Qualitative analysis of sexual health protection behavior by income the case of ho chi minh city

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 ou

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 1 : Introduction 8

1.1 Problem Statement 8

1.2 Research Objectives 9

1.3 Research Scope 1 0 1.4 Research Structure 1 0 Chapter 2 : Literature reviews 11

2.1 Theory of Planned Behavior 11

2.2 Empirical Studies 13

2.3 Chapter Summary 16

Chapter 3 : 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 : Empirical results 33

4.1 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 ofNeedScope 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

EC FDG HCMC HIV/AIDS IDI

IUD

RH STI UNFPA WHO

Attitudes and Perception Emergency Contraception Focus discussion group

Ho Chi Minh city Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome In-deep interview

Intrauterine Device Reproductive Health Sexual Transmission Infection United Nations Fund for Population Activities World Health Organization

Chapter 1 : Introduction

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, 201 0)

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 I 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% ofHIV 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 do 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 gtves 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

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?

This research was carried out in HCM city The sample size was 21 participants, including

8 male and 14 female, aged from 18-40 years old

The based theory of this study is presented at chapter 2; then, followed by empirical study Chapter 3 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 do the research: we use NeedScope model during the interview, and interpretation about the participants of this study Chapter 4 point out some results of the study, then chapter 5 gave some conclusion and policy recommendation

Chapter 2 : Literature reviews

2.1 Theory of Planned Behavior

leek Ajzen introduced the theory of planned behaviour via his article "From intentions to actions: a theory of planned behaviour" in 1985 Including 3 main categories in this theory, this theory is a development from the theory of reasoned action, which first proposed by

Martin Fishbein and leek Ajzen in 1975 These three main categories are: Attitudes and Perception- it shows the information if a person prefers to take action or not, Subjective Norms - shows the social pressure limitation that a person could stand to take action and Perceived Behavioral Control-shows the perception of a person about the ease or difficulty to performing a behavior According to this theory, a person's behavior intention

is high accuracy predicted by his or her attitudes towards action, their belief of what other thinks they would act and their thought of what they can do this behavior From the behavior intention determinants, it importantly accounts for performing actual behavior

Attitudes and Perception refers to the favorable or unfavorable evaluation or the appraisal of a person about a phenomenon or a behavior It first begins with the perception towards this phenomenon or behavior From this, leading to the belief that the outcome will happen from performing the behavior is good or bad If the attitude towards this action is good, he or she will have the positive belief of intending to perform the behavior Then, it will lead to the positive outcome of performing the behavior And vice versa, if the attitude towards this action is bad, he or she will have the negative outcome of intending to undertake the behavior, lead to less likely to perform the actual behavior This factor answers for question "Whether the person is in favor of doing it?"

perform or not perform an action The social pressure here is the people that this individual perceived that important to him or her This factor has two parts: belief about how people would like them to perform action (e.g I feel pressure from my parents to use condom in

my sexual relationship); and the positive or negative judgment about the consequences of

the belief (e.g doing what my parents think I should do is important) Based on how much this person values the social pressure, the degree of the influences will fluctuate This factor answers the question "How much the person feels social pressure to do it?"

Perceived Behavioral Control refers to a person's perception of factors will facilitate or hinder an intention to behave These could be an internal control factors (such as: knowledge, skill or ability), or external control factors (such as: opportunities, or resources) These factors could be actual or not, as long as it exists in his or her belief The importance is how strong the individual think he or she can control these factors This shows the ease or difficulty in intending of doing or not doing the behavior This factor answers the question "Whether the person feels in control ofthe action in question?"

