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African Population Studies
Union for African Population Studies
ISSN: 0850-5780
Vol. 19, Num. 1, 2004, pp. 119-141

African Population Studies/Etude de la Population Africaine, Vol. 19, No. 1, April 2004, pp. 119-141

Condom Use within Marriage and Consensual Unions in the Era of HIV/AIDS in Zimbabwe

William Muhwava*

*The author was the Principal Investigator in Zimbabwe for World Health Organization Project No.97908 “Family Planning in the Era of HIV/AIDS”. Currently, the author is the Regional Research Coordinator for East and Southern Africa for Population Services International.

Code Number: ep04007

ABSTRACT

The paper examines condom use within stable unions like marriage and consensual unions. The data from DHS show that condoms are used by less than 6 percent of married couples in Sub-Saharan Africa. The paper examines the determinants of condom use with spouse or regular partner among 1936 individuals in Zimbabwe. The results show that only 38 percent of the respondents reported using condoms consistently or occasionally with regular partners. There is little discussion about condoms in stable unions as only a fifth reported that they regularly talk about condoms with their spouses or partners. Couples who frequently discuss condoms are likely to be using them. The main barrier to discussing condoms is mistrust. In the focus group discussions, it was noted that bringing the subject of condoms to a partner might result in dire consequences like divorce, abandonment or physical abuse. The results show that people with negative perceptions about condoms are less likely to use them. The results also show that condoms are less likely to be used as a method of family planning, despite the fact that Zimbabwe has a high contraceptive prevalence rate. In this paper, women are more likely to have favorable attitudes about condoms and would like to use them, but the main barrier is their partners. Men’s influence on the condom is to prevent their use.

INTRODUCTION

The condom has been associated with a negative image, especially when used within marriages or stable relationships. According to Ankrah and Attika (1997), ”people often associate condoms with uncleanliness, illicit sex, infidelity and immoral behavior”. Reid (1996) noted for Brazil and Guatemala that “women interviewed said that condom is for women of the street, not the home”. In South Africa, condoms are for “back-pocket partners” (Reid, 1996). These sentiments seem to transcend national and cultural boundaries as the condom makes up only 4% of the global contraceptives used. In sub-Saharan Africa, condom use among married couples is between 2% and 6%, thus raising the risk of infection if there is infidelity between the couples. However, it should be noted that low condom use does not conversely imply high levels of infection, especially if the married couples are uninfected at the time of marriage and remain in monogamous relationships. This situation is ideal but difficult to fulfill, especially in countries like Zimbabwe where it has been noted that many married men have sex with someone other than their spouses (Chiroro et al., 2002).

Within marriages or in stable unions, a person may risk contracting HIV because he or she does not realize that the partner has other sexual partners. For example, in the 1999 Zimbabwe Demographic and Health Survey, only 1% of currently married women reported having had extramarital sexual activity in the last 12 months prior to the survey compared to 16% of married men who reported extramarital sexual activity. Thus, in these situations, women may think that they are at no risk and have little motivation to use protective measures like condoms.

Conversely and more commonly, married women may be aware of their husbands’ extra-marital relationships but feel helpless to act. Because of fear of reprisals, even when the woman knows the specific relationship, there are limits on what she can do to control her husband. Although women in married or stable relationships fear being infected by their husbands, whom they know are promiscuous, they feel they have no right or obligation to refuse sex or take preventative measures (Dixon-Muller and Wasserheit, 1991). In most situations, the women will be aware of their husbands’ philandering, but this does not translate to their taking effective preventative measures. A study in Zimbabwe among 72 HIV+ people by Meursing and Sibindi (1995) concluded that women do not question their husbands’ extramarital affairs and that STIs and AIDS are accepted as the risk of married life, with a few women standing up to their husbands to protest infection. In marital relationships, refusing the husband his conjugal rights (e.g. refusing sex) might result in divorce, violence, neglect or the husband taking a new wife.

Studies have shown that women remain in serial monogamy and they believe that their partners are doing the same (Chiroro et al., 2002). According to the African Marriages Act in Zimbabwe, men are permitted to have more than one wife and it is silent about extra-marital affairs. Indeed, it is a fact that most married men have several sexual partners in their lives, including commercial sex workers. Undoubtedly, such behaviour significantly increases the chances of these men being infected with HIV/AIDS and, subsequently, passing on the infection to their wives. Most married Zimbabwean women get infected and suffer silently because, by and large, the power relationship between ‘husband and wife’ in an African marriage (regardless of the Act under which the union is constituted) bestows upon the husband almost total power and control over his wife. Most women now consider being married to be the biggest HIV/AIDS risk factor in their lives because in their situations they cannot protect themselves.

Condom use in marital settings is unlikely to change unless social norms change. In the Zimbabwean culture, powerful norms about masculinity discourage condom use in marital relationships and encourage male sexual risk-taking. In the 1999 ZDHS, only 28% of the males reported using condoms with any partner, while 9% of the women reported using condoms. Condom use is especially low among married or cohabiting partners.

