Conceived and designed the experiments: AL AP. Performed the experiments: AL KS. Analyzed the data: AL AP KS PS. Contributed reagents/materials/analysis tools: LAD. Wrote the paper: AL KS AP LAD CW PS.
The authors have declared that no competing interests exist. Sanofi Pasteur MSD funded the data collection portion of the questionnaire, but was not involved in any other capacity in the study. This does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials.
To better understand trends in sexually transmitted infection (STI) prevention, specifically low prevalence of condom use with temporary partners, the aim of this study was to examine factors associated with condom use and perceptions of STI risk amongst individuals at risk, with the underlying assumption that STI risk perceptions and STI prevention behaviors are correlated.
A national population-based survey on human papillomavirus (HPV) and sexual habits of young adults aged 18–30 was conducted in Sweden in 2007, with 1712 men and 8855 women participating. Regression analyses stratified by gender were performed to measure condom use with temporary partners and STI risk perception.
Men's condom use was not associated with STI risk perception while women's was. Awareness of and disease severity perceptions were not associated with either condom use or risk perception though education level correlated with condom use. Women's young age at sexual debut was associated with a higher risk of non-condom use later in life (OR 1.95 95% CI: 1.46–2.60). Women with immigrant mothers were less likely to report seldom/never use of condoms with temporary partners compared to women with Swedish-born mothers (OR 0.53 95% CI: 0.37–0.77). Correlates to STI risk perception differ substantially between sexes. Number of reported temporary partners was the only factor associated for both men and women with condom use and STI risk perception.
Public health interventions advocating condom use with new partners could consider employing tactics besides those which primarily aim to increase knowledge or self-perceived risk if they are to be more effective in STI reduction. Gender-specific prevention strategies could be effective considering the differences found in this study.
From a public health perspective, condom use with temporary partners is a critical primary prevention strategy against sexually transmitted infections (STIs). Their consistent and proper use is the best available means for effectively preventing sexual transmission of viral and bacterial infections ranging from HIV and HPV, an oncogenic virus, to Chlamydia and gonorrhea
Public health research and interventions are often based on a knowledge, attitudes and practice (KAP) assumption, which postulate a correlation between knowledge and attitudes and practice or behavior
In an attempt to understand why people are not engaging in STI prevention practice, a wide array of factors including lack of specific STI knowledge, low risk awareness, low self-efficacy or general risk-taking tendencies amongst certain individuals are often discussed
Participation in the study was voluntary, which was explicitly stated in the study invitation letter. By answering the questionnaire, respondents accepted participating in the study and informed consent was given. Separate informed consent forms are not required by the Ethical Review Board for questionnaire studies and were not used here either. Informed consent included register linkages (such as with Statistics Sweden) which was also explicitly stated in the study invitation letter. Ethical approval was granted by the Ethical Review Board of Karolinska Institutet, Solna, Sweden.
Data is drawn from a national cross-sectional population-based survey conducted in Sweden during January-May 2007 called “Attitudes toward HPV vaccination”
Invitation to respond to web-based questionnaires was offered to potential participants via a letter. In a first reminder, paper questionnaires were offered to those respondents unable to answer via Internet. If neither had been completed, a telephone reminder was made and the questionnaire answered via a phone interview. The data collection method has previously been described
To test the implicit assumption that risk perceptions are indicative of engagement in prevention practice, knowledge, attitude and practice (KAP) were operationalized as follows: ‘knowledge’ is tested here in questions pertaining to HPV awareness and transmission and cervical cancer familiarity; ‘attitudes’ are captured in responses to STI risk perception as well as in questions pertaining to disease severity perceptions; ‘practice’ is measured via condom use with temporary partners.
Outcome variables investigated in this analysis were condom use with temporary partners in the past year and STI risk perception. Reported condom use with temporary partners was used as an indicator of engagement in a primary disease (STI) prevention strategy. Temporary partners are the focus due to the increased infection risk from serial and or concurrent partners. We chose not to focus on condom use with steady partners as infection risk is conceivably lower in steady relationships with monogamous assumptions, and factors motivating condom use in such relationships could primarily relate to birth control, as opposed to STI prevention behavior.