In these three factors, The Perceived Behavioural Control is the most important factor (Ajzen, 1985) For example, a male would like to have a safe sex by using condom,

as he has known that he might infect STI/HIV by not using condom This is Attitude towards the behaviour of buying condom And he has also heard about protecting himself

by using condom from his friend because they always use it and he intends to use it too This presents of Subjective Norm However, the pharmacy where sale condom is far, and

he think that it will be embarrassed if he come to ask for condom or suffer the curious looks from the people there Moreover, he may get some unexpected question from pharmacist

In fact, there is no curios question or sneer at all Nevertheless, this fact plays a very important role for his decision that he will not go to buy condom, even he is totally aware ofthis use of this behaviour and also get encourage from others to behave

Attitudes and Perception, Subjective Norms and Perceived Behavioural Control all affect to intention to act, as well as each other And it should be noted that three above factors only determine the i~tention to act, not the actual behaviour; then, the intention to act is the strongest indicator that may or may not lead to the behavioral action (Ajzen, 1985)

This theory has been shown to be useful when collecting information for future development of public health program (Nutbeam and Harris, 1997, Ajzen, 2002) Taking an

example, if Ministry of Education and Training and Ministry of Health want to build a sexual education program for adolescent; they have to understand of teenagers' perceptions

of HIV/STis and their action would be taken by themselves for sexual health protection And it is crucial to understand the social pressures as well as the influence around adolescent about sexual health protection Understanding all information, the program could be built and implemented more practically and efficiently

or sexual health These studies are performed on samples of adolescents and women

Wanapa Naravage and Joachim Oehler have a research of "Sexual Risk Perception among Women at Reproductive Age, Bangkok, Thailand" (2008), using qualitative and quantitative method Firstly, this study was using quantitative research to identify the variables; then the qualitative research will be taken to explain the identified variables, and in-depth understand risk perception towards STis/HIV and unplanned pregnancy This study was carried out for both married and single female from 15 to 45 years old at workplaces, shopping malls at downtown and outskirt of Bangkok, Thailand Data collection was conducted in November 2005 to January, 2006 This research found plenty

of significant information: sexual risk perception More Than Half of Women Perceived No Risk At All From HIV Infection, Unplanne9 Pregnancy Was Seen More Common Than HIV/AIDS Reported by Respondents, Majority of Respondents Are Less Concerned about HIV Infection Than About Unplanned Pregnancy, Most Participants Who Were Single Feel Less Concerned about HIV Infection Due to Lack of Early Symptoms, Unlike Pregnancy,

as well as, it discussed some about preventing sexual risk, like using condom or oral contraceptive pill This result was useful in Thailand

Research ofNguyen Thi Hoai Due, Anke Van Dam, Vu Thu Ha, Phan Thanh Tuyen about "Knowledge, Attitude, Behaviour of adolescent related to sexual and reproductive health in Hanoi and Ninhbinh", was carried out in 1999 The method is used is focus discussion group, with adolescent from 15-19 years old The key finding showed that the source to provide information about sexual health is from school, but they are poor and unelaborated The teachers still avoided mentioning about the sexual topic in lectures The most contraception method was condom The adolescent supposed the sexual education from school and family This research was not up-to-date, and its sample4 size was in adolescent

"The Love barrier - The view of young Vietnamese woman regarding their intentions to remain virgins until marriage" research of Ida Neuman (2006) investigated about how young, urban Vietnamese women's perceive their sexual and reproductive health situation and have sex before marriage It was also a qualitative method research which based on focus group discussion with young woman, her mother and her boyfriend to analyse their perception about remaining virgins until marriage This study was conducted from October to December, 2004 in Hanoi, Vietnam, interviewed 12 daughters and 11 mothers (daughters are from 19-24 years old, not married, and lived at home with their mother) Based on Theory of Planned Behaviour and using phenomenography method, this research gave the perception of young women in remaining virgins until marriage

The result of this study showed that there were some barriers in perception of women

in the research towards sexual and productive health There was a conflict between their desires to discovery and live for their love to their family perception and pressure The result also divided in terms of Attitudes and Perception, Subjective Norms and Perceived Behavioural Control, which given in summary and implications This result showed in some important view of daughter about keeping virgin before marriage; they understood the negative consequences of having sexual intercourse with their boyfriend before marriage

could cause reducing his respect to them after that, the STis, the social pressures or negative impact if getting married with other guy However, they still lacked of control in the situation could lead to sexual intercourse with their boyfriend somehow Moreover, the sexual talk between mom and daughter rarely happens; then, the information about sexual issue mostly has gotten from media channel, not from family (mother in this case) This research also pointed out some limitations, such as: the result only occur between women,

no man's views about premarital sex It also shows the cultural and language barrier when carried out this research

