This research is a cross-sectional secondary data study based on the 2022 Ghana Demographic and Health Survey (GDHS) conducted across Ghanaian communities, which followed a cross-sectional design [21]. The 2022 Ghana Demographic and Health Survey (GDHS) provides comprehensive national data on demographic and health indicators, ensuring consistency with past DHS surveys in Ghana and similar studies in other developing countries. This data enriches the extensive global database of population-based metrics for Ghana. The survey, conducted with a sample representative of the nation, included approximately 18,540 households selected across 618 clusters covering all 16 regions. Of these households, 18,065 were found to be occupied. Among the occupied households, 17,933 were successfully interviewed, reflecting an impressive response rate of 99%. In the subset of households designated for the male survey, 7263 men aged 15 - 59 were identified for individual interviews, with 7044 of them successfully participating, resulting in a response rate of 97%.

The 2022 Ghana Demographic and Health Survey (GDHS) was conducted from October 17, 2022, to January 14, 2023 by the Ghana Statistical Service (GSS) [21]. Therefore, thedataforthisresearchweresourcedfromthemalequestionnaireoftheGDHS, encompassing topics such as HIV knowledge, transmission methods, information channels, STI and HIV prevention behaviors, stigma, and HIV testing background. The survey received technical support from Inner City Fund (ICF) under the Demographic and Health Survey Program (DHS), which is funded by the United States Agency for International Development (USAID) and the U.S. President’s Malaria Initiative (PMI).

2.3.1. Inclusion Criteria

The 2022 GDHS utilized a male-specific survey to gather data from eligible individuals aged 15 to 59 residing in 17,933 households in Ghana. This study only included adolescents and young adult men aged 15 to 24 years who consented to participate and completed the study from this population in Ghana.

2.3.2. Exclusion Criteria

The following were excluded in this study: 1) men under 15 and 25 years and older; and 2) women in Ghana.

The 2022 GDHS adopted the updated sampling framework devised by GSS, utilizing data from the 2021 Population and Housing Census, with interviews conducted among 17,933 households involving 7044 men aged 15 to 59 [21]. In the current study, 2453 adolescents and young adults aged 15 - 24 years in Ghana were selected and included in the analysis.

The 2022 GDHS utilized a stratified two-stage cluster sampling technique to ensure the generation of nationally representative data encompassing urban and rural areas, as well as all 16 regions, covering diverse DHS indicators. Initially, 618 target clusters were chosen in the first stage using probability proportional to size (PPS) for both urban and rural areas within each region. Subsequently, an equal number of clusters were selected through systematic random sampling from those identified in the first phase, ensuring representation across urban and rural areas in each region. Following cluster selection, an extensive household listing and mapping operation was conducted in all selected clusters to create a comprehensive roster of households, which served as the sampling frame for household selection. To ensure the accuracy of this process, the Ghana Statistical Service (GSS) organized a 5-day training course on listing procedures for the appointed listers and mappers, with support from ICF. These personnel were divided into 25 teams, each consisting of one lister and one mapper, tasked with completing the listing operation over a two-month period. Alongside household listing, listers also recorded the geographical coordinates of each household using GPS dongles provided by ICF, adhering to guidelines outlined in the DHS Listing Manual. Tablet computers equipped with software from The DHS Program facilitated the household listing process. Finally, 30 households were randomly selected from each cluster for an interview, ensuring a standardized approach to data collection.

The Demographic and Health Survey (DHS) administered a pretest before gathering data, followed by a debriefing session with the pretest field workers. The Ghana Statistical Service (GSS) confirmed the accurate collection and documentation of data protocols. Subsequent adjustments to the questionnaires were made as necessary. The questionnaires were then definitively translated into three local languages—Twi, Ga, and Ewe. To ensure precision, independent individuals conducted back translations into English. Any translation issues were resolved before the scheduled training of trainers and the pretest. After finalizing the questionnaires, ICF staff worked with GSS staff to develop Interviewer and Supervisor/Editor’s Manuals, as well as fieldwork control forms for monitoring survey progress. These manuals provide guidance to interviewers and supervisors/editors, clarifying the purpose of various questions and sections of the questionnaires, and assisting trainers in conducting pretest and main survey training sessions. More details on the data-collection process can be found at https://www.dhsprogram.com/.

On November 27th, 2023, permission to use the GDHS datasets was obtained from the Department of Health and Human Services (DHS) Inner City Fund International (ICF). The study was conducted with high ethical considerations while adhering to established protocols. A summarized report of the 2022 Ghana DHS data by the GSS is available at https://www.dhsprogram.com/. Initially, the GSS submitted the survey protocol to the Ethical Review Committee (ERC) of the Ghana Health Service to ensure compliance with Ghana’s ethical research standards, and the ERC granted ethical clearance for the survey. Similarly, ICF submitted the GDHS survey protocol to the ICF Institutional Review Board (IRB) to obtain ethical clearance, ensuring alignment with US and international ethical research standards, and the IRB approved ethical clearance for the survey. The Department of Health and Human Services (DHHS) Inner City Fund International (ICF) gave approval on November 27th, 2023 through approval number 193342. Throughout the study, data confidentiality was strictly maintained. Ethical considerations, including informed consent, confidentiality, and privacy, were addressed by the DHS office. There was no manipulation of the microdata beyond the scope of this study, and there was no involvement of patients or the public, thus adhering to the principles of the Declaration of Helsinki.

In the present study, we conducted descriptive statistics by computing and tabulating frequencies and proportions of the socio-demographic variables due to the categorical nature of the variables. A binary logistic regression analysis was conducted to ascertain the relationship between the dependent variables, and independent variables among adolescents and young adults’ men in Ghana. To determine the probability or likelihood of an association between these variables, the odds ratios (OR) and 95% confidence interval were computed. The IBM Statistical Package for the Social Sciences (IBM SPSS version 29) was adopted in analyzing the data, while the statistical significance was set at p < 0.05.

2.8.1. Dependent Variables

The dependent variable assessed in this study was condom use behavior. This variable was evaluated through the participant’s use of condom every time they had sex with the most recent partner in the last 12 months thus, “was a condom used every time you had sexual intercourse with this person (sexual partner) in the last 12 months?” This variable was coded dichotomously as “yes” or “no”.

2.8.2. Independent Variables

Sexual correlates (sexual activity, multiple sexual partnerships, STIs, genital sores, and genital discharge) were chosen because of their dominance in the literature and their availability in the DHS dataset. Sexual activity was measured by asking the participants: “I would like to ask you about your recent sexual activity. When was the last time you had sexual intercourse?” This was originally coded as 0 = Never had sex, 1 = Active in the last four weeks, while 2 = Not active in the last four weeks. In this study, this variable was re-coded as 0 = No (Never had sex) and 1 = Yes (Active in last four weeks and not active in last four weeks). Similarly, Multiple sexual partnerships (i.e. sexual partners excluding spouse), were assessed by asking the participants; “In total, with how many different people have you had sexual intercourse with excluding your spouse?” This was coded as 0 = No (none) and 1 = Yes (1 or more). Furthermore, if the participants had any STI in the last 12 months was assessed by asking a question about their health in the last 12 months thus, “During the last 12 months, have you had a disease which you got through sexual contact?”. This was coded dichotomously as, 0 = No, 1 = Yes. Likewise, having genital sores was measured by asking, “sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer on or near your penis? This was coded dichotomously as, 0 = No, 1 = Yes. Lastly, genital discharge was measured by asking, “Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis? This variable was also coded dichotomously as, 0 = No, 1 = Yes.

Table 1 illustrates that the AYA population (N = 2453) predominantly comprised participants originating from Savannah (8%), Ashanti (7.8%), Oti (7.3%), Central (7.3%), Northern (7.2%), and Upper East (7%). The majority of participants were sourced from rural areas (54.5%), aged between 15 and 19 years (58.3%), overwhelmingly unmarried (92.1%), with primary/Middle/JSS education (57.3%), engaged in employment (64.1%), and identified as Christian (64.9%). Nearly an equal proportion of participants reported being sexually active (49%), with the remainder (51%) indicating no sexual activity. Furthermore, 34.3% engaged in multiple sexual partnerships with at least one sexual partner and above, however, only 6.8% had experienced an STI, 4.9% a genital sore, and 8.0% a genital discharge. Finally, only 20.7% reported the use of a condom during sexual activity (see Table 1).

