UNIVERSITY OF ECONOMICS HO CHI MINH CITY VIETNAM INSTITUTE OF SOCIAL STUDIES THE HAGUE THE NETHERLANDS VIETNAM - NETHERLANDS PROGRAMME FOR M.A IN DEVELOPMENT ECONOMICS QUALITATIVE ANALYSIS OF SEXUAL HEALTH PROTECTION BEHAVIOR BY INCOME – THE CASE OF HO CHI MINH CITY BY LE THI PHUONG THAO MASTER OF ARTS IN DEVELOPMENT ECONOMICS HO CHI MINH CITY, OCTOBER 2012 UNIVERSITY OF ECONOMICS HO CHI MINH CITY VIETNAM INSTITUTE OF SOCIAL STUDIES THE HAGUE THE NETHERLANDS VIETNAM - NETHERLANDS PROGRAMME FOR M.A IN DEVELOPMENT ECONOMICS QUALITATIVE ANALYSIS OF SEXUAL HEALTH PROTECTION BEHAVIOR BY INCOME – THE CASE OF HO CHI MINH CITY A thesis submitted in partial fulfilment of the requirements for the degree of MASTER OF ARTS IN DEVELOPMENT ECONOMICS By LE THI PHUONG THAO Academic Supervisor: DR PHAM KHANH NAM HO CHI MINH CITY, OCTOBER 2012 Table of Contents Chapter : Introduction 1.1 Problem Statement 1.2 Research Objectives 1.3 Research Scope 10 1.4 Research Structure 10 Chapter : Literature reviews 11 2.1 Theory of Planned Behavior 11 2.2 Empirical Studies 13 2.3 Chapter Summary 16 Chapter : Research backgrounds and research methodology 17 3.1 Research backgrounds 17 3.2 Research Methodology 19 3.2.1 Analytical framework……………………………………………………… 19 3.2.2 Qualitative methods…………………………………………………………21 3.2.3 Tool………………………………………………………………………….25 3.2.4 Participants and studied location…………………………………………….29 3.3 Chapter Summary 32 Chapter : 4.1 Empirical results 33 Description of variables 33 4.1.1 Attitude and perception…………………………………………………… 33 4.1.2 Subjective Norms……………………………………………………………39 4.1.3 Perceived Behavior Control…………………………………………………41 4.2 Determinants of sexual health protection behavior 45 4.2.1 Attitude/perception and sexual health protection behavior………………….45 4.2.2 Subjective Norms and sexual health protection behavior………………… 47 4.2.3 Perceived behavior control and sexual health protection behavior………….48 4.3 Chapter Summary 49 Chapter 5: Conclusions and policy implication 50 5.1 Conclusions 50 5.2 Policy Implication 51 5.3 Limitation 52 REFERENCES 53 Appendix A 56 Appendix B 59 Appendix C 61 Appendix D 63 Table of Figures Figure 1: Theory of Planned Behaviour 20 Figure 2: The layer of needs 26 Figure 3: The collages of NeedScope model 28 List of Tables Table 1: Sample information 30 Table 2: Attitudes and Perception variable 43 Table 3: Subjective Norms variable 43 Table 4: Perceived Behavioural Control variable 44 Table 5: Behaviour variable 44 Abbreviations A&P Attitudes and Perception EC Emergency Contraception FDG Focus discussion group HCMC Ho Chi Minh city HIV/AIDS Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome IDI In-deep interview IUD Intrauterine Device RH Reproductive Health STI Sexual Transmission Infection UNFPA United Nations Fund for Population Activities WHO World Health Organization Chapter : Introduction 1.1 Problem Statement Ho Chi Minh city is the biggest city in Vietnam with the estimated total of residents at about 7.2 million including of 2.3 million of males and 2.4 million of females which are in the age from 15 to 65 (Statistical Office in HCMC, 2010) Along with the development of urbanization, industrialization and globalization, social and cultural life has many changes in recent years However, as the traditional notions in Vietnam and other Asian countries, sexual content is taboo for talking in public Meanwhile, as said above, the impressive growth of economy also brings the huge change of society, including the sexual health issues In which, the main sexual and reproductive health issues are sexual transmitted infection, unplanned pregnancy and unsafe abortion (Low, 2006) Proportion of women in reproductive age suffer STIs is 25%, proportion of abortion and menstrual regulation is 0.8% (UNFPA, 2009) HIV / AIDS in Vietnam is really an alarming problem 156,802 people living with HIV were reported, including 34,391 AIDS patients alive and 44,232 people died because of AIDS So far, HCMC is the highest cases of people who are living with HIV accounted for 26.3% of HIV cases detected in the country (Ministry of Health, 2010) HIV transmission is primarily through heterosexual sex and injecting drug use However, the biggest challenge facing Vietnam in the field of RH is the issue of abortion The use of