The Zimbabwean society seems to condone or accept extra-marital affairs of men. Because the system of family formation favors males, women in married situations find it impossible to refuse unwanted or unprotected sex, negotiate for safe sex practices or use contraception against the husband’s wishes. A mix of all these factors works unfavorably for women. According to Chitsike (1995), “women who challenge gender injustice as it exists in our culture are called prostitutes and accused of failing in their duties to housekeeping in their marriage”. Thus, changing the traditional views of masculinity and femininity is essential in promoting sexual health among married couples. As noted by Aggleton (1996), there is growing recognition that women cannot maintain their sexual health without the support of men.

A study by Chiroro et al. (2002) concluded that efforts to reduce the spread of the HIV virus in Zimbabwe are being hampered by men's attitudes, beliefs, and stereotypes on sex, sexuality, masculinity, reproductive health and gender equality. In addition, the results from the same study showed that poor sexuality standards and habits contribute significantly to the incidence of high-risk sexual behavior among Zimbabwean men and male youths who seem to view sex not as an expression of love between two equal partners but as an activity that should result in optimal sexual gratification for the man. It is argued in the report that advocacy and action programs designed to promote and facilitate behavior change among Zimbabwean men should be supported by specific legal and policy changes that enhance women's ability to enjoy fully their reproductive health rights and take a more active role in the process of negotiating for sex with their male counterparts on an equal basis.

This paper focuses on condom use within marriages or stable unions, because condoms are least likely to be used in these situations. The condom has not gained much popularity as a contraceptive method, but in the era of HIV/AIDS, there is need to look at the condom as a prophylactic. Although condoms are highly effective in preventing unwanted pregnancy and infections, it does not seem that they are gaining popularity among married couples. In this respect, the aim of this paper is to examine factors that influence use of condom within marriages and stable unions. It is hoped that those who are working to promote gender equity and sexual health in African contexts will utilize the results from this study.

DATA

The paper presents data from two phases of the research project conducted for the World Health Organization in Zimbabwe. Phase I of the WHO Project, No 97908, involved conducting focus group discussions among different groups, equally split between urban and rural areas. The FGDS covered 4 districts (2 rural and 2 urban). Phase II of WHO Project, No.97908, was a cross-sectional survey on family planning and sexual behaviour in the era of HIV/STDs. The survey collected quantitative information on family planning and sexual health needs that could be linked to knowledge, attitudes, and to background characteristics of the individuals. A three-stage sample design was used. Two urban and two rural sites were selected. The urban locations are Gwanda Urban in Matebeleland South province and Marondera in Mashonaland East Province. The rural sites are Gwanda Rural in Matebeleland South and Mutoko in Mashonaland East. Within each urban and rural site four wards were chosen and then five enumeration areas were selected within those wards. In each ward, 23 households were selected. In the household, all males aged 20-49 years, and all females aged 18-39 were listed. Using Kish grid, the name of one of these persons was drawn randomly. In total, 1936 respondents are included in this study.

RESULTS

The breakdown of the sample size by selected background characteristics is as shown in Table 1. In this paper, consideration is only given to the sub-sample of both males and females who reported that they are currently married or living with a partner (cohabiting). This study focused on 1,936 individuals in the sample who were married or in consensual/cohabiting unions at the time of the survey.

Table 1 indicates that 80% of the urban males have secondary or higher education, while 78.1% of urban females have secondary or higher education. For both sexes, there are fewer people with secondary or higher education in rural areas compared to the urban areas. There are about 5.6% rural males and 6.2% rural females with no education (not shown in table). The differentials in educational levels by place of residence are statistically significant with rural areas having significantly lower levels of education than urban areas. The distribution by religion shows that the highest proportions are Christians for both sexes and in rural and urban areas. Almost a quarter of the respondents indicated they follow traditional religion, while 21.9% go to spiritualist churches.

The highest proportion of the rural males and rural females are engaged in subsistence farming (41.7% and 57.6%, respectively). Unemployment and self-employment rates are highest for females in urban areas compared with any other residence/gender category. There is a sizeable proportion of rural males (33.9%) who indicated that they are employed as unskilled laborers and these are likely to be in mines or commercial farms. Also, there are mostly urban males in professional and managerial positions. The respondents are mostly in the 30-34 years group. The median ages are 31.8 years for urban males, 33.0 years for rural males, 27.8 years urban females and 30.4 years for rural females.