Respondents to the question ‘When you had sex with your temporary partner(s), how often did you use a condom during the past year?’ (n = 2594) were included in analysis on condom use with temporary partners. Individuals who reported not having sex with a temporary partner in the past year were excluded, as were non-respondents and respondents with missing data on this question. The remaining respondents were aggregated into the groups: 1) Always/almost always, 2) Often/sometimes, and 3) Seldom/never.
Respondents who reported having had sexual intercourse at any time point and who also answered the question ‘How large a risk do you think you have of contracting an STI?’ (n = 9820) were included in the analysis of STI risk perception. Respondents with no sexual experience, non-respondents and respondents with missing data on this question were excluded. Data were aggregated into three categories for the descriptive analysis: 1) No/small perceived risk, 2) Somewhat large/large perceived risk, and 3) Don't know. Data were further dichotomized into two categories for the regression analysis: 1) No/small perceived risk and 2) Somewhat large/large perceived risk. Those responding ‘Don't know’ were categorized as missing (n = 534) in regression analysis.
Covariates from questionnaire and registers considered in the models included variables on age, education, income, employment type, social welfare status, geographic location, birth country, parent birth country, relationship status, oral and anal sex habits, type of sexual contact, condom use ever and with temporary and steady partners, age at first intercourse, sex partner number for self and compared to others, temporary sex partner number, sex partner gender, knowledge about reasons for and commonness of cervical cancer, knowing cause and severity perception of genital warts, having heard of HPV, predict more unprotected sex if vaccinated, pap smear screening attendance, belief that men/women can be infected with HPV, belief that HPV is sexually transmitted, and willingness to vaccinate against HPV.
To study potential associations on outcome variables, we first performed chi-square tests in cross-tabulations on knowledge (e.g. having heard of HPV), attitudes (e.g. genital wart severity perception), reported sexual behaviors (e.g. anal sex ever) and socio-demographic data from Statistics Sweden.
Hypotheses for potential variable relationships were carefully considered and directed acyclic graphs (DAGs) were constructed in order to formulate possible relationships and causal pathways, including possible interaction and effect modification
Further selection of explanatory variables for the final models was done by groups of variables pertaining to knowledge, attitudes, behavioral practices and demographics. Variables were retained based primarily on statistical significance, and examining confidence intervals, but subject-matter pertinence of variables to the outcome variables was also considered in the selection process. When constructing the multivariate models, demographic categories were first examined, followed by categories of behavior, then attitudes and finally knowledge. Exposures significant per category were added one at a time to the demographic model and all variables which were excluded were examined separately in a multivariate model to ensure their assumed non-effect held true in various multivariable constellations.
However, significant interaction effects between gender and most explanatory variables were noted. Stratification, typically used to circumvent interaction
A combined STI model adjusted for variables common in both sexes (plus age) was created to generate an odds ratio (OR) for the gender variable. A p-value of less than 0.05 was considered statistically significant in all analyses. Confidence intervals (CIs) are presented at the 95% level. Statistical analyses were performed using SAS version 9.2.
