CHAPTER 2: LITERATURE REVIEW
2.5 Condoms
The use of condoms as a protective tool against both sexually transmitted infections, including HIV and unwanted pregnancy in sub-Saharan Africa still heavily depend upon a vast array of context-dependent and structural factors including socio-demographic factors (Parker, Eaton and Klein, 2000; Maharaj, 2006; Leclerc-Madlala, 2002; Boer and Mashamba, 2007; Lagarde et al., 2001; Slaymaker and Zaba, 2003). Although there is an emerging consensus among a number of experts that condom use can be an effective prophylactic method in preventing the further spread of HIV infection, particularly in countries most affected by the pandemic – a consensus underpinned by the relative success in curbing the pandemic in some countries such as Thailand and Uganda (Hearst and Chen, 2004), it has ignited a great deal of controversy in various quarters. This has engaged the attention of several researchers who have been discussing their dynamics and gathered evidence suggesting that both rigid norms of masculinity and the nature of relationships seem to be the major obstacles to condom use (Gomez and Marin, 1996;
Adetunji, 2000; Adetunji and Meekers, 2001; Flood, 2003; Maharaj; 2006; Grady et al., 1999;
Agha, 1998; Weir et al., 1999; Davis and Weller, 1999; Meekers and Klein, 2002; Holland et al., 1991; Rivers and Aggleton, 1999; Kaler, 2004; Clark, 2004; Evans and Lambert, 2008; de Walque and Kline, 2009).
Most studies show that awareness of condoms is nearly universal, with the majority identifying condoms as an effective method of preventing HIV infection (Maharaj and Cleland, 2004;
Mozambique Demographic and Health Survey, 2003). For example, the Mozambique’s Demographic and Health Survey (National Institute of Statistic, 2005) found the majority of men and women were able to identify the condom as an effective means to protect against HIV infection. However, condom use remains relatively low, with the majority reporting that they did not use condoms at last sexual intercourse. However, studies show that condom use is
considerably higher among the younger than older populations (Rutenberg et al., 2001; Bankole and Singh, 2001).
A multi-country study on men’s family planning attitudes and behaviour also found that the levels of condom use are higher among unmarried sexually active men than married men (Salem, 2004). In 27 of the 36 countries surveyed, unmarried sexually active men are at least five times more likely to report condom use than married men. The study found that unmarried men are more likely than married men to use condoms because they want to protect themselves and partners against the risk of pregnancy and STIs (including HIV/AIDS). However, other studies suggest that married men are more likely to use condoms in non-regular sexual relationships. In Zimbabwe, it is reported that the majority of men who use condoms are doing so for pregnancy prevention outside the stable marital relationships (Adetunji, 2000). However, studies show that condoms use is also low even with occasional partners (Adetunji 2000; National Institute of Statistic, 2005). According to the National Institute of Statistic (2005), only 32 percent of men and 23 percent of women used condoms in their last sexual encounter with an occasional partner.
Moreover, while only four percent of married women had outside partners, 23 percent of married men had extramarital partners.
Studies show that in long-term, regular relationships condoms are least likely to be used (Adetunji, 2000; Meekers and Richter, 2005). In a quantitative study on female condom use also in Zimbabwe, Meekers and Richter (2005) note that consistent use with marital partners was negatively associated with the reporting of multiple partners in the past year, and positively associated with using the device for pregnancy prevention. Consistent use with regular non- marital partners was associated with numerous variables including perceived ease of use, and effectiveness for STI prevention, low perception of risk of HIV infection, and the desire to prevent pregnancy and infections. This is consistent with other studies in other parts of Africa (Maharaj and Cleland, 2004; Karlyn, 2005; Chen, 2004; Chimbiri, 2007).
Assessing the use of condoms within marriage in Malawi, Chimbiri (2007) arrived at four striking findings. Firstly, the study found that condoms were negligible within marriage.
