Journal of Health Promotion and Behavior (2017), 2(1): 88-97 https://doi.org/10.26911/thejhpb.2017.02.01.08 Biopsychosocial and Economic Determinants of Condom Use among Gay in Tulungagung District,

Fransisca Novalia Permana1), Argyo Demartoto2), Bhisma Murti1)

1)Masters Program in Public Health, Sebelas Maret University, Surakarta 2)Study Program in Sociology, Faculty of Social and Political Sciences, Sebelas Maret University, Surakarta

ABSTRACT

Background: HIV/ AIDS epidemics emerged among men who have sex with men, particularly among gay, due to unsafe anal sex practice. As studies have shown having sex without condom increases the risk of HIV/ AIDS 18 times as many as per-vaginal sex. This study aimed to examine biopsychosocial and economic determinants of condom use among gay in Tulungagung district, East Java. Subjects dan Method: This was an analytic observational study using cross-sectional design. The study was conducted in Tulungagung district, East Java, from January to February 2017. A sample of 165 gays was selected by random sampling out of all 300 gays in the community. The independent variables were perceived susceptibility, perceived seriousness, perceived benefit, perceived barrier, and self- efficacy. The dependent variable was condom use. The data were collected by a set of pre-tested questionnaire, and analyzed by multiple logistic regression. Results: Perceived seriousness (OR=2.83; 95% CI=1.14 to 7.04; p=0.025), perceived benefit (OR= 4.90; 95% CI=2.11 to 11.36; p<0.001), self-efficacy (OR=4.48; 95% CI=2.03 to 9.89; p<0.001), increased the likelihood of condom use. Perceived susceptibility (OR= 1.02; 95% CI=0.40 to 2.59; p=0.972) increased the likelihood of condom use, although it was not statistically significant. Perceived barrier (OR= 0.36; 95% CI=0.13 to 1.00; p=0.050) decreased the likelihood of condom use, and it was statistically significant. Conclusion: Perceived seriousness, perceived benefit, and self- efficacy, increased the likelihood of condom use among gay. Perceived barrier decreased the likelihood of condom use.

Keywords: biopsychosocial, determinant, condom use, HIV/ AIDS, Gay

Correspondence: Fransisca Novalia Permana. Masters Program in Public Health, Sebelas Maret University, Surakarta. Email: [email protected]. Mobile: +6285645762007.

BACKGROUND demic, the disease was likely to be hetero- HIV/ AIDS at present is becoming serious sexually identified, however the current da- global health problem (WHO, 2015). HIV ta shows that in developing countries, ho- or Human Immuno Deficiency Virus is a mosexual, that is men who have sex with virus destroying white blood cell within men, is likely to cause more transmission of human body. Whereas AIDS or Acquired HIV (Amirkhanian et al, 2010). In 2015 it Immune Deficiency Syndrome is a series of was estimated 3.5 million people who were illnesses which are generated by HIV (Ke- infected with HIV in Asia. (WHO, 2015). In menkes RI, 2014; WHO, 2016). South East Asia HIV prevalence on men In 2015 there were 36.7 million who who have sex with men (MSM) is escalating were infected with HIV globally, and 2.1 rapidly with Thailand at the first rank (UN- million people became newly infected with AIDS, 2008). HIV (WHO, 2015). Initial stage of the epi-

