Reports from Union of African Population Studies / L'Union pour l'Etude de la Population Africaine Num. 36, 1999

Union for African Population Studies, Rapport de Synthese / Summary Report, Numéro / Number 36 - 1999

SMALL GRANTS PROGRAMME ON POPULATION AND DEVELOPMENT

THREATS OF AIDS AND CONDOM USE IN A NIGERIAN URBAN COMMUNITY: IMPLICATIONS FOR FERTILITY REGULATION IN NIGERIA

Joseph Chukwudi Okeibunor

Department of Sociology and Anthropology, University of Nigeria, NSUKKA

Code Number: uaps99036

TABLE OF CONTENTS

ABSTRACT

The motive for this research is provided by the search for conditions that will increase acceptance of condom among couples of reproductives ages.

Four hundred and fifty (450) sexually active persons aged 15-64 years were sampled from Awka using the multistage sampling method. The questionnaire and focus group discussion techniques were used for data collection.

The data analysis shows that the fear of being infected with the HIV/AIDS is a factor that will make individuals to rely on condoms. Education was found to be a key factor affecting acceptance and use of condom as a protective device against HIV/AIDS. However, it was found that most of those who perceive the condom as an effective protective device against HIV/AIDS will use it in casual sex and for fertility regulation. Finally, it is predicted that a threat of HIV/AIDS will change negative attitude to condom use.

1 - Study justification and conceptual framework

1.1 - Problem statement

Since the early 1980s, sub-Sahara African countries have faced formidable challenges to their development. They have had to cope with deteriorating economies, the imposition of structural adjustment programmes, and the spread of AIDS. These economic and health situations have serious implications for mortality and fertility, threatening to delay and, in some cases, even stop the process of demographic transition, as well as compound population and development problems.

The case of Nigeria, particularly, stands out here. Nigeria has been identified as a country with one of the fastest growing populations in Africa. With a 3.3 per cent annual growth rate, it accounts for over one-fifth of the region's population. By 2025 Nigeria is expected to be the sixth most populated country in the world. This has been attributed to the high fertility rate of 6 to 7 children per woman (Federal Republic of Nigeria 1988). At the same time, Nigeria is held to have a very low contraceptive prevalence rate (see Fisher et al. 1992; Liskin et al. 1990). This is in part associated with the historical attitudes towards fertility, borne out of the emotional desire for children in reaction to the high infant mortality.

In response to the linkages between population and development (Jones 1972), therefore, the federal government of Nigeria is showing a greater interest in, and a more definite commitment to fertility regulation in the country (Faruquee and Ravi 1983; Dyson and Murphy 1985; Oyekanmi 1988; Ransome Kuti 1989; Bongaarts et al., 1990; Oyoo 1991).

Having achieved some progress in the control of certain immunizable diseases and the reduction of later childhood mortality, the government went ahead to seek ways of adjusting fertility and growth rates to what is advisable for human and national development. In recognition of the low contraceptive rate, voluntary abstinence was seen and encouraged as an effective, preventive and low cost approach to fertility regulation which is functionally equivalent to contraceptive use.

In recent times, however, the incidences of unwanted pregnancies, abortions and abandoned babies have greatly increased (FRN 1988: 1; Ogunsanmi 1990: 1). The use of condoms is therefore recommended as the most effective barrier method with no side effects and which may be used jointly with other family planning techniques. It is an appropriate device for users who want reversible methods which do not require a skilled practitioner.

Despite the apparent universal knowledge of the condom, however, it is rarely used. The majority of Nigerians feel that the responsibility for fertility regulation should be borne by the women. Thus, men have no stake in the contraceptive culture and would resist any contraceptive that interferes with their sexual satisfaction. Worse still, the female condom is very expensive and its use is limited to Britain where it is still being tested. Women in Nigeria, therefore, have to resort to ineffective methods like douching with vinegar. They are hardly conscious of the health hazards they expose themselves to.

Apart from the incidence of unwanted pregnancies, HIV/AIDS is a recent but, perhaps, much more involving reproductive health hazard. In the coming years the AIDS epidemic, which is mostly transmitted heterosexually, will have profound disruptive consequences for the society. The World Health Organization estimated that by early 1991 at least 6 million adults in sub-Saharan Africa had been infected (WHO, 1991).

The demographic impact of AIDS may be too far to establish owing to uncertainty about the extent of the epiodemic, the long duration of AIDS latency and high fertility rate. The fact, however, remains that the disease has claimed, and will continue to claim, young children as its victims. `Due to the spread of maternal AIDS, it is estimated that more than 10 million children under the age of 10 years will be orphaned during the 1990s' (Greenhalgh et al., 1992). This poses serious social problems and implications for national development.

The disease is expected to spread rapidly among young and middle-aged urban professionals, with enormous potential for disruption of economic development. Its impact is expected to be greater in the cities of those countries hardest hit by the epidemic.

In Nigeria, an estimated 1.9 per cent of the population is infected (Agbor 1992), making it a major health hazard for all in Nigeria in the decade of the 1990s. Unlike other known reproductive health hazards, HIV/AIDS currently has no cure, a fact which makes it more deadly. The effects of the HIV/AIDS on economic development of Nigeria will be better appreciated when it is realised that as of now the economically active population is already over-burdened. Unlike the developed countries of America and Germany, there is only one working adult to every child. The success of the AIDS scourge on the active population, therefore, would mean a further push on the dependency ratio. The fatal consequences of HIV/AIDS therefore calls for vigorous promotion of condom use, which has been declared the only way out as of now.

It is timely to determine whether the condom which has limited popularity for fertility regulation would be more acceptable as an effective means of controlling the spread of HIV/AIDS and its negative consequences on national development. It will also be relevant to evaluate the implication of this on fertility regulation in Nigeria. The study proposed here will also look at sociocultural factors commonly associated with condom use in Nigeria.

In handling the issues involved, it is germane to pose some general questions. The answers to which are linked to the study objectives.

i)What sociocultural factors affect condom use in Nigeria?

ii)What is the current general attitude of Nigerians towards sexuality and fertility regulation?

iii)Is there any relationship between the perceived threat of AIDS and condom acceptability and use among Nigerians?

1.2 - Significance of the study

A number of studies have addressed the issue of fertility regulation and the possible incorporation of AIDS prevention activities into family planning programmes with a view to promoting the former (e.g., Vernom et al. 1990; Varela 1988; Varela et al. 1987; Williamson 1987). But perceived threat of HIV/AIDS as a source of change in traidtional attitudes remains to be explored. In view of the current attitude of Nigerians to fertility regulation, therefore, coupled with the current high fertility, this study, it is hope:

1.3 - Conceptual framework

Condom use is affected by a number of factors stemming from sociocultural environment. A simplified conceptual framework of these factors is presented in the figure below.

In this model:

2 - Methodology

2.1 - Study location and population

Awka, the capital city of the new Anambra State, lies a little to the North of a famous commercial centre, Onitsha, in Eastern Nigeria -- midway between the Delta and Enugu State of Nigeria to the West and East respectively. By the 1963 population census, its population stood at 48,725 people. Using a 2.5 per cent annual growth rate, the population projection would thus give 97,277 people in 1991 when the study was conceptualized. The population is a mixture of Christians, Traditionalists and Muslims. It therefore represents the ethnically/culturally heterogeneous urban area of the new state.

2.2 - Methods

Focus group discussions (FGDs) were initially conducted with sexually active persons in Awka to identify the people's perception of reproductive health hazards, common ways of managing different types of receptions of the use of the condom in preventing reproductive health hazards. Following general guidelines for conducting FGDs, we organised groups made up of six to eight participants having similar characteristics with respect to sex, age and social status. These discussions were guided by a series of open-ended questions which encouraged participants to share ideas, experiences and differences of opinion. Conversation was emergent and fairly free-flowing. The group setting was not only culturally conducive but stimulated recall and a sharing of perceptions. The FGDs were tape-recorded and relevant sections transcribed in addition to a note-taker being present to record observations.

On the basis of a preliminary analysis of data collected from FGDs, a survey instrument was constructed and 450 persons interviewed. The survey population was composed of sexually active persons aged 15-64 years in Awka. Respondents were selected using a multi-stage sampling technique. The seven community wards Awka Amikwo (2,699); Awka Nkwelle (1,440); Awka Agulu (17,817); Awka Amachalla (6,674); Awka Ifite Akwa (2,377); Awka Ayom N'Okpalla (7,855) and Awka Ezioka (9,863) acted as clusters. From these clusters, four were sampled for the study using the probability proportional to size (PPS) technique. Considering the difference in the population sizes of the clusters, no cluster chosen for this study was more than 25 per cent smaller than the largest cluster chosen. Thus, Awka Agulu, Awka Ezioka, Awka Ayom N'Okpalla and Awka Amachalla the first, second, third and fourth most populated respectively were chosen. The streets in the four wards/clusters served as subclusters from where twenty streets were randomly selected. A systematic sample of houses proportionate to the number of dwelling units in each street and cluster was made. One sexually active person was selected. To ensure a fair representation of sexes, further stratification was done based on sex.

2.3 - Data analysis

The quantitative data were computer processed and analysed. Percentages and other descriptive statistics, as well as graphic illustrations were used to describe the main characteristics of the study population. Correlational analysis was done, using measures like chi-square (χ²), and Pearson's coefficient (r) to illustrate the relationships between certain socio-cultural variables and risk orientation of the respondents. Comparative analysis of the independent variables was done to predict future dependence on condom.

The different levels of awareness and perceived threat of HIV/AIDS and condom use among groups, such as religious, occupational, residential and educational groupings were determined using means and/or proportions as the case may be.

For the data from focus group discussions, emphasis was on the interpretation and description of what was actually said. To do this, the tape-recordings were transcribed. In going through the transcriptions, we listened to the tapes for phrases with contextual or special connotations and noted them for our observation. These were organised under topic headings which were finally pulled together as a summary.

While analysing the data, such statements as `all the group members', `most of the group members', `a few of the group members', `only one member of the group', etc., spoke in a particular way (Obikeze, 1990:81) were made at the summary stage. In doing so, we could focus on some of the socio-cultural risk factors that influence the people's reproductive health behaviours.

3 - Summary of findings

To summarise the findings of this study, one must bear in mind the research questions, research objectives and hypotheses. In line with these, therefore, the summary presented below is organised under special topics on the work.

3.1 - Perception of HIV/AIDS in Awka

The results from the study show a high perception of HIV/AIDS as a dreadful health condition which most of the respondents will want to avoid and protect themselves against. A few, however, do not want to be bothered about protection against AIDS for different reasons. One of the reasons is that they think AIDS is unreal and the campaign for protection against HIV infection is meant to scare people from engaging in sex. Another reason for not bothering about AIDS and the need for protection is that `it is the whiteman's disease. According to discussants in a focus group discussion session, HIV/AIDS infects the whitemen because they have `cold blood'. For the discussants, one sure way of preventing the spread of HIV/AIDS in Nigeria is to send out all the whitemen in Nigeria.

Apart from these members, majority of the respondents expressed their fear for the AIDS virus and would not want to be infected with it. As a protection against HIV/AIDS, therefore, they will insist that condom be used in casual sex. Understandably, a chi-square (χ²) test showed a statistically significant relationship between the perceived effectiveness of condom as a protective device against HIV/AIDS and the use of condom; that is, more of those who perceive the condom as an effective protective device against HIV/AIDS will use the condom.

3.2 - Perception and use of condom

The study results show a very high level of awareness and knowledge of the condom. Ninety-three percent of the respondents to the questionnaire claimed to have heard of the condom. They were also able to mention at least one use to which the condom can be put, 27.7 per cent of the respondents cited as many as three uses of the condom; that is, as protection against AIDS, other sexually transmitted diseases, unwanted pregnancies, as well as a combination of all these uses. This level of knowledge was, however, found to be significantly influenced by level of education attained by the respondents.

All the same, we can notice a wide gap between the levels of awareness and the reported use of the condom generally. For instance, the results showed that only 32.4 per cent of the respondents would recommend the condom for family planning. Only 32.7 per cent and 32.5 per cent of the males and females respectively are currently using the condom for family planning. A majority of the respondents would go for other unorthodox methods or keep off casual sex to protect themselves from unwanted pregnancies. The study shows that the perceptions of the people on the condom are responsible for this gap between awareness and usage levels.

The condom is perceived in various ways that discourage its usage. Some of such ways in which it is perceived is that `it can kill', `increases sexual urge in girls and thus increases promiscuity in society', `exposes what should be secret to public knowledge in event of accident in the use of condom'. Such negative perceptions of the condom was found to come mostly from the non-Christian segment of the sample. Also, more of those with low levels of educational attainment, as well as more of those in the older age groups hold these negative perceptions of the condom and its uses.

3.3 - Impact of perceived threat of HIV/AIDS on condom use

The people's perceptions on condom notwithstanding, the results indicated that a majority of the respondents will insist on the use of condoms when faced with the threat of contracting HIV/AIDS. This is, however, affected by the perception of the effectiveness of the condom as a protective device against HIV/AIDS. A significant relationship exist between the perception of the condom as a protective device against HIV/AIDS and willingness to use the condom in casual sex.

Furthermore, some relationships can be gleaned between those who will insist on the use of condoms under the threat of AIDS and the different family planning techniques that will be adopted to prevent unwanted pregnancies. For instance, more of those who would insist on the use of the condom as a protective device against HIV/AIDS will also use the condom as a contraceptive device.

Factors that were found to influence the use of condoms for protection against HIV/AIDS include education, urban residence and age. For instance, more of those respondents with high levels of educational attainment would insist on the condom as a protective device against HIV/AIDS than those with lower levels of educational attainment. The same could be said with the length of urban residence. However, the age variable seems to show another relationship in this regard. The result proves that more of those in the younger age groups (15-44) will insist on condoms as a protective device against HIV/AIDS than those in the older age groups (45-64).

Moreover, we found that educational attainment and length of urban residence contributed to increase reliance on the condom towards casual sex. These factors were also found favourable for increased condom use against unwanted pregnancies.

Generally, these findings agree with earlier propositions and theoretical views, as well as empirical findings [see Hernandez (1981); Coleman (1981); Mann (1989); Oni and McCarthy (1990); Boulos et al., (1991)].

Further, they agree with the consensus equilibrium model of the functional perceptive from which the theoretical orientation of the study was borne out. A certain level of health pressure will force people to seek safe measures by re-evaluating their past attitudes. Thus, in the process of protecting themselves against the threat of HIV/AIDS people will change their attitude to condoms which, in the past, lacked acceptance when perceived mainly as a contraceptive device.

4 - Recommendations and conclusion

4.1 - Recommendations

An area that calls for urgent attention has to do with the redirection of current programmes and policies on reproductive health behaviour. Current programmes have been targeting women. The women have been asked to be assertive and insist on the use of the condom, a male contraceptive device. It is, however, revealing to note that a majority of the respondents think that the responsibility for fertility regulation should be borne by women.

Moreover, it is acknowledged that the Igbo society is a male dominated society (Okonjo, 1992). To the Igbos, societal norms hold expectations of more compliant roles for the women so they cannot resort to coercive tactics, even if they did, the men would normally resist such coercion. It is, therefore, recommended that the resources directed at empowering women should be directed towards convincing men on the uses of the condom. In other words, responsibility should be placed where culture makes it fall, on the men. The men dominate sexual decision-making processes, so, should be targeted. At best, both males and females should be sensitized to use the condom.

Additionally, the current proposal to incorporate the AIDS prevention programme into family planning programmes gives the impression that the family planning programme is universally accepted. This is not true of the community studied. There is no shared responsibility in family planning. Furthermore, the barrier method, which is of relevance to the AIDS prevention programme, enjoys limited acceptance. Since it has been proved that the threat of the HIV/AIDS is strong enough to motivate people to change their attitude to the condom, it becomes logical to incorporate fertility regulation campaigns in the HIV/AIDS prevention programmes.

In summary, efforts should be directed towards practically changing the reproductive health behaviour of both women and men, with greater emphasis on men. It is only a high degree of male cooperation that will bring about widespread condom use and fertility regulation. The threat of the HIV/AIDS and the consequent perception of the effectiveness of the condom against HIV/AIDS promise a change in attitudes to condoms. This holds brighter future for fertility regulation. The men, rather than the women, should then be targeted in campaigns for safe sex and improved reproductive health practices.

4.2 - Conclusion

From the analysis of the data, there is an obvious reluctance to use the condom for fertility regulations. Most of the respondents believe that it is the responsibility of women to prevent unwanted pregnancies. It is surmised that this explains, at least in part, the low level of acceptance of the condom for fertility regulation.

In addition, the data show a low reliance on the condom as a protective device against sexually transmitted diseases. The respondents seemed to depend more on other protective devices rather than on the barrier methods. The men apparently, depend more on methods, which may be termed unorthodox "traditional" devices. These include the use of herbs and urinating immediately after sex. The female respondents on their part, depend on abstinence or self-cleansing immediately after sex.