Secondly, that there was a great deal of discussion about condoms especially among males in their social networks. Thirdly, virtually all the discussion of condoms, by both men and women, was in the context of preventing STIs and HIV/AIDS in extramarital relationships. Lastly, and most importantly, initiating discussion of condom use in marriage was likely to bring an
‘intruder’ into the domestic space (Chimbiri, 2007). The author notes, for example, that both married men and women were quite aware that they were at risk from their partner. However, their concern about infection did not lead to discussion of condom use in marriage. The author also notes that although many women suspected their husbands were unfaithful, they differed in their views about condom use within their marriage (Chimbiri, 2007: 1110)
In their study in KwaZulu-Natal, South Africa, among marred or cohabiting men and women, Maharaj and Cleland (2005) found that although couple’s knowledge of condoms and where to obtain them was high, relatively few men and women reported consistent use. Rural men and women were less likely to report consistent condom use than urban men and women. In general, women were more likely than men to have positive attitudes toward condom use in marital or cohabiting relationships (47 percent compared with 29 percent), but only about 45 percent of either sex had ever discussed the method with their partner. In addition, a higher proportion of
women than men felt at risk of HIV infection from their partners (Maharaj and Cleland, 2005)
In their study in Mozambique, Prata et al. (2006) reported that although both young men and women (aged 15-24 years) had accurate knowledge of HIV transmission modes, overall the use of condoms was low. Almost 22 percent of young men and 10 percent of young women reported condom use at last sex. In addition, this study shows that the use of condoms varied according to sex, and marital status. Young unmarried men were more likely to report having used a condom at last sex compared with ever-married young men. On the other hand, the findings showed that the use of condoms remained lower among females than males (Prata et al.; 2006).
A study in Zimbabwe by Adetunji and Meekers (2001) found that condom were less likely to be used in marital relations than in non-marital relations. For example, their findings indicate that on average one in ten men and women had used a condom within their marital relations three
months before the survey. However, over 60 percent of males and females had reported having used a condom at last sex with a casual partner, and 90 percent of males had reported having used a condom at last sex with a commercial sex worker. In addition, condom use with steady non- marital partners varied considerably by sex. In this regard, over 60 percent of males and less than 40 percent of females reported the use of a condom at the last sex with a steady non-marital partner (Adetunji and Meekers; 2001).
Analyzing the determinants of condom use among young people (15-24 years) in urban Cameroon, Meekers and Klein (2002) found that both males and females who perceived themselves at moderate-to-high risk of HIV infection were more likely than other males and females to report ever having used condoms. In addition, the study found that those males who believed that condoms reduced sexual pleasure were 36 percent less likely than those who thought otherwise to have used a condom at last sex. Moreover, men and women who believed that they were able to convince their regular partner to use a condom were more likely than other men and women to report having used a condom at last sex. The findings also showed that there was a positive association between self-efficacy and use of condom at last sex for both men and women (Meekers and Klein, 2002: 342).
Based on nationally representative samples of both men and women aged 14-54 years from 13 sub-Saharan African countries, de Walque and Kline (2009) found that in general, the use of condom in that region was still low. They also found that men reported using condoms more frequently than women, and that the unmarried report condom use more frequently than the married with their spouse. In addition, the findings show that married men from most of the countries reported using condoms with extramarital partners nearly as frequently as unmarried men. However, married women from most of the countries reported less condom use with extramarital partners than unmarried women. This, according to the authors, was especially troubling because HIV in Africa is mostly spreading through heterosexual intercourse and multiple sexual partnerships was a risk factor for HIV infection. Since marriage usually implies regular sexual intercourse, the probability to pass the virus from extramarital partner to spouse
was higher than an unmarried person who may have multiple partners but not regular sexual intercourse (de Walque and Kline, 2009).
In their study in Nigeria, Sunmola, Olley and Oso (2007) found that 68 percent and 41 percent of sexually active men and women (aged 18-34 years) who were involved in compulsory national service in Ibadan reported condom use at last intercourse before the survey. For both men and women, condom use was common if they had one or more regular sex partner and if they were purchasing condoms. In addition being single and having the intention to use a condom in the next sexual encounter were strong predictors of condom use among women. However, the study also found that there was a high risk of HIV transmission in the sample population since consistent condom use was lower, 15 percent among men and 4 percent among women (Sunmola, Olley and Oso, 2007).
Some studies have found that level of education is associated with high levels of condom use within non-spousal partnerships. In their study of four cities in sub-Saharan Africa, Lagarde et al.
(2001) found that based on the reports from men, condom use was associated with higher levels of education of the male partner in Yaoundé, Cameroon, and with higher education level of the female partner in Cotonou, Benin, and Kisumu, Kenya. Based on the reports from women, the study found that condom use was associated with higher education levels of the female partner in Kisumu, Kenya, and Ndola, Zambia, and with higher education level of the female partner in Yaoundé. However, associations with other determinants varied across cities and for men and women (Lagarde et al., 2001).