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African Population Studies/Etude de la Population Africaine, Vol. 18, No. 1, April 2003, pp. 51-65 The Low Acceptability and Use of Condoms within Marriage: Evidence from Nakuru District, Kenya Evasius K. Bauni and Ben Obonyo Jarabi1 KEMRI/WTRL, Box 230, Kilifi, Kenya and Family Health International, P.O. Box 53070, Nairobi, Kenya Code Number: ep03004 Abstract In the last two decades, there has been an increase in the prevalence of contraceptive use in Kenya. While use of modern contraceptives has been successful in preventing unwanted pregnancy, it has not been so successful in preventing HIV/AIDS. The twin risk of unwanted pregnancy and HIV/AIDS infection is a central concern of reproductive health programmes. Condoms are considered an effective barrier method because they can be used for the dual purpose of protecting against pregnancy and disease transmission. But will married couples and those in stable sexual relations accept and use them? This paper attempts to answer this question using data from Nakuru district, Kenya. From both quantitative and qualitative results, this study concludes that, not only, is the use of condoms to prevent STIs including HIV low within married and stable sexual relations, but, also, future prospects of condom use in such relations is rather bleak. Apart from using a condom for preventing a pregnancy in sexual relations, the only other reason for using it is because one does not trust the sexual partner. Majority of married couples will therefore not ask their partners to use a condom because they dread straining or breaking their relationship. This fear is amplified by the religious view of condom use being a sin.The study calls for appropriate interventions which should aim at providing married couples and those in stable sexual relations (including men) with targeted counseling services to strengthen mutual trust, a feeling they all cherish. Such services will not only facilitate the prevention of HIV/AIDS but will also minimize intra-couple tensions by enhancing mutual trust. Résumé Le taux de prévalence de l'utilisation de la contraception a beaucoup augmenté au Kenya au cours des deux dernières décennies. Si la contraception moderne a été efficace pour prévenir les grossesses non désirées, par contre elle ne l'a pas été pour prévenir le VIH/SIDA. Les risques combinés de grossesse non désirée et d'infection du VIH/SIDA constituent un problème majeur pour les programmes de santé de la reproduction. Les condoms sont considérés comme une méthode efficace de barrière car ils peuvent être utilisés avec le double objectif de prévenir la grossesse et d'empêcher la transmission de la maladie. Mais, est-ce que les couples mariés ainsi que ceux qui ont des rapports sexuels réguliers accepteront de les utiliser ? Cet article essaie de répondre à cette question en utilisant des données du district de Nakuru au Kenya. Sur la base des résultats à la fois quantitatifs et qualitatifs obtenus, on peut conclure que l'utilisation des condoms pour prévenir les MST y compris le VIH est non seulement faible chez les couples mariés et ceux qui ont des rapports sexuels réguliers mais que les perspectives de son utilisation future dans ces genres de relations sont même sombres. Outre son utilisation pour prévenir une grossesse au cours de rapports sexuels, l'autre raison qui fait qu'on l'utilise est tout simplement le manque de confiance au partenaire. La majorité des couples mariés ne demandera pas aux partenaires d'utiliser un condom de peur de briser leurs relations ou de les rendre tendues. Cette crainte est amplifiée par le point de vue religieux qui fait de l'utilisation du condom un péché. L'étude montre qu'il est nécessaire de mettre en place des interventions destinées à doter les couples mariés ainsi que tous ceux qui ont des rapports sexuels réguliers de services de counselling ciblés pour un renforcement de la confiance mutuelle, quelque chose qu'ils aiment tous sentir. Ces services vont non seulement faciliter la prévention du VIH/SIDA mais ils vont également minimiser les tensions entre couples en améliorant la confiance mutuelle. Introduction The condom dates back to Roman times, when animal bladders were used to prevent the spread of sexually transmitted diseases. The earliest published description is that of an Italian anatomist Gabriel Fallopio, who in 1564, recommended a linen sheath moistened with lotion to protect against syphilis (Potts, 1999). Only in the 18th century do we find condoms being used specifically to prevent pregnancy. In family planning, the condom - the major nonpermanent male method - was promoted and used as a barrier method. In the three decades of the 1960s, 1970s and 1980s, condom use was promoted with other methods of preventing unwanted pregnancies. However, with the onset of HIV/AIDS, sexual partners who had somehow subdued the risk of unwanted pregnancy by using efficient methods of contraceptives found themselves exposed to the risk of being infected with HIV. In an attempt to intervene, policy makers and reproductive health programme managers re-focused their attention to ways of preventing HIV/AIDS, particularly on condom use, which were promoted as contraceptives and prophylactics. Despite these efforts, condom use in Kenya has remained relatively low and largely restricted to casual sexual partners. A mere 1.5 % of women and 16 % of men were currently using condoms by 1998 (KDHS, 1998). Are there prospects of expanding the use of condoms to sexually active married people? We attempt to answer this