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Since HIV has been found in 1987 up ten transmits HIV/AIDS through oral and to present day, the number of sufferers is anal sex (Liu et al, 2012). Anal sex without getting escalating. The cumulative number condom is 18 times more likely to transmit of HIV infection that had been reported up HIV than vaginal sex, either among gay to 2016 was 198,219 HIV infection cases men or heterosexual couples. Condom with Special Capital Region of Jakarta (40, which is properly and consistently used is 500) at the top chart, followed by East Java very effective in preventing HIV and Sexual (26,052) and Papua (21,474). The majority Transmitted Disease (STD) (WHO, 2009). HIV transmission risk factors were hetero- Target of condom use promotion is sexually (51,692), IDUs (8,835), MSM (2, not only common people, but also people 304), mother-to-child (2,226), bisexual who are in high risk of being exposed by (399), and blood transfusion (201). The HIV such as sex workers and their cus- most AIDS cases was in East Java (13,623) tomers, IDUs, gay men, and transvestites followed with Papua (13,328) and Special (UNAIDS, 2004). Factor of inconsistent Capital Region of Jakarta (8,093) (Kemen- condom use among gay men has been sta- kes RI, 2016). ted as an obstacle, similar to the knowledge In East Java the highest number of on HIV/AIDS transmission and the absence people who were infected with HIV was in of support from sexual partners (Rama- (7,045), (2,693), Jember nathan et al., 2013). (2,489), Banyuwangi (2,379) and Tulung- Some gay men in China decided to agung (1,465) (Dinkes Jatim, 2015). Based commit suicide if they happen to get infect- on preliminary study conducted in Tulung- ed with HIV/AIDS, it became a motivation agung in November 2016 from the last data to use condom during sexual intercourse of September 2016 the number of HIV/ (Liu et al., 2012). There is perceived vulne- AIDS cases was 1,480 with number of men rability that is a gay man use condom as an was 55.13% and women was 44.87%. The effort to reduce the vulnerability toward HIV cases in Tulungagung mostly caused by HIV (Belcher et al, 2005). It is supported by female sex workers (511), men who have sex perceived severity, by using condom even with men (MSM) which was gay men (31), using double condoms whenever they belie- transvestites (18), IDUs (18), perinatal (30), ve their sexual partner is not safe or has and others 872 cases. HIV cases in Tulung- been infected with HIV/AIDS or looks dirty agung keeps on escalating and be- (Liu et al., 2012). coming major problem that should be over- Harawa et al (2006), states that con- come, including HIV cases among gay men dom use by gay men is determined by sub- in Tulungagung Regency (KPA Kabupaten jective perception on the advantages and Tulungagung, 2016). disadvantages of condom use. Researchers The reasons of recurrence of HIV epi- studied the biopsychosocial economic de- demic among gay men include high level of terminant among gay men by using Health unprotected sexual behavior that involves Belief Model Theory. The study aimed to people who do not know about their infec- explain the influence of biopsychosocial tion status and do not take any medicine. economic determinant toward condom use Unprotected sexual behavior is using no among gay men in Tulungagung Regency. condom during anal sex that involves men with undiagnosed HIV/ AIDS (Spiritia, 2012). Sexual behavior among gay men of- e-ISSN: 2549-1172 (online) 89 Journal of Health Promotion and Behavior (2017), 2(1): 88-97 https://doi.org/10.26911/thejhpb.2017.02.01.08

