CHAPTER 6: CONDOM KNOWLEDGE, ATTITUDE AND USE
6.6 Condoms Use
6.6.2 Current Use
more and being neither married nor cohabiting seem to be strong factors influencing ever use of condoms. In this regard, men and women living in urban areas were more likely than men and women living in rural areas to report having ever used a condom with their partners, with about 70 percent of urban men and 71 percent of urban women reporting ever use compared with 32 percent of rural men and 14 percent of rural women, respectively. Age is an important predictor of ever-use of condom. Ever use of condoms decreases with the increase in age. In other words, younger respondents were more likely to report ever using a condom than older respondents.
Likewise, formal education appears to be one of the strongest predictors of ever use of condoms.
The data shows that more educated respondents were more likely than less educated respondents to report having ever used a condom. In addition, men and women who were neither married nor cohabiting were more likely than married and cohabiting respondents to report having ever used a condom.
The analysis of the API index indicates that men with a higher socio-economic status were almost two times more likely than men with a lower socio-economic status to report having ever used a condom with their partners. About 70 percent of men with a high API reported having ever used a condom compared with 31 percent of men with a lower medium API and 37 percent with a low API. Similarly, women with a high socio-economic status were almost three times more likely than women with a lower socio-economic status to have ever used a condom with their partners.
The findings for women indicate that 66 percent of women with an upper medium or high API reported that they have ever used a condom with their partners, while 24 percent of women with lower medium and low API reported having ever used a condom. All the variables for both men and women are statistically significant.
6.6.2 Current Use
To assess current use of condoms respondents were asked the following question: “the last time you had sex, did you or your partner use a condom?” First, univariate analysis was conducted to
determine current condom use among respondents who were sexually active in the last 12 months. In addition, bivariate analysis was conducted to determine the relationship between current users and selected socio-economic and demographic characteristics. Finally, a logistic regression analysis was fitted to determine the strength of the associations. As can be seen in Table 6.9, the majority of respondents have never used a condom. However, it is worth noting that almost one quarter of men and women reported using a condom at last sex. Nevertheless, among current condom users, men were more likely than women to report that they used a condom at last sex, with almost 31 percent of men reporting condom use at last sex compared with about 20 percent of women.
Table 6.9: Percentage of respondents who used a condom at last sex
Men Women Used a condom at last sex n % n %
Yes 65 31.3 44 20.3 No 42 20.2 50 23.0
Never used 101 48.6 123 56.7
Total 208 217
Bivariate analysis consisted of examining the association between current condom use and selected socio-economic and demographic characteristics, namely place of residence, age, education, marital status, perception of risk of HIV infection, number of sexual partners in the last 12 months and household socio-economic characteristics using the Amenities Possessions Index (API). Condom use at last sex is conventionally used to assess current condom use. It is usually associated with a reference period (Bankole and Singh, 2001). In this study, the reference period is 12 months prior to the survey. Table 6.10 shows the percentage of respondents who reported condom use at last sex by selected background characteristics.
The bivariate analysis shows that place of residence, age, level of education, marital status and household socio-economic status is strongly associated with condom use at last sex. In this regard, urban men and women were more likely to report having used a condom at last sex compared with rural men and women. Whereas 43 percent of urban men reported that they used a
condom at last sex only 20 percent of rural men reported use at last sex. Likewise, whereas about 34 percent of urban women reported condom use at last sex, a lower percentage of rural women (6 percent) reported use at last sex.
Table 6.10: Percentage of respondents who used a condom at last sex by selected background characteristics
Background characteristics Men Women
n % n % Place of residence
Urban 106 42.5* 111 34.2*
Rural 102 19.6 106 5.7
Age
20-29 108 42.6* 121 27.3*
30-39 54 27.8 60 15.0 40-49 46 8.7 34 5.9
Level of Education
None 28 10.7* 51 7.8*
Primary 98 20.4 106 14.2 Secondary or higher 82 51.2 60 41.7
Marital Status
Married/cohabiting 138 15.2* 120 12.5*
Neither 70 62.9 97 29.9
API
Low 43 23.3** 67 11.9*
Lower medium 59 13.6 50 10.0 Upper medium/high 106 44.3 100 31.0
Perception of Risk of HIV infection
Low 107 31.8 163 19.6 High 100 31.0 53 22.6 Number of sexual Partners
1 116 29.3 201 20.4
2+ 92 33.7 16 18.8
All 208 217 Note:* Significant P ≤ 0.05 percent; ** significant P ≤ 0.01 percent
Of note is the decrease in condom use at last sex as the age of the respondent increases. In other words, men and women aged 20-29 year-old were more likely than men and women of older age
groups to report having used a condom at last sex. Likewise, level of education, in particular, seems to influence condom use at last sex regardless of the sex of respondent. The data indicates that the use of condoms increases with the level of education. Thus, men and women with secondary or higher education were more likely than men and women with less than secondary education to report the use of condom at last sex. In addition, respondents who were neither married nor cohabiting were more likely to report the use of condoms at last sex than married and cohabiting respondents.
