CONDOM USE VIS-A-VIS THE HIV/AIDS PANDEMIC AMONG ADOLESCENTS IN MALAWI.

CONDOM USE IN RELATION TO THE HIV/AIDS PANDEMIC AMONG ADOLESCENTS: THE CASE OF SOME SELECTED SCHOOLS IN ZOMBA [MALAWI].

BY

                             MARISEN MWALE [M Ed, B Ed]

                                     

                                      LECTURER

DEPARTMENT OF EDUCATION AND TEACHING STUDIES

E-mail : marisen.mwale@yahoo.co.uk

Mailing address :  Mzuzu University

                                Private Bag 201

                                Luwinga

                                Mzuzu 2

                                Malawi.

The author is an Educational Psychologist whose specialty is Adolescent Psychology and his research focus is adolescent sexuality, reproductive health and HIV/AIDS.

ABSTRACT

HIV infection among Malawian youth is growing at an unequivocally  alarming rate. Recent estimates according to the National AIDS Commission [NAC] (2005) indicate that about 16% of youths between the ages of 15 and 24 years are infected. The study explores factors perpetrating aversion to condom use in adolescent sexual dynamics and its implications on behavioural change relative to the HIV/AIDS pandemic. Data were collected through questionnaires and focus group discussion. The respondents were secondary school students drawn from three schools in Zomba [Southern Malawi] aged between 12 and 22. Results suggest that misconceptions, skepticism, apathy, rumors and negative symbolism imbue the condom as a protective device against HIV infection among adolescents. This is compounded by the fact that hitherto the condom has since been associated with promiscuity and prostitution. Nevertheless there are signs of a negative reversal to the disdain and trend with positive perception of risk to HIV infection being expedited among adolescents in the study area.

INTRODUCTION

The HIV/AIDS pandemic is threatening to plunder populaces the world over in no measure comparable to any other epidemic hitherto experienced in human history. More so it is the youthful and most productive sector that is unrelentlessly succumbing to the vicious repercussions of the pandemic. A bifocal scrutiny of the majority of those teetering at the brink of death from AIDS related infections explicitly depicts they are either in their late twenties or early thirties (Szekeres, 2000). Bearing in mind that the HIV virus has an optimal incubation period of not less than ten years before one overtly manifests the final end disease- AIDS- it suffices with unequivocal plausibility that a majority of those falling prey to the death trap contract the virus during adolescence.

In Malawi, where 35% of the population is aged 12-24, the average age at first intercourse is 14 for both male and female adolescents, but many begin sexual experimentation far earlier. McAuliffe (2005) noted that 66% of secondary school students in a survey he conducted were sexually active and most had initiated sexual activity between 10 and 14 years of age. Unprotected sex is putting young people at the risk of contracting HIV/AIDS. There is a preponderance of HIV/AIDS cases among the people aged 15-24 in Malawi with females being disproportionately affected (UNAIDS/WHO, 2004). Anatomical, physiological, socio-economic and other socio-cultural factors contribute to young women’s heightened vulnerability to contracting HIV/AIDS. In addition to greater biological susceptibility, another reason for higher infection levels among young women is that their sexual networks commonly consists of older men, who have had more sexual partners and are more likely to be HIV positive (UNAIDS/WHO, 2004). According to the National AIDS Control Program Strategic Plan (NACPS) as cited by Gulure (2003) it is stated that within the next decade in Malawi AIDS cases in youth are expected to double. AIDS is posing new dilemmas for the youth, circumscribing their life choices and impinging on the way in which they explore their sexual identities.

Young people have been well documented as a special needs group in the field of sexual and reproductive health, not least for their combination of risky sexual behaviours and frequent lack of information and access to services (Bauman and Siegel, 2004). According to Khalokho (2000), their reasons for being unable or unwilling to adopt safe practices reflects a socio-economic and cultural environment that motivates them to begin having sex at an early age. Some aspects of this environment are universal in that they are linked to the very nature of adolescence. These include rapid and uneven physical, psychological, and social growth and development and the onset of sexual activity that is often combined with a lack of knowledge and skills with which to make health choices.

Adolescence is often characterized by patterns of thinking in which immediate needs tend to take priority over long-term implications and by the initiation of behaviours that may be perpetrated over a lifetime. This particular poignancy about adolescent attitudes has been documented by Awusabo-Asare (2003). He argues that the pandemic particularly hits the adolescents because risk-taking is for them part of identity creation, particularly in conditions of lengthening adolescence. In South Africa, Varga (2004) claims that many of the young see no reason for caution because they already regard themselves as the corrupted and doomed generation. For adolescents in Malawi, infection with the HIV virus is one of the most concrete and pernicious risks of unprotected sexual intercourse.

There is mounting concern about the spread of HIV infection among the adolescent population in Malawi. As noted in Kadzamira et. al (2001), a significant percentage of youth has unprotected sex with multiple partners. In a survey conducted by McAuliffe (2005), two thirds of adolescent respondents agreed with the statement that ‘monogamy is impossible among young people’. As an area for further research the same study stipulated the need to delve into the reasons why adolescents cherish such beliefs as the impossibility of monogamy as well as why the preponderance of risky sexual behaviours persists to be normative among them irrespective of the unequivocal awareness of the dynamics and dangers of contracting HIV/AIDS. Surveys conducted in the mid-90s showed that only around 35%-55% of the sexually active male youth had ever used condoms and even smaller proportions used condoms consistently (Namanja, 1997). In yet another survey, only 24% of male condom users reported using condoms consistently with their girlfriends and only 24% of male condom users reported using condoms consistently with casual sex partners. The crux of the dilemma in this grave scenario may not be the implications of such negligent attitudes as it were but the digging into reasons why there is this tendency to downplay risk.