contraceptive method is reflected in low rate while the abortion rate continues to rise in Vietnam The average women abortion rate is 2.5 times This number was the highest in Southeast Asia and was one of the highest rates in the world Strikingly, while education program and media communication system have attempted to raise awareness of people, they not really change their behaviour apparently Many young women lacked basic knowledge about sex, including not believing in using condoms or not asking their partner to use condoms Furthermore, a negative view on abortion has caused many women choose the unsafe and illegal abortions In Vietnam, mortality rate from unsafe abortions is one per week In Vietnam, sex education in school already gives the basic knowledge, such as biology, gender and personal development, hygiene, and family life However, the teaching methods used are often not suitable for sensitive topic like this (WHO, 1999) School is main source to provide knowledge about sexual health, but this information is poor and unelaborated Teachers still avoid mentioning about this topic in their lectures (Nguyen et al., 1999), which brings the lack of sufficient and efficient information and causes the curiosity to the adolescent about sexual health So, it could lead to the shortage in sexual health protection, insufficient knowledge about transmission diseases, unplanned pregnancy and abortion As the economy of HCMC has been growing rapidly, rising in income and income inequality has probably changed many of people’s behaviour, including sexual health protection behaviour However, the relationship between protection behaviour and income, which has important policy implication, has not been fully understood The income has positive correlation with education factor (Pereira and Martins, 2004), but not with sex health protection behaviour This study also tries to figure out what the difference between income groups in intended behaviour towards sexual health protection 1.2 Research Objectives From this problem statement, this research examines the sexual health protection behavior of urban HCMC participants using qualitative method First of all, this research try to find out the attitudes and perception (A&P) towards sexual health protection, subjective norm about sexual health protection and perceived behavioral control of sexual health protection behavior Besides, this research also tries to exam the relationship between A&P and sexual health protection behavior, between subjective norms and sexual health protection behavior, between perceived behavioral control and sexual health protection behavior Moreover, this research tries to figure out these connections by income groups, including low-income and high-income groups 1) What is the attitudes and perception, subjective norms, perceived behavioral control towards sexual health care/protection? 2) What is the connection between attitudes and perception, subjective norms, perceived behavioural control to sexual health protection behaviour? 3) What are the differences in these connections among income group? 1.3 Research Scope This research was carried out in HCM city The sample size was 21 participants, including male and 14 female, aged from 18-40 years old 1.4 Research Structure The based theory of this study is presented at chapter 2; then, followed by empirical study Chapter reviewed research backgrounds and research methodology, in which study presented about analytical framework, qualitative method: explain why we should use qualitative method for this research, tool to the research: we use NeedScope model during the interview, and interpretation about the participants of this study Chapter point out some results of the study, then chapter gave some conclusion and policy recommendation 10 REFERENCES Ab Rahman A., Ab Rahman R., Ibrahim MI., Salleh H., Ismail S B., Ali S.H., Muda W M , Ishak M., Ahmad A (2011), Knowledge of sexual and reproductive health among adolescents attending school in Kelantan, Malaysia, Southeast Asian J Trop Med Public Health, Vol 42 No Ajzen I (1985), From intention to actions: A theory of planned behaviour Action-control: From cognition to behaviour Kuhl J and Backmann J Heidelberg, Springer: 11-39 Ajzen I and Fishbein M (1980), Understanding