Both men and women with a higher socio-economic status were more likely than men and women with a lower socio-economic status to report having used a condom at last sex. About 44 percent of men with an upper medium or high API reported having used a condom at last sex compared with 14 percent of men with a lower medium API and 23 percent of men with a low API. In addition, 31 percent of women with upper medium or high API reported that they used a condom during the last sex event compared with 10 percent of women with a lower medium API and 12 percent of women with a low API. The bivariate analysis shows that the association between current condom use and perception of risk of HIV infection and number of sexual partners is not statistically significant. However, men who reported more than one partner in the past 12 months were slightly more likely to report condom use at last sex than men with only one partner. Similarly, women who reported feeling a higher risk of HIV infection were more likely to report condom use at last sex than women who reported a lower risk of HIV infection.
Multivariate analysis
In order to assess which factors are the strongest determinants of condom use at last sex in the last 12 months, a logistical regression analysis was applied. The dependent or outcome variable is whether or not they had used a condom at last sex. The dependent variable consisted of two values: ‘Yes’ which was coded “1” and ‘No’ which was coded “0”. The value coded “1” has been taken as a reference group. The independent or predictor variables are place of residence, age, level of education marital status, household socio-economic status, perception of risk of HIV infection and number of partners in the last 12 months. Separate models for male and females
have been fitted to account for gender differences in condom use at last sex. The results are given in Table 6.11
The results of logistic regression analysis for men show that a number of the selected socio- economic and demographic characteristics have a statistically significance unadjusted effect on condom use at last sex. The unadjusted logistic regression results show that men living in rural areas were less likely than those living in urban areas to report having used a condom at last sex (odds ratios = 0.33). Similarly, men aged 40 years and above were less likely to report that they used a condom at last sex (odds ratios = 0.13). On the other hand, the findings show that men with secondary or higher education were almost 9 times more likely than less educated men to report that they used a condom at last sex (odds ratios = 8.75). Men who were neither married nor cohabiting were also about 9 times more likely to report having used a condom at last sex than married and cohabiting men (odds ratios = 9.43). Furthermore, men who reported more than one sexual partner in the last 12 months were more likely than those who with only one partner to report condom use at last sex, but this was not significant (odds ratios = 1.23). Perception of risk of HIV infection was not related to condom use. Men who perceived themselves at higher risk of HIV infection were less likely to report using a condom use at last sex.
Table 6.11: Odds ratios for men who used a condom at last sex, 12 months before the survey: logistic regression results
Odds ratios and 95% confidence intervals
Model I Model II Unadjusted Adjusted Place of Residence
Urban 1.00 1.00 Rural 0.33*(0.18 – 0.62) 1.19 (0.46 – 3.12)
Age
20-29 1.00 1.00
30-39 0.52 (0.26—1.05) 1.96 (0.74-- 5. 15) 40-49 0.13* (0.04 – 0.39) 0.30 (0.09 – 1.03)
Level of Education
None 1.00 1.00
Primary 2.14 (0.59-7.80) 1.69 (0.41 – 7.04) Secondary or higher 8.75* (2.45 – 31.27) 3.97 (0.85 – 18.55)
Marital Status
Married/Cohabiting 1.00 1.00 Neither 9.43* (4.82 – 18.45) 6.99** (2.84 – 17.23)
API
Low 1.00 1.00
Lower medium 0.52 (0.19 – 1.45) 0.53 (0.17 – 1.64) Upper medium/high 2.63* (1.18 – 5.88) 1.06 (0.34 – 3.26)
Perception of risk of HIV infection
Low 1.00 1.00
High 0.97 (0.54 – 1.74) 0.84 (0.41- 1.75) Number of Sexual Partners
1 1.00 1.00 2 + 1.23 (0.68 – 2.21) 1.16 (0.56 – 2.40)
Note:* Significant P ≤ 0.05 percent; ** significant P ≤ 0.01 percent
Meanwhile, after controlling for other variables, only marital status continues to have a statistically significant effect on condom use at last sex (odds ratios = 6.99). The other variables no longer have a statistically significant effect on the use of condoms at last sex. These findings may have important implications for policy design and interventions since they suggest that people make decisions based on wrong judgements regarding both the circumstances and
appropriateness of condom use. Indeed, the fact that only marital status continued having a strong association with condom use at last sex seems to suggest that the use of condom is highly dependent on marital status rather than other socio-demographic variables assessed in this study which, in turn, suggests a low personal risk perception. In this regard, the results suggest that men may have more worries regarding pregnancy or disease prevention depending on whether one is single, married or cohabiting which is not enough to curb the HIV epidemic (see also Agha et al., 2002).