Almost 90% of study participants were born in Sweden (
Women n (%) | Response rate% | Men n (%) | Response rate% | |
|
||||
18–21 yrs | 2385 (26.9) | 56.2 | 553 (32.3) | 46.0 |
22–24 yrs | 1910 (21.5) | 53.9 | 385 (22.4) | 42.2 |
25–28 yrs | 2683 (30.3) | 55.5 | 498 (29.0) | 40.8 |
29–31 yrs | 1877 (21.2) | 55.4 | 276 (16.1) | 41.2 |
|
||||
Sweden | 7851 (88.6) | 58.6 | 1535 (89.6) | 45.0 |
Other Nordic country | 78 (0.8) | 52.7 | 14 (0.8) | 43.7 |
Other country | 842(9.5) | 39.3 | 141 (8.2) | 30.1 |
|
||||
Sweden | 7163 (80.8) | 59.4 | 1407 (82.1) | 45.7 |
Other Nordic country | 384 (4.3) | 56.3 | 65(3.8) | 35.9 |
Other country | 1308 (14.7) | 45.1 | 240(14.0) | 38.0 |
|
||||
< High school | 2208 (25.2) | 49.6 | 474 (28.0) | 39.4 |
High school or equal | 3529 (40.3) | 54.4 | 776 (45.9) | 42.1 |
> High school | 3010 (34.4) | 63.8 | 438 (25.9) | 50.7 |
|
||||
No | 8112 (91.6) | 57.3 | 1583 (92.4) | 44.3 |
Yes | 743 (8.3) | 40.3 | 129 (7.5) | 29.9 |
|
||||
< 10,000 | 5681 (64.9) | 54.1 | 950 (56.2) | 42.3 |
10,000–20,000- | 1725 (19.7) | 58.7 | 266 (15.7) | 44.0 |
>20,000 | 1341 (15.3) | 61.0 | 472 (27.9) | 44.6 |
|
||||
Married/registered partner/in a relationship | 6333 (71.7) | NA | 950 (55.8) | NA |
Single | 2492 (28.2) | 752 (44.1) | ||
|
||||
Full time | 2835 (32.3) | NA | 872 (51.1) | NA |
Part time | 1216 (13.8) | 101 (5.9) | ||
Unemployed | 528 (6.0) | 114 (6.6) | ||
Student | 3070 (34.9) | 540 (31.6) | ||
Parental leave | 685 (7.8) | 9 (0.5) | ||
Disability/other | 440 (5.0) | 68(3.9) | ||
|
||||
Large city | 3028 (34.2) | 53.0 | 568 (33.1) | 40.4 |
Northern Sweden (small city/rural) | 1351 (15.2) | 57.4 | 275 (16.0) | 46.6 |
Southern Sweden (small city/rural) | 4476 (50.5) | 56.4 | 869 (50.7) | 43.3 |
|
||||
Internet | 4032 (45.5) | NA | 777 (45.3) | NA |
Post | 3612 (40.7) | 514 (30.0) | ||
Telephone interview | 1211 (13.6) | 421 (24.5) | ||
|
||||
Heterosexual contacts | 7573 (91.4) | NA | 1463 (95.0) | NA |
Homosexual contacts | 74 (0.8) | 31 (2.0) | ||
Bisexual contacts | 633 (7.6) | 46(2.9) | ||
|
||||
0 | 5553 (70.8) | NA | 882 (63.1) | NA |
1 | 935 (11.9) | 193 (13.8) | ||
2–4 | 987 (12.6) | 226 (16.1) | ||
5–9 | 276 (3.5) | 77 (5.5) | ||
10–14 | 51 (0.6) | 19 (1.3) | ||
14+ | 33 (0.4) | 0 | ||
|
||||
< 15 | 1380 (17.8) | NA | 210 (15.6) | NA |
15–18 | 5207 (67.3) | 900 (66.9) | ||
19+ | 1148 (14.8) | 235 (17.4) |
Forty-one percent of men reported always/almost always using condoms with temporary partners, while the corresponding figure among women was 34%. Half the women who responded to the question reported seldom or never using condoms with temporary partners, while 40% of men responded in this manner. Approximately 10% of sexually active respondents reported considering themselves to have a large risk of contracting an STI, with approximately 5% reporting not knowing (
Women n (%) | Men n (%) | p-value |
|
|
0.1320 | ||
No risk or small risk | 6832 (82.7) | 1277 (83.4) | |
Fairly large or large risk | 981 (11.8) | 160 (10.4) | |
Don't know | 440 (5.3) | 94 (6.1) | |
|
|
||
Always/almost always (100-75%) | 711 (33.6) | 196 (40.8) | |
Often/sometimes (74-25%) | 340 (16.0) | 91 (18.9) | |
Seldom/Never (24-0%) | 1063 (50.2) | 193 (40.2) |
*P value from chi square test, assessing differnce in responses between men and women.