Attitudes And Predicting Social Behavior, Prentice-Hall, Englewood Cliffs Ajzen, I (1991), “The Theory of Planned Behavior, Organizational Behavior and Human Decision Processes”, University of Massachusetts at Amherst, 50, 179-211 Ajzen, I (2002), Perceived Behavioral Control, Self-Efficacy, Locus of Control, and the Theory of Planned Behavior, Journal of Applied Social Psychology, 32, 665-683 Ajzen, I and Fishbein, M (1975), Belief, attitude, intention, and behavior: An introduction to theory and research Reading, MA: Addison-Wesley Akerlof, G A and Dickens, W T (1982), “The economic Consequences of Cognitive Dissonance”, The American Economic Review, 1982, Vol 72, No 3, pp 307-319 Committee for population, family and children of Vietnam, “Adolescents and Youth in Vietnam”, Population, Family and Children of Viet Nam, 2003 Dapice, D.,Gomez-Ibanez, J A., Nguyen X T (2010), Ho Chi Minh city: The Challenges of Growth, United Nations Development Programme, Policy Dialogue Paper Number Duranton, G and Puga, D (2000), “Diversity and Specialization in Cities: Why, Where and When Does it Matter?”, Urban Studies 37: 297-308 53 Fennell, J., “Men bring condoms, women take pills: Men’s and Women’s Roles in Contraceptive Decision-Making”, The journal of the Sociology of Mental Health section of the American Sociological Association, 2011 November 1, 1:153-172 General Office for Population Family Planning of Vietnam (2011), Statistic of reproductive health and family planning Green J., Thorogood N., “Qualitative Methods for Health Research”, second edition, SAGE Publications Ltd, 2009 HIV/AIDS Control and Prevention Committee of HCMC (2012), Report of situation in HCMC – first six months of 2012 Low WY (2006), “Adolescent health: what are the issues and are we doing enough?” Singapore Med J, 47:453-5 Mack N., Woodsong, C., Macqueen, K M., Guest, G., Namey E (2005), Qualitative Research Methods: Data Collector’s Field Guide, Family Health International Meekers, D and Klein M (2002), “Understanding Gender Differences in Condom Use Self-Efficacy among Youth in Urban Cameroon”, The journal of AIDS Education and Prevention, January, Vol 14, No 1: 62–72, Ministry of Health (2010), Report: Result in the prevention of HIV/AIDS in 2010 Ministry of Health (2012), Viet Nam AIDS Response Progress Report 2012 Mundle,M., Haldar, A., Baur, B., Haldar, S., Chattopadhyay, S and Soren, A B (2011), Perceptions of couples about contraception in Eastern India, Southeast Asian J Tropical Medicine Public Health, Vol 42 No.2 Naravage, W and Oehler, J (2008), “Sexual Risk Perception among Women at Reproductive Age, Bangkok, Thailand”, Journal of Public Health, Vol.38 No.2 NeedScope system, Focus research: http://www.focus.co.nz/webpages/what_is_needscope.html 54 NeedScope, Using emotion to build world-class brands: http://www.tnsgallup.no/arch/_img/9079170.pdf Neuman, I., “THE LOVE BARRIER, The Views of Young Vietnamese Women Regarding their Intentions to Remain Virgins until Marriage”, Department of Public Health Science Division of International Health – IHCAR, 2006 Nguyen, T H D., Dam A V., Vu, T H , Phan T T (1999), “Knowledge, Attitude, Behavior of adolescent related to sexual and reproductive health in Hanoi and Ninhbinh”, Institute for Reproductive and Family Health Nutbeam, D and Harris, E (1997), Theory in a Nutshell: A Guide to Health Promotion Theory, Sydney, McGraw-Hill Pereira, P T and Martins, P S (2004), “Returns to education and wage equations”, Applied Economics, Taylor and Francis Journals, vol 36(6), pages 525-531 Pope, C and Mays, N (2006), “Qualitative methods in health research”, Chapter 1, 2006/5/9, 19:49, PAGE #1 Statistical Office in Ho Chi Minh city (2010), Statistical Yearbook, Chapter II Population and Labor United Nations Fund for Population Activities (2009), Population and Development in Vietnam, towards a new strategy 2011 – 2020 United Nations Fund for Population Activities (2011), Vietnamese Youth: Summary of Statistical Indicator From the Population and Housing Census Vietnam 2009 World Health Organization (1999), Programming for adolescent health and development Report of WHO/ UNFPA/ UNICEF study group on programming for adolescent health, Technical Report Series no 886 WHO, Geneva 55 Appendix A The guideline of interview, interviewer will follow this guideline to figure out the information during the interview with participants Introduction Express no wrong or right answer, all about sharing experience 1) Respondent’s introduction: Age, occupation, family status, how many kids (if appropriate)? How old are they now? What is your work and interests/hobbies? 