The results of logistic regression analysis for women are shown in the Table 6.12. Table 6.12 shows that women living in rural areas were less likely than those living in urban areas to report having used a condom at last sex (odds ratios = 0.16). Similarly, women aged 30 and above were less likely than women aged less than 30 years to report having used a condom at last sex. As is the case with men, women who are relatively more educated, that is, with secondary education or higher were 8 times more likely than other age groups to report having used a condom at last sex (odds ratios = 8.39). Likewise, women who were neither married nor living together were almost three times more likely to report having used a condom at last sex than their married and cohabiting counterparts (odds ratios = 2.99).
Table 6.12: Odds ratios for women who used a condom at last sex, 12 months before the survey: logistic regression results
Odds ratios and 95% confidence intervals
Model I Model II Unadjusted Adjusted Place of Residence
Urban 1.00 1.00 Rural 0.16*(0.05 – 0.29) 0.13* (0.04 – 0.43)
Age
20-29 1.00 1.00
30-39 0.47 (0.21 - 1.06) 0.49 (0.18-- 1. 30) 40-49 0.17* (0.04 – 0.74) 0.22 (0.04 – 1.14) Level of Education
None 1.00 1.00
Primary 1.94 (0.61 - 6.16) 0.83 (0.22 – 3.15) Secondary or higher 8.39* (2.68 – 26.31) 1.41 (0.32 – 6.17)
Marital Status
Married/ Cohabiting 1.00 1.00 Neither 2.99* (1.49 – 5.98) 1.98 (0.89 – 4.39) API
Low 1.00 1.00
Lower medium 0.82 (0.25 – 2.67) 0.96 (0.26 – 3.60) Upper medium/high 3.31* (1.41 – 7.76) 0.97 (0.34 – 2.75)
Perception of Risk of HIV Infection
Low 1.00 1.00
High 1.20 (0.57 – 2.54) 0.90 (0.38- 2.14) Number of Sexual Partners
1 1.00 1.00 2 + 0.90 (0.25 – 3.31) 0.36 (0.09 – 1.50)
Note:* Significant P ≤ 0.05 percent
On the other hand, the logistic regression results shows that women with a higher socio-economic status were more likely than women with a lower socio-economic status to report having used a condom at last sex. Women with a upper medium or high API were three times more likely than women with low API to report having used a condom at last sex (odds ratios = 3.31). Women who perceived a high risk of HIV infection were also more likely to use a condom than women
who perceived a lower risk of HIV infection but this was not significant. The association between condom use at last sex and number of sexual partners was not statistically significant. After adjusting for other factors, only one variable had a statistically significant effect on condom use at last sex. Place of residence remains the strongest predictor of condom use at last sex for women. Urban women were significantly more likely than rural women to report condom use at last sex. These results suggest that if a woman lives in a rural area, independent of other socio- demographic factors, including her level of education she will rarely use a condom. This is not surprising at all given the fact that rural areas tend to be less open about sexual matters than urban areas.
The nature of relationships
In general, studies have shown that the use of condoms is generally dependent upon the nature of relationships. Thus the nature of relationships could have some influence on condom use in the present study. Some studies suggest that condom use is much lower in long-term, stable relationships than less stable relationships (Varga, 2000; de Walque and Kline, 2009; Maharaj and Cleland, 2004; Adetunji, 2000; Agha, 1998). Understanding the nature of a relationship and the use of condoms was explored in more detail in the focus group discussions and in-depth interviews.
There is greater resistance to condom use in marital or cohabiting relationship or long-lasting relationships than in occasional or casual encounters. Many respondents in both focus group discussions and in-depth interviews reiterated that if people were married or were living as married, then it was not acceptable to use condoms. They argued that married couples should not use condoms because marriage implied loyalty to one another. According to some women in the focus group discussions, condoms were only acceptable for couples who were not in a long-term relationship.
“It is acceptable to use condom. However, married people should be loyal. But for people who are not yet married, they should use condoms”.