Table 1: Percent Distribution of Sample by Background Characteristics by Residence and Gender

Characteristic

Categorization

Rural

Urban

Total

Male

Female

Male

Female

 

Education

Primary or lower

48.0

59.5

20.0

21.9

38.0

Lower secondary

21.8

20.2

20.4

26.6

22.4

Upper secondary

27.9

18.7

41.4

46.6

33.5

Tertiary

2.3

1.6

18.2

4.9

6.1

Chi-square=352.511***

Religion

Christians

39.8

55.0

64.0

54.5

52.9

Spiritualists

21.4

25.3

17.0

22.8

21.9

Traditionalists

38.8

19.6

19.0

22.7

25.2

Chi-square=83.138***

Occupation

Agriculture

41.7

57.6

0.5

1.9

26.2

Sales and Service

3.9

1.4

23.2

7.5

8.3

Professionals

4.3

2.4

15.8

5.8

6.6

Manual laborers

33.9

0.8

47.0

3.0

19.4

Self and unemployed

16.2

37.9

13.5

81.8

39.5

Chi-square=1433.668***

Age Group

25 and below

9.0

25.9

11.3

36.5

21.5

25-29

16.4

21.8

20.7

25.1

21.1

30-34

25.1

15.3

20.2

17.8

19.5

35-39

18.5

35.4

20.2

19.9

23.7

40 and above

31.0

1.6

27.6

0.7

14.2

Chi-square=451.104***

N

487

509

406

534

1936

*** p < .01

In this analysis, a new variable that defines the marital and partner status of individuals is used. The marital/partner status variable has been divided into four categories: married with a non-regular partner in the past three years (extra-marital), married with no other partner (monogamous), cohabiting with a non-regular partner, and cohabiting with no other partner (monogamous). Table 2 provides a breakdown of other characteristics within these groups.

Table 2: Percent Distribution of Sample by Background Characteristics by Marital Status and Partner Type

Characteristic

Categorization

Married

Cohabiting

With Non-
Regular Partner

Monogamous

With non-
Regular Partner

Monogamous

Residence &

Urban male

15.5

64.8

5.4

14.3

Gender

Rural male

8.2

78.4

3.1

10.3

Urban female

0.0

83.7

0.2

16.1

Rural female

1.1

93.5

0.2

5.2

Chi-square=156.715***

Education

Primary or Lower

6.4

78.3

1.1

14.2

Lower secondary

6.5

72.1

3.2

18.2

Upper secondary

5.4

79.5

1.5

13.6

Tertiary

12.6

59.7

7.6

20.2

Chi-square=44.612***

Religion

Christians

5.8

79.4

1.9

13.0

Spiritualists

7.6

66.2

2.6

23.6

Traditionalists

7.0

78.0

2.3

12.7

Chi-square=34.842***

Occupation

Agriculture

5.3

87.2

0.4

7.1

Sales and Service

13.1

70.6

2.5

13.8

Professionals

8.6

82.0

0.8

8.6

Manual laborers

12.5

67.3

6.9

13.3

Unemployed

2.5

73.4

1.0

23.0

Chi-square=177.388***

Age Group

<=24

3.1

68.8

2.9

25.2

25-29

6.8

71.6

2.9

18.6

30-34

6.6

80.4

1.1

11.9

35-39

5.9

83.6

0.9

9.6

40+

11.7

75.9

3.3

9.1

Chi-square=85.867***

N

126

1474

41

295

*** p < .01

The proportion of married respondents who have had non-regular partners in the last three years is highest among urban males, followed by rural males (15.5% and 8.2%, respectively). No married women in urban areas reported having a sexual relationship with someone who is not a spouse or a cohabiting partner in the last three years. About 4.3% of the rural females reported that they have had an extra-marital relationship. The highest percent that reported fidelity were urban females. About 83.7% of females in urban areas reported they are currently married and monogamous compared to only 64.8% of the urban males. The proportion of cohabiting respondents who have had other sexual partners is highest among urban males (5.4%) compared to only 0.2% and 0.6%, for urban and rural females, respectively.

The highest proportion of those who are married and have had a non-regular partner are those with tertiary education (12.6%). The respondents with no education and secondary education reported the highest fidelity of about 79%. The highest proportion of those who are cohabiting and have had a non-regular partner are those with tertiary education (7.6%). Among those with no or primary education, 6.4% reported that they are married but have had an extra-marital relationship, while 78.3% are married but have not had any extra-marital sexual relationship. Among those with lower secondary education, 6.5% reported that they are married but have had an extra-marital relationship, while 72.1% are married but have not had any extra-marital sexual relationship. Among those with senior secondary education, 5.4% reported that they are married but have had an extra-marital relationship, while 79.5% are married but have not had any extra-marital sexual relationship. Among those with tertiary education, 12.6% reported that they are married but have had an extra-marital relationship, while 59.7% are married but have not had any extra-marital sexual relationship. The differentials in partner type by level of education are highly significant.

The respondents who work in manual skilled jobs and those in the sales and service sectors reported the highest proportion of non-regular partnership among the married. This pattern has been noted in the FGDs, where people working in less-paying jobs in urban areas are separated from their families for long periods, and they tend to have other relationships in the urban areas. Those who are not employed are not likely to have non-regular partners. This might be because they lack the resources to do so, because such relationships tend to be monetary and expensive. Among those married with no extra-marital affairs, those in subsistence farming reported the highest. Workers in the agriculture sector reported the highest proportion of fidelity in married relationships (87.2%), while the manual laborers reported the lowest fidelity (67.3%).

With respect to age, the proportion of married respondents with extra-marital affair is highest among those aged 40 years and over (11.7%) and lowest among those aged 15-24 years (3.1%). Over 80% of those aged 30-34 and 35-39 reported that they are married and have not had any extra-marital relationships. However, only 68.8% of those aged 15-24 reported that they were married and faithful.