question using data from Nakuru district of Kenya. As one of the districts with the highest HIV prevalence rates estimated at 26 % in 1998 by the National AIDS and STIs Control Programme, Nakuru was selected to be the study area in a multi-country study on "Family Planning and Sexual Behaviour in the Era of STIs and HIV/AIDS". The study was funded by WHO and carried out by the African Population and Health Research Centre of the Population Council, Nairobi. The other countries participating in the study were Uganda, Tanzania, Zimbabwe, Zambia and South Africa. The study had three main objectives: to ascertain the perspectives of sexually active men and women about the risks of HIV/AIDS and unwanted pregnancy; to investigate the strategies considered by sexually active individuals as most appropriate, practical and effective to cope with these risks; and to explore the opportunities for, and constraints on, changing behaviour, with particular emphasis on partner communication. The study was designed to hold discussions with and interview sexually active men and women in both rural and urban areas in three phases: Phase 1 was the focus group discussions; Phase 2 was the household-based sample survey; and Phase 3 was the in-depth interviews. This paper presents results drawn from all the three phases. Methodology The study was limited to persons aged 18 to 49 years, because the majority were sexually active and the contraceptive prevalence was higher in this age range than during adolescence or after age 50. Twelve focus group discussions (FGDs) were held in both urban and rural areas in July 1998 targeting three groups: (i) women using a family planning method, (ii) women not using a family planning method, and (iii) sexually active men. A randomly selected sample of 1,422 sexually active male and female respondents (defined in this study as males aged between 20 and 49 years and females between 18 and 39 years) was interviewed in June-July 1999. During this survey, quantitative information on knowledge, attitudes and practices of people on the needs of family planning and sexual behaviour was collected. Results from the household sample survey provided the sampling frame for the selection of individuals interviewed during phase III of the study. In-depth interviews with 40 sexually active men and women (in both urban and rural areas) were carried out in October 1999 in order to investigate attitudes on sexual activity and to obtain meaningful answers to sensitive questions. They were selected by their risk levels to unwanted pregnancy and HIV/AIDS as determined by their sexual behaviour, or that of their partners, which was assessed from answers to survey questions. The in-depth interviews were designed to elicit detailed information, over and above what had been collected from the same respondents in the household survey. The interviews sought information about the perceptions and personal experiences of respondents in relation to family planning, sexual behaviour, and STIs, including HIV/AIDS. In this paper, we use part of the data that addressed acceptability and use of condoms by sexually active men and women in Nakuru district. Results Characteristics of Respondents Background characteristics of the 1,422 respondents interviewed are presented in Table 1. The distribution according to age shows a similar pattern for males and females. About 67 % of the males and 70 % of the females were in the age range 20-34 years. This is the age range where sexual activity is expected to be very high.Overall, the respondents were distributed equally between urban and rural areas although there was a predominance of males over females in urban areas. The study population was relatively highly literate given that only about 6 % of the respondents had never attended school. The proportion of women who had never attended school was twice that of males, at 8 % and 4 % respectively. The majority (53%) of the males had secondary education unlike the females whose majority (55%) had primary education. About 95 % of the respondents reported themselves as Christians, 26 % Catholic and 69 % Protestants. Islamic religious influence was minimal as less than 1% of the respondents were Muslims. Seventy one per cent of the respondents were currently married with more females (76%) than males (67%). Although 23 % of the study population had never married, the proportion for males was double that for females. On the other hand, more females, 3.4 %, than males, 1.7 %, were cohabiting with their partners. About 24 % and 56 % of the respondents were occupied in agricultural and non-agricultural sectors respectively. The majority of those engaged in agriculture worked on their own farms with females (33%) double the proportion of males (16%). Sixty three percent of the males were in the private sector where sales and services were the main pre-occupations. Thirty three percent of the females, compared to 6 percent of males, were unoccupied - a clear indication of economic dependency. Knowledge and Acceptance of Condoms Evidence from the FGDs Knowledge about condoms was widespread in all the study sites but their acceptability and use was limited, particularly within marriage. The use of condom as a method of family planning and a response to the twin risk of unwanted pregnancy and STI infection, including HIV/AIDS, was rejected by one third of women groups and all men groups. All the women focus groups plus one group of men pointed out that men resist using condoms in marriage but are ready to and actually use them in sexual contacts out of marriage.
