báo cáo hóa học:" Are Nepali students at risk of HIV? A crosssectional study of condom use at first sexual intercourse among college students in Kathmandu" pot

RESEARC H Open Access
Are Nepali students at risk of HIV? A cross-
sectional study of condom use at first sexual
intercourse among college students in
Kathmandu
Ramesh Adhikari
1,2
Abstract
Background: Condoms offer the best protection against unintende d pregnancies and sexually transmitted
infections. Little research has been conducted to determine the prevalence and investigate the influencing factors
of cond om use at first sexual intercourse among college students.
Methods: A self-administered questionnaire was completed by 1137 college students (573 male and 564 female)
in the Kathmandu Valley. Analyses were confined to 428 students who reported that they have ever had sexual
intercourse. The association between condom use at first sexual intercourse and the explanatory variables was
assessed in bivariate analysis using Chi-square tests. The associations were further explored using multivariate
logistic analysis in order to identify the significant predictors after controlling for other variables.
Results: Among the sexually active students, less than half (48%) had used condoms during first sexual intercourse.
The results from the logistic regression analysis revealed that age, caste and/or ethnicity, age at first sexual
intercourse, types of first sex partner, alcohol consumption and mass media exposure are significant predictors for
condom use at first sexual intercourse among the college students. Students in the older age groups who had first
sex were about four times (16 to 19 years old) (OR = 3.5) more likely and nine times (20 or older) (OR = 8.9) more
likely than the students who had sex before 16 years of age to use condoms at first sexual intercourse.
Moreover, those students who had first sex with commercial sex worker were five times (OR = 4.9) more likely
than those who had first sex with their spouse to use condoms at first sex. Furthermore, students who had higher
exposure to both print and electronic media were about twice (OR = 1.75) as likely as those who had lower media
exposure to use condoms. On the other hand, students who frequently consumed alcohol were 54% (OR = 0.46)
less likely to use condoms at first sexual intercourse than those who never or rarely consumed alcohol.
Conclusions: The rate of condom use at first sexual intercourse is low among the students. It indicates students
are expo sed to health hazards through their sexual behaviour. If low use of condom at first sex continues,
vulnerable sexual networks will grow among them that allow quicker spreading of sexually transmitted diseases
and HIV. Findings from this study point to areas that policy and programmes can address to provide youth with

access to the kinds of information and services they need to achieve healt hy sexual and reproductive lives.
Correspondence:
1
Geography and Population Department, Mahendra Ratna Campus,
Tribhuvan University, Kathmandu, Nepal
Adhikari Journal of the International AIDS Society 2010, 13:7
/>© 2010 Adhikari; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License ( which permits unrestricted use, distribut ion, and reproduction in
any medium, provided the original work is properly cited .
Background
The Federal Democratic Republic of Nepal is a land-
locked country in south Asia. It lies between the two of
the mos t populous countries of the world: China in the
north and India in the south, east and west. These
countries are rank ed as the first and the second largest
countries of the world, respectively, in size of popula-
tion. T he total population of N epal was 27.5 million in
2009 [1]. About one in five of Nepal’ s people are in the
age group of 15 to 24 years [2].
HIV/AIDS has beco me a global problem and has
spread all over the world. The latest statistics estimate
that approximately 33.4 million people worldwide were
living with HIV/AIDS by the end of 2008. Of these, 4.7
million people were in Asia. India, Nepal’ s neighbour,
accounts for roughly half of Asia’ s HIV prevalence.
With the exception of Thailand, every country in Asia
has a n adult HIV prevalence of less than 1%. However,
owing to the region’s large population, Asia’scompara-
tively low HIV prevalence translates into a substantial
portion of the global HIV burden in terms of numbers