Table 3: Percent Who Are Current Users or Non-users of Condoms with Spouse or Cohabiting Partner

Characteristic

Categorization

Condom Use

Consistent or Occasional Users

Non users

Residence &

Urban male

65.0

35.0

Gender

Rural male

32.2

67.8

Urban female

36.3

63.7

Rural female

24.2

75.8

Chi-square=174.478***

Partner type

Married with non-regular partner

53.2

46.8

Married and Monogamous

37.7

62.3

Cohabiting with other non-regular partner

61.0

39.0

Cohabiting and Monogamous

30.5

69.5

Chi-square=28.531***

Education

Primary or Lower

27.8

72.2

Lower secondary

37.8

62.2

Upper secondary

46.1

53.9

Tertiary

59.7

40.3

Chi-square=74.558***

Religion

Christians

40.8

59.2

Spiritualists

36.1

63.9

Traditionalists

34.3

65.7

Chi-square=6.846***

Occupation

Agriculture

24.6

75.4

Sales and Service

56.9

43.1

Professionals

56.3

43.8

Manual laborers

47.9

52.1

Unemployed

35.3

64.7

Chi-square=98.687***

Age Group

25 and below

33.1

66.9

25-29

38.6

61.4

30-34

47.7

52.3

35-39

34.7

65.3

40 and above

37.5

62.5

Chi-square=21.620

TOTAL

38.1

61.9

N

738

1198

*** p < .01

This section presents results that relate condom use with the primary spouse or regular partner to background characteristics and attitudes about condoms. Table 3 presents the distribution of ever-use of condoms with primary regular partner. The dependent variable comes from the two questions in the section on condoms: “Have you and ever used a condom?” Then those who respond positively are asked, “Do you use a condom always, occasionally or at the beginning of the relationship”, with that regular partner. Thus, those who respond that they have never used condoms or used at the beginning of the relationship are coded as “non-users” while those who responded that they always or occasionally use with their regular partners were coded as “current users”.

Overall, the level of use of condoms with the primary regular partner is about 38.1%. However, the levels of condom use vary by the control variables. About 65% of the urban male respondents reported that they always or occasionally use condoms with regular partner. On the contrary, only 24.2% of rural females reported that they always or occasionally use condoms with regular partner. The differentials by sex and place of residence are highly significant.

Those who are cohabiting but who also have other non-regular partners reported the highest proportion using condoms with their regular partners (61%) relative to any marital status group. The two groups who indicated that they are in monogamous relationships are less likely to use condoms with their regular partners (30.5% and 37.7% for married and cohabiting, respectively). The differentials by partner type are highly significant.

Use of condoms consistently or occasionally increases dramatically as the level of education increases. There is a significant positive relationship between education and condom use. The relationship between use of condoms and religion is also significant. The least educated, that is no education or primary, are less likely to use condoms in regular relationships (27.8%) compared with those with tertiary education (59.7%). The Table indicates that Christians reported the highest use of condoms (40.8%) and those who described themselves as Traditionalists recorded the lowest condom use (34.3%).

The relationship of condom use with occupation is significant. Those respondents working in sales and services recorded the highest ever use of condoms (56.9%), followed by those in professional employment (56.3%) and those in subsistence agriculture recorded the lowest (24.6%). Use of condoms tends to increase with age but peaks at age group 30-34 and falls. Condom use among the youngest age group is about 33.1% while for the oldest respondents it is about 37.5%. The chi-square tests shows that there are age differentials in condom use.

Table 4 examines the distribution of condom use according to the agreement with three statements related to perceptions of condom use. The first statement is: “Using condoms is an effective way of preventing AIDS.” It would be expected that those who strongly agree with this statement are most likely to use condoms. Among those who agreed that condoms are effective in preventing HIV/AIDS, 42.3% use the condom always or occasionally with their regular partner, whereas about 32.3% of those who disagreed with the statement use condoms always or occasionally. The results are highly significant and in the expected direction.

A virtually identical pattern is found for the categories of agreement with the statement, “Using condoms is an effective way of preventing pregnancy.” The most common response is ‘agree,’ and 42.6% of the respondents in this category always or occasionally use condoms with their regular partners. The lowest level of condom use with regular partner, 25.4%, is within the category of ‘disagree’responses, while 26.6% are of mixed opinion.

The third perception in Table 4 is given by the response to the question: “Who usually has the most influence over whether or not to use a condom: the man, the woman, or both have equal influence?” The frequencies of this variable (not shown in table) clearly demonstrate the dominant influence of the man; ‘man’ is the response about 4 times as often as ‘woman’, although ‘equal’ is about a third of all the responses. The frequency distribution shows 42.6% for man, 10.4% for woman, 30% for equal and 17% for no opinion. This pattern is not surprising because the condom is indeed a male method. In fact, condoms and male sterilization may be the only methods for which the man’s acceptance is essential; the woman without the man’s knowledge could use most other methods. Beyond the special character of the condom, however, the responses are consistent with other evidence of male dominance over reproductive and sexual decisions in Zimbabwe.