Evidence from the In-depth Interviews Majority of the respondents (78%) approved the use of condoms in a casual relationship but disapproved its use within marriage.
Evidence from the Sample Survey For the respondents who were either married or cohabiting with a partner, 696 were using a family planning method. Out of this number, 14 % were using condoms. There was limited use of condoms in marriage since the majority (74%) of the reported non-users of condoms were married. The level of condom use for the unmarried was more than double that of the married respondents. Of the respondents currently using condoms, 38 and 10 % were unmarried males and females respectively while for the married it was 15 and 4 % for males and females respectively. Focusing on those who were married, some of their characteristics about condom use are shown in Table 2. Although 39 % of the respondents agreed that it is acceptable for a married couple to use condoms, only 8 % of them were currently using condoms and 26 % had ever used. Ever use with a regular partner was 20 % implying that the extra 6 % (from the 26% of ever use) was with non-regular partners. It is not conclusively clear who a regular partner is. He or she could be a marriage/cohabiting partner, or any person with a regular sexual relationship. Concerning condom use in the past, married males reported 36 % ever use irrespective of type of partner and 24 % ever use with regular partner. The corresponding proportion of ever use for married females was constant at 17 %. This suggests that while 12 % of the ever use by married males involved non-regular partners, condom ever use by married females was confined to regular partners. For both married male and female respondents, there was a sizeable drop between ever use with regular partners and current use: from 24 % to 15 % for males and from 17 % to 4 % for females. This means that condoms are not consistently used. Most of the respondents held some negative attitudes towards condom use. For example, 67 % of the married respondents agreed that condoms encourage promiscuous behaviour; yet another group of 56 % agreed that the only reason to use a condom is because one does not trust the partner. Males are more likely than females to agree that condoms encourage promiscuous behaviour and that the only reason to use a condom is because one does not trust the partner. The possibility of condom use in marriage was further restricted given that the very males, who were against using condoms in marriage, were also reported to have more control (at 38% compared to only 13% for females) over whether or not to use a condom. Even with the current threat of HIV/AIDS, only 23 % (14% males and 31% females) of the married respondents agreed that a married couple can use condoms every time they have sex to protect themselves. This resistance, even in the face of a death threat, is a clear manifestation of how strong they are opposed to condom use in marriage. Why Condoms Are not Acceptable in Marriage Negative Associations Evidence from the FGDs The main reason from the focus groups suggests that resistance to condom use is related to its negative associations, for example, promiscuity. The groups reiterated that the use of condom within marriage is an indication of unfaithfulness, leading to mistrust.
Evidence from the Sample Survey Sixty eight percent of the respondents who were not currently using condoms agreed with the assertion that condoms encourage promiscuous behaviour and 53 percent agreed with the assertion that the only reason to use a condom is that you don't trust your partner. Problems Associated with Using Condoms Evidence from the FGDs A number of problems were reported in connection with using condoms hence the strong reservations about their acceptability. First on the list was the apparent fear by three quarters of the focus groups that condoms rupture in the process of sexual intercourse. This apparent fear was based more on what the respondents had heard from other people and less from actual experience. The second problem cited was the notion that the use of a condom reduces sexual pleasure for both the man and the woman. The other problem mentioned by one third of the groups concerned the stigmatization that goes with the possession and use of condoms. The groups reiterated that if a person is known to be using condoms, this person is taken to be promiscuous hence a sense of loose morals towards him or her. The issue of condom disposal after use was also associated with stigmatization. Unless condoms are properly disposed off, there are embarrassing moments when they are seen strewn all over in the gardens and rubbish heaps with the result that children pick them up and use them as balloons. Three out of the eight women groups cited religious reasons as factors inhibiting condom use. Some churches forbid the use of modern contraceptives (including the condom) arguing that such use amounts to killing the innocent hence committing a sin in the process. These strong religious beliefs emanated largely from rural women groups.