[3].
Like other countries in Asia, Nepal is susceptible to
HIV. The country is indeed facing critical challenges
posed by the rapid spread of HIV/AIDS. By October
2009, about 15,000 cases of HIV infection and about
2600 cases of AIDS had been officially reported. Among
these HIV cases, more than two in five cases (41%) were
in the college/university-going ( 15-29 years) age group
[4]. However, given the limitations of Nepal’spublic
health surveillance system, the actual number of infec-
tions is thought to be much higher. The Joint United
Nations Programme on HIV/AIDS (UNAIDS) estimat ed
that 75,000 people were living with HIV at the end of
2007 [5]. It has been found that one in every 200 young
males (0.5%) and one in every 300 females (0.3%) aged
15 to 24 are infected by HIV in Nepal [1].
Studies show that college students engage in a variety
of behaviours that put them at risk for serious health
problems [6,7]. College students are at risk of sexually
transmitted infections, including HIV, due to their pro-
pensity to take risks, often with multiple partners,
accompanied by an inconsistent use of condoms [8,9].
Ample research has also examined the prevalence of
excessive alcohol and other substance use, risky sexual
behaviour, and other harmful health behaviours that are
not uncommon among college students [10-13].
Similarly, a study found that young adults represent
one of the groups at highest risk for HIV infection [14].
A study conducted in colleges in Nepal showed that
about two in five male college students (39%) had pre-

marital sexual experiences. Among these, more than half
reported that they had multiple sex partners.
Furthermore, more than one in five (23%) had sexual
experience with commercial sex workers, and less than
half of them (49%) had used condoms in every act of
sexual intercourse with a sex worker [15]. Such risky
sexual behaviour increases the risk of contracting an
STI or HIV which jeopardizes academic achievement
and performance of the students [13,16,17].
Differences in levels of condom use in various popula-
tion groups and settings have been identified in the lit-
erature. In particular, groups with the lowest levels of
education have consistently been the least likely to use
condoms, both with non-marital and marital partners
[18-22]. Some studies also revealed an in crease in con-
dom use in the younger age groups [18,23,24] compared
to the older groups. Some studies found that later sexual
activity has also been associated with an increased use of
condoms [25-27]. Furthermore, alcohol use is highly
prevalent among college students, and contributes to
rising rates of sexual risk taking [28-31]. Empirical e vi-
dence also suggests that the mass media has an impor-
tant role in shaping individual reproductive attitudes
and behaviours [32-34]. In fact, th e mass media variable
is a reliable predictor of condom use among individuals
[35,36]. One study showed that men who heard about
AIDS through either electronic or print media were 30%
to 50% more likely to have used a condom than men
not exposed to these media [37].
Many researchers and public health policy makers are

particularly interested in the subject of first sexual con-
tact. A person’s first sexual intercourse often occurs
before the age of 20. This is linked to two factors: t he
association between behaviours in the first sexual rela-
tionship and the establishment of behavioural patterns
throughout life [38-40]; and the recognition that sexual
initiation at a very young age is a risk factor for preg-
nancies before the age of 20 and acquiring sexually
transmitted diseases, including HIV [26,41].
Condom use at first sex is easily remembered. Some
studies have found a strong link between first condom
use and lifetime use: a 20-fold increase in lifetime use
and a 10-fold increase in current use if a condom was
used at first sexual contact [42]. There is a limited body
of literature that points to condom use at first sexual
contact among young people, especially students, and
none of the studies has analyzed the data on condom
use at first sex in Nepal.
It is useful to kn ow about condom u se during first
sexual intercourse in Nepal so that priorities and
approaches for interventions to prevent risky sexual
behaviour can be better designed. This article aims to
determine t he prevalence of and investigate the factors
associated with condom use at first sexual intercourse
among college students in Nepal.
Adhikari Journal of the International AIDS Society 2010, 13:7
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Specifically, it is assumed that students who have sex
at a n earlier age, who consume alcohol frequently, who
have sex with irregular p artners, and who have lower