Condom use is less likely for those who say ‘man’ (42.1%) or those who say ‘woman’ (43.6%) relative to those who say ‘equal’ (47.4%) and the difference is highly significant. Men in Zimbabwe tend to dislike the condom, so when their influence is used it is generally to prevent condom use. The influence of women is more likely to promote condom use.

Table 5 reports the association between condom practices and regular partner discussions by the frequency of discussions on condom use.

Overall, the results show that as the frequency of discussions on condom use increases, the percentage of respondents actually using condoms also increases. Of those respondents who have discussed condoms many times, 85.5% have used condoms with a regular partner. Only 7.1% of those who have never discussed condom use with a regular partner have actually used them.

Of the respondents who have discussed condom use many times, 59.9% have used condoms occasionally and 27.9% have used them always. Of those who have discussed condom use a few times, 11.1% have used condoms always and 70% have used condoms occasionally. For those who have discussed condom use once, 52.9% have used condoms occasionally, while 40.2% used at the beginning of the relationship. For those who have never discussed condom use, only 13.3% have always used condoms with regular partner, 57.8% occasionally and 28.9% at the beginning of the relationship.

Results concerning condom use discussion and dual protection are significant. Among those who have discussed condom use many times, there is a high likelihood of using condoms in combination with another method. Respondents who have talked about condom use many times, few times or once also show higher percentages of disagreement about condom use with their regular partner.

Table 5: Cross-tabulation of Condom Use and Discussing Condoms with Regular Partner

How Frequently Have you Discussed Condom Use with your Regular Partner?

Many times

Few times

Once

Never

Total row %

Have you ever used condoms

Yes

85.5

68.1

54.0

7.1

49.0

with your regular partner

No

14.5

31.9

46.0

92.9

51.0

n =

346

665

163

628

Chi-square=723.258***

How frequently do you use

Always

27.9

11.1

6.9

13.3

16.4

Condoms with your regular

Occasionally

59.9

70.0

52.9

57.8

64.4

Partner?*

Beginning

12.1

18.8

40.2

28.9

19.2

n =

297

467

87

45

Chi-square=72.413***

Have you used condoms in

Yes

60.8

37.6

35.2

17.5

43.5

combination with another type of family planning?*

No

39.2

62.4

64.8

82.5

56.5

n =

296

465

88

63

Chi-square=62.420***

Have you ever disagreed with your regular partner about

Yes

38.3

19.2

24.5

6.1

24.9

using condoms?*

No

61.7

80.8

75.5

93.9

75.1

n =

347

660

159

49

Chi-square=54.072***

** p < .05 *** p < .01 NS = not significant

* These questions are limited to those respondents who have ever used condoms with their regular partners

Table 6 displays the results from cross-tabulations of the belief that the respondent’s regular partner is having sex with someone else by questions concerning condoms and AIDS. There are no significant differences in condom use between people who believe that their partners are having sex with someone and those who do not.

Condom use in combination with other family planning methods significantly differs between categories of the belief of a regular partner’s other sexual activities. Those who believe that their partners are having sex with somebody are more likely to have used condoms with another method of family planning. On the contrary, persons who believe that their partner is not having sex with anybody else are more likely not to use condoms and any other family planning method.

Respondents who believe that their regular partner is having sex with someone else have a higher percentage of having discussed using condoms at least once or more times. Equally, these respondents are also much more concerned about contracting AIDS from their regular partner. On the other hand, those who do not believe that their partners are having sex with anybody else are more likely not to discuss using condoms with their regular partner.

Respondents who believe that their regular partner is having sex with someone else have a higher percentage of being concerned about contracting AIDS from their regular partner while respondents who believe that their regular partner is not having sex with someone else have a lower percentage of concerned about contracting AIDS from their regular partner.

Respondents who believe that their regular partner is having sex with someone else have a higher percentage of occasionally using condoms. The same applies to those who are not sure about their partners.

MULTIVARIATE RESULTS

The multivariate results for use of condoms are presented in this section. As indicated earlier, those who have never used the condom or used only at the beginning of sexual relationship are classified as non-users; and those who responded that they always or occasionally use condoms are classified as users. Four logistic regression models are fitted. The first model includes only the control variables: age, education, occupation, place of residence, sex and partner type (Table 7). The other three models are presented in Table 8. The first model in that table includes the control variables and condom perception variables. The second model in Table 8 considers the control variables and AIDS-related concerns. The third model in the same table includes the control variables and condom discussion among regular partners.

The model in Table 7 for the whole sample shows that all the background variables are significant predictors of use of condoms. Most of the independent variables in that table are significant predictors of use of condoms. The age category that shows significant higher condom use with regular partner is the 30-34 age group, which is more likely to use condoms always or regularly with regular partners compared to those aged 24 years or younger. Respondents who are 40 years and above are less likely to use condoms always or occasionally with their regular partner compared to those 15-24 years. The patterns for the male and female models are similar to the combined model except for women aged 40 years and over who are more likely to use condoms in regular relationships than the young age group.