STI risk perception was correlated to condom use with temporary partners for women but not men. Women were approximately three times as likely to report perceiving a high risk of contracting an STI when they report often/sometimes and seldom/never using condoms compared to those women who report always/almost always using condoms with temporary partners. There were no correlations between condom use and variables related to HPV-related cancer or condyloma awareness, knowledge, or disease severity perception.
Women in families receiving social-welfare were more likely to report seldom/never using condoms with temporary partners (OR = 1.59, CI: 1.02–2.46) (
Adjusted OR | Adjusted OR | p-value |
||||
(95% CI) | (95% CI) | |||||
Covariate | Always/almost always | Often/sometimes | Seldom/never | Often/sometimes | Seldom/never | |
n (%) | n (%) | n (%) | ||||
|
|
|||||
Married/in relationship | 289 (31.5) | 113 (12.3) | 516 (56.2) | 0.86 (0.64–1.17) |
|
|
Single | 420 (35.3) | 226 (19.0) | 543 (45.7) | 1.0 | 1.0 | |
|
|
|||||
< High school | 91 (27.2) | 53 (15.9) | 190 (56.9) |
|
|
|
High school | 395 (31.9) | 209 (16.9) | 634(51.2) | 1.33 (0.95–1.87) |
|
|
>High school | 223 (41.4) | 78 (14.5) | 238 (44.1) | 1.0 | 1.0 | |
|
|
|||||
< 10000 | 505 (34.7) | 229 (15.7) | 721 (49.5) | 0.74 (0.33–1.63) | 1.16 (0.86–1.56) | |
10000–20000 | 109 (27.2) | 74 (18.5) | 217 (54.3) | 1.0 | 1.0 | |
>20000 | 87 (37.3) | 33 (14.2) | 113 (48.5) |
|
1.26 (0.85 |
|
|
|
|||||
No | 661 (34.4) | 319 (16.6) | 942 (49.0) | 1.0 | 1.0 | |
Yes | 50 (26.0) | 21 (10.9) | 121 (63.0) | 0.74 (0.39–1.43) |
|
|
|
|
|||||
Sweden | 593 (33.1) | 282 (15.7) | 916 (51.1) | 1.0 | 1.0 | |
Nordic country | 22 (24.4) | 14 (15.6) | 54 (60.0) | 1.54 (0.75–3.17) | 1.51 (0.86–2.62) | |
Other country | 63 (46.3) | 23(16.9) | 50 (36.8) | 1.11 (0.71–1.72) |
|
|
|
|
|||||
<15 | 91 (21.8) | 58 (13.9) | 269 (64.3) | 1.26 (0.85–1.87) |
|
|
15–18 | 497 (36.4) | 236 (17.3) | 634 (46.4) | 1.0 | 1.0 | |
19+ | 100 (42.5) | 33 (14.0) | 102 (43.4) | 0.96 (0.60–1.53) | 1.12(0.80–1.58) | |
|
|
|||||
One | 278 (33.3) | 73 (8.7) | 484 (58.0) | 1.0 | 1.0 | |
2 to 4 | 347 (37.0) | 177 (18.9) | 414 (44.1) |
|
|
|
5 to 9 | 70 (26.7) | 66 (25.2) | 126 (48.1) |
|
|
|
10 to 14 | 11 (22.0) | 13 (26.0) | 26 (52.0) |
|
0.74 (0.33–1.63) | |
15+ | 5 (17.2) | 11 (37.9) | 13 (44.8) |
|
0.60 (0.20–1.79) | |
|
|
|||||
None/small | 537 (41.4) | 166 (12.8) | 595 (45.8) | 1.0 | 1.0 | |
Rather big/large | 130 (19.6) | 149 (22.5) | 383 (57.8) |
|
|
|
Don't know | 42 (28.4) | 24 (16.2) | 82 (55.4) |
|
|
|
|
|
|||||
Yes | 264 (28.3) | 152 (16.3) | 518 (55.4) | 1.16 (0.86–1.56) |
|
|
No | 421 (37.9) | 178 (16.0) | 512 (46.0) | 1.0 | 1.0 | |
|
0.1516 | |||||
Heterosexual | 624 (34.4) | 301 (16.6) | 891 (49.0) | 1.0 | 1.0 | |
Bisexual | 78 (28.6) | 35 (12.8) | 160 (58.6) | 0.74 (0.46–1.17) | 1.25 (0.90–1.72) | |
Homosexual | 6 (28.6) | 4 (19.0) | 11 (52.4) | 1.11 (0.24–5.05) | 0.81 (0.24–2.73) |
*based on likelihood ratio test.
Adjusted OR | Adjusted OR | p-value |
||||
(95% CI) | (95% CI) | |||||
Covariate | Always/almost always | Often/sometimes | Seldom/never | Often/sometimes | Seldom/never | |
n% | n% | n% | ||||
|
|
|||||
< High school | 26 (36.1) | 10 (13.9) | 36 (50.0) | 1.03 (0.40–2.61) |
|
|
High school | 119 (39.4) | 54 (17.9) | 129 (42.7) | 0.95 (0.52–1.74) |
|
|
>High school | 51 (48.6) | 27 (25.7) | 27 (25.7) | 1.0 | 1.0 | |
|
0.0554 | |||||
< 10000 | 138 (46.1) | 50 (16.7) | 111 (37.1) | 0.59 (0.50–2.78) | 0.68 (0.74–3.26) | |
10000–20000 | 29 (34.5) | 19 (22.6) | 36 (42.9) | 1.0 | 1.0 | |
>20000 | 28 (30.1) | 22 (23.6) | 43 (46.2) | 1.18 (0.29–1.19) | 1.56 (0.37–1.24) | |
|
|
|||||
One | 77 (43.0) | 15 (8.4) | 87 (48.6) | 1.0 | 1.0 | |
2 to 4 | 89 (42.0) | 47 (22.1) | 76 (35.8) |
|
0.67 (0.42–1.08) | |
5 to 9 | 27 (37.0) | 23 (31.5) | 23 (31.5) |
|
0.62 (0.31–1.23) | |
10 to 14 | 3 (18.7) | 6 (37.5) | 7 (43.7) | 1.57 (0.37–6.62) | ||
|
|
|||||
Yes | 67 (33.7) | 36 (18.1) | 96 (48.2) | 0.87 (0.49–1.55) |
|
|
No | 115 (44.7) | 53 (20.6) | 89 (34.6) | 1.0 | 1.0 | |
|
0.1531 | |||||
Heterosexual | 182 (40.7) | 82 (18.3) | 183 (40.9) | 1.0 | 1.0 | |
Bisexual | 6 (31.5) | 6 (31.5) | 7 (36.8) | 2.14 (0.63 |
0.83 (0.25 |
|
Homosexual | 8 (57.1) | 3 (21.4) | 3 (21.4) | 0.69 (0.15 |
|
*based on likelihood ratio test.
Women's relationship status was correlated with condom use with temporary partners whereas men's was not (
Both men and women who reported ever engaging in anal sex were more likely to report seldom/never using condoms with temporary partners (OR = 2.14, CI: 1.35–3.39 for men; OR = 1.43, CI: 1.15–1.79 for women).
Variables on oral sex habits, condom use with steady partner in the past year, condom use ever, pap smear screening attendance, knowing the cause of cervical cancer and willingness to vaccinate against HPV if it was cost-free were significant in the univariate analyses for women but became non-significant in the final models for condom use (data not shown).