In the study "Knowledge of sexual and reproductive health among adolescents attending school in Kelantan, Malaysia" (20 11 ), authors assessed the understanding of participants via a self-administered, anonymous questionnaire of quantitative method Exclusive of demography, this study mentioned about knowledge of human reproductive organs, pregnancy, contraception, HIV and STDs, abortions and their sources of sexual and reproductive health information At the similar culture to Vietnam, Malaysia was also facing the hesitance in talking about sexual issues between family members Most sources

of sexual and reproductive health information came from friends (64.3%) and mass media (60.2%); not from parents (6.5%) or teachers (17.2%) Insisting the WHO statement (2005) that knowledge levels among school age towards sexual and reproductive health vary by location, age and sex, the study also gave some findings about the misunderstanding of adolescent, such as: not having pregnancy at "first time" More importantly, majority of students did not know that sexual intercourse is a cause of STDs, but knowing about HIV The study pointed out the lack of education at school and family or community about sexual knowledge

Another study also mentioned about the perceptions of contraception, named

"Perceptions of couples about contraception in Eastern India" (Mundie et at., 2011) The samples of this study were married women from urban and rural at West Bengal, India The method was quantitative research, with 2000 respondents, via a predesigned questionnaire Interviewing method was also used, but with only the female partner randomly In this study, the variables were age, age at marriage, age at first conception,

parity, birth interval, occupation, literacy level, socioeconomic condition, knowledge about contraceptive, current use of contraception and ever use of contraception The result distinguished to the age of females (younger than 18, 18-23, 24-29, 30-35 and from 36 upper), region (Hindu, Muslim, others) Only 5% of respondents had main role in family planning decision maker; most came from both sides (husband and wife) in home (55.2%) Most important finding at this study was that literacy is essential determinants of knowledge towards family planning methods

In all above empirical studies, some of them are executed in Vietnam long time ago, so the result is not appropriate for current circumstance Some of them are implemented with the sample of adolescent Some of them used quantitative method with pre-designed questionnaire, which unable to show the in-deep understanding of participants So, based

on Theory of Planned Behavior, our study carried out to know the Attitude and Perception, Subjective Norms and Perceived Behavioral Control towards the sexual health protection behaviour Using advantages of qualitative method, we try to know the in-deep understanding of participants with this kind of sensitive topic Next chapter presented why this study chose qualitative method, and also explain about the NeedScope model we use during interview with participants Details of participants are also given at next chapter

Chapter 3 : Research backgrounds and research

methodology

Vietnam's transition from an underdeveloped economy to a middle-income country has coincided with the rapid urbanization process The latest census data in 2009 showed that Vietnam's urban population over 25 million, accounting for 29.6% of the total population,

an increase of 40.4% compared to the previous census results in 1999 Ho Chi Minh City and other cities in Vietnam are growing along with the process of urbanization According

to the economists, the city exists for enterprises and employees will be more productive activities in close proximity This is called the advantage gained from the gathering in the same place (Duranton and Puga, 2004) When businesses close together, they can support each other in many aspects of production, labor, distribution, services or consumer And HCMC is typical in gathering production and residential activities Economic growth of HCMC is 11% or even faster 50%, while the average economic growth of Vietnam is nearly 7% in the past 10 years Vietnam's urban population nominal rate is 3.6% per year, from 1999 to 2005, but the actual rate is properly 5%, if counting for migrants and the urban extension Meanwhile, the official population of the city in 2007 was 6.6 million, an increase of 3.1% annually since 2002 Nevertheless, the entire population including migrant workers can be up to 8 7 million people Independent estimates also showed an absolute increase of 400 to 500 thousand people per year in the city (Dapice et al., 201 0)

