CHAPTER 6: CONDOM KNOWLEDGE, ATTITUDE AND USE
6.8 Summary
“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)
knowledge among sexually active populations in Mozambique are documented (Bankole and Singh, 2001; Prata et al., 2006). In this study, however, almost all the respondents of the study sample reported that they knew of condoms. In addition, the findings also suggest that a high number of participants knew where they could get a condom if they needed one. Nevertheless, although not surprising, the data also shows that men were more likely than women to be aware of a source of supply of condoms. Worryingly but not surprising is the fact that the findings also indicate that women were far less likely than men to report that they were confident about how to use a condom effectively. Indeed, it may be somewhat worrisome that about a half of women reported that they did not know how to use a condom effectively in a context where HIV/AIDS is rampant.
The findings show that the respondents have a relatively high level of positive beliefs about the efficacy of condoms. In this regard, both quantitative and qualitative findings show high levels of awareness about condoms and the role they might play in preventing STIs including HIV/AIDS and unwanted pregnancies. However, many men and women still express negatives attitudes towards condoms. Consistent with what has been reported in other studies men were more likely than women to hold negative attitudes towards condoms. This is in line with another study conducted in Côte d’Ivoire which found that more men than women hold negative attitudes about condoms (Guiella and Madise, 2007). For example, about a half of men and only 12 percent of women reported that condoms reduced sexual pleasure. Likewise, while almost a half of males reported that condoms encouraged promiscuous behaviour, only about one-third of females held similar views. In addition, whereas about half of males (59 percent) associate the use of condoms with lack of trust, only one-third of females agreed.
Qualitative findings point out that the issue of trust among partners; concerns about the efficacy of the product (defects on certain brands of condoms), sexual pleasure and intimacy are among the top reasons given for not using condoms. This is consistent with similar findings reported elsewhere (Bankole and Singh, 2001; Agha et al., 2002; Thomsen, et al., 2004). A study by Thomsen et al (2004) in Mombasa, Kenya, reported that there were at least 50 reasons for not using condom by men in that location. Those reasons included, among others, beliefs that
condoms prevent sexual pleasure; that condoms were defective, that they were harmful, that they were unnecessary, that it was too hard to use in the moment of ‘heat’ as well as other external forces (Thomsen et al., 2004). Similarly, in Mozambique, Agha et al. (2002) also found that while the first reason for not using condoms was the association of lack of trust in partner. The dislike of condoms was the second most frequently cited reason among both urban females and males (Agha et al., 2002).
The findings of this study suggest that partner communication about condoms is sporadic and still a challenge. For example, more than a half of males reported that they had ever discussed condoms with their partners, while the percentage is considerably lower for females. On the other hand, the findings suggest that condoms are no longer an unknown subject in relationships.
Living in urban areas, being young, having secondary or higher education and being neither married nor cohabiting is positively associated with partner communication about condoms.
These findings are consistent with other studies in sub-Saharan Africa (Guiella and Madise, 2007; Abdool Karim, 2001; Abdool Karim et al., 1994; Muhwava, 2004). For example, a study by Abdool Karim (2001) in KwaZulu-Natal, South Africa found that almost 94 percent of respondents believed that asking their partners to use condoms indicated a lack of trust (Abdool Karim, 2001: 194). Another study by Amuyunzu-Nyamongo and his associates (2005) in four sub-Saharan Africa countries concluded that negotiating the use of condoms became difficult once the issue of trust in relationships was introduced. According to the authors, that situation was even worse for those young women who might have received money or gifts from their partners (Amuyunzu-Nyamongo et al., 2005).
Furthermore, communication about condom is also very low among those men and women who said that they had never used a condom at all. This may be due to the fact that the subject of condoms; particularly in long-term relationships is an uncomfortable topic for both men and women (Chimbiri, 2007). But, on the other hand this may suggest a low personal risk perception among study participants. In this regard, many men and women who never used a condom reported that condoms had never become a topic of discussion within their relationships. One of the reasons given for this is that they had never needed to use them. This reality may reveal the
extent to which risk assessment is low among respondents. These findings are consistent, for example, with what Agha et al. (2002) have found in eight sub-Saharan Africa settings. They concluded that the fact that in most countries both married male and female respondents frequently reported trusting their partners, disliked condoms and that they did not use a condom because of not having them in the hands was a clear indication how important personal risk perceptions were in determining condom use in stable relationships (Agha et al., 2002).
As expected, men were more likely than women to report that they have ever used a condom.
However, socio-demographic variables play a significant role in this. In fact, the bivariate analysis results indicate that place of residence, age, education and marital status are positively associated with ever using a condom among men and women of the study sites. Thus, the findings suggest that living in urban areas, being young, having secondary or higher education as well as being neither married nor cohabiting enhances ever use of condoms. It is noteworthy that among both men and women ever use of condoms is strongly associated with education and marital status.