Although women and men had similar distributions of risk perception (
Low risk | High risk | Adjusted OR | p-value |
|
n (%) | n (%) | (95% CI) | ||
Covariate | High risk | |||
|
|
|||
Married/in relationship | 5546 (93.4) | 393 (6.6) |
|
|
Single | 1271 (68.5) | 584 (31.5) | 1.0 | |
|
|
|||
18–21 | 1532 (81.7) | 343 (18.3) |
|
|
22–24 | 1435 (83.5) | 283 (16.5) |
|
|
25–28 | 2224(89.9)) | 251 (10.1) |
|
|
29–31 | 1641 (94.0) | 104 (6.0) | 1.0 | |
|
|
|||
Zero | 5107 (95.8) | 222 (4.2) | 1.03 (0.72–1.48) | |
One | 693 (81.3) | 159 (18.7) | 1.0 | |
2 to 4 | 594 (64.9) | 321 (35.0) |
|
|
5 to 9 | 112 (42.7) | 150 (57.2) |
|
|
10+ | 28 (33.7) | 55 (66.3) |
|
|
|
|
|||
Always/almost always | 537 (80.5) | 130 (19.5) |
|
|
Often/sometimes | 166 (52.7) | 149(47.3) | 3.06 (2.22–4.23) | |
Seldom/never | 595 (60.8) | 383 (39.2) | 3.11 (2.41–4.03) | |
|
|
|||
Zero | 199 (89.2) | 24 (10.8) | 1.62 (0.94–2.8) | |
One | 4828 (96.3) | 185 (3.7) | 1.0 | |
2 to 4 | 1177 (75.7) | 378 (24.3) |
|
|
5 to 9 | 302 (59.0) | 210 (41.0) |
|
|
10 to 14 | 61 (49.6) | 62 (50.4) |
|
|
15+ | 63 (50.4) | 62 (49.6) |
|
|
|
|
|||
More | 633 (69.6) | 276 (30.3) |
|
|
Less | 3216 (93.2) | 233 (6.8) |
|
|
Same | 2286 (85.8) | 379 (14.2) | 1.0 | |
Don't know | 477 (90.0) | 53 (10.0) | 0.81 (0.54–1.20) |
Low risk is defined as responses no or low risk for contracting STIs and high risk defined as responses rather high or high risk for contracting STIs.
*Based on likelihood ratio test.
**Odds ratios here describe probability of high self-perceived risk for contracting an STI assuming always/almost always use of condoms with temporary partners.
Low risk | High risk | Adjusted OR | p-value |
|
n (%) | n (%) | (95% CI) | ||
Covariate | High risk | |||
|
|
|||
Heterosexual | 1223 (89.9) | 137 (10.1) | 1.0 | |
Bisexual | 32 (69.6) | 14 (30.4) |
|
|
Homosexual | 20 (69.0) | 9 (31.0) | 2.33 (0.83–6.40) | |
|
|
|||
Yes | 478 (84.3) | 89 (15.7) |
|
|
No | 736 (92.2) | 62 (7.8) | 1.0 | |
|
|
|||
Married/in relationship | 832 (93.9) | 54 (6.0) |
|
|
Single | 440 (80.7) | 105 (19.3) | 1.0 | |
|
|
|||
Zero | 821 (96.7) | 28 (3.3) |
|
|
One | 151 (84.8) | 27 (15.2) | 1.0 | |
2 to 4 | 165 (79.3) | 43 (20.7) | 1.55 (0.88–2.74) | |
5 to 9 | 47 (63.5) | 27 (36.5) |
|
|
10 to 14 | 10 (55.6) | 8 (44.4) |
|
Low risk is defined as responses no or low risk for contracting STIs and high risk defined as responses rather high or high risk for contracting STIs.
*Based on likelihood ratio test.
Condom use with steady partners was not associated with STI risk perception, whereas use with temporary partners was for women. Women reporting having had more sex partners than other people (versus less or same number), were twice as likely to perceive large STI risk. Men's STI risk perception was correlated with anal sex whereas women's was not (
Variables related to HPV-related cancer or condyloma awareness, knowledge or disease severity perception were non-significant in the univariate and multivariable models for STI risk perception (data not shown).