(Rural non-married females, FGD # 06)
Similarly, some men in the in-depth interviews were also adamant that for married people the use of condoms was out of the question, unless there was no trust between partners. Such beliefs not only show the extent to which sexual moralities are so entrenched within marital relationships (Smith, 2007) but also many men and women still associate condoms with infidelity, a finding consistent with earlier studies (Preston-Whyte, 1999, Varga, 1999).
“Well, I do not use condoms. I do not even want to hear about them. Only when I am on a trip, maybe I can use them, I do not know”.
(Urban married males, IDI # 18)
“As long as we are married we cannot use condoms. We must take control of ourselves and avoid betrayals”
(Rural non-married male, IDI # 14)
Nevertheless, some women in the focus group discussions acknowledged the importance of using condoms even in cohabiting relationships. The infidelity usually practiced by their partners was given as the main reason. Some females reported that because men are generally unfaithful, it was up to the women to force the use of condoms in relationships that carried some risks. Some women who perceive themselves at risk of HIV infection because of their partner’s sexual behavior are likely to take measures to protect themselves. For example, a woman with an unfaithful husband may get the support of the society for her actions, thus giving legitimacy to her actions. On the other hand, it is of interest to note that women did not talk about abandoning their sexual relationships which they perceived as risky. Rather, they talk about persuading their partners to practice protective practices including using condoms with their sexual partners outside the marital relationships.
“My daughter’s father does not want to use condoms, but he has other women. He used to say: ‘I do not need to use condom’. I have told him: ‘you want to have children and you do not want to take care of your life’. There are men that do not understand. It only depends on women to use condoms”.
(Urban married females, FGD # 02)
Likewise, some men in focus group discussions also had positive views about condoms within marriage. While they argued that marriage symbolized trust and fidelity between the partners they recognized that men in particular are sometimes tempted to have sex outside marriage.
These views not only confirm that extramarital sex is a common phenomenon in the study sites but they also show that men tend to feel that they cannot resist sexual temptations outside of their marriage. This may be due to fact that extramarital sex for men is tolerated whereas for women it is strictly taboo. From this point there is no doubt that if protective practices are not fully observed, particularly correct and consistent use of condoms, these men can acquire and pass the virus to their marital or cohabiting partners.
“As soon as a couple gets married the couple should not have sex outside, because the marriage requires them to be faithful. Therefore, they should not have sex outside their marriage.
Nevertheless, people end up "stealing" because they cannot fight against temptation”. If a man cannot resist temptation, the man should use a condom with his partner. Within marriage it is not acceptable to use condoms unless one of the married partners is HIV positive”.
(Rural married males, FGD # 12)
Sometimes the reluctance to use condom may be related to age. Some women in focus group discussions expressed that they would not use condoms because condoms are for young people.
In addition, some admitted that they do not know how to use a condom. In fact, studies have shown that the use of condom is positively associated with age and level of education. Condom use is greater among the younger population as well as those with higher levels of education, a finding consistent with other studies (Agha, 1998; Lagarde et al., 2001). The quote below may well illustrate that sentiment
“We do not use condom, my dear. But you young people do. In our youth there were no condoms. We used to have sex with no condom. Our husbands died without using one. Condoms are for you young people. We do not know how to use them.”
(Urban married females, FGD # 03)
Timing of Condom Use
One of the most frequently mentioned aspects during the interviews was the timing of condoms use. Although few participants reported the use of condoms, in both focus group discussions and in-depth interviews respondents said that men and women who decided to use the condoms generally started using condoms at the beginning of their relationships. They argued that they use condoms at the onset of a relationship because it is a time when they are starting to establish trust and intimacy - they do not fully trust each other at this stage. After they have stayed together long enough and the necessary trust has been established, they decide to give up using condoms.
“I think we stop using a condom when we have sex with the same person many times and we gain trust, because in the first days of sex you are still getting to know each other, after sometime has passed, maybe two, four or more months we stop using condoms because we think we know each other well, therefore we stop”
(Rural married males, FGD # 12)
Some women said that the beginning of a relationship is the right moment to start using condoms because partners were in the process of getting to know each other. Trust is an important factor which affects sexual decision-making about condoms (Longfield, Klein and Berman, 2002). Both men and women seek to establish trust at the beginning of the relationship. However, men and women may perceive certain advantages of using condoms while they are in the process of
‘studying’ each other. For example, for women it is not only important to create greater familiarity during the period the partners try to ‘know’ each other, but it has the advantage of preventing unwanted pregnancies and diseases. This is illustrated in the following quote: