, putting them at high risk for HIV/AIDS and other sexually transmitted infections (STIs).^10,11

In terms of behavioral variables, many men have sex while under the influence of alcohol or other drugs. These substances are sometimes consumed before sexual intercourse, and in other cases, they are consumed during sexual activity.¹² As a result, several studies have found a strong link between drug use and inconsistent condom use,¹³ despite the fact that the strength of this correlation varies depending on the type of drug.¹⁴ Sexual sensation seeking and sexual compulsivity also constitute two intrinsically linked and significant predictors of risk behavior.¹⁵ Generally, men with high levels of compulsivity and sensation-seeking engage in relationships with multiple partners,¹⁶ have sex under the influence of alcohol,¹⁷ do not use condoms during vaginal or anal intercourse,¹⁸ and have higher STI incidence rates.¹⁹ The study clearly demonstrated a weak but positive relationship between condom knowledge and use. There was also significant mediation of the relationship between condom knowledge and use by condom use attitude. Knowledge of condom use correlated mildly with attitude and attitude with condom use.²⁰

In Ethiopia, the use of condoms was inconsistent and large number of Ethiopians, including military and police personnel, did not use condoms during sex with non-regular partners²¹ According to the study, a significant proportion of Ethiopian military personnel had multiple sexual partners, with lower levels of condom use with non-regular sexual partners.²² Despite condom availability and promotion for use in STI prevention, condom use remains too low in Ethiopia²³ As a result, it is reasonable to consider assessing condom use and associated factors among sexually active military personnel in Eastern Ethiopia.

Methods and Materials

Study Design, Area, and Period

The cross-sectional study design was conducted, in the eastern military command; Harar and Dire Dawa base camp, eastern Ethiopia from February 1 to 28 2020. Dire Dawa and Harar are two major towns located about 500 kilometers from Addis Ababa, Ethiopia’s capital city. They live next to each other and are only 50 kilometers apart. There is one referral hospital, one primary hospital, one level three army hospital, 15 health centers (seven in rural areas and eight in urban areas), 32 health posts, three private hospitals, two higher clinics, and 32 mid-level clinics in Dire Dawa. There is one specialized hospital, one public hospital, one police hospital, one health-care military center, one private hospital, and five health centers in Harari regional state.

Population and Eligibility Criteria

The survey was conducted among military staff members of the eastern command present during the study period and willing to participate. The single population formula was used to determine the sample size. Accordingly, the formula for sample size determination uses is: n = (Zα/2) 2 *[(p1q1)/(d) 2]; where n denoted military staff members sample size, Zα/2 is the reliability coefficient of standard error at 5% level of significance = 1.96, p = prevalence rate of 73.6% military personnel in eastern Ethiopia utilizing condoms regularly when having sex with non-regular sexual partners (73.6%).²⁴ and d refers to the level of standard error tolerated (5%). Hence, the calculation yielded a sample size of 298 military personnel. By considering a 10% non-response rate, the final sample size is 327.

Sampling Technique/ Procedure

During the study period, a total of 3650 military staff members were present in the eastern command primary at the Diredawa (1320) and Harari (2330) sites. A total of 314 study subjects were selected. A systematic sampling technique was used to select a representative sample of respondents from the study population by using the list of military staff from the eastern command for both sites as the sampling frame. A total of 3650 military personnel were assigned to the Harar and Dire Dawa camps in proportion. As a result, every 12th were enrolled in the study to provide study participants (Diredawa, N = 118; Harar, N = 209). The first participant was chosen at random using a lottery method. To avoid repetition, each participant was assigned a unique identification number.

Data Collection Method and Quality Control

The data was collected using a self-administered interview method with a properly designed and pre-tested questionnaire tool that was adapted and modified from various guidelines.^22,25

The questionnaire included questions about socioeconomic factors, behavioral factors, knowledge and attitude factors, sexual behavior, and availability. The questionnaire was written in English, translated into Amharic, and then translated back into English by different language experts to ensure consistency. A pretest was done on 5% of the sample out of the study area to check the sequence of questions, lingering questions, and time taken for questionnaires.