SUBJECTS AND METHOD intention of the research, anonymity that 1. Research Design was without mentioning the name of re- The study design used in this study was search subject, confidentiality which meant analytic observational with cross sectional keeping the information given by research approach. The study was conducted in Ja- subjects restricted. nuary and February 2017 in Tulungagung 4. Data analysis Regency Data processing was conducted by using 2. Population and Sample editing technique which meant reexamine The population in general was the entire the instruments filled out by research sub- gay men, whereas targeted population was jects, scoring was giving value on each the members of Pelangi gay community question item and sum up them up, data that consisted of 300 people which is limit- coding was giving code to research data for ed by inclusion and exclusion criteria. statistic analysis, data entry was putting the There were a total of 165 subjects data out of the questionnaires into com- which were selected by probability samp- puter in accordance with statistics data, ling technique with simple random samp- tabulating was data processing that aimed to make table that may give statistics illus- ling type. The data collection technique used was questionnaires and the data pro- tration. cessing used was multiple logistic regres- Data analysis technique consisted of sion. univariate analysis that aimed to explain 3. Variables Research characteristics of each data. Bivariate ana- Independent variables of the study were lysis aimed to analyze the relationship of perceived vulnerability, perceived severity, two variables using chi square test with 2x2 perceived benefits, perceived obstacles and contingency table to discover how big the self efficacy. Independent variable was con- influence of dependent over independent. dom use. Multivariate analysis with multiple logistic Data collection was conducted in ob- regressions aimed to measure the influence servation by using questionnaires. It con- of more than one independent variables sisted of favorable and unfavorable ques- toward dependent variable. The intensity of tions that had been through face validity association was presented by the value of and content validity and reliability test of OR and CI. alpha cronbach ≥ 0.60. Variables in the study were perceived RESULTS vulnerability (0= not vulnerable, 1= vulner- Characteristics of research subjects in Table able), perceived severity (0=not severe, 1= 1 were the result of univariate analysis. severe), perceived benefits (0= not benefi- Data in Table 1 showed that out of 165 re- cial, 1= beneficial), perceived obstacles (0= search subjects half of them were between with obstacles, 1= without obstacles), self 20-35 years which was as many as 98 efficacy (0= poor self efficacy, 1= strong self people (59.39%), those who were <20 years efficacy), condom use (0= not always, 1= were 65 (39.39%), whereas >35 tahun were always). 2 (1.21%). Based on education, the obtained The researchers considered the re- data showed that half of the research search ethics, namely the distribution of subjects‘ education was ≥High School which inform consent, which meant an approval was as many as 155 people (93.9) whereas sheet given to research subjects to know the there were 10 (6.1) whose education

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School. Based on occupation, the obtained the data was obtained that almost all data showed that most of the research research subjects had income

Table 1. Characteristics of Research Subjects Characteristics Criteria n % Age <20 years 65 39.4 20-35 years 98 59.4 >35 years 2 1.2 Education

Table 2. Bivariate analysis on independent variables with dependent variable Condom Use CI (95%) Variables Criteria OR Lower Upper p No (%) Yes (%) Limit Limit Not 65 (50.0%) 65 (50.0%) 0.67 0.31 1.42 0.293 Perceived vulnerable Vulnerability Vulnerable 14 (40.0%) 21 (60.0%)

Not Serious 35 (72.9%) 13 (27.1%) 0.22 0.11 0.47 <0.001 Perceived Serious 44 (37.6%) 73 (62.4%) Severity

Not 63 (59.4%) 43 (40.6%) 0.25 0.13 0.51 <0.001 Perceived Beneficial Benefits Beneficial 16 (27.1%) 43 (72.9%)

With 72 (55.0%) 59 (45.0%) 4.71 1.91 11.57 <0.001 obstacles Perceived Without 7 (20.6%) 27 (79.4%) Obstacles Obstacles

Poor Self 55 (68.8%) 25 (31.3%) 0.18 0.92 0.35 <0.001 Efficacy Self Efficacy Strong Self 24 (28.2%) 61 (71.8%) Efficacy

Gay men who had perceived vulnera- to use condom than those who did not have bility toward disease were 0.67 times likely perceived vulnerability toward disease. The e-ISSN: 2549-1172 (online) 91 Journal of Health Promotion and Behavior (2017), 2(1): 88-97 https://doi.org/10.26911/thejhpb.2017.02.01.08 result (p= 0.010) meant there was no influ- Gay men who had perceived obstacles ence of gay men‘s perceived vulnerability were 4.71 times likely to use condom than toward condom use. those who did not have perceived obstacles. Gay men who had perceived serious- The result (p<0.001) meant that there was ness toward disease were 0.22 times likely influence of gay men‘s perceived obstacles to use condom than those who did not have toward condom use. perceived seriousness toward disease. The Gay men who had strong self efficacy result (p <0.001) meant there was influence toward condom were 0.18 times likely to of gay men‘s perceived seriousness toward use condom than those who had poor self condom use. efficacy. The result (p<0.001) meant that Gay men who had perceived benefits there was influence of gay men‘s self effi- were 0.25 times likely to use condom than cacy toward condom use. those who did not have perceived benefits. Table 3 was data of multivariate ana- The result (p<0.001) meant that there was lysis on some variables related with depen- influence of gay men‘s perceived benefits dent variable. toward condom use

