Global Leadership Training Programme in Africa 20142016
Activity Report of Field Research

Factors affecting hormonal contraceptive use and its association with HIV risky sexual
behaviors among women in Siaya, Kenya: a cross-sectional study
Hodaka Kosugi1

I.
•

Summary

English Summary

This is the activity report on my field work conducted in Kenya from January to May 2017 under the
Global Leadership Training Programme in Africa (GLTP) of the United Nations University Institute for
the Advanced Study of Sustainability (UNU-IAS).
The fieldwork was not only useful for my research but also helpful in deepening my understanding of lifeand culture in rural Kenya and obtaining practical experience. The GLTP enhanced both my academic
and practical skills. I believe that this experience will help me commit to the health and well-being ofpeople living in Africa through my career in the future.
The following is the abstract of my research.
Background: HIV infection remains a global health problem with 36.7 million people living with HIV
worldwide. Sub-Saharan Africa bears the greatest burden of the HIV epidemic, and about three-quartersof people living with HIV reside in this region. The main route of HIV transmission is via heterosexual
sex and women of reproductive age bear the brunt of the epidemic in sub-Saharan Africa.
Such women are also at risk of unwanted pregnancy. Appropriate contraceptive methods can prevent
unwanted pregnancies. Hormonal contraceptives are highly effective at preventing pregnancy but provide
no HIV protection. They even might put women at higher risk of HIV acquisition because of the inverse
relationship between condom and hormonal contraceptive use. Condoms must be used consistently toprevent HIV infection. Thus, dual protection, using condoms in combination with hormonal
contraceptives, is recommended.
Objectives: This study aims to examine the association between hormonal contraceptive use and HIVrisky sexual behaviors such as inconsistent condom use among hormonal contraceptive users and factors
associating with dual protection in areas with high HIV prevalence.

1 Master’s Student, Graduate School of Medicine, The University of Tokyo, Host University: University of Nairobi, School of

Public Health, Kenya, 9 January – 4 May 20171

Methods: I conducted a cross-sectional study among 834 women aged 18-49 years old in Siaya County,
Kenya. Siaya has the second highest HIV prevalence rate of 23.7% among all 47 counties. Trained female
research assistants interviewed each participant using a structured interview format. Then, I conducted amultiple logistic regression analysis to identify associations between hormonal contraceptive use andHIV-risky sexual behaviors and factors associating with dual protection.
Results: Hormonal contraceptive use was significantly associated with inconsistent condom use with
their partners among both ever-married women and never-married women, even in the HIV-prevalentsetting. Associated factors with dual protection included self-efficacy in using condoms, partner’s HIVpositive status, and risky sexual behaviors in the past 90 days.
The comprehensive result of this research will be published as a Master’s thesis in March 2018.

•

Japanese Summary

本稿は 2017 年 1 月から 5 月にかけて、国連大学サステナビリティ高等研究所の「アフリカでのグローバルリダーシップトレーニングプログラム (GLTP)」からの支援を受けて、ケニアで実施したフィールドワークの報告書である。
このフィールドワークは筆者の修士研究の一環として実施したが、データ収集のみでなくのケ
ニアの田舎の暮らしや文化を理解する上でも大変有意義なものとなった。また、フィールドワ
ークの実践により、研究能力やマネジメント能力が向上したと考えている。この経験を活かし、今後アフリカの人々の健康と豊かな生活に貢献していきたい。
以下は本研究の概要である。
【背景】サブサハラ・アフリカ地域は、HIV の感染が最も深刻な地域であり、異性間性交渉が主要な感染経路である。一方、同地域では望まない妊娠の防止を目的にホルモン投与避妊法(経口ピル、注射、インプラント等)が広く普及している。
ホルモン投与避妊法は、費用対効果の高い避妊法であるが、コンドームとは異なり、HIV 感染症を予防できない。先行研究では、ホルモン注射剤利用者の HIV 感染リスクが約 2 倍に上昇している。そこでホルモン投与避妊法は、利用者の望まない妊娠に対する危機意識を低下させ、コンドームを使用しない性交等の HIV 感染リスク行動を助長しているとの仮説を立てた。
ホルモン投与避妊法が利用者の免疫系に与える影響についての臨床研究は多く存在する。しかし、利用者の行動面への影響についてはほとんど知られていない。ケニアは、HIV 成人感染率
が 6%に達する一方、サブサハラ・アフリカ地域の中でも特にホルモン投与避妊法が普及している国である。
【目的】本調査では、ケニアにおけるホルモン投与避妊法の利用と HIV 感染リスク行動の関連、及び、ホルモン投与避妊法とコンドームの併用率（デュアル・プロテクション）について特定することを目的とする。
2

【方法】本調査では ケニア西部に位置するシアヤカウンティ内の 6 つの医療施設にて、生殖可
能年齢の女性 834 名に質問紙を用いた構造化面接を実施した。シアヤカウンティはケニア国内
で特に HIV の感染が深刻な地域である（HIV 成人感染率:23.7%）。多重ロジスティック回帰分
析を用いて、ホルモン投与避妊法と HIV 感染リスク行動の関連、コンドームとの併用との関連要因について分析を実施した。
【結果】HIV 感染が深刻な地域において、既婚女性、未婚女性共にホルモン投与避妊法と過去90 日間のコンドームの利用頻度は統計的に有意に関連していた。また、ホルモン投与避妊法とコンドームの併用は、コンドームの利用に関する自己効力感の他、パートナーの HIV ステータ
スや不特定多数との性交渉経験等の HIV リスク行動が有意に関連していた。
なお、本研究は筆者の修士論文として発表されるため、最終的な調査結果の発表は 2018 年
3 月になる見込みである。

II.
1.

Research Activity

Introduction

HIV infection is a global health problem with 36.7 million people living with HIV worldwide. SubSaharan Africa bears the greatest burden of the HIV epidemic, and about three-quarters of people living withHIV reside in this region (1). Women of reproductive age are at considerable risk of HIV infection in SubSaharan Africa, where the main route of HIV transmission is via heterosexual sex (2).
Such women are also at risk of unwanted pregnancy. Appropriate contraceptive methods canprevent unwanted pregnancies, improve maternal and child health, and enable women to pursue other life
goals (3). Hormonal contraceptive methods, such as oral contraceptive pills, injectable contraceptives, andimplants are highly effective at preventing pregnancy but offer no HIV protection (4). Hormonal
contraceptives can put women at higher risk of HIV acquisition, especially in high HIV-prevalence areas.
The rates of HIV acquisition were almost twice as high among women in HIV-serodiscordant partnerships
using injectables in seven African countries (5). Possible biological risk factors include changes in the
immune system, genital tract flora, and HIV receptors (6-8). However, little has been studied about
behavioral risk factors—the association between hormonal contraceptive use and risky sexual behaviors suchas inconsistent condom use in Sub-Saharan Africa, where HIV infection is prevalent.
This study, therefore, aims to examine the association between hormonal contraceptive use andHIV-risky sexual behaviors, such as inconsistent condom use, and factors associated with dual protection
among hormonal contraceptive users in areas with high HIV prevalence.
2.

Study Area

We conducted this study in Siaya County, Kenya (Figure. 1).
Kenya has one of the highest levels of hormonal contraceptive prevalence in sub-Saharan Africa
while being one of the most HIV-affected countries with HIV epidemic rates with an overall adultprevalence of 6.0% in 2013 (9,10).

3

Siaya County is one of 47 counties and is located along the shores of Lake Victoria in southwest
Kenya. It covers 2,530.5 square km and is home to 842,304 people (male–47%, female–53%). The
majority of the population (89%) is living in rural areas (11). It has a higher fertility rate of 5.5 children
per woman compared with the national average of 4.6 children per woman (12). Siaya has the second
highest HIV prevalence rate of 23.7% among all 47 counties after Homa Bay County of 25.7 %; the rate
among women is higher (25.3%) than that among men (21.8%). In 2013, almost 10,000 people were
newly infected with HIV in Siaya County alone (10).

Figure 1. Map of Siaya County

3.

Methods

This study was a cross-sectional study in public health facilities that provide family planning andother health services. I randomly selected six facilities from each administrative sub-County (Ugenya,
Ugunja, Alego-Usonga, Gem, Bondo and Rarieda) in Siaya County, Kenya (Figure 1). I chose the numberof participants from each target facility using probability proportional to size sampling, based on thenumber of women of reproductive age living in each sub-County.
Kenyan female research assistants conducted interviews with 834 women of reproductive age(18-49 years old) who were sexually active (Figure 2). The interview was based on a structured
questionnaire. It included questions about demographic characteristics, contraceptive use, and sexual
behaviors in the past 90 days, condom use self-efficacy scale and other social and behavioral
characteristics. Each interview was taken in a confidential environment after obtaining written informed
consent in the selected facilities. Each interview took approximately 30 minutes.
4Inclusion criteria•Sexually active women aged 18 to 49 who
reported to have had sexual intercourse at least
once within 30 days before the time of interview
Exclusion criteria•Women who started using hormonal
contraceptives for the first time within 90 days
before the time of interview•Women who had previously used hormonal
contraceptives but stopped using them within 90
days before the time of interview

Figure 2. Sampling methods

Multiple logistic regression analysis was conducted to identify associations between hormonal
contraceptive use and HIV-risky sexual behaviors and factors associated with dual protection.
Observational study
I also observed family planning (FP) services and conducted informal interviews with staff and
FP clients at several public health facilities and communities. Insights obtained from observation aresupposed to be reflected on the final result.

Health talk about FP by community health workers

4.

Client receiving implants

Research Findings

Socio-demographic characteristics
Of the 1096 women who were approached in the clinics, 834 met the inclusion criteria. One did notcomplete the interview. I excluded from the analysis 260 who were previously diagnosed as HIV positiveand 60 who were pregnant at the time of the interview (Figure 2). Four-fifths (80.9%) were Luo and 16.4%
were Luhya. Most of them were Protestant or other Christian (76.6%) and 23.2% were Catholic. The mean
5age was 27.6 years old (SD: 7.4). The majority (86.0%) were or had been married. Almost all (94.4%) had
delivered at least one child.
Figure 3. Contraceptive method used in the past 90
days (n=407）

Contraceptive use
Among 513 participants, 407 (79.3%)
used some kinds of contraceptive methods
including condoms at least once in the past 90
days (Figure 3). Among ever-married women,
339 (76.9%) reported contraceptive use and 289(65.5%) used non-barrier modern contraceptives
including hormonal contraceptives and female
sterilization in the past 90 days. Among the 72
never-married women, on the other hand, nearlyall (94.4%) reported contraceptive use but lessthan half (43.1%) reported having used nonbarrier modern contraceptives in the past 90
days.

0

100

200

300

400

Any nonbarrier modern…
Pill
Intrauterine device
Injectable
Implant
Female sterilization
Barrier method
Male condom
Female condom
Traditional…

Dual protection was practiced by 10.2%of ever-married women and by 26.4 % of nevermarried women at least once in the past 90 days.
Figure 4 represents methods used for dual
protection. However, only 3.4% and 8.3% usedcondoms consistently in the past 90 days among
ever-married women and never-married women
respectively (Figure 5, 6). Also, 26 of the married
women had non-regular partners, and dual method
use among them was relatively high at 30.8%, butalso only 11.5% used condoms consistently.

Figure 4. Types of dual methods (n=64)

Condom and pill
Condom and intrauterine
deviceCondom and injectable
Condom and implant
Condom and female
sterilization
0

10

20

30

40

Figure 6. Contraceptive use among single women (n=72)
In the past 90 days

5.6

51.4

9.7

Last sex

47.2
22.2

Every sex
0%

26.4

10%

20.8
34.7

20%

Non-use/traditional methods

16.7

30%

Condom only

40%

8.3
50%

Dual-methods

60%

22.2
34.7

70%

80%

90%

100%

Non-barrier modern methods

6Association between non-barrier modern contraceptive use and inconsistent condom use
In multivariate analysis, non-barrier modern contraceptive use was significantly associated withinconsistent condom use among both ever-married women (the adjusted odds ratios [AOR], 0.25; 95%
confidence interval [CI] 0.09-0.52; P<0.001) and never-married women (AOR 0.15; CI 0.05-0.46; P=0.001)
after adjusting for socio-demographic factors and partner’s HIV status. However, it was not significantly
associated with inconsistent condom use with non-regular partners among married women (AOR 0.67; CI
0.11-4.17; P=0.665).
Factors associating with dual protection
Associated factors with dual protection included self-efficacy in using condoms, partner’s HIVpositive status and risky sexual behaviors (exchanging sex for money and multiple sex partnership) in thepast 90 days after adjusting for socio-demographic factors and partner’s HIV status.
5.

Discussion

Inconsistent condom use was significantly associated with non-barrier modern contraceptive use
among both ever-married and never-married women. However, it was not significantly associated withinconsistent condom use with their casual partners among married women. As a result, dual protection waspracticed by only 3.4% of ever-married women and 9.4% of never-married women consistently over the 90
days. Especially among ever-married women, condom use was limited, and more than 9 out of 10 had
unprotected sex in the past 90 days. In Kenya, more than 90% of new HIV infections occur through sex,
and 44.1% of new cases happen among married couples (10). Therefore, consistent condom use among
hormonal contraceptive users must be promoted in HIV-prevalent settings such as Kenya.
Associated factors with dual protection included self-efficacy in using condoms, partner’s HIVpositive status, never-married marital status. Dual protection was also significantly associated with risky
sexual behaviors such as multiple sex partnership and exchange of sex for money. It suggests that dual
protection was probably adopted as a protection against HIV infection or unwanted pregnancy, although
HIV risk perception and HIV knowledge were not significantly associated with dual protection practice.
6.

Conclusion

This study found that hormonal contraceptives can be associated with inconsistent condom use withpartners in HIV-prevalent settings. Dual protection was practiced by 10.2% of ever-married women and by
26.4% of never-married women at least once, but only one-third of them used condoms consistently with
their partners in the previous 90 days. As a result, only 10.3% of married women used dual protection orcondoms consistently. In sub-Saharan Africa, new HIV infections dominantly occur through unprotected
sex and new infections among married couples are high. To avoid HIV infection, condoms must be usedduring every sexual intercourse. Therefore, promoting condom use among hormonal contraceptive users
must be a very urgent agenda in HIV-prevalent settings such as Kenya.
Acknowledgement

This fieldwork was financially supported by Global Leadership Training Program (GLTP) of theUnited Nations University Institute for the Advanced Study of Sustainability (UNU-IAS). I would like toexpress my gratitude to Ms. Kana Miyamoto, Ms. Rieko Sato, Dr. Shuntaro Nozawa, Dr. Natsuko Imai, andProf. Saito Osamu. I am also deeply grateful to my Kenyan supervisor Dr. Sam Wafula, School of Public
Health, University of Nairobi for the insightful technical support I received from him. I cannot express my7

gratitude enough to my six research assistants, Dr. Ino Jonathan, sub-County Medical officer, and the staffof Ugenya sub-County Medical Office of Health. I also would like to express my deep gratitude to all theparticipants. Thanks to their support and cooperation, I could complete this fieldwork.

III.
1.

Reflection to the GLTP in Africa

My motivation to participate in the GLTP

I applied for the GLTP because I was interested in health and well-being of people living in
Africa and believed fieldwork would be the best way to deepen my insight into my study topic for my
Master’s research and get firsthand experience of conducting research in Africa. I also believed I could
improve my research skills as well as other competencies through participating in this kind of training
programme.
2.

Field experiences

The study site was where I had worked as a JICA volunteer from 2014 to 2016, and my excolleagues of the public health office gave me support for conducting my research.
I spent the first week in Nairobi discussing the study proposal and receiving feedback from mylocal supervisor, Dr. Sam Wafula, at the University of Nairobi and applying for ethical clearance from thegovernment of Kenya. After the first week, I spent most of my time in the study site, Siaya County, while
I visited my supervisor monthly and communicated with him through email and over the phone.
As I collected data in six different locations, I traveled frequently and stayed in several towns forthe first time. It enabled me to interact with local people without time constraints. I was sometimes
invited to dinner and to events such as weddings and funerals, which enabled me to observe local culture
in diverse ways. During data collection at hospitals, research assistants interviewed women visiting the
hospitals. I was normally at the study site with them, and I enjoyed chatting with many local people andinteracting with rural communities.
Unfortunately, there were not many opportunities to interact with students of the host university,
as all public universities in Kenya were on strike most of the time; however, I could present my initialresearch findings to faculty staff and receive feedback. Also, I could present it to public health officers inthe study. Through my four-month stay in Kenya, I really enriched my network with health professionals
and researchers in Kenya.

With study participants

Data analysis with research assistants
8With a community health worker

3.

Chatting with children

Challenges

It was my first field work outside of Japan; thus, I faced several challenges. However, they werealso opportunities for me to develop the capability to manage difficulties and carry out research indifficult situations. One was an unexpected delay in getting a research permit from the government of
Kenya. I waited for two months. I should not have believed what officers told me on the phone, and I
should have visited the office to confirm the progress earlier, which was what I learnt from thisexperience. My local supervisor helped me a lot to solve this issue.
Also, I was responsible for my research; thus, many things were different from when I worked asa JICA volunteer. Sometimes, I felt pressured to finish data collection by the end of term. I sometimes
quarreled with research assistants who did not show up on time. I think this problem would not have
happened if I had controlled myself and communicated with them well. I built good relationships withthem and quarrels turned out to be a good opportunity to understand each other. I learned to control
myself even when I am under pressure.
4.

How to make use of this experience to your future career development

Thanks to participating in the GLTP, I can confirm that I am truly interested in public healthissues, especially in Africa. I believe that the experience in Kenya as a researcher will contribute toimproving my academic and professional skills in my future career. I am currently seeking opportunities
to work in Africa as a public health specialist after finishing my master’s programme next year. I want tocontribute to the health and well-being of people in African countries using this experience.
5.

Encouragement to other students

I found the GLTP was a unique program, and I can recommend it to other students for thefollowing reasons. First, it not only supports their research financially but also from many aspects. For
instance, they can receive support and insightful feedback from the local supervisor and build connections
with researchers from the recipient university. Without support from the GLTP, I would have had tospend a lot of time and effort to find a local collaborator by myself. They might be required to conduct
research with a local collaborator in many African countries. They can also present their research to the
public and get valuable feedback from researchers of the United Nations University and otherparticipants. Finally, the GLTP will enable them to communicate with other students with different

9backgrounds. They can communicate and exchange information about fieldwork with students from otheruniversities who are going to conduct research in the same country, which might be very helpful.
I hope GLTP trainees in subsequent years will also have valuable experiences in their fieldwork
in Africa and improve their skills in their research fields.



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