CULTURAL CONTEXT AND ATTITUDES TOWARDS AND PRACTICES OF CONDOM USE: FINDINGS FROM A STUDY AMONG VIETNAMESE INJECTING DRUG USERS IN AUSTRALIA
Hien Thi Ho1, 2*, Zarah Rahman1, Jacqueline Rudolph3, Lisa Maher2,4
ABSTRACT
Evidence suggests that culture infl uences health beliefs and behavior, including risk-taking behaviors. This study explores sexual attitudes and practices pertaining to condom use among a group of ethnic-Vietnamese injecting drug users (IDUs) in Australia.
Ethnographic fieldwork and in-depth interviews (n=58) were conducted in South Western Sydney. Interviews were electronically recorded and transcribed verbatim. Open coding was used to classify data into themes, and data were examined for regularities and variations in relationships between and within themes.
Results illustrated the relationships between traditional Vietnamese cultural beliefs (mainly
rooted in the Triple Teachings of Confucianism, Buddhism, and Taoism) and participants’ beliefs and attitudes toward sexual relationships. The infrequent use of condoms with regular sexual partners and frequent use of condoms with casual partners were embedded in cultural factors such as trust and obligation, stoicism and self-control, belief in fate, and the desire for balance and harmony in body and in mind.
These fi ndings highlight the need to understand the cultural contexts of risk for sexual transmission of HIV, particularly in relation to condom use, in order to design and implement culturally appropriate and effective prevention interventions.
Keywords: Culture, Beliefs, Attitudes, Practices, Sexual Risk, HIV, Condom Use, Injection Drug Use
1 Hanoi School of Public Health, Hanoi, Vietnam
2 School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia 3 Department of Anthropology, University of Colorado, USA
4 Kirby Institute for Immunity and Infection, UNSW Australia, Sydney, Australia.
INTRODUCTION
Research evidence indicates that numerous, complex and intertwined factors infl uence the risk-taking behaviors, preventative practices, and health-seeking behaviors of individuals and communities. Among these, cultural beliefs stand out as salient, yet insuffi ciently understood, factors that infl uence health. This article presents data on the impact of cultural infl uences on sexual beliefs and risk-taking behaviors in a sub-population of injecting drug users (IDUs). In addition to exposure to health risks through injecting practices, IDUs and their sexual partners may also be at risk of sexual transmission of HIV. In particular, we examine cultural infl uences on attitudes towards condom use among a group of ethnic- Vietnamese injecting drug users (IDUs) living in Sydney, Australia.
Health beliefs are cultural products and have been observed to infl uence decisions about medical treatment, treatment adherence, patient satisfaction, and clinical outcomes.
Additionally, health beliefs infl uence preventative practices, perceptions of risk, and risk behaviors1. As Douglas contends, lay perceptions and judgments of risk are infl uenced by cultural and social processes, which are based on “shared meanings” of risk within a cultural group2. This explains the emergence of culturally distinct patterns for perceiving and dealing with particular risks3. The infl uence of culture on sexual norms and sexual risk- taking behaviors has been well documented in many communities around the world4. These studies have found that culture infl uences values regarding sexuality, marriage, gender norms, and motherhood and directly infl uences sexual risk behaviors. As a result, public health programs, especially those related to sexual
health, are more effective when they take into account the cultural beliefs and attitudes of the target group, a concept and practice referred to as “cultural sensitivity”5.
This cultural framework and its relation to condom use practices will be examined within a population of IDUs of Vietnamese descent living in Sydney, Australia. The majority of Vietnamese living in Australia arrived as refugees after the fall of Saigon, ending the Vietnam War in 1975. The epidemiology of HIV infection among Vietnamese in Australia mirrors that of Vietnam, being primarily driven by injection drug use, with the potential for transition to a sexually driven epidemic. During the 1990s, several studies documented high levels of harm associated with injection drug use among Vietnamese in Australia, suggesting that Vietnamese IDUs were at increased risk of blood borne viral infections, including HIV and hepatitis B and C5 and the need to develop culturally appropriate interventions for this group6. This current paper aims inform the development of culturally sensitive prevention interventions by investigating the ways in which traditional Vietnamese culture interacts with condom use practices.