exposure to mass media use condoms less at first sexual
intercourse. The findings o f this study address the gap
in knowledge by providing the information on condom
use at first sexual intercourse that could assist pro-
gramme managers of government agencies and non-
governmental organizations and the Government of
Nepal in designing appropriate and timely education-
based interventions in institutions of secondary and
higher education.
Methods
Data and sampling framework
The data used in this paper comes from a cross-sec-
tional survey on attitude and behaviour towards premar-
ital sex among college students of Kathmandu, the
capital of Nepal, carried out in 2006. The survey
involved a total of 1137 students (573 male and 564
female) studying in 12 colleges affili ated to Trib huvan
University in Kathmandu. An alyses were confined to
428 stude nts who reported that they have ever had sex-
ual interco urse. The scientific committe e, which
included the Ethical Review Board of the University
Grant Commission in Nepal, approved the proposal and
provided funding for this study.
A two-stage random sampling technique was applied.
The first stage included a random selection of 12 col-
leges in Kathmandu. In order to select these colleges, a
list of all the private and public colleges affiliated with
Tribhuvan University and located in the Kathmandu
Valley (which includes three districts: Bhaktapur, Lalit-
pur and Kathmandu) was obtained from the office of

the Vice Chancellor in Kathmandu. This list included
colleges that provide intermediate (commonly known as
Grades 11 and 12), undergraduate and graduate degrees.
In the second stage, two classes were randomly selected
from each sampled college. The number of students in a
class ranged from 40 to 60. All the colleges are co-edu-
cational, and all male and female students present on
the day of the interview in the sampled classes were
requested to participate in the study.
Research instrument and data collection
Due to the sensitive nature of the study and the educa-
tional background of the respondents, a self-admini-
strated, structured questionnaire in the Nepali language
was used to obtain information. The questionnaires
were first developed in English and then translated into
Nepali. Almost all sections pertaining to the behavi oural
aspect were based on Behavioral Surveillance Survey
questionnaire developed by Family Health International/
Impact [43]. However, necessary modifications were
made to suit the sample population. The ques tionnaires
were pre-tested among students in a college that had
not been selected as part of the study, and later refined
as required. The pre-test was conducted to determine
whether the questionnaires were in sequential order and
the wording in Nepali was understandable or not. Most
of the questions were close ended; a few open-ended
questions were also included.
Female and male students filled in the questionnaire
separately in different classrooms. Each student was
allocated a separate bench, as in an exam setting, before

the questionnaire was distributed to them. A mal e
researcher supervised the male students’ class while a
female researcher su pervis ed the female students’ class.
Students were then requested to place the filled-in ques-
tionnaire on a table in the corner of each class.
Ethical considerations
Before starting the study in a sampled college, approval
from the campus administrative authority was obtained.
All the participants involved in the study were full y
informed about the nature of the study, the research
objectives, and the confidentiality of the data. A fter this,
verbal consent was obtained from the participants
before they were enrolled in the study. The consent
form was also written in the local language, stating the
study’s objectives, nature of the participant’ sinvolve-
ment, risk and benefits, and confi dentia lity of the data.
Students were requested to read the consent form care-
fully. They were given clear options on voluntary parti-
cipation. It was also made clear that they could refuse
to answer any of the questions and terminate the inter-
view if and when they desired.
All of the approached students agreed to participate in
the study. Confidentiality of infor mation was ensured by
removing personal identifiers from the completed ques-
tionnaires. The names of sampled colleges were not
made publi c and thus, it is not possi ble for anyone out-
side the research team to trace reported incidents of
sexual behaviour to respondents. Resp ondents were thus
protected from any possible adverse repercussions of
participating in the study.

Variables
The measurable outcome of the study is condom use at
first sexual intercourse, a dichotomous variable indicat-
ingwhetherornottherespondenthadusedacondom
during the first sexual encounter.
The independent variables used in the study were: sex
of the respondent; age; c aste and/or ethnicity; level of
education; age at first sexual intercourse; marital status;
types of first sexual partner; permanent place of resi-
dence; alcohol consumption; mass media exposure; and
living arrangement. All these variables were organized
Adhikari Journal of the International AIDS Society 2010, 13:7
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into two or three categories, based on those used in
other literature, as well as on the frequency distribution
of the variables.
The indicators of exposure to mass media include an
exposure to radio, television and newspapers. The
majority of the students rent rooms in the Kathmand u
Valley so it is ass umed that not all of them have TVs in
their rooms. Thus, radio and TV were combined and
treated as electronic media, and newspaper as print
media. Almost all students were exposed to at least one
type of media (either electronic or print). Because of
this, the mass media variable was organized into two
cat egories. If a student was exposed to only one type of
media, it was considered as low exposure; if a student
was exposed to both print and electronic media, it was
considered as high exposure.
Similarly, some ethnic groups in Nepal offer alcohol to

