Reproductive health and HIV awareness among newly married Egyptian couples without formal education

Reproductive health and HIV awareness among newly married Egyptian couples without formal education

    Reproductive health and HIV awareness among newly married Egyptian couples without formal education Wael F. Saleh, Sameh F. Gamaleldi...

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    Reproductive health and HIV awareness among newly married Egyptian couples without formal education Wael F. Saleh, Sameh F. Gamaleldin, Hatem I. Abdelmoty, Ayman N. Raslan, Usama M. Fouda, Mohamed N. Mohesen, Mohamed A.F.M. Youssef PII: DOI: Reference:

S0020-7292(14)00244-6 doi: 10.1016/j.ijgo.2014.02.027 IJG 7978

To appear in:

International Journal of Gynecology and Obstetrics

Received date: Revised date: Accepted date:

7 November 2013 24 February 2014 8 May 2014

Please cite this article as: Saleh Wael F., Gamaleldin Sameh F., Abdelmoty Hatem I., Raslan Ayman N., Fouda Usama M., Mohesen Mohamed N., Youssef Mohamed A.F.M., Reproductive health and HIV awareness among newly married Egyptian couples without formal education, International Journal of Gynecology and Obstetrics (2014), doi: 10.1016/j.ijgo.2014.02.027

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ACCEPTED MANUSCRIPT CLINICAL ARTICLE Reproductive health and HIV awareness among newly married Egyptian couples

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without formal education 1

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Wael F. Saleh a,*, Sameh F. Gamaleldin b, Hatem I. Abdelmoty a, Ayman N. Raslan a,

a

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Usama M. Fouda a, Mohamed N. Mohesen c, Mohamed A.F.M. Youssef a, d

Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University,

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Cairo, Egypt

Department of Andrology and Sexology, Faculty of Medicine, Cairo University, Cairo,

Department of Obstetrics and Gynecology, Faculty of Medicine, Beni Suef University,

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Beni Suef, Egypt d

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Egypt

Egyptian International Fertility IVF Center (EIFC-ET), Cairo, Egypt

* Corresponding author: Wael F. Saleh Department 22, Maternity Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt. Tel.: +20 1227457993. E-mail address: [email protected]

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The preliminary results of the study were presented at the FIGO Africa Regional

Conference of Gynecology and Obstetrics, October 2–5, 2013, in Addis Ababa, Ethiopia.

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Keywords: Awareness; Egypt; HIV; Newly married; Premarital counseling; Premarital

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testing; Reproductive health

Synopsis: Only two participants from 150 couples were aware of the free HIV hotline.

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Television and friends were the main sources of reproductive health knowledge.

ACCEPTED MANUSCRIPT ABSTRACT Objective: To assess awareness of several reproductive health and HIV issues and to

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determine the sources of reproductive health knowledge.

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Methods: A cross-sectional survey of 150 randomly recruited, newly married couples without formal education attending gynecology or andrology outpatient clinics in Cairo,

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Egypt, was conducted from January 2012 to January 2013. Participants were

reproductive health and HIV awareness.

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interviewed separately and asked to respond to a semi-structured questionnaire on

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Results: Most participants had not received premarital counseling or undergone premarital testing. Awareness about HIV was relatively high: 117 (78.0%) women and

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128 (85.3%) men had heard of HIV and had some awareness of the modes of HIV transmission. Only 24 (16.0%) women had ever used a condom compared with 36

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(24.0%) men. Only two men out of the 150 couples questioned were aware of the free HIV hotline. Television and friends were the main sources of reproductive health knowledge.

Conclusion: Routine premarital counseling and testing by reproductive health, gynecology, and andrology specialists need to be enforced. Mass media is an essential source of knowledge about HIV and reproductive health. Premarital, reproductive health, and HIV education programs need to be improved.

