Gender Beliefs and Technology-Facilitated Condom Negotiation Among Urban Refugees and Displaced Youth in Kampala, Uganda: The Role of Equitable Relationship Power and Condom Efficacy

Background: Harmful gender norms about sex, consent and decision-making affect sexual communication and safer sexual negotiations. HIV prevention researchers continue to highlight the importance of safer sexual communication about sexual health topics including condom use as a step towards safer sex practices. There is limited evidence on adolescents’ use of technological tools for sexual health communication and promotion. Scant measures exist on adolescents’ attitudes towards using technological tools to negotiate safer sex. The purpose of this exploratory investigation was: 1) validate the technology-facilitated condom negotiation attitudes (TCNA) scale suitable to urban refugee youth in Uganda, based on the original embarrassment about negotiation and use sub-scale developed by Helweg-Larsen & Collins (1994); and 2) explore the influence of relationship power and condom self-efficacy in the relationship between gender beliefs and TCNA.

Methods: Data were obtained from a diverse cross-sectional sample of refugees and displaced youth aged 16-24 years (N=445; young women: n=333; 74.7%) living in five slums in Kampala, Uganda. We adapted the condom negotiation sub-scale to assess young people’s attitudes towards using sexting to negotiate condom use. Gender beliefs were measured using an 8-item gender belief scale. Relationship power was assessed using the sexual and relationship power sub-scale. Condom efficacy was assessed using a 7-item scale. Sexual communication (active vs passive) was assessed using a single item on the frequency of sending or receiving sexy messages. We conducted confirmatory factor analysis for the TCNA scale, relationship power, condom self-efficacy, and gender beliefs. We then assess the structural relationships using weighted least squares method to identify direct and indirect effects of gender beliefs on TCNA via relationship-power and condom-use self-efficacy.

Results: The measurement-only models of TCNA, gender beliefs, condom-use self-efficacy and relationship power provided a good fit to the data according to the model-fit indices. The final structural equation model had acceptable fit indices: χ²/df ratio=2.57, RMSEA=0.05 (90% CI [0.054, 0.065]), CFI=0.951, TLI=0.942. Results show that gender beliefs are directly positively associated with TCNA (β=0.166, p<.01), and equitable relationship-power (β=0.620, p<.001). Unequitable relationship-power is associated with condom-use self-efficacy (β=-0.101, p<.05) and TCNA (β=-0.262, p<.001). Passive sexual communication is positively associated with condom efficacy (β=0.894, p<.001), but negatively associated with TCNA (β=-0.258, p<.001), while active sexual communication is positively associated with condom efficacy (β=0.093, p<.001), and TCNA (β=0.276, p<.001). Condom efficacy is positively associated with TCNA (β=0.765, p<.001). Relationship-power and condom efficacy partially mediated the relationship between gender beliefs and TCNA. Gender beliefs had an indirect effect on TCNA via a chain of mediators [belief to inequitable relationship power to reduced condom efficacy to increased TCNA] (β=-0.048, p<.001).

Conclusion and implications: The TCNA scale was found to be valid among urban refugee youth in Uganda. Rapid spread of internet and mobile technologies has altered how young people negotiate their sexual health. Technology-facilitated sexual health promotion interventions among urban refugee youth need to use gender transformative approaches to address harmful gender norms, inequitable relationship power, and increase condom self-efficacy to facilitate youth’s safer sexual communication and negotiation.