the gods in religious ceremonies, and people have to
consume alcohol in these ceremonies. Therefore, this
variable w as categorized into two: (1) never/rarely con-
sume alcohol and (2) frequently consume alcohol (two
or three times a week).
The variable, “ living arrangement”, is also organized
into two categories: those students who live with their
family members were considered as “ with biological
family"; those who live away from family members were
considered as “ without biological family”. The other
independent variables were categorized in the same way.
Methods of analysis
All completed survey questionnaires were entered into a
database after manual coding and validation. Data entry
and validity checks were performed for all the question-
naires by using the computer software programme,
dBase IV. The cleaned and validated data w as trans-
ferred into the SPSS software programme for further
processing and analysis.
Both bivariate and multivariate techniques were
applied in the analysis. The Chi-square test was used to
test the association between the variables. Those vari-
ables that were significant in the bivariate analysis were
further reexamined in the multivariate analysis (binary
logistic regression) i n order to identify the significant
predictors after controlling for other variables. Before
the multivariate analysis, multicollinearity among vari-
ables was assessed, and the least important variable,
which was highly correlated to other variables, was
removed from the logistic model.

Results
Characteristics of the respondents
Among the students, ab out tw o in five (39%) (47% boys;
28% girls) had sexual intercourse irrespective of their
marital status. Among these sexually active students
(n = 428), around 27% were aged 15 to 19. Eleven per-
cent reported that they had had sex before the age of
16. A large majority of the sexually active students were
from outside of t he Kathmandu Valley. More than a
third (34%) of the students consumed alcohol frequently
(two or three times a week). Almost half of the students
resided with their biological families. Almost all students
were exposed to at least one type of mass media (either
electronic or print). Furthermore, both male and female
college students were general ly aware of HIV/AIDS and
knew of at least one mode of transmission of HIV/AIDS
(data not shown).
Socio-demographics correlate with condom use
Among the sexually active students, just less than half
(48%) had used condoms d uring their first sexual con-
tacts. Table 1 shows t he clear association b etween con-
dom use at first sexual intercourse and different socio-
demographic characteristics. Of those who used con-
doms at their first sex, a significantly higher proportio n
than their comparison group: were males; were aged 15
to 19; were from the Brahmin and Chhetri communities;
had first sex at age 16 or older; were unmarried; had sex
with a boyfriend/girlfriend; were from outside the Kath-
mandu Valley; had high exposure to the mass media;
and lived with their biological families (Table 1).