Until 2010, HCMC population is 7.2 million, while age from 15 to 65 is 4.7 million, male has 2.3 million, and female has 2.4 million (Statistical Office in HCMC, 2010) Along with the huge development of economic, cultural, social life of people also increase a big step The penetration of many outside culture around the world also brings a lot different thinking to the urban Reported from survey in 2010 outlined in the online conference with ministries, departments, representing 63 Department of Information and Communication across the country on 11th Oct that besides the percentage of households with home

telephone, personal computer, statistics also show that the rate in HCM City households have Internet connection is 33%, the percentage of households using Internet is 35%.This helps to open opportunities to reach to the world cultures

However, the consequences also accompany with this development The Ministry of Public Health in Vietnam has reported that there are about 300,000 people in Vietnam has infected with HIV since this disease was discovered about 30 years ago Currently, HCMC has the highest rate of people has HIV which is at 560 infected over 100,000 people The proportion of HIV I AIDS infected of male: female was 4:1, and the majority of women got HIV I AIDS infection from their partners (Ministry of Health, 201 0) By analysing the cases

of HIV in HCMC, what happened in the first 5 months of 2012 similar to 2011: working age 20-39 still account for a large portion of infection cases 82.9% The transmission occurred mostly via drug injection and sexual intercourse (male-male and male-female) Entire 24 districts and 322 communes and townships have case of HIV infection Moreover, prevalence of women has continued to increase: 28.3% in 2011, and 31.4% in the first five months of 2012 (HIVIAIDS Control and Prevention Committee of HCMC, 2012)

Beside the risk of the sexual transmission disease, women in Vietnam are facing with unplanned pregnancies, and abortion These are big challenges to women, especially for young women who had unsafe sex as it will be huge changes in their lives The problem of unwanted pregnancy and unsafe abortion among adolescents and young people is a problem

in Vietnam is very interested, especially Ho Chi Minh City According to the General Office for Population Family Planning of Vietnam in 2011, Vietnam has the highest in Southeast Asia and the fifth in the world of abortion in adolescents (aged 15-19 years) Every year, there are average about 300,000 cases of abortion at the age of 15-19, accounting for 22% of all abortions And there is more serious when it is in an uptrend Particularly in HCMC, the number of abortions is three times more than (66 cases/100 live births), the number of abortions has about 4% in adolescents and young adults The concern

is abortion ranked third among the causes of death for pregnant women and one of the causes of infertility

3.2 Research Methodology

This study used only qualitative method to explore the understanding of participants

towards sexual health protection (or some time called sexual risk prevention) Qualitative methods have much to offer those studying health care and health services (Pope and May, 2006) With this kind of sensitive topic, the qualitative method is used as the flexible way

to discover the in-deep understanding of people The respondents of this research were the

21 women and men, with a range from 18 to 40 years old HCMC with the rapid development and population explosion as we mention above was chosen as the place for this research We had the face to face discussion in the in-deep interview (IDI) The discussion took place during Jun and July, 2011 The respondents were chosen in HCMC, should be sufficient with some kinds of condition, called screening, as above description; and selected with different level of income

This study used only qualitative method, using NeedScope method Firstly, we used the designed questionnaire to look for the relevant respondents The respondents of this research could be the urban woman and men, with a range age from 18 to 40 years old This phase endured until we find out enough respondents to take in to in-deep interview We face-to-face discussed about perception of sexual health protect

3.2.1 Analytical framework

The research use Theory of Planned Behavior as the foundation theory to finds the result about sexual health protection The questions for the interview also followed the basic of theory, and the framework of this research is as below

Figure 1: Theory of Planned Behaviour

What comes to your mind when saying about "sex"?

What do you think about sex relationship?

What do you know about sexual risk and sexual risk prevention?

Subjective Norms shows the beliefs about the normative expectations of others to their intentional behavior In this study, subjective norms showed the information about what important people of participants think about of sexual risk prevention The more

participants value their important people's social approval, the stronger the influences of them could take into account with participants Therefore, the motivation could affect the participants' intentional behavior The significant people here could be their parents, close friends, siblings, or their partner To explore the result of subjective norms, the questions were used:

Who you could share or ask if you have concern about sex relationship/sexual risk prevention?