This population-based study revealed that condom use with temporary partners was not associated with STI risk perception for men whereas it was for women, despite a higher percentage of men reporting consistently having used condoms with temporary partners than women. It is particularly notable that correlates to STI risk perception differ substantially between men and women. Awareness and severity perceptions of HPV and HPV-related cancer were not associated with either condom use or risk perception, whereas education level was positively associated with condom use. Women who were youngest at sexual debut also had two-fold increased odds of reporting non-condom use with temporary partners compared to women with later sexual debuts. Also, women with immigrant mothers were almost twice as likely to report using condoms consistently with temporary partners compared to women with Swedish-born mothers. Number of reported temporary partners was the only common factor associated for both men and women with condom use and STI risk perception.
Based on an underlying KAP assumption, we expected to find those with higher levels of HPV awareness or disease severity perceptions also reporting more consistent condom use with temporary partners. The fact that these variables were not at all associated was surprising, as was the finding that they were not associated with STI risk perception either. This may point to an ineffectiveness of KAP assumptions in explaining this area of risk and prevention practice. This also points to education level's correlation to condom use as an effect of socio-economic status rather than an effect of disease knowledge. High socio-economic status often reduces barriers to prevention for both chronic and infectious diseases
Our findings regarding men's STI risk perception and condom use correlates are particularly disconcerting considering the prioritized and liberal views of sexual education in Swedish schools
In societies where health risk exposure information is abundant, as is the case today in countries with high GDP per capita such as Sweden or the U.S., few epidemiological studies aim to measure how individuals interpret their risk exposure and whether or how this is in turn associated with prevention behavior. Our study shows vast gender differences in how risk is perceived and correlated to prevention behavior. Future attempts to measure possible causes and effects of risk perceptions should also aim to measure gender differences.
Other studies have indicated differences in prevalence of male and female condom use but no other large-scale population-based studies using similar variables have evaluated men and women with separate models
It should be recognized however that as data were collected cross-sectionally we cannot make any inference about cause and effect. This makes it difficult to interpret the significance shown here of reported relationship status in the models as concurrency is unknown. Another potential limitation to our study is respondents self-define ‘temporary’ when asked about condom use with temporary partners in the past year. To avoid recall bias we limited our questions to only asking about sexual relationships in the past year.
Women with mothers born outside the Nordic countries reported more frequent condom use with temporary partners than those with Swedish or Nordic-born mothers. We have not found adequate explanation in the literature for this unexpected finding. One interpretation might be that these women are raised with different values and hence develop different practices than their peers, but it could also be due to differences in reported versus practiced behavior. In light of our findings, maternal and cultural influences on STI prevention behavior merit further investigation.
Specific to HPV, early sexual debut is a well-known risk factor for developing cervical cancer. This is thought to be due to exposing the cervical transformation zone to HPV infection for a longer time-period and/or an average increased number of lifetime sexual partners
Other studies have shown low condom use to be related to a wide variety of factors, including decreased sensation, partner disapproval, non-communication, low levels of emotional intimacy and alcohol use
This study's population-based sampling frame enhances its generalizability in Sweden and also its relevance in other contexts with similar demographics and social climates. The majority of studies on STI risk and condom use rely on convenience-sampling amongst a selected group, e.g. university students or sex workers. To our knowledge, few national population-based studies of this nature have been conducted outside the Nordic region. With consideration given to the sensitive character of the questions and healthy young population targeted, our ∼50% participation rate can be seen as acceptable
Because the survey was based on a random selection of the population, this minimizes the problem of selection bias. However there is always the potential for a non-response bias, in which those who chose not to participate deviated in regard to the outcome variables under investigation. The possibility of non-response bias in the sexual habits questions cannot be ruled out completely, although the distribution of sexual habits and number of survey respondents whom had not made their sexual debut appeared to be reasonable, reflecting the relative heterogeneity expected in the population. Furthermore, both men and women proportionally indicated similar risk perception levels (
Having had multiple sexual partners, or having a partner who has had multiple sexual partners, puts one at risk for a variety of infections such as HIV, Chlamydia, HPV and gonorrhea
The authors thank Julia Fridman Simard for input on data analysis and Pouran Almstedt for data management.