2) Today, we’re going to talk about you and your partner How long have you been with your partner/spouse? Behavior Information 3) What comes to your mind when saying about “Sex”? What else? 4) How you see attitudes to sex changing these days? What you notice among the people you know – with respect to how important sex is; what role it plays in their lives, how comfortable they are with it, what their relationships are like What is your view about sex? Let respondent talk freely, clarify/Probe where appropriate 5) What are you aware of sexual risk and protect method? Any others? What of these methods you ever hear of? 6) Which one have you got experience with? How? From what source did you come to know about this? Tell me more about it? 7) Who could you share if you have concern about sex sexual risk prevention? How could you share? Tell me more about it? IF NOT USING ANYTHING (BEHAVIRORAL /NATURAL METHOD): 8) What you normally if you not want you/your partner to get sexual risk? 56 Apart from pregnancy prevention, what are the main reasons for using/not using contraceptive method? IF USING CONDOM: 9) Why you use this method? What is advantage/disadvantage? 10) Any opinion/ feedback from your partner? How does it make you feel? 11) Who normally buys the pills/condoms? And where? IF USING ORAL CONTRACEPTIVE METHOD: 12) What type/brand of ORAL CONTRACEPTIVE you know? Which one you/your partner use currently? 13) Why you use this method? What is advantage/disadvantage? What you look for in using this method? 14) IF MORE THAN ONE METHOD USED, ASK: which one you prefer to use? Probe about oral contraceptive or emergency contraceptive pills use? Or abortion? 15) Any opinion/ feedback from your partner about this method? 16) Who normally buys the pills/condoms? And where? Now using Female/Male collages picture to discuss with, we introduce contraception method and ask respondent to match with group in collages Then, talking about the people in the collages 17) What does it say about their personality and the type of person they are? 18) Are they single or married? How is their partner like? What kind of man/woman are they looking for? 19) Can we talk ta bit about their relationship with their partner 20) What about their sex life 57 21) What does sexual freedom mean to them? 22) What does safe sex mean to them? 23) What are their concerns about sex / the problems they wish they could avoid or find a solution to? 24) Who could influence their intent of using this method? And how? 25) What would they look for in a contraceptive? 58 Appendix B Detailed description of sample: No Gender Age Occupation More information IDI1 Female 21 IDI2 Female 24 IDI3 Female 35 Restaurant receptionist IDI4 Female 29 Human resource IDI5 Female 40 IDI6 Female 39 IDI7 Male 29 Sale staff In relationship with girlfriend IDI8 Male 23 Studying In relationship with girlfriend IDI9 Female 24 Personal business In relationship with boyfriend IDI10 Male 39 Work in family job IDI11 Male 34 Personal business Part-time job, working as There is one infant kid, husband cashier in supermarket work in logistics company Secretary in foreign company Engaged, preparing for marriage There are two children, husband work in steel trading Husband work in the same company Housewife, before was teacher House/Land agent, owned business 59 kids, husband is a worker kids, working with husband kids, wife works in the same office In relationship with girlfriend No Gender Age Occupation IDI12 Female 31 Work at bridal shop kid, husband is photographer IDI13 Male 26 Work at fashion shop In relationship with girlfriend IDI14 Male 34 Own Barber shop kid, wife is makeup staff IDI15 Male 35 Own telephone card shop Married, no kid IDI16 Male 27 IDI17 Female 31 Diplomatic staff kid in primary school IDI18 Female 27 Office staff kid IDI119 Female 21 Studying IDI20 Female 35 Work in family company kids IDI21 Female 28 Officer staff Not, not in any relationship Human