Most people who are important to you think that you should use sexual risk prevention method when having sex?

How much their sharing do you want to be like them?

Perceived Behavioral Control shows the beliefs about the presence of factors that may facilitate or difficulty the performance of the behavior According to theory, the person's intention to behavior will be much greater if they could handle the factors that may affect to their action In this study, we need to discover which kind of factor could have facilitate or impede the action of participants is using the risk prevention method, and how much this factor could lead to the determinant of using risk prevention methods To discover this, the question was used:

What advantage/ disadvantage of using sexual risk prevention method

3.2.2 Qualitative methods

With the sensitive social theme, qualitative research, along with NeedScope method, promises more practical result potentially Qualitative method is also appreciated for health research itself Qualitative methods have much to offer those studying health care and health services (Pope and May, 2006) Comparing to quantitative method is for seeking to confirm hypotheses about phenomena, to quantity variation; qualitative method is for seeking to explore phenomena, to describe variation, describe and explain relationship, to describe individual experiences, to describe group norms (Mack et a!., 2005) Using the open-end question format, qualitative method has the flexibility in some aspects of study

the response of participants affect the how and which questions researchers· ask next Moreover, the study design of qualitative method is iterative, data collection and research questions are adjusted according to what is learned With the most important difference to quantitative research is flexibility, qualitative method brings the most comfortable atmosphere to the discussion and gives the spontaneous and pure response from participants Besides, these open-end questions give respondents the opportunity to responds by their own words, which could apart from what researcher expect, and give useful, rich and explanatory answers in nature

There are three most common qualitative methods Participant observation, which is for collecting data appropriately, based on observe what behavior participant act in their usual circumstance, naturally In-depth interview is used in this study, which is for collecting data on individual's experience, personally, one-to-one, face-to-face talk; this method is normally used in case of being explored sensitive The private atmosphere will give the pleasant and comfort for respondents Focus group discussion is for collecting the data on the cultural norms of group and creating the general view of points of one concern

in the cultural groups

Taking the advantage of qualitative research, and NeedScope model, the in-deep interview started after participants were screened First of the discussion, we share some general information about participant; share the opinion about the sex, sexual relationship, then about sexual risk and sexual risk prevention Because this respondent was screened to make sure that he/she feel open-heart to share sensitive information This conversion leads

to their sexual life and which kind of prevention method they use currently or before At this step, we based on which kind of method they use to ask for next question This could

be condom, oral contraception pill, cervical cap, or behavioral method It depended on participant choice, and then we lead the next question Besides, the discussion talked about the person who participant believes in sharing sensitive information with Following respondents information, we asked to know how strong this person could affect the participant's intentional behavior Besides, the discussion revealed the factors that affect to their behavior For example, the respondent talked about using condom will make him feel

itchy; we follow his sharing to ask about which advantage or disadvantage of using condom, and more That information may be just the spontaneous action that they're not aware of act, but they could give many benefits in the result Then, we asked them for using the NeedScope model In this phase, showing them the show card with six groups, represent for men or women nowadays, and asked them to match with some kind of prevention method that they list above; then, guided participant to talk about this archetype The questions are the same with what they were asked above, but repeat for six groups When talking about other person, not himself, the participant would be very free to talk about this Through which, it shows the most nature perception, opinion in them, especially

at archetype who has the same choice of method with them Through this method, we could have the purest information from participants which we wish to have at this study

As the Theory of Planned Behavior above, in the in-deep interview, we try to figure out the attitudes and perceptions, subjective norm and perceived behavior control Difference to quantitative method, at qualitative method, we elicit the sharing of participants via the open question, then rely on the answer, we ask the next question As above description, we have some specific questions for each part of sections to elicit the information During the interview, we did not try to keep the order of the questions that have to follow the flow of attitudes, subjective norm and then perceived behavior control Instead, we based on the sharing of the respondents, and then try to elicit the needed information Certainly, the question has to follow the flow of guide line question The detail

of the question guide is in appendix Here, I would like to highlight the key and the purpose

of questions in the in-deep interview

First of all, we mention about the definition of the attitudes and perception, subjective norm and perceived behavior control In the Theory of Planned Behavior, it already describes the key idea of three above elements To go to the purpose of predicting if

an individual intends to do something, we need to know:

Whether the person is in favor of doing it: it comes to know the "Attitude"

How much the person feels social pressure to do it: it comes know the

"Subjective Norm"

Whether the person feels in control of the action in question: it comes to know the "Perceived Behavioral Control"

In this study, we need to know what the A&P about sexual risk prevention is First

of all, the interviewer has to know what is the sexual risk and sexual risk prevention Sexual risks are mentioned at this research is the STis, HIV/AIDS and unplanned pregnancy Sexual risk prevention methods are mentioned was the method used before, during or after the intercourse In this research scope, they could be condom, daily oral contraception pill, emergency contraception pill, IUD and behavioral method

To elicit the participant' responses about this, the interview begins with the question about their sexual lives, then linked to their sharing about sexual risk and sexual risk prevention method they used to use or use currently The question is:

What do you think of sexual risk/ sexual risk prevention?

What kind of sexual risk prevention you know?

About the subjective norms towards using sexual risk preventions, the study mentioned about the think of the most people who are important to respondent towards using prevention method Most people here could be parents, close friends, friends, relatives or sexual spouse To find out who is important and how strong they affects to respondents' intention to behave, that start from this kind of questions:

From which one/source did you come to know this prevention method?

How do you parents said if they know you use/not use this prevention method?

How does your spouse feel/feedback if you use/not use this prevention method?

About the perceived behavior control towards sexual risk preventions, this research referred about the ease or difficulty towards using/not using the prevention methods They could be the side effects of oral contraception pill, or could be the unpleasant feeling when using this method The questions are:

What are the main reasons for using/ not using this method?

Why do you use this method?

If the side effects like this, how to you feel when using this method?

What are the concerns about this prevention method you wish you could avoid or find a solution to?

What would you look for in using this method?

During the interview, we played a very important role for the spontaneous answers,

it revealed the highest priority of participant to the question For example, if the question is

"why did you use the condom?" the answered is "I do not want to get pregnant before marriage" spontaneously That means the most important thing in their mind is

"pregnancy", not "STis"

3.2.3 Tool

This research was using the NeedScope method during the discussion to creating the comfortable and trusted environment NeedScope™ is a qualitative and quantitative research system for understanding and managing emotion throughout the marketing process, which is used by research market organization around the world This method is described as below

NeedScope Model

Originally, The NeedScope model which is a state of the art model, aims to unravel the relationships between consumer needs and brand images NeedScope is a qualitative and quantitative research system for understanding people's emotion It uses the archetypes model, which classified based on two sets of archetypes: Affiliation (warm and receptive)

vs Individualism (assertive and independent) and Dynamic vs Static (outward vs inward).For every layer of consumers' needs, there is a corresponding layer of brand image which associate with one services or product In our paper, this is a tool to understand in-deep interviewee when talking about sensitive issue

Technically, NeedScope has three elements form foundation; which make the system uniquely able to measure and understand emotion This is Consumer-Brand relationship model, Psychological model, and Projective tool

Figure 2: The layer of needs

Source: The NeedScope System™

Consumer-Brand relationship model:

Consumer needs are complex and multi-layered, including Functional needs, Identity needs, and Emotional needs Functional needs surface clearly and we're easy to catch up For example, with the cell phone brand, everyone acknowledges the original function of cell phone is for immediate and direct communication, including talk/hear and send/receive message However, the Emotional needs lurk beyond the functional and identity needs That causes why this person likes Nokia

and others prefer IPhone, because it reflect their emotional needs via choosing brand of cell phone; it is showing their modernity or economy Even they are affordable for main functions Similarly, a product or service also has multi-layers, from Product features, Social Values, to Symbology The point of a product or service is consistent between these layers at Consumer and Brand This research does not mention consumer and brand particularly; however, the research still using brand as just a tool to unravel the perceptions of interviewee