Table 3 The result of multivariate analysis with multiple logistic regression CI 95% Variables OR p Lower Limit Upper Limit Perceived vulnerability (high) 1.02 0.40 2.59 0.972 Perceived severity (high) 2.83 1.14 7.04 0.025 Perceived benefits (high) 4.90 2.11 11.36 <0.001 Perceived obstacles (high) 0.36 0.13 1.00 0.050 Self Efficacy (strong) 4.48 2.03 9.89 <0.001 N observation 165 -2 log likelihood 172.136 Nagelkerke R2 38.6%

Table 3 explained the result of multivariate condom on gay men and statistically signi- analysis between independent variables to- ficant. ward dependent variable such as perceived vulnerability (OR= 1.02; CI 95%= 0.40- DISCUSSION 2.59; p= 0.972) increased the use of con- 1. The Influence of Perceived Vulne- dom on gay men although statistically in- rability toward condom use among significant. Perceived severity (OR= 2.83; gay men CI 95%= 1.14-7.04; p= 0.025) increased the Perceived vulnerability does not influence condom use on gay men and statistically the use of condom among gay. Members of insignificant. Perceived benefits (OR= 4.90; the community were more concerned with CI 95%= 2.11-11.36;p<0.001) increased the their own and their partners‘ pleasure when condom use on gay men and statistically having sexual intercourse by frequently not significant. Perceived obstacles (OR= 0.6; using condom. Although we they had un- CI 95%= 0.13-1.00; p=0.050) decreased the derstood that they would be vulnerable to use of condom on gay men and statistically sexual transmitted diseases as well as HIV/ significant. Self efficacy (OR= 4.48; CI 95% AIDS if they did not use condom. The = 2.03-9.89; p<0.001) increased the use of strong attraction to their permanent part- ners who they believed were not infected

92 e-ISSN: 2549-1172 (online) Permana et al./ Biopsychosocial and Economic Determinants of Condom Use with HIV/ AIDS led them to seldom use bers of community to use condom consis- condom when they had sex. The thought if tently despite the pleasure of sex without they were infected with HIV, the medicine condom. was available and could be accessed in Perceived severity is an individual hospitals or clinics so that they still could belief on disease severity or seriousness. It prolong their life expectation. is based on health information or know- Rosenstock (1988), states perceived ledge that may come from the difficulties of vulnerability in Health Belief Model is one the disease which gives impact to our life of the factors that encourage someone to (McCormick-Brown, 1999). lead healthy life. The study is similar with Satyabakti The study is in accordance with a stu- (2016), that states HIV/ AIDS is a danger- dy conducted by McDaid et al (2010), that ous disease. As gay, they often change sex the government, civil society organization partner and do not use condom consistent- have attempted to give information about ly, it leads them to be at high risk for HIV/ HIV prevention and transmission by means AIDS. This perception generates the feeling of print media, radio, television, as well as of threatened and fear of being infected, coaching with skilful cadres. However there thus influences gay men to use condom are a lot of participants who do not attend during sexual intercourse. and are not yet well-informed so that it is Eda et al (2012), states that perceived possible that the use of condom by gay men severity of HIV/ AIDS will affect someone is still low. Enggarwati (2015), states that in doing prevention effort since they think the more someone is at risk for a disease, it is better to prevent than to get infected does not necessarily make one conduct with incurable disease. prevention action. Different study conducted by Siahaan The study is unlike the study by Bel- (2009), states that many of gay men al- cher et al (2005), that conveys a gay man ready discover the effect of not using con- who uses condom is as an effort to reduce dom that is they may get infected with HIV/ the vulnerability to HIV AIDS and other sexual diseases that need 2. The influence of perceived severity complicated medication and therapy. HIV/ toward condom use among gay AIDS is incurable, there is no medicine yet men for it. However it does not make gay men Perceived severity influences the use of use condom for they concern more on the condom. The community understood that fulfillment of needs for varied sexual activi- HIV/AIDS can be transmitted through high ties and strong intention to mutually satisfy risk sexual behavior and it may lead to without using condom. Enggarwati (2015), death. Someone who suffers from HIV/ mentions that the level of severity of the AIDS will be excommunicated by family, disease toward either the disease it self and society, and friends because general people financial condition in terms of treatment do not know appropriately how HIV/AIDS cost, does not make gay men change their is transmitted. They only know that if sexual behavior, their satisfaction makes someone suffers from HIV/AIDS means them accept their fate with HIV/AIDS. they should avoid the person since it is contagious and may lead to death. When the feeling of afraid to be excommunicated comes to mind, it will encourage the mem- e-ISSN: 2549-1172 (online) 93 Journal of Health Promotion and Behavior (2017), 2(1): 88-97 https://doi.org/10.26911/thejhpb.2017.02.01.08

