Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, Fertility Jon Øyvind Odland www.mdpi.com/journal/ijerph Edited by Printed Edition of the Special Issue Published in IJERPH Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, Fertility Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, Fertility Special Issue Editor Jon Øyvind Odland MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade Special Issue Editor Jon Øyvind Odland The Norwegian University for Science and Technology Norway Editorial Office MDPI St. Alban-Anlage 66 Basel, Switzerland This is a reprint of articles from the Special Issue published online in the open access journal International Journal of Environmental Research and Public Health (ISSN 1660-4601) from 2017 to 2018 (available at: http://www.mdpi.com/journal/ijerph/special issues/teenage reproductive health) For citation purposes, cite each article independently as indicated on the article page online and as indicated below: LastName, A.A.; LastName, B.B.; LastName, C.C. 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Contents About the Special Issue Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Preface to ”Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, Fertility” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Jon Øyvind Odland Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, Fertility Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 1176, doi: 10.3390/ijerph15061176 . . 1 Bimala Sharma and Eun Woo Nam Condom Use at Last Sexual Intercourse and Its Correlates among Males and Females Aged 15–49 Years in Nepal Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 535, doi: 10.3390/ijerph15030535 . . . 5 Miriam Clark, Rohanna Buchanan and Leslie D. Leve Young Women’s Perspectives of Their Adolescent Treatment Programs: A Qualitative Study Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 373, doi: 10.3390/ijerph15020373 . . . 22 Elizabeth Kemigisha, Viola N. Nyakato, Katharine Bruce, Gad Ndaruhutse Ruzaaza, Wendo Mlahagwa, Anna B. Ninsiima, Gily Coene, Els Leye and Kristien Michielsen Adolescents’ Sexual Wellbeing in Southwestern Uganda: A Cross-Sectional Assessment of Body Image, Self-Esteem and Gender Equitable Norms Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 372, doi: 10.3390/ijerph15020372 . . . 37 Maria Lisa Odland, Gladys Membe-Gadama, Ursula Kafulafula, Geir W. Jacobsen, James Kumwenda and Elisabeth Darj The Use of Manual Vacuum Aspiration in the Treatment of Incomplete Abortions: A Descriptive Study from Three Public Hospitals in Malawi Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 370, doi: 10.3390/ijerph15020370 . . . 47 Panagiotis Tsikouras, Dorelia Deuteraiou, Anastasia Bothou, Xanthi Anthoulaki, Anna Chalkidou, Eleftherios Chatzimichael, Fotini Gaitatzi, Bachar Manav, Zacharoula Koukouli, Stefanos Zervoudis, Grigorios Trypsianis and George Galazios Ten Years of Experience in Contraception Options for Teenagers in a Family Planning Center in Thrace and Review of the Literature Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 348, doi: 10.3390/ijerph15020348 . . . 56 M ́ onica Frederico, Kristien Michielsen, Carlos Arnaldo and Peter Decat Factors Influencing Abortion Decision-Making Processes among Young Women Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 329, doi: 10.3390/ijerph15020329 . . . 74 Marzhan A. Dauletyarova, Yuliya M. Semenova, Galiya Kaylubaeva, Gulshat K. Manabaeva, Bakytkul Toktabayeva, Maryash S. Zhelpakova, Oxana A. Yurkovskaya, Aidos S. Tlemissov, Galina Antonova and Andrej M. Grjibovski Are Kazakhstani Women Satisfied with Antenatal Care? Implementing the WHO Tool to Assess the Quality of Antenatal Services Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 325, doi: 10.3390/ijerph15020325 . . . 87 v Sara Rivenes Lafontan, Johanne Sundby, Hege L. Ersdal, Muzdalifat Abeid, Hussein L. Kidanto and Columba K. Mbekenga “I Was Relieved to Know That My Baby Was Safe” : Women’s Attitudes and Perceptions on Using a New Electronic Fetal Heart Rate Monitor during Labor in Tanzania Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 302, doi: 10.3390/ijerph15020302 98 Anna A. Usynina, Vitaly Postoev, Jon Øyvind Odland and Andrej M. Grjibovski Adverse Pregnancy Outcomes among Adolescents in Northwest Russia: A Population Registry-Based Study Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 261, doi: 10.3390/ijerph15020261 110 Rina Pradhan, Karen Wynter and Jane Fisher Factors Associated with Pregnancy among Married Adolescents in Nepal: Secondary Analysis of the National Demographic and Health Surveys from 2001 to 2011 Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 229, doi: 10.3390/ijerph15020229 122 Anna B. Ninsiima, Els Leye, Kristien Michielsen, Elizabeth Kemigisha, Viola N. Nyakato and Gily Coene “Girls Have More Challenges; They Need to Be Locked Up”: A Qualitative Study of Gender Norms and the Sexuality of Young Adolescents in Uganda Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 193, doi: 10.3390/ijerph15020193 134 Frederik Tilmann von Rosen, Antonella Juline von Rosen, Falk M ̈ uller-Riemenschneider, Inken Damberg and Peter Tinnemann STI Knowledge in Berlin Adolescents Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 110, doi: 10.3390/ijerph15010110 150 Jennifer M. Grossman, Lisa J. Jenkins and Amanda M. Richer Parents’ Perspectives on Family Sexuality Communication from Middle School to High School Reprinted from: Int. J. Environ. Res. Public Health 2018 , 15 , 107, doi: 10.3390/ijerph15010107 164 Prince Oppong-Darko, Kwame Amponsa-Achiano and Elisabeth Darj “I Am Ready and Willing to Provide the Service Though My Religion Frowns on Abortion”— Ghanaian Midwives’ Mixed Attitudes to Abortion Services: A Qualitative Study Reprinted from: Int. J. Environ. Res. Public Health 2017 , 14 , 1501, doi: 10.3390/ijerph14121501 178 vi About the Special Issue Editor Jon Øyvind Odland , Professor of Global Health. NTNU (the Norwegian University of Science and Technology). MD, PhD, Specialist Obstetrics, and Gynecology. Visiting Professor, Department of Public Health, University of Pretoria, South Africa (2013–); Visiting Professor, OB/GYN Department, College of Medicine, University of Malawi (2013–); Key National Expert, Sustainable Development Working Group, Arctic Council (2010–); President of the Norwegian Forum for Global Health Research (2009–2011); and Chair of AMAP Human Health Assessment Group (2009–). President, International Union of Circumpolar Health (2012–2015). Teacher and supervisor in Health Education, Obstetrics and Gynecology, and Public Health at Bachelor, Master, and PhD level in Norway, Russia, Denmark, Greenland, Faroe Island, Iceland, Canada, Malawi, South Africa, Zimbabwe, Ghana, Australia, Argentina, and Vietnam. Appr. 200 peer-reviewed publications in international journals. vii Preface to ”Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, Fertility” We are proud to present 14 papers that focus on teenager health in this Special Issue entitled “Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, and Fertility”. Maternal mortality is still globally high, and reducing it is a top priority. Teenage pregnancies have more complications and are also unwanted in many cases. This contributes to high maternal mortality with both obstetric complications and the burden of unsafe abortion. Additionally, many teenagers live in areas with heavy pollution that affect the mother and the unborn child. Global public health is a very important issue that aims to prevent disease, prolong life, and promote physical, mental, and social well-being. Teenagers are the future, and maternal death is a disaster that should be prevented. Hence, research should aim to improve teenage reproductive health and influence policy makers. There are a variety of topics on this issue, with some conclusions and ways forward as described in different papers. This book is meant to facilitate young scientists to develop studies and methodologies with the aim of improving teenage health, especially reproductive health on a global level. Young research, done by young people, for young people! Jon Øyvind Odland Special Issue Editor ix International Journal of Environmental Research and Public Health Editorial Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, Fertility Jon Øyvind Odland Department of Public Health and Nursing, Faculty of Health Sciences, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway; jon.o.odland@ntnu.no Received: 4 June 2018; Accepted: 4 June 2018; Published: 5 June 2018 We are proud to present 14 papers with focus on teenager health in this Special Issue entitled “Teenage Reproductive Health: Pregnancy, Contraception, Unsafe Abortion, Fertility”. Maternal mortality is still globally high and reducing it is a top priority. Teenage pregnancies have more complications and are also unwanted in many cases. This contributes to the high maternal mortality with both obstetric complications and burden of unsafe abortion. Additionally, many teenagers live in areas with heavy pollution that affects the mother and the unborn child. Global public health is a very important issue that aims to prevent disease, prolong life, and promote physical, mental and social well-being. Teenagers are the future, and maternal death is a disaster that should be prevented. Hence, research should aim to improve teenage reproductive health and influence policy makers. There are a variety of topics in this issue, with some conclusions and ways forward as described in different papers. Oppong-Darko et al. [ 1 ] describe the dilemma between religious beliefs and traditions and the conflict with reproductive