Project Tool:

The NeedScope accesses the emotive layer by allowing respondents to project their emotions through other people by photosets and collages Based around the NeedScope archetypal model, they are more powerful than traditional projective tool as it is always easier for talking about other people than about ourselves, especially in sexual health protection perception With NeedScope, respondents talk about perceptions from perspective of the people in the collages

The collages include 6 groups of people, separates for male and female These collages are used as an archetype during the discussion Each group does not strictly discriminate in ethnic, religion or age , but has distinct personalities or feelings which could represent for different characteristic ofpeople in society The collages distinguish the kind of personality as below:

First group is represented by red colour; they have the same personality such as: Bold, Dynamic, and Independent

Second group is represented by purple colour; they are confident, assertive, forthright

Third group is represented by blue colour; they are illustrated as focused, competent and intelligent

Fourth group is represented by brown colour; they are the same characteristic such as kind, gentle and sensitive

Fifth group is represented by orange colour; their personality is described as warm, approachable and practical

The last group is represented by yellow colour; they are fun-loving, carefree and spontaneous people

Figure 3: The collages ofNeedScope model

Source: The NeedScope System™

In order to reduce the case of shy people that could make the discussion become silent and useless, we should have the standard to recruit the relevant people in our groups The recruitment included the income at the first stage, then, during the face-to-face discussion, we could repeat about this stuff just for confirmation, we could give some conclusion then about this information

The discussion details are designed based on our research requirement The discussion flow is followed the discussion guide First of all, the interview will start with some sharing about participants' thinking and understanding about sex relationship and sexual health protection In the second step, we give them the show card with 6 groups of people; let them give their ideas about these people: how these people think about sexual health protection, or which kind of method they will use When taking about another person, not themselves, participants will feel very free and comfortable to sharing what they think the person in collages will do, but actually, this is what they think they will do Through which, we will have the most accurate information from our participants This is the purpose of using NeedScope model in this study

3.2.4 Participants and studied location

Participants are recruited from HCMC They were screened based on some of questions which to identify the suitable person to join this survey The participants are selected randomly at many areas: supermarket, office area, or residential place in urban HCMC With the characteristic of sensitive topic, I'm not assumed that all people are willing to share their point of view HCM is a huge development city with many of immigrants from other cities or provinces, the diversity of occupation was also reflected in the participants Except the professional person which pertain to topic, like: pharmacist, doctor, nurse, manufacturing, sale or distribution of any contraceptive related products or servic~s,

because their professional knowledge about topic will make the bias in result So, the careers were divided to some kinds of: white collar, blue collar, business owner, retire, housewife, jobless, others Actually, in the discussion after that, we finalized the occupation once more The gender, age were recorded to select the balance of gender, age in the

;

discussion later Certainly, the participants are in range which we wanted to research, from

18 to 40, and the education is from high school graduated Besides, respondents should be open-mind and quite talkative people who are willing to share and describe fluently their thinking The detail of screening question is shown at the appendix D After screening, the respondents go to in-deep interview; this could bring a comfortable atmosphere for respondent to share there thinking at this sensitive topic, at face-to-face, one-to-one discussion

The respondents in this study, after screening, are 21 people, which are 8 male, 13 female Respondents have different kinds of occupation, such as: officer, human resource, part-time, business owner, students, receptionist in restaurant, clothes seller They could

be married, have spouse, or not in any relationship at this time, which means variety of occupation, education, and income

The information of participants is described as below:

Table 1: Sample information

1013 Female 35 Restaurant receptionist Engaged, preparing for marry

Husband work in the same

1014 Female 29 Human resource

company

1015 Female 40

Housewife, before was

3 kids, husband is a worker teacher

No Gender Age Occupation More information

IDI6 Female 39 House/Land agent, owned 2 kids, working with husband

business 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

Work in family job 2 kids, wife works in the same IDilO Male 39

office IDI11 Male 34 Personal business In relationship with girlfriend IDI12 Female 31 Work at bridal shop 1 kid, husband is photographer