Table 1. Sociodemographic characteristics of the participants (N = 2453).

The Chi-Squaretestresults showing the association between sexual correlates (sexual activity, multiple sexual partnerships, having an STI, genital sores, genital discharge), and condom use behavior are presented in Table 2. The findings indicate that only 19.3% of sexually active participants (786) utilized a condom during the last sexual intercourse. Similarly, only 29% of participants who engaged in multiple sexual partnerships (841) used a condom during their last sexual intercourse. Likewise, only 21.6% of participants with a history of STIs, 12.5% of participants with a history of genital sores, and only 21.3% of participants with a history of genital discharge, utilized condom during their last sexual intercourse. Overall, engaging in multiple sexual partnerships (P < 0.001), and having a history of genital sores (P = 0.019) were significantly associated with condom utilization (see Table 2).

Table 2. Chi-Square test showing the association between sex-related experiences and condom use behavior.

Note: Chi-square tests (cross tabulations) were used to calculate the prevalence estimates and the Association between Sex-Related Correlates or Experiences and Condom Use Behavior. P stands for p-value set at a significance value of α = 0.05.

The binarylogisticregressionanalysis findings (Model I) showing the relationship between sexual correlates (sexual activity, multiple sexual partnerships, having an STI, genital sores, genital discharge), and condom use behaviors are summarized in Table 3. The results of the logisticregressionmodel indicate that there were significantly higher odds of condom utilization among participants who engaged in multiple sexual partnerships (AOR = 29.87, 95% CI = 12.19 - 73.21, P < 0.001) outside their spouse than participants who had only one sexual partner (their spouse) or were never in any sexual relationships (see Table 3). Likewise, there were higher odds of condom utilization among participants with a history of genital discharge (AOR = 1.28, 95% CI = 0.73 - 2.24, P = 0.396) than those who had no history of genital discharge. Overall, just like the Chi-square test, the logistic regression results indicate that having a history of genital sores (P = 0.013) was significantly associated with condom utilization (see Table 3).

Table 3. Logistic regression analysis test showing the relationship between sex-related experiences and condom use behavior.

AOR = Adjusted Odd Ratio, CI = Confidence Intervals, Model 1 = Condom use behavior is analyzed as an outcome variable. P stands for P-value set at a significance value of α = 0.05.

This study is built upon a self-report cross-sectional primary GDHS study, potentially influenced by flaws like social desirability bias. This bias could lead participants to underreport or be affected by recall bias, potentially skewing the outcomes. The study’s design cannot definitively establish a causal link between condom use and sex-related factors due to its cross-sectional nature. Additionally, the broad or rigorous item pool in the measure used for the youngest age group [15]-[19] may impact their responses. The exclusion of female AYA in Ghana deprives the study of gender implications crucial for a comprehensive evaluation of sexual reproductive health outcomes. Future research should address this by studying both male and female AYAs concurrently to facilitate a better understanding of safe sexual interactions. Despite these limitations, this study represents a significant advancement as the first examination of sexual correlates of condom use among AYA men in Ghana using the latest GDHS data. It offers valuable insights with its large, nationally representative sample size, contributing to HIV prevention evidence in Ghana by focusing on the general AYA male population without segmenting based on behavior, sexual orientation, or gender identity.

Understanding condom use behavior among AYA men is essential to underpin the sexual behaviors and norms that shape adult life and influence both behavior and health. This study has outlined the under-utilization of condoms that is common among AYA men aged 15 - 24 years old in Ghana. Several sex-related correlates, particularly multiple sexual partnerships and a history of genital sores have some significant correlation with condom use behavior. Initiatives targeting the reduction of adverse sexual reproductive health outcomes should prioritize expanding safe-sex behavioral interventions and communication strategies focused on ensuring the consistent accessibility of condoms for young men with a history of multiple sexual encounters; thereby encouraging regular condom usage in Ghana.