The differentials by sex are significant, showing females are less likely to use condoms always or occasionally with their regular partners compared to males.

The differentials by place of residence are also significant, showing that the respondents in rural areas are less likely to use condoms always or occasionally with their regular partners compared to those respondents in urban areas. The urban/rural divide is more significant and pronounced for the males than the females.

Table 7: Odds Ratios of Use of Condoms with Spouse or Regular Partner

Variables

Categories

Total Sample

Males

Females

Age

<=24 (Ref)

1.00

1.00

1.00

25-29

1.08

0.83

1.20

30-34

1.58***

1.32

1.89***

35-39

1.13

1.00

1.16

=>40

0.81

0.61**

1.69

Sex

Male (Ref)

1.00

Female

0.48***

Place of Residence

Urban (Ref)

1.00

1.00

1.00

Rural

0.50***

0.31***

0.88

Education

None and Lower Primary (Ref)

1.00

1.00

1.00

Lower Secondary

1.22

0.89

1.74***

Higher Secondary

1.47***

1.22

1.84***

Tertiary

1.71***

1.53

1.31

Occupation

Agriculture (Ref)

1.00

1.00

1.00

Sales and Service

1.50***

1.27

1.86***

Professionals

1.49**

1.17

2.21***

Manual

1.24

1.09

2.32***

Self and Unemployed

1.26

1.29

1.60***

Religion

Christians (Ref)

1.00

1.00

1.00

Spiritualists

0.90

0.68***

1.15

Traditionalists

0.83

0.70***

1.09

Partner Type

Married with other non-regular (Ref)

1.00

1.00

1.00

Married and monogamous

0.67**

0.70

0.68

Cohabiting with other non-regular

1.23*

1.10

5.66

Cohabiting and monogamous

0.49***

0.59**

0.38**

* p <10 ** p < .05 *** p < .01

There are educational differentials in use of condoms. Respondents with high secondary and tertiary education are more likely to use condoms always or occasionally with their spouse or cohabiting partners than those with no or primary education. Condom use with regular partner tends to increase as the level of education increases. Considering the effect of education by sex, it clearly shows significant differences are observed among females.

Occupation is a significant predictor of use of condom in regular relationships. Those working in agriculture or subsistence farmers are less likely to have used condoms with their spouses or regular partners than those in other occupational categories. Couples in professional employment, sales and service workers are significantly likely to use condoms always or occasionally with their regular partners or spouses compared to agricultural workers. However, there are no significant differences in use of condoms between agricultural workers, manual workers and the unemployed or self-employed. Occupation is not significant when considering the male model. However, for the female model, the occupational differences are highly significant, with women in paid employment being more likely to use condoms than subsistence farmers.

Religion is a significant predictor of condom use with spouse or cohabiting partners among males. Christians are more likely to have ever used condoms with their spouses or regular partners relative to other religious groups. Traditionalists are less likely to have used condoms with their spouses or regular partners than Christians.

Table 7 also shows that partner type is an important predictor of condom use in regular relationships. Married persons who have extra-marital affairs are more likely to use condoms always or occasionally with their spouses than those who are married without extra-marital affairs. However, the married persons with extra-marital affairs are less likely to use condoms always or occasionally with their spouses than those who are cohabiting and have other sexual partners. Unmarried persons having one regular partner and no other sexual partners are less likely to use condoms always or occasionally with their regular partner than those who are married and having other non-regular sexual relationships. Thus, respondents who have other sexual partners besides their regular partners are significantly more likely to use condoms with their regular partners.

In Table 8, results from other covariates of other factors of ever use of condoms are presented. The models are fitted controlling for background variables but the odds ratios for background variables are not shown in the table.

Model I in Table 8 shows the effects of condom-related perceptions on ever use of condom with spouse or regular partner. It is hypothesized that those with a positive attitude about condoms are more likely to use them. It can be clearly noted from Model I that one’s perception about the condom ultimately affects use of the method. The first independent variable is the perception of who should suggest condom use. Respondents with no opinion about who should suggest condom use are less likely to use condoms than those who suggest men. Thus, neutrality or having no opinion about condoms has a negative effect on condom use.

Model I also shows that those who agree that condoms are effective in preventing HIV/AIDS are more likely to use condoms always or occasionally than those who disagree with the effectiveness of condoms. This is a very informative finding because those who are aware of the preventative effect of condoms are adopting positive behavior with their spouses or regular partners. For the same variable, those who disagree are less likely to use condoms with their regular partners compared to those with a positive view about the effectiveness of condoms in preventing HIV transmission.

The Table indicates that those who disagree that condoms encourage promiscuous behavior are more likely to use condoms than those who agree, although the results do not show statistical significant difference. There is also no significant difference in condom adoption between those with a negative view and those with no opinion about condoms encouraging promiscuity.