.- IDI13 Male 26 Work at fashion shop In relationship with girlfriend

IDI14 Male 34 Own Barber shop 1 kid, wife is makeup staff IDI15 Male 35 Own telephone card shop Married, no kid

IDI16 Male 27 Human resource operation In relationship with girlfriend

of insurance company IDI17 Female 31 Diplomatic staff 1 kid in primary school IDI18 Female 27 Officer staff 1 kid

Female 21 Studying Not married, in relationship with IDI119

boyfriend

No Gender Age Occupation More information

IDI20 Female 35 Work in family company 2 kids

IDI21 Female 28 Officer staff Not, not in any relationship

This chapter explained about research methodology, why using qualitative method is the most suitable for this kind of topic And it also described about NeedScope model, how we use this tool to get the in-deep understanding from respondents This chapter also gave detail information of participants, how to recruit the sample Applying the NeedScope model in the interview, basing on the theory of planned behavior, we try to get the most appropriate and spontaneous answers from interviewee And next chapter described this study's results in detail

Chapter 4 : Empirical results

4.1.1 Attitude and perception

Most participants perceived that sex is an instinct It is a necessity of life, as well as the foundation of love, stable cohesion and sustainable marriage The average age of first marriage has increasing for both male and female The average age is 26.2 for male and 22.8 for female (UNFPA, 2011) Naturally, the distance between puberty and first marriage also rise, causes the higher risk of premarital sex In this research, majority of respondent perceived that sexual relationship should be avoided in premarital relationship, that what they are advised from family; however, they also perceived that in current times,

it is less important about keeping chastity as before; the relationship suddenly get bored if two persons just follow normal dating like go to cinema or get some drinks

That is normal, but it is just serious in Eastern perception If it comes, just follow the instinct, as long as do not make the consequences (IDI9)

Before, I also think about keeping, but when going to a serious relationship,

I see that just go out for drinking or going around the city, or watching movies are so normal, kiss eye, kiss lip are also normal And because of we're truly in love (IDI2)

Whether the person has different idea about sex, they do have the same idea that this topic is not what can effuse to everyone, especially with parents This conclusion is similar

to a study in Hanoi, sexuality I sexual health is a difficult subject The mother said they would soil her daughter's mind if actively talking about this issue, as well as they believe that their daughter have a sex education in school (Ida Neuman, 2006).When parents are not actively open, the children feel shy to mention too; or some situations, children start mention to this topic but parents do not response Overall, participants found that they did not interview with one voice and perspective about sex with their parents Therefore, it is not the topic in family

Sometimes, I feel that my brother and I live in one world, and my parents live in a totally different world (IDI9)

Right after knowing I got boyfriend, my mother ask me to go back to hometown to have discussion (ID/17)

As most people interviewed, their view of sexual relationships is the relationship of trust and long term They say love and sex are parallel with each other It is a way to develop a long term relationship, more serious and sincere

After this, we feel more understanding each other (IDI8)

This point is difference between groups with low-income and high-income In particular, high-income groups think that there is a separation between love and sex This group said that sex is a no obligation relationship between two people; they saw it as a regular expression between men and women

I see that is normal for male, even though they do this many times before marriage, why not for the female, I do not like this (IDI9)

Meanwhile, low-income group said that sex is a sensitive issue For unmarried people, they thought sex means binding themselves to the others; there is no chance to come up with better ones They felt that this lead to marriage, even though the confliction appear after sex, and easily lead to divorce later For those who are married (and no sex before marriage), they believed preserve of virginity before marriage is important for the girl

I think it would not have sex before marriage, whether or not having social restrictions I have daughters, I also managed them it does not have sex before marriage, and then it is detrimental For example, people are sure that you are not married, after married then we belong together Before, my husband often invited me to go out for dating, but there was no stories related images like this; no, two of us did not ask for anything before, even