Training on the study’s purpose, instruments, and data collection procedures were given. Daily, the data was cleaned and checked for consistency. The entire data collection process was overseen by the research team. Finally, trained data collectors collected information at a military camp.

Operational Definition and Measurement

Consistent Condom Use

Those military staff that use condoms at every single sexual intercourse in the past 12 months. The options were always/all the time, sometimes, rarely, and not sure. In this study, those participants who used condoms all the time they had sex in the last 12 months were classified under the category of consistent condom use.²⁶

The knowledge of condom utilization was assessed by nine questions measuring knowledge was asked for the respondents to measure their knowledge level of respondents and the mean score was calculated to use as a cut point. Those who scored less than or equal to the mean were considered to have poor knowledge and those who scored greater than the mean value were considered as having good knowledge.

The attitude towards condom utilization was assessed by eleven questions measuring the attitude asked of the respondents and the mean score was calculated to use as a cut point. Those who scored less than or equal to the mean were considered as having a negative attitude and those who scored greater than the mean value were considered as having a positive attitude.

Data Analysis and Processing

Data were coded and entered and analyzed by using SPSS version 20 software packages. Each completed questionnaire was checked for completeness and cleaned. Each completed questionnaire was cleaned and checked for completeness. A descriptive analysis of the patients was performed, with the mean, standard deviation, and proportion of the studied variable. Percentages were used to represent dichotomous variables. To assess factors associated with condom use, bivariate and multivariable logistic regression analyses were performed. A binary logistic regression model was fitted to check for the association between independent variables and the outcome variable. The model fitness was checked by Hosmer–Lemeshow statistics and Omnibus tests. All variables with p < 0.25 in the bivariate analysis were included in the final multivariate analysis to identify the true predictors of the outcome variable. A multi-collinearity test was carried out to check the presence of correlation between independent variables using the standard error and collinearity statistics. The direction and strength of statistical association were measured by odds ratio (OR) along with the 95% confidence interval (CI). P value <0.05 was used to declare statistical significance.

Results

Sociodemographic Characteristics

A total of 327 participants were involved with a 100% response rate. The age range of the study participant was from 18 to 49 years with a mean age of 30.8 (SD=± 6.825) years. Among the study participants, 270 (82.57%), 171 (52.29%), 181 (55.35%), 168 (51.38%), and 164 (50.15%) were male in sex, single in marital status, with monthly incomes ranging from 2000 to 4000 birrs, secondary in educational status, and Soldier in military rank, respectively (Table 1).

Table 1 Socio-Demographic Characteristics of Sexually Military Personnel in Eastern Ethiopia, 2020

Behavioral Characteristics of Participants

Among the participants, 133 (59.33%) have consumed alcohol at some point in their lives, with 110 (89.4%) taking it on occasion. Among the respondents, 13 (33.64%) have chewed Khat in their lifetime, with 7 (53.8%) chewing it in the last 12 months (Table 2).

Table 2 Behavioral Characteristics and Knowledge of Condom Utilization Among the Sexually Active Military Personnel in Eastern Ethiopia, 2020 (n=327)

Knowledge of Condom Utilization

Overall, 86.2% (95% CI: 82, 89) of the study participants have good knowledge about condom utilization. The majority of participants were aware that using condoms is an effective way to prevent pregnancy/method of contraception (95.7%), to prevent STI and HIV (96.3%), important in multiple sexual partners (76.2%), important to check the expiry date (91.1%), and one condom cannot be used more than once (89.6%) (Table 2).

Sexual Behavior of the Participants

All 327 (100%) of study participants had had sexual intercourse at some point in their lives; of these, 275 (84.1%) and 104 (31.8%) had more than one sexual partner in the previous twelve months, and last month, respectively. One hundred and sixty-six (50.76%) of the participants had acquired a sexually transmitted infection at some point in their lives (Table 3).