Similarly, according to the results, men are more likely than women to report that they used a condom at their last sexual encounter. Indeed, men are more likely to report current condom use than women. For example, the unadjusted logistic regression analysis results indicate that men with secondary education and more were almost nine times more likely to report having used a condom at last sex than less educated men. Among women, the unadjusted logistic regression analysis results indicate that women with secondary or higher education were eight times more likely to report having used a condom at last sex than less educated women. Even having primary education alone does have a positive association with current condom use. These findings are quite consistent with other studies (Lagarde et al., 2001; Green, Fulop and Kocsis, 2000; Bankole and Singh, 2001). For example, a study by Lagarde et al., (2001) in four sub-Saharan African cities found that out of a large number of factors examined, education was found to be the most consistent determinant of condom use in non-spousal partnerships (Lagarde et al., 2001).
Likewise, in an eighteen sub-Saharan African country study including Mozambique, Bankole and Singh (2001) found that more educated men were more likely to report having used a condom.
They also added that even having only a primary school education compared to no schooling showed a positive relationship with ever use of condom in most of the countries (Bankole and Singh, 2001: 18).
In addition, the logistic regression analysis results suggest that men who were neither married nor cohabiting were more likely to have used a condom at last sex than married and cohabiting men.
The logistic regression analysis results for women also point to the similar trends. Indeed, women who were neither married nor cohabiting were more likely to have used a condom at last sex than married and cohabiting women. Focus group discussions and in-depth interviews gave a number of different reasons for non use of condoms, particularly among married and cohabiting partners.
Those reasons include the nature of relationship, trust, sexual pleasure and intimacy, among others. Similar results have been reported elsewhere (Muhwava, 2004; Bauni and Jarabi, 2003).
For example, Muhwava (2004) in Zimbabwe found that while condom use was higher in Zimbabwe than other African countries, negative conceptions about condoms still existed and that affected their use in regular or marital relationships. According to the author, both men and women were strongly against the use of condoms in marital relationships (Muhwava, 2004: 13).
Similarly, a study in Zambia (Agha, 1998) found that women in regular relationships may view them as precursor to marriage, and may become careful with something which can jeopardize their marital prospects, including engaging in casual sex. Thus, single women may establish casual relationships with men in order to form emotional ties leading to marital partnership and greater financial and emotional security, as well. Furthermore, given that Zambian women have low socio-economic status, they have limited ability to negotiate condom use in sexual relationships. For women like those, relational factors were very important in determining whether or not their partners used condoms. The author conclude that women’s reports of higher condom use in casual or non regular sex than in marital sex was consistent with the finding that men are more likely to use condoms outside of marriage than within marriage (Agha, 1998).
The same pattern is also observed with regard to the frequency of condom use among men and women of the study areas. Qualitative findings suggest that sustained condom use was dependent
not only on the nature of relationship but also upon its duration. The findings indicate that when the relationship tended to last longer, the possibility of sidelining condoms becomes high. These findings are in line with other study findings (Longfield, Klein and Berman, 2002). Indeed, in their study Longfield, Klein and Berman (2002) found that most participants listed factors that are linked to discontinuation of use and establishment of trust among youth. One of the most recurrent factors was that related to the timing in relationships. Respondents described that youth usually abandon condom use after feeling that they ‘know’ their partner well, spending time in relationships, feeling reassured that partners are sexually faithful, and confirming trust through further ‘investigations’. Furthermore, the discontinuing of condom use indicated advancement in relationships to more serious levels, especially consideration of marriage. In addition, participants indicated that some youth believed that trust was the only form of protection they need against STIs and HIV. Consequently, many explained that youth presumed that they did not need to use condoms with trusted partners or partners that they love (Longfield, Klein and Berman, 2002)
Meanwhile, the quantitative results suggest a slight improvement in the reports of condom use compared with other previous findings in Mozambique but it is still not enough to curb the progression of HIV infection. Furthermore, the results of bivariate analysis also suggest that consistent condom use among men and women is very low. Nevertheless, men were more likely than women to report that they always used a condom. For men the bivariate analysis results indicate that living in urban areas, being younger, having secondary education or more, being single or never married, and having an upper medium or high API is associated with consistent condom use. For women, the patterns are not so different. In fact, bivariate analysis results for women indicate that living in urban areas, being younger, having secondary or higher education, being neither married nor cohabiting, and having an upper medium or high API is associated with consistent condom use. The results of logistic regression analysis for men show that education and marital status have statistically significant unadjusted effects on consistent condom use.
Thus, men with higher levels of education are ten times more likely to report consistent condom use than less educated men. Similarly, married or cohabiting are more likely to report consistent condom use than men in marital and cohabiting unions.
The results of logistic regression analysis for women indicate that place of residence; education and marital status variables have statistically significant unadjusted effects on consistent condom use. Thus, women living in rural areas were less likely that those living in urban areas to report consistent condom use. However, women with higher levels of education were five times more likely to report consistent condom use than women with less education. These findings are in line with other studies about condom use in sub-Saharan Africa (de Walque and Kline, 2009;
Hounton et al., 2005). Based on nationally representative samples from 13 sub-Saharan Africa countries, de Walque and Kline (2009) came to the conclusion that levels of condom use were generally low, that men reported using condoms more frequently than women, and that unmarried individuals reported using condoms more frequently than married individuals with their spouses.
However, it was disturbing to note that while married men reported condom use in extramarital relationship as unmarried men did, married women reported very low levels of condom use in extramarital relationships (de Walque and Kline, 2009).