ACCEPTED MANUSCRIPT 1. Introduction North Africa is one of few regions in the world where knowledge about HIV and about

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reproductive and sexual behavior continues to be limited [1]. Similar to the situation in

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many African countries, early marriages are common in Egypt. The 2006 census revealed that 63% of Egyptian females aged 16 years and older were married and that

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29.2% of the total marriages that took place that year involved girls younger than 20

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years of age. Among the registered marriages that took place in 2006, 20% of the wives were illiterate and approximately 50% of them were married to illiterate husbands [2].

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On June 12, 2008, a presidential decree concerning changes in the Child Law was issued in Egypt. Two of the main articles of the decree were an increase in the minimum

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age of marriage to 18 years, and the establishment of premarital testing and counseling as a prerequisite to the issue of a marriage certificate [3]. Premarital examination and

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testing include clinical assessment for familial disorders, infertility problems, and basic investigations such as complete blood count, liver and kidney functions, and HIV testing, as well as semen analysis for males.

Few studies have gathered data about premarital counseling and testing in Egypt or in other parts of Africa. The present study was prompted by the results of a study of educated young Egyptian women by El Gelany and Moussa [4], as well as by our daily observation that gynecology and andrology outpatient clinic attendees have misconceptions or inaccurate knowledge about HIV, reproductive health issues, and sexually transmitted diseases. Furthermore, community-based obstetrics, gynecology, and andrology research studies of HIV awareness and reproductive health issues in

ACCEPTED MANUSCRIPT Egypt are rare. The aim of the present study was to assess awareness of premarital counseling, use of premarital testing services, knowledge about HIV, use of condoms,

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and to identify the main sources of knowledge about reproductive health matters among

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recently married Egyptian couples without formal education.

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2. Materials and methods

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Data were derived from a community-based cross-sectional survey conducted between January 1, 2012, and January 31, 2013, at Kasr Al Ainy School of Medicine, Cairo

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University, Cairo, Egypt. Participants were randomly recruited from newly married couples attending either gynecology or andrology outpatient clinics. On average,

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gynecology and andrology outpatient clinics examine approximately 50–75 female patients and approximately 25 male patients per day, respectively. Approximately 10%

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of the attendees at outpatient clinics are newly married couples within the first two years of marriage who have not had any formal education. Based on a 5% margin of error, a 90% confidence level, and a population of approximately 30 000, we estimated that a minimum sample size of approximately 300 participants was required.

We invited the first 250 women and 250 men presenting to the outpatient clinics to participate, from among which 150 couples that had agreed to participate and that fitted the inclusion criteria were selected for interview by random sampling. Inclusion criteria were couples within the early years of marriage who had not received any formal education. The study was conducted according to the guidelines of the institutional

ACCEPTED MANUSCRIPT ethics committee. The survey was peer reviewed and approved by the outpatient

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management committee.

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After agreeing to participate in the study, the names of the participants were coded to ensure confidentiality. A brief statement about the study and its objectives was read to

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the participants in Arabic to obtain informed consent. The participants were assured that

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their involvement would be voluntary, that the one-to-one interview would be private and confidential, and that they could leave the study at any time. Each partner was

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interviewed separately. All interviews were conducted in Arabic by one of the authors and participants' responses were not made available to the other partner or to any other

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individual. The interview comprised a semi-structured questionnaire about attendance at premarital counseling, use of premarital testing services, knowledge of HIV, use of

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condoms, and the main source of knowledge about reproductive and sexual health matters prior to marriage.

Data were analyzed using SPSS version 15 (IBM, Armonk, NY, USA). Values were expressed as mean ± SD or as a number (percentage) when appropriate. General demographic information was recorded, including age, duration of marriage, religion, employment status, residence, and reasons for clinic attendance. Data were compared using the Fisher exact text. P<0.05 was considered statistically significant.