METHODS
Observational fi eldwork and in-depth interviews were conducted in three Sydney neighborhoods with high proportions of IDUs of Asian descent and street-based drug markets in 2002-2005.
Eligibility criteria for participants in this study were: 1) Vietnamese cultural background;
2) aged 16 years and over; and 3) injected drugs in the last 6 months. Ethical approval for the study was granted by the University of New South Wales Human Research Ethics Committee, and participants were reimbursed
$AUD 20 for each interview. Participants were recruited using a mix of theoreticaland snowball sampling strategies, drawing on street-based and social networks and previous research contacts. Theoretical sampling, or purposive selection of information-rich cases for in-depth understanding, continued until
“data saturation” or the point at which no new insights were obtained.
A total of 58 in-depth interviews with Vietnamese IDUs were conducted: 23 in English, 30 in Vietnamese, and 5 in a mixture of English and Vietnamese. Interviews were conducted on the street; in restaurants, bars, and coffee shops; and in private homes. Interviews were tape-recorded, transcribed verbatim in the language in which the interview occurred, and translated into English where necessary.
Qualitative data were processed manually using open coding to classify data inductively into initial categories or themes, followed by axial coding to examine the data for regularities and variations in relationships between and within themes7. The analysis presented here focuses on sexual beliefs and practices, relationships and partner-types and attitudes towards prevention and safe sex.
RESULTS AND DISCUSSIONS
Low rates of condom use among Vietnamese IDUs were reported in the quantitative component of the larger study from which these data were drawn. The majority of survey participants (91%) reported ever having unprotected sex and most of survey participants (79%) reported preferring not to use condoms. Consistent condom use within the last month varied according to type of sexual relationship: 53% (9/17) had used a condom with new sexual partners, 28% (8/29)
with casual sexual partners, and 19% (10/53) with regular sexual partners. Participants in the study also had a high mean number of sexual partners with whom they had ever had unprotected sex (6 partners).
Attitudes toward condom use
Preference was one reason given by study participants for choosing to not use a condom during sexual intercourse. In-depth interviews confi rmed that many respondents do not like and are not accustomed to using condoms. Condoms were perceived as
“unnatural” and resulted in a “loss of feeling”
during intercourse. Participants described condom use in a number of ways, such as
“doesn’t feel good”, “loss of feeling”, “don’t enjoy”, “don’t have the same pleasure”, and “feel nothing”. While recognizing the risks associated with unprotected sex, this dislike of condoms frequently kept both male and female study participants from using condoms even when having sex with new or casual partners.
I don’t believe in condom, no. Because I don’t feel it, that’s why. You know, I put the condom on, and I don’t feel it. I don’t believe in condom.
And I say to you alright, if I know even she’s got AIDS, I want to have sex with her, I’ll take my chances without the condom, I have sex with her. I don’t care, just go for it. And that’s it, you know. Yeah, I tell you Vietnamese people never use the bubble [condom] (Phi, 39 year- old male).
Study participants also commonly complained of the “hassle” of using condoms. Respondents found it inconvenient to buy and carry condoms, take one out during sexual intercourse, use it correctly, and dispose of it afterwards. Most
participants reported not always carrying condoms with them and, therefore, not being able to use them in instances of unplanned or unanticipated sex. Higher condom usage was reported during planned sex.
Vietnamese use condom less than Westerners maybe because black-hair people don’t use it often. That’s why they don’t bring it with them.
Westerners they can make love anytime, that’s why they always have [condoms]. Vietnamese, we go out with girlfriend, we only think we are going out. We leave condoms at home (Hung, 25 year-old male).
In addition to personal preference or convenience, the data also revealed a very strong negative association with condom use, which might be linked to Vietnamese cultural values and results in stigma associated with buying, carrying, and using condoms. The strength of this stigma associated with condom use is illustrated in the following excerpt.
