CHAPTER 6: CONDOM KNOWLEDGE, ATTITUDE AND USE
6.7 Consistency of Condoms Use
Studies have shown that for condoms to be effective as a preventive tool against HIV infection and other sexually transmitted infections it requires consistent and correct use (UNAIDS, 2000;
Agha, 1998; Adetunji and Meekers, 2001; Davis and Weller, 1999). It is believed that the effectiveness of condoms at preventing HIV transmission is estimated to be as low as 60 percent
if not used correctly and consistently or as high as 96 percent if used correctly and consistently (Davis and Weller, 1999; UNAIDS, 2000). Thus, in this study the frequency of condom use was assessed to ascertain the extent to which condoms are used in the study areas.
Consistency of condom use was the last indicator to measure the use of condoms in the study areas. Thus, those respondents who answered the question whether or not they used a condom at last sex were then asked to indicate how often they used a condom. A three-category ordinal scale was applied to measure the frequency of condom use, namely always, occasionally and never.
The last category was included to ascertain the real percentage of consistent condom use in the study settings. Table 6.13 presents the results.
Table 6.13: Percentage of respondents who reported consistent condom use
Men Women n % n % Frequency of condom use
Always 32 15.4 22 10.1*
Occasionally 75 36.0 72 33.2 Never 101 48.6 123 56.7 Total 208 217
Not surprisingly the number of consistent condom users is quite low. A small percentage of men and women reported consistent condom use. Table 6.14 shows that for both men and women there is strong association between the frequency of condom use and all selected explanatory variables. In addition, the results of the bivariate analysis also suggest that consistent condom use in both sexes is very low. Nevertheless, men are more likely than women to report that they always used a condom, with about 15 percent of men reporting consistent condom use compared with 10 percent of women. Of note but also not surprising is that large proportions of both men and women reported that they have never used a condom though women outnumber men in this regard. These findings seem to be in line with what have been found with regard to the low levels of condom use in Mozambique (National Institue of Statistics, 2002; Prata et al., 2006).
Nevertheless, these findings may represent a significant improvement compared with previous data, but not yet enough to curb the progression of HIV/AIDS.
The bivariate analysis was applied to assess the levels of consistent condom use. The independent variables includes place of residence, age, education, marital statues, perception of risk, number of sexual partners in the last 12 months and household socio-economic status. Table 6.14 shows the percentage of respondents who reported that they always used a condom, by selected background characteristics. The results indicate that, for men, age, education, marital status and socio-economic status are strong predictors of consistent condom use. Thus, younger men aged 20-29 years were more likely than men of older age groups to report that they always used a condom with 21 percent reporting consistent use compared with 9 percent of men in the older age groups, respectively.
Table 6.14: Percentage of respondents who reported consistent condom use, by selected background characteristics
Background characteristics
Men Women
n % n % Place of residence
Urban 106 19.8 111 16.2*
Rural 102 10.8 106 3.8
Age
20-29 108 21.3* 121 12.4 30-39 54 9.3 60 10.0 40-49 46 8.7 34 2.9
Level of Education
None 28 3.6** 51 3.9*
Primary 98 8.2 106 8.5 Secondary or higher 82 28.0 60 18.3
Marital Status
Married/cohabiting 138 5.1** 120 4.2**
No 70 35.7 97 17.5
API
Low 43 9.3* 67 7.5
Lower medium 59 6.8 50 4.0 Upper medium/high 106 22.6 100 15.0
Perception of Risk of HIV Infection
Low 105 14.3 164 9.8 High 101 15.8 53 11.3
Number of Sexual Partners
1 116 12.1 201 9.5 2 + 92 19.6 16 18.8
Total 208 217 Note:* Significant P ≤ 0.05 percent; ** significant P ≤ 0.01 percent
Men with secondary or higher education were more likely than less educated men to report that they always used a condom. Furthermore, the findings indicate that men who were neither married nor cohabiting were more likely than married and cohabiting men to report consistent condom use, with 36 percent of them saying so compared with only 5 percent of married and cohabiting men. Finally, the findings indicate that men with a higher socio-economic status were
more likely than men with a lower socio-economic status to report that they always use a condom. About 23 percent of men with an upper medium or high socio-economic status reported consistent condom use compared with 9 percent of men with a low socio-economic status and 7 percent of men with a lower medium socio-economic status.
For women, the bivariate analysis indicates that place of residence; education and marital status are associated with consistent condom use. Thus, women living in urban areas were more likely than those living in rural areas to report that they always used a condom, with about 16 percent of them reporting that they always used a condom compared with just 4 percent of rural women. In addition, women aged between 20-29 years were more likely than women aged 30 and above to report that they always used a condom. Similarly, women with secondary or higher education were more likely than less educated women to report that they always used a condom.
Furthermore, the findings indicate that women who were neither married nor cohabiting were more likely than married and cohabiting women to report that they always used a condom, with 18 percent reporting so compared with just 4 percent of married and cohabiting women. Although not statistically significant (P ≤ 0.075), women with an upper medium or high API were more likely than women with a lower medium and a low APIs to report that they always used a condom. In this regard, 15 percent of women with an upper medium or high API reported consistent condom use compared with 8 percent of women with a low API and 4 percent with a lower medium API. All the variables described are statistically significant for both men and women.