3. Results

ACCEPTED MANUSCRIPT The participants were aged between 19 and 30 years. The mean age of the women at marriage was 20.7 ± 1.7 years whereas that of the men was 27.8 ± 2.1 years. The

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demographic characteristics of the participants are shown in Table 1. The reasons given

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by the participants for visiting the outpatient clinic are presented in Table 2. The participants' responses to the questionnaire regarding awareness about HIV and

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premarital counseling and testing are shown in Table 3. Twelve (8.0%) women and 16

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(10.7%) men had received premarital counseling. Approximately two-thirds of the participants had not used the premarital testing service. The majority of the respondents

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had heard about HIV and were able to identify at least one correct mode of HIV transmission (Table 3). Twenty-five (16.1%) women and 26 (17.3%) men were able to

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identify two modes of transmission. None of the participants suggested transmission of HIV from mother to baby as a mode of HIV transmission. However, when asked directly

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if HIV may be transmitted through pregnancy, delivery, or breastfeeding, the majority of the respondents (92 [61.3%] women and 87 [58.0%] men) answered correctly that this may happen. Only 24 (16.0%) women had ever used a condom compared with 36 (24.0%) men. Only two (1.3%) men from the study group were aware of the free HIV hotline.

Prior to marriage, the main source of sexual health knowledge for 47 (31.3%) of the women had been friends, for 37 (24.7%) it had been television, and for 20 it had been family (13.3%). Among the men, for 50 (33.3%) of the respondents their friends had been their main source of sexual health knowledge prior to marriage, for 32 (21.3%) it had been television, and for 21 (14.0%) it had been the internet (Table 4).

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4. Discussion

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Premarital health counseling seems to be acceptable in predominantly Muslim

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countries. A cross-sectional survey of 484 Saudis (balanced male and female numbers, married and single older than 18 years) who attended the Primary Health Care Centers

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in Riyadh, Kingdom of Saudi Arabia, indicated that 364 (75.2%) of the participants

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agreed to the idea of premarital health counseling [5]. However, in the present study, the vast majority of married couples (approximately 90%) had not received premarital

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counseling. Furthermore, approximately two-thirds of the couples had not used the premarital testing service. A search of PubMed did not find any studies relating to

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premarital counseling and testing in Egypt. The apparent lack of research in this area is in line with the 2007 findings of Zaky et al. [6]. The findings of the present study suggest

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that there is a need for further community-based gynecology and andrology research concerning premarital testing and counseling.

The majority of respondents in the present study were aware of HIV, probably from information disseminated by mass media. Nevertheless, 33 (22%) women and 22 (14.7%) men had not heard of HIV. This may be because the participants lacked formal education. Among those who were aware of HIV, transmission during intercourse and receiving contaminated blood or blood products were the most common correct responses regarding modes of HIV transmission. Incorrect modes of transmission (e.g. transmission by coughing, sneezing, kissing, mosquitoes, or toilets) were also mentioned by several respondents. The findings reported in the present study relating to

ACCEPTED MANUSCRIPT HIV awareness are similar to findings in India and Nepal. Only 37% of non-married Indian women aged between 15 and 24 years had ever heard of HIV and only 25% of

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Nepalese women in the same age group had ever heard of HIV [7,8].

Condom use is an important method of preventing HIV and sexually transmitted

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diseases [9]. In the present study, 126 (84%) women and 114 (76%) men had never

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used condoms. Approximately 90% of those participants who had used condoms did so during the treatment of genital infections. At the School of Medicine, Cairo University, it

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is common practice to advise patients to use condoms temporarily while they are receiving treatment for genital infections. Approximately 10% of participants that had

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used a condom did so as a temporary contraceptive method. The number of participants that had used condoms was much higher than the results of the 2005