Well, stigma has a lot to really infl uence just the way people going out to get it, going out to buy condoms, going out to get needles and that.
I was pretty young then so I didn’t know about it that much. I would be scared to leave a pack of condom under the carpet in my room because they will look bad, my parents will be upset, or embarrassed even (Lan Anh, 25 year-old female).
While dislike of condoms has been reported in research across different groups, our data indicate that cultural pressures to maintain face and uphold the reputation or name of the family may work to deter Vietnamese IDUs from using condoms.
Condom use with regular partners
Trust and obligation between sexual partners also greatly influenced the desire and willingness of participants to have protected sex. While male Vietnamese IDUs were more likely to report condom use with female sex workers, they rarely, if ever, reported using condoms with regular sex partners. Vietnamese often link condom use to extramarital sex, premarital sex, and prostitution, not to loving, socially sanctioned relationships.
I hardly use condoms, only when I play with prostitutes. I don’t use condoms with my wife, because she’s clean, she’s only with me, she doesn’t sleep around so she can’t be dirty (Minh Khoi, 36 year-old male).
I only have sex with like with like my partner, you know, I don’t sleep around, so I don’t really need condom, you know what I mean. It’s safe if I just have it with that one person. If I sleep around, I would wear a condom. If I only have sex with that one person, so I don’t really need it and don’t really like condom (Truc Quynh, 29 year-old female).
Some participants stated that they regarded unprotected sex as a way to demonstrate their trust and love to their partner. There is great hesitancy to let suspicion and distrust taint a relationship, and respondents felt an obligation to guard the feelings of partners.
If you do that [use condom], they will feel inferior because they think why you have to do that? It is not good, do you understand? Some people they don’t like it if I wear condoms (Au, 33 year-old male).
These fi ndings are consistent with the results of research conducted by Rhodes and Cusick8
with HIV-positive drug users and their sexual partners in London, indicating that trust and obligation are not just characteristics of Vietnamese relationships. Rhodes and Cusick found that there was a tension between viral risk management and relationship management. Trust and intimacy provide a sense of security and safety in a relationship, and unprotected sex is found to be a powerful symbol of trust. For these reasons, unprotected sex is sometimes found to be an acceptable risk, demonstrating the power of emotions in risk management.
Condom use with casual partners
The quantitative data of this study indicated that patronage of female sex workers was common among male IDUs, with a small group regularly visiting sex workers, both in Australia and during travel to Southeast Asia. Although only three survey participants reported purchasing sex in the last month, 53% had ever purchased sex, and 19% had purchased sex in the last twelve months. These accounts are consistent with research conducted among Vietnamese men living in metropolitan Sydney that also found commercial sex to be common (approximately 20% of study participants) and condom usage with sex workers to be inconsistent9. Low levels of condom use increased the vulnerability of Vietnamese IDUs to contracting and transmitting sexually transmitted infections.
In contrast to regular sex partners, participants reported using condoms with commercial sex
workers or casual partners – where there is no expectation of trust – more frequently. This was seen in the quote above, from Minh Khoi.
CONCLUSIONS
This paper has provided insights into condom use practices within a specifi c cultural context shared by Vietnamese IDUs in Sydney, Australia. This group is at high risk of hepatitis C virus (HCV) and potentially HIV infection through risky injecting practices10,11,12. Our data highlights the potential risk for sexual transmission of HIV among this group. For instance, infrequent condom use is a risky sexual behavior that was common among IDUs in this study.
Differences in attitudes towards condom use by partner type were observed. For regular partners, apart from the fact that condom use can lead to
“loss of feeling” , trust and obligation, as well as beliefs in fate are key barriers to safe sex.
The relationship context is a potential target for interventions designed to increase safe sex with regular partners.
Our analysis highlights the importance of cultural factors in shaping risk behaviors13. In order to be acceptable, interventions need to take into account of these factors, and in particular, the importance of trust and how condom use with regular partners may be seen as a betrayal of trust. Tools such as behavioral change communication14 are potentially useful in unpacking and addressing these infl uences as well as attempts to improve negotiation skills among IDUs.
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