In order to assess the determinants of consistent condom use, a logistical regression analysis was done. Respondents who reported ‘always’ using condoms were classified as consistent users while those who reported occasional or never using condoms were classified as non users or not consistent users. Thus, the variable has two values: consistent use coded as “1” and inconsistent use coded as “0”. The value coded “1” has been taken as a reference group. The independent or predictor variables include place of residence, age, level of education, marital status, household socio-economic status, perception of risk and number of sexual partners in the last 12 months.
Separate models for males and females have been used to account for gender differences in consistency of condom use. The results are given in Table 6.15 and Table 6.16, respectively.
The results of logistic regression analysis for men show that education and marital status variables have statistically significant unadjusted effects on consistent condom use. Thus, men with secondary or higher education were more than ten times more likely to report consistent condom use than men with less education (odds ratios = 10.53). Similarly, neither married nor cohabiting men were ten times more likely to report consistent condom use than men in marital and cohabiting unions (odds ratios = 10.40). Place of residence, age and socio-economic status do not have statistically significant unadjusted effects on consistent condom use. Nevertheless, it is important to note that men living in rural areas were less likely than men living in urban areas to report consistent condom use (odds ratios = 0.49). Likewise, men aged 30-39 years and those age 40-49 years were also less likely than younger men to report consistent condom use (odds ratios
= 0.38 and 0.35, respectively).
Table 6.15: Odds ratios for men who reported consistent condom use: logistic regression results
Odds ratios and 95% confidence intervals
Model I Model II Unadjusted Adjusted Place of Residence
Urban 1.00 1.00 Rural 0.49(0.22 – 1.08) 2.35 (0.68 – 8.24)
Age
20-29 1.00 1.00
30-39 0.38 (0.14—1.06) 1.58 (0.72 - 6. 75) 40-49 0.35 (0.11 – 0.08) 1.66 (0.41 – 6.78) Level of Education
None 1.00 1.00
Primary 2.40 (0.29-20.05) 1.49 (0.15 – 15.19) Secondary and more 10.53* (1.35 – 82.03) 4.42 (0.41 – 47.36)
Marital Status
Currently married/ living together 1.00 1.00
No 10.40** (4.21 – 25.67) 12.54** (3.44 – 45.71)
API
Low 1.00 1.00
Lower medium 0.71 (0.17 – 3.01) 1.69 (0.29 – 9.97) Upper medium/high 2.85 (0.93 – 8.79) 2.46 (0.44 – 13.71)
Perception of Risk of HIV infection
Low 1.00 1.00
High 1.13 (0.53 – 2.43) 1.02 (0.42- 2.48)
Number of Sexual Partners
1 1.00 1.00 2 + 1.77 (0.83 – 3.79) 2.0 (0.81 – 4.97)
Note:* Significant P ≤ 0.05 percent
In addition, men with an upper medium or high API were almost three times more likely to report consistent condom use than men having a low medium API (odds ratios = 2.85 and 0.71, respectively). Conversely, men with a lower medium API were less likely than men with a low API to report consistent condom use (odds ratios = 0.71). Condom use is higher among men with
two or more partners than men with fewer partners but this is not statistically significant. In addition, men with a higher perception of risk of HIV infection were more likely to report condom use than men with a lower perception of risk of HIV infection but this is also not significant. After controlling for other variables, only marital status continues to have a strong statistically significance adjusted effect on consistent condom use. Thus, men who were neither married nor cohabiting were more than twelve times more likely to report consistent condom use than men in marital and cohabiting unions (odds ratios = 12.54).
Table 6.16 shows the results of logistic regression analysis of consistent condom use for women.
The results indicate that place of residence; education and marital status variables have statistically significant unadjusted effects on consistent condom use. In this regard, it could be seen that women living in rural areas were less likely than those living in urban areas to report consistent condom use (odds ratios = 0.20). Again, women with secondary or higher education were five times more likely to report consistent condom use than women with less education (odds ratios = 5.50). Furthermore, women who were neither married nor cohabiting were almost five times more likely to report consistent condom use than women in marital and cohabiting unions (odds ratios = 4.89). Age, perception of risk of HIV infection, number of sexual partners in the last 12 months and household socio-economic status do not have statistically significant unadjusted effects on consistent condom use for women.