Binary logistic regression analysis was used to measure
the strength of the associatio n between various indepen-
dent variables and the probabilities of using condoms at
first s ex. Only those variables that had significant asso-
ciation i n bivariate analysis we re reassessed in the logis-
tic model. Before the multivariate analysis,
multicollinearity among th e variables was assessed. It
was found that the varia bles, “marital status” and “types
of first sex p artner”,werehighlycorrelated(r=0.7).
Therefore, the variable, “ marital status” ,wasnot
included in the logistic model.
Analysis from logistic regression showed that age
group, caste and/or ethnicity, age at first sexual inter-
course, types of first s ex partner, alcohol consumption,
and mass media exposure were significant predictors
for condom use at first sexual intercourse. Students
aged 20 or older were less likely to use condoms (OR
= 0.40) than students aged 15 to 19. Similarly, students
from castes other than Brahmin and Chhetri were 40%
(OR = 0.60) less likely to use condoms during their
first sexual intercourses than those from other castes
and ethnic groups. Furthermore, students who had
sexual intercourse for the first time in the age groups
of 16 to 19 and 20 or older were almost four times
(OR = 3.5) and nine times (OR = 8.9) more likely,
respectively, than students who had first sex before
16 years to use condoms at first sexual intercourse
(Table 2).
Adhikari Journal of the International AIDS Society 2010, 13:7
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Those students who had first sex with a commercial
sex worker were about five times more likely than those
who had first sex with their spouse to use condoms dur-
ing first sexual intercourse. An inverse relationship was
observed between alcohol consumption and condom
use. Those student s who had frequently consumed alco-
hol were 54% (OR = 0.46) less likely to use condoms at
first sexual intercourse than those who did not consume
alcohol. On the other hand, students who had higher
exposure to both print and electro nic media were about
twice (OR = 1.75) as likely as who had lower media
exposure to use condoms during their first sexual inter-
courses (Table 2).
Discussion
This study shows that condom use at first sexual inter-
course is low among college students in Kathmandu,
Nepal. If condom use at first sex remains low, vulner-
able sexual networks will grow among the students,
allowing faster spreading of sexually transmitted diseases
and HIV. Our study found that condom use at first sex-
ual intercourse varied according to different criteria.
Age group, caste and/or ethnicity, age at first sexual
intercourse, types of first sex partner, alcohol consum p-
tion and mass media exposure were significant predic-
tors for using condoms at first sexual intercourse.
Table 2 Adjusted odds ratio (OR) and 95% confidence
interval (CI) for using condoms at first sexual intercourse
by selected predictors
Selected predictors OR 95% CI
Sex of the respondents

Female (ref.) 1.00
Male 1.34 0.81-2.21
Age group
15-19 (ref.) 1.00
20 and above 0.40** 0.23-0.71
Caste/ethnicity
Brahmin/Chhetri (ref.) 1.00
Other 0.60* 0.39-0.94
Age at first sexual intercourse
Up to 15 years (ref.) 1.00
16-19 years 3.53** 1.58-7.90
20 or more years 8.96*** 3.75-21.42
Types of first sex partner
Spouse (ref.) 1.00
Boyfriend/Girlfriend 4.52*** 2.48-8.22
Commercial sex worker 4.98*** 2.54-9.74
Permanent place of residence
Outside Kathmandu valley (ref.) 1.00
Kathmandu valley 0.64 0.32-1.30
Alcohol consumption*
Never/rarely consumed (ref.) 1.00
Frequently consumed 0.46** 0.28-0.75
Mass media exposure
Low exposure (ref.) 1.00
High exposure (both print and electronic media) 1.75* 1.08-2.83
2 Log likelihood 504.68
Cox & Snell R Square 0.185
Note: *** = p < 0.001 ** = p < 0.01 * = p < 0.5
Table 1 Condom use at first sexual intercourse by
background characteristics (n = 428)

Condom use
Yes No Percent Number
Sex of the respondents*
Female 40.3 59.7 100.0 159
Male 52.0 48.0 100.0 269
Age group**
15-19 58.6 41.4 100.0 116
20 and above 43.6 56.4 100.0 312
Caste/ethnicity**
Brahmin/Chhetri 53.1 46.9 100.0 243
Other 40.5 59.5 100.0 185
Level of education
Intermediate 52.3 47.7 100.0 88
Undergraduate 47.2 52.8 100.0 233
Graduate degree 44.9 55.1 100.0 107
Age at first sexual intercourse**
Up to 15 years 23.4 76.6 100.0 47
16-19 years 50.3 49.7 100.0 195
20 or more years 51.1 48.9 100.0 186
Marital status***
Married 34.5 65.5 100.0 165
Unmarried 55.9 44.1 100.0 263
Types of first sex partner***
Spouse 28.9 71.1 100.0 121
Boyfriend/girlfriend 57.2 42.8 100.0 180
Commercial sex worker 52.0 48.0 100.0 127
Permanent place of residence*
Outside Kathmandu Valley 49.5 50.5 100.0 378
Kathmandu Valley 34.0 66.0 100.0 50
Alcohol consumption*