In the same model (Model I), acceptability of using condoms in marriages has a positive effect on condom adoption in stable unions. Those who say that it is unacceptable to use condoms in marriage are less likely to use condoms always or occasionally in regular relationships. Also, those who expressed no opinion about acceptability of condoms in marriages are less likely to use them compared with those with a positive attitude.

The last variable in Model I shows a significant positive relationship between condom use and acceptability of women to ask their husbands to use condoms. Those who say that it is unacceptable for married women to ask their husbands to use condoms are less likely to use condoms in regular relationships. However, there is no significant difference between those with a positive attitude and those with no opinion.

Model II in Table 8 shows the effects of measures of AIDS-related concerns on ever use of condoms. It is expected that where an individual is concerned about the risk of contracting HIV, they are likely to adopt protective measures, such as using the condom. In Model II, there is no significant difference in condom use between those who suspect that a regular partner is having sex with someone else and those who do not or are unsure. However, those who are unsure are more likely to use condoms with the regular partner although the results are not statistically significant. Also, there is no significant difference between those who are concerned and those not concerned about getting infected with a regular partner in condom use with regular partner. An important finding in Model II is the positive relationship between those who have tried something to reduce risk of infection and condom use. Those who have tried to reduce their risk of infection are more likely to use condoms with their regular partners than those who have not tried anything.

Model III in Table 8 shows the effects of discussions about condoms with regular partner on ever use of condoms with that partner. It is hypothesized that those who discuss condom issues with their regular partners are more likely to adopt them. The first variable in Model III supports the hypothesis, and confirms that those who frequently discussed condoms with their partners are more likely to use them. The respondents who have never discussed condoms with their partners are less likely to use compared to those who have discussed condoms many times. Also, those who discussed condoms once or a few times with their partners are less likely to use them compared to those who discussed many times. However, there are no significant differences in condom use with regular partner between those who have agreed or disagreed about using condoms.

QUALITATIVE FINDINGS

In an effort to find explanations for condom use behavior within stable unions, some qualitative research was done using focus groups discussions. In this paper, we analyzed FGDs conducted among married men and women, although the overall research project also collected information on the unmarried youths. This section aims at explaining the low usage of condoms in stable relationships, especially among those who are aware of its prophylactic and family planning advantages. The quantitative results presented above are highly corroborated by findings from the qualitative study that condoms are not used much in marital or stable relationship situations.

First, the urban-rural divide in condom use in marital relationships is quite apparent from the discussions. Although all FGDs reported a high awareness and knowledge of condoms, there are variations in their acceptance. Participants in rural areas mentioned that condoms are widely accepted but the major problem is their unavailability/cost and lack of knowledge on how they should be used. Some of the views include:

In our rural areas, condoms are not available, so we cannot talk about something that we cannot get [Males-Rural]

If my husband suggests condoms, I will be very happy. I know I will not have to take pills for limiting the number of our children. He has agreed to use pills because we want few children [Female -Rural].

Conversely, males in urban areas were candidly critical about condom use in marriages. It can be inferred that most urban men for various reasons have multiple relationships and they reason that what they do outside the marriage is likely to be what their spouses would also do. Urban men were cited as the main barriers to condom use, as the excerpts below indicate.

If males accept condoms, women are ready. Males do not want to have sweet wrapped in paper. [Female -Urban]

If the husband brings the condom at home, it is accepted but if the wife does, they turn and accuse the wife of promiscuity. [Female -Urban]

Condoms have a negative image and they are associated with promiscuity. Many groups felt that condoms are despised because they seem to indicate promiscuous behavior or loose morals. They regarded the condom as something that should be used outside the home – probably for enjoyment. Married men also said that they would be both surprised and enraged if a wife suggested the use of a condom to her husband. Generally, condoms are seen as “… things to be used with prostitutes only”.

Condoms are used mostly by commercial sex workers [Female -Harare]

No, the condom is for affairs outside the home [Males-Rural]

There will be a problem if my wife asks me to use a condom because I will query if she has something on her mind. [Males-Harare]

The fact that the groups indicated that condoms are for out-of-marriage relationships, shows there is the underlying meaning that condoms are used with partners you do not trust.

I agree that it should be used outside the home when you meet different women because you do not trust them. [Males-Bulawayo]

People should be taught to use condoms with sexual partners they are not sure of. Even if you suspect your husband to be having an affair, insist on him using a condom for relationships outside marriage. But anyway, you do not know what he actually does when he is outside. [Female -Urban]

Condoms are more associated with extra-marital affairs and infidelity, so bringing the subject for discussion might lead to a lot of mistrust.

This is a big problem because if you initiate discussion on condom use, he will beat you and you cannot report anywhere. [Female -Gwanda]

Women in married relationships have to pretend that they are ignorant about condoms or even if they know them, they should pretend to be ignorant as displaying knowledge about condoms will bring retribution from their husbands. The female groups indicated that displaying knowledge to their husbands would often be translated or misconstrued that the women is using the condoms with someone else and the consequences were dire, the most expressed ones were being beaten up or abandoned by the partner.

A large proportion of the rural FGD participants acknowledged that condoms could be used as a method of family planning as long as the partners have agreed and the condom does not break. The minority who answered negatively mentioned the likelihood of the condom breaking and lack of knowledge on using it as their main reservations.

I do not agree with the idea of relying only on the condom for family planning. It might break [Harare-Males]

Condoms should be used only after we have both agreed to do so. The woman must not cheat me and use it without my knowledge [Males-Gwanda]

The urban FGD’s felt condoms should not be used for family planning but for affairs outside marriage.

You cannot use the condom in the home as a family planning method. The husband would not agree to use it for such a long time. [Female -Harare]

A very disturbing feature is that some groups, especially those in rural areas of Mashonaland could not link condoms to HIV prevention. They feel that HIV is linked to some traditional medicine, where women are locked by their husbands from having extra-marital sexual intercourse. The description of the practice is that the husband applies some traditional medicine on his wife, and if the woman has sexual intercourse with another man, then the man develops symptoms, which are like AIDS. They also state that diseases acquired through this traditional practice are not curable like AIDS and hence they believe that the disease (AIDS) has been there for a long time and thus, condoms will not protect anyone against HIV.

DISCUSSION

While condom use is higher in Zimbabwe than other African countries, negative perceptions about condoms still exist and this affects their use in regular or marital relationships. Both men and women are strongly against the use of condoms in marital relationships. Only about 38 percent of the respondents reported using condoms consistently or occasionally with their regular partner, while only a fifth reported current use of the condom. Married or cohabiting women view condoms as “things their husbands can use with other women” and not with them. Men believe that their wives or regular partners are not knowledgeable about condoms, and if the woman exhibits knowledge about condoms, then she is perceived as having extra-marital affairs. From both the male and female perspectives, condoms “encourage promiscuity”, hence the major obstacles to condoms use are related to concern about illicit sex.

Only a fifth of the respondents indicated that they regularly discuss condom use with their regular partners. Initiating discussion on condom use or suggesting condom use is often associated with mistrust. In some cases, attempts to bring up the subject have led to dire consequences like divorce, abandonment and wife battering. So, women risk their health for the sake of maintaining their marriages or relationships. Men are more likely to have a negative influence on use of condoms. Women are more likely to accept condoms but without their partners’ cooperation they cannot use them. Men’s influence on condom use is actually to prevent it.

Even as a form of contraception condoms are not very common. Less than half of the respondents reported having ever used/tried condoms as a method of family planning. It is evident that the Zimbabwean society still places greater emphasis on female-based methods of contraception. The burden of childbearing is placed on the woman, as is the burden to control fertility. Even among couples that have adopted modern family planning methods, they are unlikely to be using the condom. This explains why fertility might be declining in Zimbabwe and yet HIV prevalence rates remain high.

The multivariate analyses indicate that those who have negative attitudes about condom are less likely to use it. The most important programmatic implication is to de-stigmatize the use of condoms by people in stable unions or marital relationships. Efforts should be made to promote the positive portrayal of condoms. The image problems of condoms could have been created by the “sexual health movement” which emphasizes their use in risky relationships. So, trying to portray marriage as risky factor causes a lot of problems for people in such unions to be associated with condoms.

Posters and media have been carrying messages on condoms being useful with “partners you do not trust”. The problem is further exacerbated by the fact that condoms are widely available in bars, brothels, love motels etc, which are places often associated with promiscuity. The messages should be that “condoms are for people who trust and care for each other”; in other words, care enough to protect your spouse or loved one.

This paper addresses important issues in the Behavioral Change Communication (BCC) framework which includes: personal risk assessment, awareness of the severity of HIV/AIDS, interpersonal trust, social norms, motivation and self-efficacy. The ability of people to use and negotiate for condom use in stable unions is affected by these factors, and any interventions should focus on these factors.

REFERENCES

  • Aggleton, P. 1996. ‘Global Priorities for HIV/AIDS Intervention Research’. International Journal of STD & AIDS, 7(Suppl. 2): 13-16.
  • Ankrah E. M. and Attika S.A. 1997. Adopting the female Condom in Kenya and Brazil: Perspectives of Women and Men. Family Health International. Arlington, Virginia.
  • Chiroro P., Mashu A. and Muhwava W. 2002. ‘The Zimbabwean male psyche with respect to HIV/AIDS’. Reproductive Health and Gender Issues. Centre for Applied Psychology, Harare, Zimbabwe.
  • Chitsike C. 1990. ‘NGOs, culture and multiculturalism’. Gender and Development 3(1): 19-24.
  • Dixon-Muller R. and Wasserheit J. 1991. The culture of Silence: Reproductive Tract Infections among Women in the Third World. New York: International Women’s Coalition.
  • Meursing K. and Sibindi F. 1995. ‘Condoms, family planning and living with HIV in Zimbabwe’. Reproductive Health Matters 5: 56-67.
  • Reid E. 1996. ‘HIV and development: Learning from others’. In Sherr L., Hankins C., and Benett., AIDS as a gender issue: Psychosocial Perspectives. Taylor and Francis.

Copyright 2004 - Union for African Population Studies


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