health and abortion laws in Ghana, which is a typical low-income country (LMIC). They conclude that the midwives make it clear that unsafe abortions are common, stigmatizing and contributing to maternal mortality, which are issues that must be addressed. They introduce various suggestions to reduce this preventable tragedy. Grossman et al. [ 2 ] have a very interesting paper about parents’ conversations with their teenagers about reproductive health and risks in sexual behavior. It seems like once teens entered high school, more parents described feelings comfortable with their conversations. However, parents also more often reported that their teens responded more negatively to the communication in high school than they had in middle school. These findings may help parents to anticipate their own as well as their teens’ responses to family conversations about sex at different developmental time points and to strategize how to effectively talk with their teens about sex and relationships to improve their teens’ overall reproductive health. von Rosen et al. [ 3 ] describe how sexually transmitted infections (STIs) pose a significant threat to individual and public health. They disproportionately affect adolescents and young adults. In a cross-sectional study, they assessed self-rated and factual STI knowledge in a sample of 9th graders in 13 secondary schools in Berlin, Germany. Differences by age, gender, migrant background and school type were quantified. Knowledge of human immunodeficiency virus (HIV) was widespread, but other STIs were less known. Almost half of the participants had never heard of chlamydia, 10.8% knew the HPV vaccination, and only 2.2% were aware that no cure exists for HPV infection. While boys were more likely to describe their knowledge as good, there was no general gender superiority in factual knowledge. Overall, children of immigrants and students in the least academic schools had less knowledge. It seems that adolescents suffer from suboptimal levels of knowledge on STIs beyond HIV. Urgent efforts are needed to improve adolescent STI knowledge in order to improve the uptake of primary and secondary prevention. Ninsiima et al. [ 4 ] went deep into the gender aspect in developing countries with their report from Uganda and wrote a paper titled “Girls Have More Challenges; They Need to Be Locked Int. J. Environ. Res. Public Health 2018 , 15 , 1176; doi:10.3390/ijerph15061176 www.mdpi.com/journal/ijerph 1 Int. J. Environ. Res. Public Health 2018 , 15 , 1176 Up”: A Qualitative Study of Gender Norms and the Sexuality of Young Adolescents in Uganda. Unequal power and gender norms expose adolescent girls to high risks of HIV, early marriages, pregnancies and coerced sex. In Uganda, almost half of the girls below the age of 18 are already married or pregnant, which poses a danger to the lives of young girls. This study explores, in a very good way, the social construction of gender norms from early childhood, and how it influences adolescents’ agency. Adolescents’ agency appears constrained by context-specific obstacles. Programs targeting behavioral change need to begin early in the lives of young children. They should target teachers and parents about the values of gender equality and strengthen the legal system to create an enabling environment to address the health and wellbeing of adolescents. Pradhan et al. [ 5 ] published a paper titled Factors Associated with Pregnancy among Married Adolescents in Nepal: Secondary Analysis of the National Demographic and Health Surveys from 2001 to 2011. They still find higher risk associated with living in the least resourced region, early sexual debut, and older husband. Despite national efforts to reduce pregnancies among married adolescent women in Nepal, prevalence remains high. Integrated and cross-sectoral prevention efforts are urgently required. A reduction in poverty and an improvement in infrastructure may also lead to lower rates of adolescent pregnancy. Contributions to international health science from Russian authors are rapidly increasing. Usynina et al. [ 6 ] discuss adverse pregnancy outcomes among adolescents in Northwest Russia. The study is based on the upcoming and rapidly developing Arkhangelsk Birth Registry, aiming to assess whether adolescents have an increased risk of adverse pregnancy outcomes (APO), compared to adult women. Adolescents were more likely to be underweight, smoke, have infections of the kidney and the genital tract, compared to adult women. Compared to adults, adolescents were at lower risk of low birth weight, a 5 min Apgar score <7, and need for neonatal transfer. Adolescents had no increased risk of other APO studied in the adjusted analysis, suggesting that a constellation of other factors, but not young age per se, is associated with APO in the study