Table 6.16: Odds ratios for women who reported consistent condom use: logistic regression results
Odds ratios and 95% confidence intervals
Model I Model II Unadjusted Adjusted Place of Residence
Urban 1.00 1.00 Rural 0.20*(0.07 – 0.62) 0.30 (0.07 – 1.31)
Age
20-29 1.00 1.00
30-39 0.79 (0.29 - 2.14) 0.13 (0.34-- 3. 75) 40-49 0.21 (0.03 – 1.68) 0.48 (0.05 – 4.53) Level of Education
None 1.00 1.00
Primary 2.27 (0.47 - 10.93) 1.05 (0.18 – 6.08) Secondary and more 5.50* (1.16 – 26.12) 1.33 (0.119 –98.53)
Marital Status
Married/ Cohabiting 1.00 1.00 No 4.89* (1.73 – 13.79) 3.71 *(1.24 – 11.17) API
Low 1.00 1.00
Lower medium 0.52 (0.10 – 2.78) 0.76 (0.13 – 4.19) Upper medium/high 2.19 (0.76 – 6.34) 0.95 (0.27 – 3.38)
Perception of Risk of HIV infection
Low 1.00 1.00
High 1.18 (0.44 – 3.19) 0.81 (0.28- 2.37) Number of Sexual Partners
1 1.00 1.00 2 + 2.21 (0.58 – 8.45) 0.24 (0.29 – 5.35)
Note:* Significant P ≤ 0.05 percent
After controlling for other variables, only marital status remains a strong predictor of consistent condom use. Thus, women who were neither married nor cohabiting were almost four times more likely to report consistent condom use than women in marital and cohabiting unions (odds ratios
= 3.71).
The focus group discussions and in-depth interviews show both men and women are aware of condoms and their importance in protecting against the risk of sexually transmitted infections and unwanted pregnancies. Consistent condom use is deemed critical to curb the HIV infection (Davis and Weller, 1999; Slaymaker, 2004; Prata et al., 2006). But consistent use of condoms seems to be a big challenge even in secondary relationships. Secondary relationships can be defined as an extramarital relationship or relationship which happens simultaneously with the regular and committed relationship. Three reasons may be behind such a challenge: The first is a moral reason, that is, to avoid negative meanings attached to condoms, (which symbolize uncleanness, disease and lack of trust). Individuals may avoid condoms even in secondary relationships in order to preserve the status of the relationship. The second is that men may continue using their power to influence sexual decision-making as appears to be the case in stable or ‘committed’ relationships (Varga, 2000). Thirdly, women who are secondary partners, but are not necessary sex workers also may not be keen to be seen or perceived as secondary (and
‘unclean’) partners. This poses similar dilemmas to those in marital and cohabiting unions.
Although women in secondary relationships may perceive themselves as secondary partners, they may not cease to have some expectations to become primary partners or improve their relationship status. Furthermore, because of their socio-economic vulnerability, women may avoid confrontation which could jeopardize their relationships. Recent studies have shown that while married men report significant condom use in extramarital sex, married women report alarmingly low levels of condom use in extramarital encounters (de Walque and Kline, 2009).
Indeed, some male respondents in rural focus group discussions acknowledged that inconsistent condoms use is a big problem. They argued that men and women forget about using condoms for a variety of reasons including alcohol consumption.
“In the first days a couples are usually aware of condoms. They may practice safe sex, but after a month or two they end up forgetting about them. Many of those who have AIDS acquired it because they forgot that they should use a condom. Some have sex while they are drunk and they forget or they are in a hurry and they end up having sex without a condom”.
(Rural married males, FGD # 12)
On the other hand, inconsistent condom use can also be illustrated in the following comments by one male respondent in the in-depth interviews. He recognizes that condoms are available in stores. Even though he says that he does not use condoms frequently, he buys and uses them when he is suspicious of a new partner. The quote also suggests that sometimes men use condom with suspicious partners in order to protect their spouses.
“There are condoms for sale here, in stores. But I do not buy them because I do not use condoms with my wife. When I have an outside girlfriend and I am suspicious of her, I buy condoms before having sexual intercourse, because I cannot infect my wife. But only occasionally I do use them.”
(Rural married male, IDI # 13)
One female respondent admitted during the in-depth interviews that at beginning she insists on using condoms with her partner but after a short while they stop using them. The respondent reported that in general men usually try to convince their partners that there is no need to use condoms, because as they argue, the relationship has developed and trust is already established, therefore they can have sex without condoms.
“I insist that he should use a condom. I do not say that we will use it forever. But because we are at the beginning of the relationship we use it, but thereafter we will stop.
(Urban non-married female, IDI # 09)
One urban male respondent confirmed in the in-depth interviews what other respondents said about consistency in using the condoms. He said that the rationale for the termination of condom use is the life span of the relationship. They use condoms at the beginning, but the longer the relationship lasts the more likely they are to stop using condoms.
“What happens is that you can tell people that AIDS exists. They will use condoms for some time but after some time they will say ‘we have been dating each other for some time, there is no risk of an infection’. People think like that.”
(Urban married male, IDI # 15)
In addition, some respondents blamed the failure to use condoms on the “heat of the moment”, which is generally associated with the fear that their partner may change their mind about having sexual intercourse and as a result there is a tendency to engage in unprotected sexual activities.
Indeed, in a rural focus group discussion one man admitted that he has had unprotected sex in similar situation.
“I cannot deny that I have had sex without condoms even knowing that I have to use them.
What happened is that we were together for some time and one day I was careless about using condoms just because I did not have them in my hands. And because we were kissing each other and condoms were a little bit far from where we were, so I started wondering: ‘if I stop, in order to fetch condoms will she still be in mood for sex?’, I was afraid that she would change her mind and say that she does not want sex anymore”
(Rural non-married males, FGD # 18)