Never/rarely consumed 52.7 47.3 100.0 283
Frequently consumed 37.9 62.1 100.0 145
Mass media exposure*
Low exposure 44.5 55.5 100.0 290
High exposure (both print and
electronic media)
54.3 45.7 100.0 138
Living arrangement
With biological family 50.9 49.1 100.0 224
Without biological family (friends/
alone)
44.1 55.9 100.0 204
Total 47.7 52.3 100.0 428
Note: *** = p < 0.001 ** = p < 0.01 * = p < 0.5
Adhikari Journal of the International AIDS Society 2010, 13:7
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The study also found that students aged 15 to 19 were
more likely to use condoms duri ng first sexual inter-
course compared with students aged 20 or older. Results
from this study are consistent with those of many other
studies [18,23,24]. The finding of this study was also
consistent with that of other literature: that later sexual
intercourse has also been associated with increased use
of condoms [25-27].
Many oth er studies have found significant dif ferences
in condom use according to the type of relationship
with sex partners, defined as casual or fixed/steady
[44-46]. Our study also supported the finding of other
studies that the level of condom use is higher in those
who had first sex with casual or non-steady partners

than in those who had first sex with spouses or steady
partners. Regarding alcohol consumption, results from
this study are similar to most other studies: alcohol use
contributes to a lower use of condoms and elevated
rates of sexual risk [28-31].
Mass media exposure is another important predictor
for condom use at first sexual intercourse. Those stu-
dents who were exposed to both electronic and print
media were more likely to use condoms than those who
had low exposure to these media. This finding is similar
to that of other studies [35,36]. Diffusion theorists po s-
tulate that the mass media effect contraceptive use by
stimulating partners to discuss contraceptive use [47].
Through the sharing of information and mutual feed-
back, people give meaning to information, understand
each other’s views and influence each other [48]. Thus,
discussion of contraceptive use leads to the development
of a better understanding between partners of their
reproductive health goals.
There are some limitations to this study. First, because
of the cross-sectional design of the study and the nature
of the items used in the logistic regression analysis, t he
analysis can only provide evidence of statistical associa-
tion between those items and condom use at first sex
and can not show cause-effect relationships. Second, all
measures w ere self-reported. Thus, responses may have
been biased by recall errors or intentional misreporting
of behaviour. However, the privacy conditions around
the study and the use of self-administered question-
naires are likely to have minimized purposeful

misreporting.
Conclusions
The rate of condom use at first sexual intercourse is low
among the students. It indicates students are exposed to
health hazards through their sexual behaviour. If low
use of condoms at first sex continues, vulnerable sexual
networks will increase among the students, allowing
more growth in the spread of sexually transmitted dis-
eases and HIV.
Our study showed a positive effect of the mass media
on condom use at first sex; information about condom
use and sexual risk behaviour, including unsafe sex,
should be provided through the mass media. Similarly,
students who had sex a t a later age were more likely to
use condoms at first sex. Therefore, awareness pro-
grammes that encourage postponement of sexual debuts
could benefit the students. Findings from this study
point to areas that policy and programmes can address
to provide youth with access to the kinds of information
and services they need to achieve healthy s exual and
reproductive lives.
Acknowledgements
The University Grant Commission, Nepal, provided funding for this study.
The author wishes to thank the administrators of all the sampled college in
the Kathmandu Valley for their support. He also thanks the students for their
participation in the study.
Author details
1
Geography and Population Department, Mahendra Ratna Campus,
Tribhuvan University, Kathmandu, Nepal.

2
Institute for Population and Social
Research, Mahidol University, Salaya, Thailand.
Authors’ contributions
RA conceived the study and its design, undertook the analysis, and wrote
the manuscript.
Competing interests
The author declares that they have no competing interests.
Received: 28 October 2009 Accepted: 2 March 2010
Published: 2 March 2010
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doi:10.1186/1758-2652-13-7
Cite this article as: Adhikari: Are Nepali students at risk of HIV? A cross-
sectional study of condom use at first sexual intercourse among college
students in Kathmandu. Journal of the International AIDS Society 2010 13 :7.
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