setting. Lafontan el al. state that it is very simple and easy to use electronic baby monitoring in Tanzania [ 7 ]. They carried out semi-structured individual interviews post-labor at two hospitals in Tanzania. The results indicated that the use of the monitor positively affected the women’s birth experience. It provided much-needed reassurance about the wellbeing of the child. The women considered that wearing the Moyo improved care due to an increase in communication and attention from birth attendants. However, the women did not fully understand the purpose and function of the device and overestimated its capabilities. Scientific literature from Kazakhstan is increasing and improving. The paper from Dauletyarova et al. [ 8 ] discusses if Kazakhstani women are satisfied with antenatal care, implementing the WHO tool to assess the quality of antenatal services. Ninety percent of the women were satisfied with the antenatal care. Women who were dissatisfied had lower education. These women would have preferred more checkups, shorter intervals between checkups, more time with care providers and shorter waiting times. The overall dissatisfaction was associated with long waiting time and insufficient information on general health in pregnancy, results of laboratory tests, treatment during pregnancy and breastfeeding. Abortion policies are very important in teenager health in all parts of the world. Frederico et al. [ 9 ] discuss factors influencing abortion decision-making of young women in Mozambique. The study found determinants at different levels, including the low degree of autonomy for women, the limited availability of health facilities providing abortion services and a lack of patient-centeredness of health services. Strategies are suggested to increase knowledge of abortion rights and services, and to improve the quality and accessibility of abortion services in Mozambique. Tsikouras et al. [ 10 ] describe ten years of experience in contraception options for teenagers in a family planning center in Greece, comparing its situation with developing countries. They conclude that during adolescence, the existence of a family planning center and participation in family planning programs play a crucial role in helping the teenagers to improve their knowledge and choose an effective contraception method. This is a very important and general finding. 2 Int. J. Environ. Res. Public Health 2018 , 15 , 1176 Back in Africa, Odland et al. [ 11 ] discuss a serious reduction of the use of manual vacuum aspiration (MVA) in hospitals in Malawi. It is a cheap and safe method, included in national strategies, but with variable use in daily routines. However, there was a major increase in MVA application at one district hospital, probably because of good education and dedicated leadership. Even with national guidelines, the implementation and follow up is highly depending on local engagement and leadership. Kemigisha et al. [ 12 ] deliver a very interesting report on adolescents’ sexual wellbeing in Southwestern Uganda. The objective of the study was to assess sexual wellbeing in a broad sense (i.e., body image, self-esteem, and gender equitable norms) and associated factors in young adolescents in Uganda. The study with 58% females was carried out in 2016. Self-esteem and body image scores were high in both genders, but girls had higher scores, compared to boys for all outcomes. A higher age and being sexually active were associated with lower scores on gender equitable norms. Gender equitable norms scores decreased with increased age of adolescents. Comprehensive and timely sexuality education programs focusing on gender differences and norms were recommended. Clarke et al. [ 13 ] have the only US study in the Special Issue. They discuss the histories of maltreated adolescents in treatment programs in Oregon, through a qualitative study. The results highlight the need for providing adolescent girls with reliable and practical information about risky sexual behavior and drug use from reliable and trustworthy helping professionals. Strategies for developing and maintaining trust and delivering specific content are important in all programs and their implementation. Finally, Sharma and Nam [ 14 ] describe the condom use at last sexual intercourse and its correlates among males and females aged 15–49 Years in Nepal. Being unmarried was the most important predictor of condom use among males. Higher education was associated with increased likelihood of condom use in females. However, mobility, having multiple sexual partners and HIV knowledge were not significant correlates of condom use in both sexes. A big difference was observed in the variance accounted for males and females; indicating use of condoms was poorly predicted by the variables included in the study among females. Condom