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Demographic Health Survey, which showed that the condom use rate was very low in the general population (2.5% among married women aged 15–49 years) [10]. The level of condom usage among the men in the present study was comparable to that reported in a more in-depth study of condom use conducted by Kabbash et al. in 2007 [11]. Among 2304 randomly selected male participants from four governorates in Egypt, only 23.9% of participants had ever used condoms, mainly for contraception. The majority of participants knew about HIV (90.8%) but only a few felt they were at risk of genital tract infections (11.2%) or HIV infection (10.3%). Only one-quarter of the participants knew how to use condoms correctly. Inhibitions to condom use included a perceived lack of need (75.7%), refusal by a partner (57.6%), and a fear of using condoms (31.9%) [11]. Among the 150 couples questioned in the present study, 36 (24%) men but only 24

ACCEPTED MANUSCRIPT (16%) women reported that they had ever used condoms. This apparent discrepancy is because some of the male participants were married to more than one wife and four

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male participants had extramarital sexual relations for which they used condoms.

For 69 (46%) women and 72 (48%) men, mass media (i.e. television, radio,

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newspapers, and the internet) was their main source of reproductive and sexual health

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knowledge prior to marriage. A recent study of educated young women in Egypt reported that television and the internet were the media used most commonly by the

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participants (approximately 55% and 75%, respectively) [4]. However, information obtained from mass media is not always sufficient and sometimes vague [12]. In the

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present study, more men (n=21) than women (n=11) used the internet as their primary source of reproductive health knowledge prior to marriage (although this was not

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significant; P=0.06), which is in line with more men using the internet in Egypt compared with women. The use of mass media to disseminate accurate reproductive health information may be more crucial for couples that have not had premarital counseling or used the testing service. Some media reports have suggested that approximately 400 000 informal marriages take place in Egypt each year [13,14], which further strengthens the argument for using mass media to improve reproductive and HIVrelated information dissemination in African countries.

Surprisingly, friends were a significant source of reproductive health information compared with family, which might be because tradition prohibits the discussion of “taboo” subjects among family members [10]. According to Shama et al. [15], the family

ACCEPTED MANUSCRIPT does not play a major role in educating adolescents about HIV. Few respondents used health professionals as a source of reproductive health information, which may in part

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be because traditionally it is considered unusual for non-married individuals to seek

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advice from reproductive health services. Furthermore, many people in the Egyptian community believe that anything related to sexuality is disgraceful and should be

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avoided and, hence, they avoid asking the essential questions [15]. The present study

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demonstrates the need for the active involvement of reproductive health specialists, gynecologists, and andrology specialists to provide premarital counseling and testing,

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universities, or religious institutions.

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particularly given that reproductive health education is not disseminated by schools,

An alarming finding of the present study was that among the 150 couples questioned,

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only two participants (1.3%) had heard about the HIV free-phone hotline. The two men had heard about this service from television. In other countries, such as the USA, the National AIDS Hotline (NAH) has been a primary information and referral service for the public, providing nonjudgmental confidential information [16]. Hotlines are known to be a successful way of disseminating information to the mass population. Rosenbaum and Calhoun [17] cited a number of possible reasons for the success of hotlines, such as: the caller having better control; the anonymity of both the caller and the operator; and the ability of hotlines to overcome geography. The findings of the present study highlight the need for an urgent audit of the knowledge and use of the free health-related hotlines among the uneducated segments of the population in Egypt and perhaps in other African countries.

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The present study comprised married couples with certain demographic criteria (e.g.

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lacking formal education), which could be seen as a limitation. Sub-populations (e.g.

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rural area residents or employed versus unemployed) were not stratified because of their small numbers. However, the results highlight the need to enforce routine

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premarital counseling and testing, as well as the need for well-designed premarital,

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reproductive health, and HIV information programs with active involvement of reproductive health specialists, gynecologists, and andrology specialists. The present

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study also identified the influential role of mass media and the need for its appropriate use to facilitate the dissemination of reproductive and sexual health information in Egypt

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Conflict of interest

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and possibly in other African countries.

The authors have no conflicts of interest.

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38_20100604011533/Rendered/PDF/548890PUB0EPI11C10Dislosed061312010.pdf.