All the same, most of the respondents are aware of the uses of the condom against unwanted pregnancy and sexually transmitted diseases. Unfortunately, they tend to reject it for alternative devices for various reasons. Most of the reasons are based on fears, misconceptions and lack of interest. From the focus group discussions, majority of the older respondents point out that the use of the condom heightens sexual desire and promote promiscuity. The unemployed male counterparts in a discussion highlighted the cost, arguing that it is cheaper to get antibiotics only in the event of an infection rather than buy and use condoms every time they had sex.

What seems like an astonishing response, however, came from most of the prostitutes. They believe that the condom is dangerous and can kill. Unlike what was reported of the prostitutes surveyed in the Dominican Republic, prostitutes interviewed in Awka would resist the use of condoms in sex.

In spite of this attitude, they recognised the dangers associated with their sexuality for which the condom is claimed effective. All the same, they would resist the condom and adopt ways they considered functionally equivalent to condoms. These alternative response modes are adopted to ensure that their clients have no infections before "business" usually commences.

This finding illustrates the power of the prostitutes over their clients in Awka community. The prostitutes indicated that a "deal" will be terminated if a client is suspected to be a carrier of any sexually transmitted disease. The client loses his money which must had been paid before being subjected to the rigorous tests. Only "deals" with clients confirmed free of any disease are finally consummated.

In addition to these pre-sex tests, they go for laboratory examinations periodically to detect sexually transmitted diseases. Any infection detected is treated locally. They rely on herbs and concoctions from the local herbalists, against sexually transmitted diseases.

The HIV/AIDS, however, incites some higher levels of fear in the respondents. It was found that in spite of the misconceptions held in some quarters on the mode of transmission of the HIV/AIDS, a good number of the respondents would insist on the use of condoms when faced with the threat of HIV/AIDS. As a matter of fact, a majority of those who would use the condom in casual sex indicated that they would do so because they appreciated the effectiveness of the condom as a protective device against the HIV/AIDS.

Also from the analysis, most of the respondents who would insist on the use of condoms in sex, as a protection against HIV/AIDS, would also use the condom as a contraceptive. Thus, we had to investigate the processes of the people's perception of the condom and their awareness of the various uses of the condom. The respondents' knowledge/awareness of the number of effective uses to which the condom can be put was found to correlate positively with a background variable like level of educational attainment. This becomes important if related to the finding that those who do not perceive the effectiveness of the condom against HIV/AIDS exhibit poorer dispositions toward the condom. Moreover, those who think of the condom only as a device against unwanted pregnancy or other sexually transmitted diseases think there are more convenient devices that are functionally equivalent to the condom.

The analysis shows that those with higher levels of educational attainment tended to recognise more uses of the condom, protection against HIV/AIDS infection. A similar but insignificant association exists between length of residence in urban area and awareness of the uses of condoms. The insignificance can be explained by the fact that some of the respondents who had just moved into Awka may have been previously in other urban areas and not indicated. Furthermore, attitudes toward the uses of the condom differ significantly among the various religious groups.

Ultimately, a majority of those who perceive the protectiveness of the condom against HIV/AIDS, and those who would insist on the use of the condom against HIV/AIDS would tend to use it not only for casual sex but as a contraceptive. And with greater educational achievement and increased enlightenment on the use of the condom, we can predict that more people will use it, not only as a protective device but as a contraceptive as well.

Before concluding, it is necessary to relate the study findings to the theoretical orientation. To appreciate its consistency, we can itemize the findings as follows:

These findings conform not only to the theoretical orientation, but also with other propositions. For example Dwyer and Haws (1990) had suggested that economic and health pressures will emerge, in spite of the existing cultural and social pressures against condom and fertility regulation, to motivate couples to change their reproductive health behaviours. The advocates of the technological viewpoints in condom promotion, had equally suggested that the recognition of the effectiveness of the condom is an important factor working against the sociocultural background (Hernandez 1981).

The findings of this study support these view. It has been shown that the more aware the people are of the uses of condoms, protection against the HIV/AIDS inclusive, the more they tend to employ it in sex. The study also showed that the more conscious the respondents are of safe sex and use the condom in casual sex, the greater the tendency to use it for fertility regulation.

Thus, it is recommended that more efforts be put into sensitizing the people about their safe sex needs, and fertility regulation programmes be incorporated into AIDS control programmes.

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