use was more associated with sociodemographic factors than with sexual behaviors and HIV knowledge. There is a very important public health aspect in all the published papers in this Special Issue. Another good development is that young scientists are using the International Journal of Environmental Research and Public Health as a starting point in their career. All papers have been through a thorough review process, and many of them are now basis for the study towards academic degrees and introduction to further studies. Due to the age connection, young scientists are writing about health issues for young people. Let us hope for a new Special Issue soon, with contributions from other parts of the world. Teenagers have special health concerns in a very important transition period from child to adult. This is independent of geography, culture and religion. In total, this Special Issue provides very useful information for all parts of the world, even for those who are not presented in this nice collection of papers. References 1. Oppong-Darko, P.; Amponsa-Achiano, K.; Darj, E. “I Am Ready and Willing to Provide the Service. Though My Religion Frowns on Abortion”—Ghanaian Midwives’ Mixed Attitudes to Abortion Services: A Qualitative Study. Int. J. Environ. Res. Public Health 2017 , 14 , 1501. [CrossRef] [PubMed] 2. Grossman, J.M.; Jenkins, L.J.; Richer, A.M. Parents’ Perspectives on Family Sexuality. Communication from Middle School to High School. Int. J. Environ. Res. Public Health 2018 , 15 , 107. [CrossRef] [PubMed] 3. Von Rosen, F.T.; von Rosen, A.J.; Müller-Riemenschneider, F.; Damberg, I.; Tinnemann, P. STI Knowledge in Berlin Adolescents. Int. J. Environ. Res. Public Health 2018 , 15 , 110. [CrossRef] [PubMed] 4. Ninsiima, A.B.; Leye, E.; Michielsen, K.; Kemigisha, E.; Nyakato, V.N.; Coene, G. “Girls Have More Challenges; They Need to Be Locked Up”: A Qualitative Study of Gender Norms and the Sexuality of Young Adolescents in Uganda. Int. J. Environ. Res. Public Health 2018 , 15 , 193. [CrossRef] [PubMed] 3 Int. J. Environ. Res. Public Health 2018 , 15 , 1176 5. Pradhan, R.; Wynter, K.; Fisher, J. Factors Associated with Pregnancy among Married Adolescents in Nepal: Secondary Analysis of the National Demographic and Health Surveys from 2001 to 2011. Int. J. Environ. Res. Public Health 2018 , 15 , 229. [CrossRef] [PubMed] 6. Usynina, A.A.; Postoev, V.; Odland, J.Ø.; Grjibovski, A.M. Adverse Pregnancy Outcomes among Adolescents in Northwest Russia: A Population Registry-Based Study. Int. J. Environ. Res. Public Health 2018 , 15 , 261. [CrossRef] [PubMed] 7. Lafontan, S.R.; Sundby, J.; Ersdal, H.L.; Abeid, M.; Kidanto, H.L.; Mbekenga, C.K. “I Was Relieved to Know That My Baby Was Safe”: Women’s Attitudes and Perceptions on Using a New Electronic Fetal Heart Rate Monitor during Labor in Tanzania. Int. J. Environ. Res. Public Health 2018 , 15 , 302. [CrossRef] [PubMed] 8. Dauletyarova, M.A.; Semenova, Y.M.; Kaylubaeva, G.; Manabaeva, G.K.; Toktabayeva, B.; Zhelpakova, M.S.; Yurkovskaya, O.A.; Tlemissov, A.S.; Antonova, G.; Grjibovski, A.M. Are KazakhstaniWomen Satisfied with Antenatal Care? Implementing the WHO Tool to Assess the Quality of Antenatal Services. Int. J. Environ. Res. Public Health 2018 , 15 , 325. [CrossRef] [PubMed] 9. Frederico, M.; Michielsen, K.; Arnaldo, C.; Decat, P. Factors Influencing Abortion Decision-Making Processes among Young Women. Int. J. Environ. Res. Public Health 2018 , 15 , 329. [CrossRef] [PubMed] 10. Tsikouras, P.; Deuteraiou, D.; Bothou, A.; Anthoulaki, X.; Chalkidou, A.; Chatzimichael, E.; Gaitatzi, F.; Manav, B.; Koukouli, Z.; Zervoudis, S.; et al. Ten Years of Experience in Contraception Options for Teenagers in a Family Planning Center in Thrace and Review of the Literature. Int. J. Environ. Res. Public Health 2018 , 15 , 348. [CrossRef] [PubMed] 11. Odland, M.L.; Membe-Gadama, G.; Kafulafula, U.; Jacobsen, G.W.; Kumwenda, J.; Darj, E. The Use of Manual Vacuum Aspiration in the Treatment of Incomplete Abortions: A Descriptive Study from Three Public Hospitals in Malawi. Int. J. Environ. Res. Public Health 2018 , 15 , 370. [CrossRef] [PubMed] 12. Kemigisha, E.; Nyakato, V.N.; Bruce, K.; Ruzaaza, G.N.; Mlahagwa, W.; Ninsiima, A.B.; Coene, G.; Leye, E.; Michielsen, K. Adolescents’ Sexual Wellbeing in Southwestern Uganda: A Cross-Sectional Assessment of Body Image, Self-Esteem and Gender Equitable Norms. Int. J. Environ. Res. Public Health 2018 , 15 , 372. [CrossRef] [PubMed] 13. Clark, M.; Buchanan, R.; Leve, L.D. Young Women’s Perspectives of Their Adolescent Treatment Programs: A Qualitative Study. Int. J. Environ. Res. Public Health 2018 , 15 , 373. [CrossRef] [PubMed] 14. Sharma, B.; Nam, E.W. Condom Use at Last Sexual Intercourse and Its Correlates among Males and Females Aged 15–49 Years in Nepal. Int. J. Environ. Res. Public Health 2018 , 15 , 535. [CrossRef] [PubMed] © 2018 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/). 