Table 3 Behavioral Characteristics and Condom Utilization of Sexually Active Military Personnel in Eastern Ethiopia, 2020 (n = 327)

Condom Utilization

The overall consistent condom utilization over one year was 59.9% (95% CI: 54, 65). According to this study, all study participants (100%), 275 (84.1%), 240 (87.3%), and 186 (77.5%) had used condoms in their lifetime, in the last 12 months, in the last one month, and the last sexual practice, respectively (Table 3). When asked why they did not use condoms, they said it was due to a lack of satisfaction, the cost of purchasing condoms, and a lack of condoms near their camp. Some also mentioned a lack of shops and health centers in remote areas where troops could stay.

Attitude Towards Condom Utilization

Overall (54.4%) (95% CI: 47%, 58%) of the study participants have a positive attitude toward condom utilization. Among the participants, the majority have a positive attitude toward using condoms for the care of their partners (91.4%), that they are effective in preventing HIV/STI infections (92.3%), that a married woman can ask her husband to use a condom (78.3%), and that a married man can use a condom with his wife (83.5%) (Table 4).

Table 4 Attitude Towards Condom Utilization Among Sexually Active Military Personnel in Eastern Ethiopia, 2020 (N = 327)

Factors Associated with Consistent Condom Utilization

In bivariate analysis variables like gender, age, marital status, educational status, work experience, rank, cigarette smoking, alcohol drinking, and overall attitude were statistically significant at a p-value less than 0.25 and considered as a candidate for multivariable analysis. In multivariable analysis, being female, being married, educational status of college and above, and military ranks of officer and above, being an alcohol drinker and negative attitude remains statistically significant at a p-value less than 0.05 (Table 5).

Table 5 Bivariate and Multivariate Analysis of Factors Related to Condom Use at Eastern Command, Ethiopia, 2020

When compared to their male counterparts, females were 58% less likely (AOR = 0.42; 95% CI: 0.17, 0.92) to use condoms regularly. Participants aged 30–35 years were 3.12 times (AOR = 3.12; 95% CI: 1.43, 11.38) more likely to use a condom consistently than participants aged 18–24 years. Participants aged 35 years and older were 2.42 times (AOR = 2.42; 95% CI: 1.83, 9.30) more likely to use a condom consistently. College and above in educational status was 1.52 times (AOR = 1.52; 95% CI: 1.20, 5.43) more like used consistently condoms compared to illiterate individuals. Married and others in marital status were 78% times (AOR = 0.22; 95% CI: 0.05, 0.91), 81% times (AOR = 0.19; 95% CI: 0.08, 0.87) less likely to utilize condom consistently, respectively, compared to single individuals. Being an officer in military rank was 3.21 times (AOR = 3.12; 95% CI: 1.14, 10.15) and other ranks were 3.08 times (AOR = 3.08; 2.33, 8.52) more likely to use consistently condom compared to Soldier participants. Being an alcohol consumer/drunker was 53% times (AOR = 0.47; 95% CI: 0.03, 0.71) less likely consistent use condom, and those who have a negative attitude was 48% times (AOR = 0.52, 95% CI: 0.06, 0.5) less likely consistent use of condom compared to their counterparts over one year (Table 5).

Discussion

This study assessed condom use and its associated factors among sexually active military personnel in Eastern Ethiopia. It revealed that one in every five military personnel use condoms inconsistently. Being female, being married, educational status of college and above, and military ranks of officer and above, being an alcohol drinker and having a negative attitude were significantly associated with the outcome variable.

According to our study, 59.9% (95% CI: 54, 65) of military personnel use condoms consistently. This is in line with a study conducted in the western command which was 59.4%.²⁷ This could be because they share the same military culture, which is constantly spreading among them. However, when compared to a study conducted among different groups of people in Ethiopia, including military personnel and police officers, 75% of them used condoms regularly.²¹ The high mobility of military and police personnel from location to location may explain why a large proportion of respondents preferred condoms. In contrast to this, the finding of this study was higher than that of a study done in Axum,²⁸ Addis Ababa,²⁹ Nigeria,³⁰ and Botswana.³¹ This difference might be due to the difference in the study area, study period, and source of population.