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Survey, 1996. Kathmandu: Department of Health Service, Ministry of Health; 1997:159–

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66. http://www.popline.org/node/169366

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use among males (15–49 years) in Lower Egypt: knowledge, attitudes and patterns of

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use. East Mediterr Health J 2007;13(6):1405–16. Lagarde E, Pison G, Enel C. Risk behaviors and AIDS knowledge in a rural

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community of Senegal: relationship with source of AIDS information. Int J Epidemiol 1998;27(5):890–6. [13]

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http://news.bbc.co.uk/2/hi/middle_east/8466188.stm. Published January 19, 2010. Accessed April 13, 2014. [14]

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intervention: a review. J Community Psychol 1977;5(4):325–39.

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120 (80.0)

115 (76.7)

Rural

30 (20.0)

35 (23.3)

Muslim

139 (92.7)

142 (94.7)

Christian

11 (7.3)

8 (5.3)

128 (85.3)

77 (51.3)

Employed

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Non-employed 22 (14.7) 73 (48.7) Values are given as mean ± SD or as a number (percentage).

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a

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Employment

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Religion

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Urban

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Table 1 Demographic characteristics of the participants. Male partner Female partner (n=150) (n=150) Mean age, y 27.8 ± 2.1 20.7 ± 1.7 Average marriage duration, y 1.4 ± 0.3 1.3 ± 0.2 Residence

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Female partner (n=150) 36 (24.0) 48 (32.0) 36 (24.0) 12 (8.0) 5 (3.3) 13 (8.7)

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Table 2 Reasons for presentation to the outpatient clinic. Male partner Reason (n=150) Genital infection/discharge 21(14.0) Delayed conception 50 (33.3) Menstrual irregularity NA Contraception NA Sexual dysfunction 51 (34.0) Other reasons 28 (18.7) Abbreviation: NA, not applicable. a Values are given as a number (percentage).

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Table 3 Premarital counseling and testing, and HIV awareness among the participants. Male partner Female partner Questions (n=150) (n=150)

P value

Premarital counseling and testing

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Did you receive formal premarital counseling?

16 (10.7)

12 (8.0)

No

134 (89.3)

138 (92.0)

62 (41.3)

64 (42.7)

88 (58.7)

86 (57.3)

128 (85.3) 22 (14.7)

117 (78.0) 33 (22.0)

22 (14.7)

33 (22.0)

102 (68.0)

92 (61.3)

26 (17.3)

25 (16.7)

0.0

0.0

87 (58.0) 27 (18.0) 36 (24.0)

92 (61.3) 24 (16.0) 34 (22.7)

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24 (16.0) 126 (84.0)

0.08

0.0 150 (100.0)

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Did you do the premarital tests required to get married? Yes

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No

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HIV awareness Have you heard about HIV? Yes No

How many modes of HIV transmission do you know? I do not know

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2 modes

3 modes Can HIV be transmitted through pregnancy, delivery, or breastfeeding? Yes No I do not know

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1 mode

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Yes

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Have you or your husband/wife ever used a condom? Yes 36 (24.0) No 114 (76.0) Are you aware of the free HIV hotline? Yes 2 (1.3) No 148 (98.7) a Values are given as a number (percentage). b Unprotected sexual intercourse; blood transmission; and mother to baby.

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Table 4 Main source of knowledge about reproductive and sexual health prior to marriage. P value Male partner Female partner Source (n=150) (n=150) Television 32 (21.3) 37 (24.7) 0.49 Radio 10 (6.7) 13 (8.7) 0.52 Friend 50 (33.3) 47 (31.3) 0.71 Family relative 16 (10.7) 20 (13.3) 0.48 Newspaper 9 (6.0) 8 (5.3) 0.80 Internet 21 (14.0) 11 (7.3) 0.06 Health professional 12 (8.0) 14 (9.3) 0.68 a Values are given as number (percentage).