4 International Journal of Environmental Research and Public Health Article Condom Use at Last Sexual Intercourse and Its Correlates among Males and Females Aged 15–49 Years in Nepal Bimala Sharma 1,2 and Eun Woo Nam 1,2, * 1 Yonsei Global Health Center, Yonsei University, Wonju 03722, Korea; bimalasharma@gmail.com 2 Department of Health Administration, Graduate School, Yonsei University, Wonju 03722, Korea * Correspondence: ewnam@yonsei.ac.kr; Tel.: +82-33-760-2413; Fax: +82-33-762-9562 Received: 14 December 2017; Accepted: 13 March 2018; Published: 16 March 2018 Abstract: This study aimed to assess the prevalence and correlates of condom use at last sexual intercourse among people aged 15–49 years in Nepal. Secondary data analysis was performed using the Nepal Demographic and Health Survey 2011. The study was restricted to the respondents who reported ever having had sexual intercourse; 9843 females and 3017 males were included. Condom use was assessed by asking if respondents used condoms in their most recent sexual intercourse. Chi-square test and multivariate logistic regression analysis were performed using Complex Sample Analysis Procedure to adjust for sample weight and multistage sampling design. Overall, 7.6% of total, and 16.3% of males and 6.2% of females reported using condoms in their last sexual intercourse. Living in Far-Western region, age and wealth quintile were positively associated with condom use in both males and females. Being unmarried was the most important predictor of condom use among males. Higher education was associated with increased likelihood of condom use in females. However, mobility, having multiple sexual partners, and HIV knowledge were not significant correlates of condom use in both sexes. A big difference was observed in the variance accounted for males and females; indicating use of condoms is poorly predicted by the variables included in the study among females. Condom use was more associated with sociodemographic factors than with sexual behavior and HIV knowledge. Keywords: condom use; correlates; sociodemographic factors; gender; multiple sexual partners; HIV knowledge; Nepal 1. Introduction The shift towards later marriage in most countries has led to an increase in premarital sex. The prevalence of condom use has increased almost everywhere, but rates remain low in many developing countries [ 1 ]. Condoms, one method of family planning (FP), provide substantial protection against human immunodeficiency virus (HIV) infection [ 2 ]. Although the South Asian Region still has a low prevalence of HIV, the highest number of people with HIV outside Africa resides in India, a bordering country of Nepal. The importance of maintaining the low prevalence status in the region cannot be overemphasized [3]. Previous studies found that condom use was associated with a large number of community factors such as type of residence [ 4 , 5 ], socio-demographic factors such as age and sex [ 5 – 7 ], marital status [ 8 – 10 ], education [ 4 , 9 ], occupation [ 6 , 9 , 11 ], and economic status [ 1 , 5 , 7 ]. Previous studies show mixed evidences regarding the relationship between multiple sexual partners and condom use [ 11 , 12 ]. Greater knowledge of sexually transmitted infections (STIs) was also found to be associated with increased likelihood of condom use during the last sexual encounter [11]. Int. J. Environ. Res. Public Health 2018 , 15 , 535; doi:10.3390/ijerph15030535 www.mdpi.com/journal/ijerph 5 Int. J. Environ. Res. Public Health 2018 , 15 , 535 The potential for HIV infection is increasing with the changing social and economic environment in Nepal. Increasing internal and international migration of the population, modernization, and development of transportation and communication networks are creating more favorable environments for social interactions between people. This is providing the opportunity for pre-marital, extramarital, and unsafe sexual activity among them, thereby increasing their risk of acquiring HIV and unwanted pregnancies [ 13 – 16 ]. Different studies conducted among young people have reported that unsafe sexual behavior is prevalent and increasing [ 15 – 18 ]. In addition, extramarital sexual intercourse is also not uncommon among adult population in Nepal [ 19 , 20 ]. The vulnerability of HIV infection among low risk population such as wives is expected to increase, which might bridge the infection to the general population [ 21 ]. Condoms are effective in preventing both pregnancy and STI/HIV [ 22 ]. Condom use varies by marital status, with unmarried individuals more likely to use them while married couples tend to choose hormonal or permanent FP methods to prevent unwanted