In this study, being female in gender was negatively associated with consistent condom utilization. Similarly, female military personnel in Cameroon used condoms less frequently.³² Furthermore, studies conducted in Peru,³³ and Uganda³⁴ found that females were less likely to use a condom in their most recent sexual encounter. This may be exacerbated by the fact that male partners may have a greater influence on adolescent contraceptive decisions.³⁵ In addition, gender inequality may influence females’ consistent use of condoms. This could be due to women’s lack of empowerment and participation in decision-making, which results in a low female gender index.

This study further indicated that marital status was significantly associated with condom utilization. It pointed out that married military personnel uses condoms inconsistently when compared to their counterparts. This is in line with a study carried out in Cameroon³² and Nigeria.²⁵ The possible reason is that married people rarely use condoms to protect against STIs and HIV infection unless there is a case of discordance.

Furthermore, in the current study, military personnel with a college education or higher were more likely to use condoms regularly. This is in harmony with the study done in Addis Ababa²⁹ and Northwest Ethiopia.³⁶ This could be related to the fact that as people’s educational levels rise, so will their awareness of the benefits of consistent condom use. However, this finding contradicts a study conducted among Nigerian soldiers, which found no significant relationships between the respondent’s educational status and condom use.³⁰ Other factors, such as social and cultural factors, may influence condom utilization among educated people, which could explain the large disparity.

In this study, military rank including Crop, Sergent, Lieutenant, and Captain was positively associated with consistent condom utilization. This is in line with a study conducted in Cameroon³² and Nigeria²⁵ This could be explained by the military staff receiving high military rank, which motivates them to give value and protect themselves and their partners from sexually transmitted infections by using condoms on a consistent basis. Another possible explanation is that as military personnel’s ranks rise, their age rises as well, which plays a critical role in making them more mature and less susceptible to peer pressure.

Despite the fact that alcohol is commonly consumed by military personnel and predisposes them to risky sexual behavior.²⁴ However, in the current study, being an alcohol drinker was associated with a lower likelihood of using a condom regularly. This is supported by the previous studies done among Botswana Defense Force revealed that the odds of decreasing condom use were high among drinkers.³¹

In the current study, the overall positive attitude of participants toward the use of condoms was only about 54.4%, and individuals with negative attitudes were less likely to use condoms. This is supported by a study conducted in Cameroon, which also revealed that the main reasons for inconsistent condom use included condom use-related stigma among Cameroonian soldiers.³⁷ According to a study conducted among Addis Ababa military and police personnel, the perception was the main reason for condom nonuse.²⁹ Lower condom use was associated with the perception that condoms make sex less enjoyable, as well as negative attitudes toward condoms, according to a study conducted among the Republic of Congo Defense Force.¹¹ Personal factors such as aversion to the condom, as well as anxiety and depression, were also found to be negatively associated with condom use in a review study.³⁸

Limitation of the Study

These findings have limitations that need to be addressed in future research. First, due to financial constraints, the questionnaire does not include some of the factors that must be addressed. As a result, it is recommended that professionals use the qualitative section of the questionnaire to assess the cognitive-affective characteristics of sexual risk behavior. Furthermore, because some of the variables are so sensitive, they are prone to social desirability bias. Furthermore, because the study was cross-sectional, it was unable to establish a cause-and-effect relationship between the outcome variable and the independent variables.

Conclusions and Recommendation

This study indicated that about two in every five military personnel use condoms inconsistently. Furthermore, those with a higher level of education, and a military rank (Crop, Sergent, Lieutenant, and Captain) were more likely to use condoms regularly. Being female, alcohol consumption, and married, on the other hand, were less likely to use condoms consistently. Thus, designing appropriate intervention and behavioral change strategies, and increasing the accessibility or availability of condoms around military camps will undoubtedly have a significant benefit for consistent condom utilization among military personnel, protecting or reducing the risk of acquiring sexually transmitted infections.