resource operation of insurance company More information In relationship with girlfriend Not married, in relationship with boyfriend 60 Appendix C Table of variables: Attitudes &Perception No of participants Towards condom 21 Towards daily pill 13 Towards EC pill 15 Towards IUD 10 Subjective Norms Sexual Spouse Comments This is the number of participants which having the attitude & perceptions about using protection method No of participants 19 Comments There are 19 participants said that sexual spouse have strong affect to them Parents Only cases mentioned about their parents’ influence Friends 21 Most of participants share the influence of friends to their behaviour of using protection method 61 Perceived Behavioural Control Afraid of side effects No of Comments participants 18 Side effects from using of condom, oral pill and IUD Afraid of complexity of usage Behaviour 10 Complexity of using oral pill and IUD No of Comments participants Condom 15 Daily pill 11 IUD EC pill Not using This is number of participants which using or not using protection method One person could use more than one method 62 Appendix D The following is the sample screener: Hi, we are conducting a survey about sexual health protection for a research purpose of society There are some personal and sensitive questions which you may feel uncomfortable to answer, however, all your answer if can, will completely keep confidential Are you willing to join in? 1) Would you please tell me how old are u? Birth year? Below 18 Thanks and Close 18 – 25 26 – 30 Continue 31 – 35 36 – 40 Over 40 Thanks and Close Note: make sure the age in our range research 18-40 2) Would you please tell me how much is your income? Note: record the information 63 3) Record the gender of respondent Male Continue Female Thanks and Close Others 4) Would you please tell me the status of your current marriage? There is wife/husband and living with husband/wife as a family There is wife/husband but living as a family with others There is wife/husband but don’t living as a family with Continue husband/wife or others Single but living as wife/husband with others Single and not living as wife/husband with others Divorce or widow/widower Note: record the status, make sure we have respondent across the group 64 5) Would you please tell me that during your relationship have u ever had sex? No Thanks and Close Not giving answer Thanks and Close Yes 6) Continue Would you please tell me that you apply any method for sexual health protect? No Continue Yes Note: record the information 7) Would you please tell me your highest educational level? Primary school graduated Thanks and Close Secondary school graduated High school graduated College/ University studying Continue College/ University graduated Post graduated/ Master 65 8) I will speak out some statement Would you please tell me which one is the most correct to describe about you? There is no wrong or right here Join in conversation with some one I’ve known In a party, I usually Join in conversation with many people, even strangers Start the story In a group, I usually… Wait for some on who start first When talking with people I I feel easy to continue the story don’t know I have less thing to talk to them I feel nervous and anxious When meeting a new person I feel enthusiastic and exciting Note: make sure at least un-black cells is selected -> to make sure the respondent willing to start the story 66 For more information, we would like to invite you to talk about sexual health protection All information will be serve for research purpose of society and totally confidential Would you please join with us? No Thanks and Close Yes Continue and send invitation 67 ... HEALTH PROTECTION BEHAVIOR BY INCOME – THE CASE OF HO CHI MINH CITY A thesis submitted in partial fulfilment of the requirements for the degree of MASTER OF ARTS IN DEVELOPMENT ECONOMICS By LE... knowledge about the sexual risk prevention method is showed the benefit in choosing the method for them By knowing the benefit and disadvantage of the method, they had the choice of what they actually... besides the percentage of households with home 17 telephone, personal computer, statistics also show that the rate in HCM City households have Internet connection is 33%, the percentage of households