pregnancies [ 23 ]. However, as both populations, unmarried and married individuals may be at risk of STIs and HIV, promoting condom use among both groups is one of the recommended strategies for dual protection; and this was the basis for conceiving the study. The FP program is one of the priority programs of the Nepalese government. The Ministry of Health distributes condoms free of charge through all health facilities, including outreach clinics and Female Community Health Volunteers. However, their utilization seems low as compared to other birth spacing methods in Nepal [ 24 ]. Global trend analyses of sexual behavior recommend that public health interventions should address the broader determinants of sexual behavior, such as gender, poverty, and mobility, in addition to individual behavioral change [ 1 ]. Thus, a conceptual framework for action on the social determinants of health of the World Health Organization was considered to examine the factors associated with condom use in the study. This model highlights the importance of socioeconomic factors as determinants of behaviors [ 25 ]. Existing efforts to address HIV/STI vulnerability and risk in the population focus primarily on risk-taking behavior, and largely fail to address contextual issues that create and facilitate risky behavior and situations in Nepal [ 26 ]. Although existing literature shows that unsafe sexual practices conducive to transmitting HIV infection are prevalent, there is limited evidence regarding condom use among the general population. This study aimed to assess the prevalence and correlates of condom use at last sexual intercourse among males and females aged 15–49 years in Nepal. 2. Methods 2.1. Study Area, Study Design, and Sampling Nepal is a developing country in Southeast Asia with a human development index of 0.548, and a life expectancy of 69.6 years [ 27 ]. Geographically, the country is divided into three ecological belts: the Northern Range Mountain, the Mid-range Hill, and the Southern Range Terai (flat land). An analytical, cross-sectional study was conducted from the secondary data of the Nepal Demographic and Health Survey (NDHS) 2011. A publicly available dataset was obtained from the MEASURE DHS website [ 28 ]. The dataset was created by merging relevant information from the women’s questionnaire and the men’s questionnaire. The details of the questionnaire and procedures can be found in the website and survey report [28,29]. The NDHS used a multistage cluster sampling procedure for data collection. In the first stage, a total of 95 urban and 194 rural enumeration areas (wards in the village development committees and sub wards in the municipalities) were selected using a proportionate probability sampling method. In the second stage, households within each enumeration area (EA) were selected using systematic sampling technique. In this stage, 35 households in each urban EA and 40 households in each rural EA were randomly selected. The NDHS 2011 completed a survey of 12,674 females and 4121 males. The study was restricted to the respondents who reported ever having had a sexual encounter in the 6 Int. J. Environ. Res. Public Health 2018 , 15 , 535 past; 9843 females and 3017 males were selected for the analysis. Therefore, total sample size for the study was 12,860 individuals. 2.2. Measurement of Variables 2.2.1. Condom Use Condom use was measured by the question, “Was a condom used the last time you had sexual intercourse?” The responses were categorized as (i) “yes = 1” and (ii) “no= 0” for the analysis, as measured in previous studies [6,8,11]. 2.2.2. Explanatory Variables The explanatory variables are shown in Table 1. Ethnicity was categorized into three groups: upper caste (Hill Brahmin, Hill Chhetri, Terai Brahmin, and Terai Chhetri), lower caste (Hill Dalit and Terai Dalit), and others (all other recorded ethnicities) [ 30 ]. Economic status was evaluated by NDHS 2011 using principal component analysis of more than 40 assets as variables [ 31]. The calculated score was divided into 5 quintiles and provided in the NDHS dataset ranging from poorest to richest. Most of the other variables were categorized as they were measured by the NDHS 2011 [ 29 ]. HIV knowledge was measured using ten relevant questions selected from the NDHS survey questionnaire (Table A1). Correct responses were coded as “1” and incorrect or uncertain responses were coded as “0”. The items were summed to create an HIV knowledge score, with higher scores indicating more knowledge about HIV transmission and prevention [32]. 2.3. Data Analysis Methods The data were analyzed using SPSS version 24.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to describe the characteristics of the study population and the prevalence of condom use. The chi-square ( χ 2 ) test was used to analyze the association between the explanatory variables and condom use. Multivariable logistic regression analysis was conducted in a hierarchical order adapting the concept from a previous study using the NDHS 2011 [ 33 ]. Model 1 comprised community factors, model 2 included the factors of model 1 and sociodemographic factors, model 3 included the factors of model 2 and behavioral factors, and model 4 comprised the factors of model 3 and HIV knowledge. The analyses were conducted separately for males and females. Adjusted odds ratios (AORs), 95% confidence intervals (CIs), and p values were presented. The level of significance was set at 5%. Based on the sample weights, strata, and cluster given in the survey dataset, a Complex Sampling Plan File was prepared. All the analyses were performed using the Complex Sample Analysis procedure, which is recommended to adjust for sample weight and multistage sampling using the DHS data [34]. 2.4. Ethical Approval The NDHS 2011 was approved by the Nepal Health Research Council and Ethical Review Board of ICF Macro International. The dataset is completely anonymous and distributed in the public domain. Therefore, an independent ethical approval was not required. 3. Results Of a total of 12,860 respondents, 76.6% were females, 19.1% were in the age group of 25–29 years, and 93.9% respondents were married. Of the total number of participants, 41.1% had no formal schooling, 52.6% were involved in agriculture, and 17.0% respondents were from the poorest groups. In the study, 34.5% of the respondents were from the upper caste, and 84.6% were Hindus. The majority of the respondents were from the Terai region; 33.9% respondents were from Central development region; and 86.0% were from rural areas. In the last 12 months, 14.0% of the total respondents reported being away from home for more than one month. Of the total respondents, 12.3% had multiple sexual 7 Int. J. Environ. Res. Public Health 2018 , 15 , 535 partners in their lifetime. Lifetime multiple sexual partnership was 28.7% among currently unmarried and 11.2% among married. The mean HIV knowledge score was 7.5 out of a maximum of 10. The mean age at first sex was 17.8 years. During their last sexual intercourse, 7.6% of the respondents, 16.3% of males, and 6.2% of females used condoms with their partners (Table 1). Table 1. Sociodemographic Characteristics of the Study Population ( N = 12,860). Variables Number Percentage/Mean# Sex Male 3017 23.4 Female 9843 76.6 Age group (in years) 15–24 3151 24.9 25–29 2494 19.1 30–34 2142 16.8 35–39 2068 15.9 40–49 3005 23.3 Ethnicity Lower caste 1812 14.6 Others caste 5846 50.9 Uppers caste 5202 34.5 Religion Others 802 7.0 Buddha 1064 8.4 Hindu 10,994 84.6 Current marital Status Others 790 6.1 Married 12070 93.9 Education No education 5167 41.1 Primary 2559 20.0 Secondary 4030 30.9 Higher 1104 8.0 Occupation Did not work 2167 18.4 Skilled/unskilled manual 1368 10.7 Agriculture 6803 52.6 Service * 2522 18.3 Wealth quintile Poorest 2565 17.0 Poorer 2334 18.7 Middle 2399 21.0 Richer 2540 21.3 Richest 3022 21.9 Ecological region Mountain 2094 6.5 Hill 5000 39.8 Terai 5766 53.7 Development region Eastern 2971 23.6 Central 3065 33.9 Western 2292 20.6 Mid-western 2445 12.2 Far-western 2087 9.6 Type of residence Urban 3639 14.0 Rural 9221 86.0 Mobility No 7826 60.2 Yes 1821 14.0 Missing 3360 25.8 Multiple sexual partners ** Yes 1627 12.3 HIV knowledge Score Mean 11,009 7.5 Age at first sex Mean 12,756 17.8 Missing 1851 16.8 Condom use *** No 10,193 79.5 Yes 1106 7.6 Missing 1561 12.9 * Professional/technical/managerial; ** 28.7% among currently unmarried and 11.2% among married; *** 16.3% of males and 6.2% of females; #Percentage was adjusted for sample weight, multistage sampling and cluster weight. Thus, the percentage is not equal to unweighted count. 8 Int. J. Environ. Res. Public Health 2018 , 15 , 535 Table 2 shows the proportions of condom use by explanatory variables. Condom use at last sexual intercourse was more than double among males than among females (16.3% vs. 6.2%). The percentage of people using condoms was found decreased along with the increase in age, ranging from 14.0% in the age group of 15–24 years to 4% in the age group of 40–49 years. The highest proportion of condom use (11.3%) was found in the upper caste and the lowest (4.2%) in the lower caste. Condom use percentage was almost similar across different religious groups ranging from 7.6% among other religious group to 8.9% among Hindus. The percentage of people who used condoms at last sexual episode was 62.3% among respondents currently unmarried, and 7.3% among those married. The frequency of condom use was 3.2% in the no schooling group and 24.3% among the respondents with higher education. Similarly, the proportion of condom use was lowest (5.5%) among agricultural work