Evidence from the In-depth Interviews Further inquiry as to the reasons for the resistance to condom use revealed that only 5 out of 40 respondents (13 %) cited condom rupture as a problem with using condoms. Even then, 2 of these 5 respondents had never used condoms meaning that the problem of condom rupture cited by these 2 is rather speculative since it is not based on experience.
In spite of the low level of condom acceptability, 21 respondents (53%) reckoned that there were no problems whatsoever in using condoms. However, it is worth noting that 8 of these respondents had never used condoms to be certain that indeed there are no problems in their use. Seven respondents (18%) declared that they did not know of any problems in using condoms since they had never tried using them. Future Prospects of Condom Use Whether Condoms Can Be Used to Prevent the Dual Risk Evidence from the FGDs As to whether condoms can be used as a family planning method, one quarter of the focus groups responded with an outright 'No' and a similar number of groups were positive. The former cited problems associated with condom use as reasons for non-acceptability of condoms as a family planning method. For those who said that the condom is the best family planning method, they believed that it has dual protection against both unwanted pregnancy and STIs/HIV. However, their perceived acceptance was conditional: that men will be talked into accepting to use condoms.
Evidence from the In-depth Interviews Opinions were sought on the use of condoms either at the same time as, or instead of, other methods of family planning. While 12 respondents (30%) preferred condoms to other family planning methods, 18 respondents (45%) disapproved condom use instead of other methods. Condom preference was based on the argument that condoms would offer enough protection to the twin risk of unwanted pregnancy and STIs/HIV. The majority (83%) in this group were females.
A group of 6 respondents (15%) would prefer to use dual methods. They were convinced that by using a condom with another method, the dual risk would be greatly reduced through the double protection offered.
Whether One Can Ask the Spouse to Use a Condom Evidence from the FGDs As to whether one could suggest to the spouse that they use a condom as a protective measure against a perceived risk of HIV, the overwhelming response was 'No' due to the unpalatable consequences that would arise.
Evidence from the In-depth Interviews Even in a situation where one spouse is suspected to be having sexual relations with other partners, the majority of the respondents expressed reluctance in asking the spouse to use a condom. The fact that females would be the ones to ask their male counterparts to use condoms made the matter even worse. A very desperate group of 8 respondents (20%) said that there was nothing they could do to protect themselves against the perceived risk of HIV. The fact that all the 8 were females is a manifestation of the dependency syndrome - where females have to depend on decisions of their male partners in most of the family matters.
Evidence from the Sample Survey Of those who were not currently using condoms: 62 % recommended use of condoms as the appropriate action to take to avoid AIDS while engaging in sex; 70 % agreed that using condoms is an effective way of preventing pregnancy; and 52 % agreed that using condoms is an effective way of preventing AIDS. In the main study, both male and female respondents were asked to consider their own chances of contracting HIV/AIDS. From this self-assessment, those whose chances were high or medium were regarded as being at risk of HIV/AIDS. From a total of 1,364 respondents, nearly 20 % were classified as being at risk of HIV/AIDS. Of those at risk of HIV: 28 % agreed that to protect themselves against HIV, a married couple can use condoms every time they have sex; and 60 % agreed that using condoms is an effective way of preventing AIDS. Of those who were currently married: 39 % agreed that it is acceptable for a married woman to ask her husband to use a condom; 48 % agreed that using condoms is an effective way of preventing AIDS; and 68 % agreed that using condoms is an effective way of preventing pregnancy. Were non-users of family planning having different perceptions about condom use from family planning users? Evidence from the Sample Survey Given that 51 % of the total sample were sexually active yet not using any family planning method, we sought to determine whether this group's perceptions and inclinations about condom use were different from those held by users of family planning methods. By comparing Tables 2 and 3, there was no difference between users and non-users of family planning methods in terms of how they perceive condom use. For example: 67 % users and 68% non-users believed that condoms encourage promiscuous behaviour; and 56 % users and 58 % non-users held the opinion that the only reason to use a condom is because one does not trust the partner. Discussion Currently, condoms are the most effective barrier method because they can be used for disease prevention in conjunction with other methods, or alone for the dual purpose of protecting against pregnancy and disease transmission (FHI, 1998). However, while knowledge of condoms is widespread in the study area, its use remains very low and largely limited to sexual encounters outside marriage. This finding is supported by the findings of the 1998 KDHS which show that: (i) the proportion of sexually active men and women who were currently using condoms was about eight times the proportion of married couples using condoms; (ii) of all women aged 15-49, only 3 % used a condom with the spouse while 15 % of the women used them with someone else. The corresponding percentages for married men aged 15-54 were 7 % with spouse and 60 % with someone else. Even the HIV/AIDS scourge has not spurred adequate drive to raise the level of condom use. For example, Bauni and Obonyo (2000) established that: only 17 % of the respondents at risk of HIV were currently using condoms leaving a high 83 % engaging in risky sexual relations; and that 43 % of those who were not currently using a condom and who also had multiple sex partners, had never used a condom during their extra-marital affairs. Condoms are associated with unfaithfulness and therefore not acceptable in most stable sexual relationships. The introduction of condom use in a long-term relationship, where they have not been previously used, threatens the trust that is implied (whether it exists or not) in most of such relationships. Changati also observed that for most married men and women, condoms were associated with outside partners hence should be used only for casual sex and with prostitutes (Changanti et al, 1994). Because of being associated with infidelity, possession or use of condoms within marriage or in a steady relationship implies lack of trust of partner hence a potential cause for a breakup. It is the fear of the resultant feelings and subsequent consequences that constitutes the major obstacle to condom use to prevent STIs including HIV in stable sexual relationships. Despite the male dominance in making decisions over a wide range of family issues, including sex, husbands also fear asking their wives to use condoms (since they do not want to create suspicion that they have affairs outside of marriage). Future prospects of condom use within marriage are further complicated by concerns by religious groups who contend that condoms symbolise complacency, immorality and moral decadence and their use is committing a mortal sin. To this, add the minor practical problems of condom rupture, being slippery, not pleasurable and difficulties of disposal, and the chances of married couples adopting condom use look rather bleak, at least in the context of the communities in this study. Conclusion Knowledge about the role of condoms in preventing unwanted pregnancy as well as STIs, including HIV/AIDS, is widespread. Yet the levels of condom use have remained low even among high-risk groups such as those with multiple sex partners. The main reason for the low level use of condoms among married couples and those in a regular sexual relationship is the negative association of condom use with promiscuity, a behaviour that leads to distrust within relationships and stretching them almost to a breaking point. Most married couples fear straining their marriages or worse still, breaking them. Neither women nor men will suggest the use of condoms to prevent infection with HIV, not even when the risk is clearly high. They contend that the only reason to use a condom, other than for preventing a pregnancy is because you do not trust your sexual partner. In addition, the religious couples have the fear of using condoms, committing a sin and straining their relationship with God. Clearly, married couples and those in stable sexual relationships must protect themselves from catching HIV/AIDS by adopting preventive and practical measures which they accept and are comfortable with. For example, since they contend that mutual trust is the bedrock of their relationships, then, it should be enhanced and made real through innovative well targeted (including men) counseling services. In this way, we shall not only assist married couples to prevent HIV/AIDS, but, also, to live more mutually trusting sexual relationships which are less stressful. 1Acknowledgements: The authors are grateful to African Population and Health Research Centre for the leadership and technical backup and World Health Organization (WHO) which coordinated the modalities of the study and also provided the necessary funding. They also wish to recognize the assistance of Mr. John Litunda and Mrs. Pamela Audi for their administrative and technical support, Mr. George Dzombo and Ms Mercy Mwaria, medical staff of Langalanga Health Centre, Menengai Nursing Home, Kabazi Health Centre, and Ndabibi Health Centre, the 18 interviewers, and all those who participated as respondents during the three phases of the study. References
Copyright 2003 - Union for African Population Studies The following images related to this document are available:Photo images[ep03004t3.jpg] [ep03004t2.jpg] [ep03004t1.jpg] |
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