3. The influence of perceived benefits condom as the means to prevent HIV/AIDS toward condom use among gay infection. men. 4. The influence of perceived obstac- Perceived benefits influence the use of con- les toward condom use among gay dom among gay men. Pelangi Community men understood the benefits if using condom to Perceived obstacles have influence toward protect themselves from sexual transmitted the use of condom. Pelangi Community had disease such as HIV/ AIDS. Sometimes they sexual behavior which is at high risk for believed that condom they used did not leak being infected with HIV/ AIDS. By using and was able to protect their sexual organ condom will be able to prevent from being from HIV/ AIDS when cuts and blisters oc- infected since condom limits skin to skin cured during sexual intercourse. Mean- contact that reduce pleasure of sexual inter- while, they always got free condom from course. They always get free condom and Tulungagung Regional AIDS Countermea- lubricant from the government which are sure Commission and they used it because distributed to the community they believed that their sexual partner was Rosenstock (1988), states that perceiv- infected with HIV/AIDS and felt protected ed obstacles is a determinant of behavioral when they used condom. change in order for the new behavior to get People are likely to adopt healthy be- adopted. People needs to believe that bene- havior when they believe the new behavior fits of new behavior is more than the old will reduce their possibility to get infected one. with a disease. People will not use condom Downing (2010), states that there is a if they do not believe the benefits of con- relationship between perceived obstacles dom to prevent from being infected with and condom use. Sexual activity which is HIV through sexual intercourse (Belcher et conducted freely and at risk, is derived from al., 2005). lust and addiction followed by sexual arou-

The study is in accordance with Sirait sal phase to get sexual satisfaction. Gay men et al (2013), that states there is significant do not concern about the risk of getting in- relationship between perceive benefits and fected with STD and HIV/AIDS. preventive behavior. The better one‘s posi- The study by Harawa et al (2006), tive perception is toward HIV/ AIDS pre- states that the obstacles in using condom ventive behavior, the bigger possibility to give bigger influence on the preventive be- do the behavior. Study by Satyabakti (2016), havior than threat of the disease it self. The states that gay men are able to prevent and obstacles are reducing the pleasure of sexual feel protected when they use condom dur- intercourse and being accused of having ing sexual intercourse. sexual transmitted disease. The other study by Padang (2012), Different study conducted by Priyoto showed that there is no relationship bet- (2014), states that an action is possible to ween perceived benefits and the use of con- be taken despite the individual‘s belief to- dom among gay men. They are reluctant to ward the advantage of taking the action. use it during sexual intercourse. It is be- They have had the skills to negotiate with cause the existence of dominant factors of their partner that using condom will still sexual satisfaction fulfillment, emotional lead to satisfaction and their partners are satisfaction, inconvenient, and stigma over convinced to use condom during sexual in- tercourse.

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5. The influence of self efficacy to- change the behavior of gay men who are ward condom use among gay men fond of high risk sexual activities. The efficacy influences the condom use. In Different study conducted by Aditya Pelangi Community almost all members (2012), that states the ability to use condom could use condom appropriately. The infor- does not influence the use of condom. Gay mation was obtained from the socialization man who is less proficient in negotiating for the appropriate use of condom from with his partner make him does not use

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