A recent study by Maluwa Banda (1999) advanced that only 43% of the sexually active students surveyed had used a condom during their first sexual intercourse and 16% of the respondents admitted contracting an STI at least once. Again this posits an unfathomable challenge for all stakeholders poised at mitigating the AIDS pandemic among adolescents since it becomes apparent that as the age group grapples with the negotiation of their sexual identities the risk of contracting HIV/AIDS is also exacerbated.

 The current study apart from focusing on diverse variables antecedent to adolescent susceptibility to contracting HIV exclusively considered the aspect of condom use among adolescents in Zomba a district in Southern Malawi. Irrespective of the fact that condoms have been empirically proven to negate the incidence of HIV/AIDS in the least analysis, the results of the study reflected that 65.5 % of the entire respondent sample who affirmed having indulged in heterosexual vaginal intercourse across all research sites refuted having used the condom in their sexual debuts first or otherwise. The major paradox was however why such was the case despite the fact that the majority of respondents displayed a 100% unprecedented knowledge of transmission and preventive dynamics.

RESEARCH SETTING

The study was conducted in Zomba a municipality town in southern Malawi. Most of the student respondents who participated in the study come from the same Zomba district with the majority of the populace being Yao in ethnicity. Like any other ethnic grouping the Yao have their own cultural practices among which are jando and msondo initiation ceremonies. These ceremonies are basically rites of passage geared at preparing adolescent boys and girls for adult roles and responsibilities as well as a smooth transition into adulthood. As was expected most of the respondents had undergone the ceremonial rites, which as portrayed by empirical research conducted by several authorities including National AIDS Commission [NAC] (2005) instill traditional knowledge that sometimes breeds dissonance within the adolescents and contradict with personal values and AIDS messages that the youth have indoctrinated over time. Although empirical findings elsewhere (Anaffi, 1999; Bongaarts and Reining 1989) demonstrate that some proclivities within the rites of passage such as male circumcision may negate to some extent the transmission of HIV, such positive aspects are undermined by formidable barriers to condom use. In such cultural rites for instance nothing is supposed to interfere with male sexual feelings of pleasure [male condoms] and women are not supposed to insert things into their vagina [female condoms]. This attitude breeds a recipe for the spread of HIV/AIDS among adolescents in the study area. Bearing in mind ethical considerations and the dignity and welfare of respondents, consent and permission were obtained to administer the data collection exercise and report the findings.

MATERIALS AND METHODS

The study applied both the quantitative and qualitative paradigms in a triangulative approach to render tangible data that was based on as many dimensions as possible relating to the topic of concern yet without pre-empting and militating against future research possibilities in the area of adolescent sexuality in Malawi. A triangulative approach encorporates two or more paradigms, designs or research methods in order to add more meaning to the findings or to diversify the data collection techniques. The respondents who participated in the study were secondary school adolescents, drawn from three schools considered the accessible population respectively. The research sites were chosen on the grounds of proximity to the researcher as well as to cater for the gender disparity. The following were purposively selected:

·        Mulunguzi co-educational Secondary School

·        Zomba Catholic’s boys Secondary School

·        St Mary’s girls Secondary School

All the above secondary schools, are conventional secondary schools with Zomba Catholic being a national secondary school for boys within the town periphery enrolling a cross section of students from several districts. Mulunguzi secondary school is more urban oriented with most students being enrolled from primary schools within Zomba and a few from the surrounding rural primary schools. Like Zomba Catholic school, St Mary’s girls school is within the urban milieu enrolling students from several districts. The gender aspect was considered as a criterion for sampling with two of the schools being single sex schools [Zomba Catholic enrolling boys and St Mary’s enrolling girls] while Mulunguzi school is co-educational.

The student sample consisted of 180 students that were selected by using the systematic random sampling method. Systematic random sampling not only reduced bias and other extraneous variables that were apt to affect the research process but also made the findings representative of the targeted population of adolescents in Zomba. Students were selected from Forms 3 and 4. Sixty students each were selected from Zomba Catholic and St. Mary’s schools. From Mulunguzi school, 30 girls and 30 boys were selected. In this way, the sample consisted of an equal number of boys and girls.

Various instruments were used to assess diverse areas concerning HIV/AIDS. Some of the items were solicited from a standardized Knowledge, Attitude, and Behaviour [KAB] model referred to in Maluwa Banda (1999) with others being modified Likert items adopted from the Protection Motivation Model as utilized by Abrahams and Seagal (1994) in a study conducted in the United States. The KAB model in HIV/AIDS research is aimed at soliciting respondents’ awareness of transmission dynamics relative to the pandemic as well as their affective ideals. It also aims at soliciting respondents’ perceptions of risk and the subsequent intention or non-intention to change behaviour remains within the scope of the model. Protection Motivation Models on the other hand utilize constructs adopted from Health Belief Models with the aim of evaluating respondents’ susceptibility to disease regimen.  Part A of the questionnaire sought data on students’ socio-demographic characteristics. Questions concerning age, religion, number of siblings in the family, and form of family were advanced [items 1-7]. Questions in part B sought to gather data on the knowledge and attitude consistency domains of the KAB model. The items sought to solicit information about modes of HIV transmission, prevention, as well as attitude vis-à-vis behaviour consistency [items 8-15]. Questions in part C were designed to gather data on the students’ attitudes towards HIV/AIDS with most of these items having been adopted from the Protection Motivation Model as applied by Abrahams and Seagal (1994). The response items sought to appraise self-efficacy, response efficacy as well as adaptive and maladaptive cognition relative to condom use vis-à-vis the HIV/AIDS pandemic [items 16-24].

A focus group discussion was also conducted to compliment and consolidate the other device in a bid to foster a triangulative approach. The focus group was triangulated with the questionnaire because the later does not provide a chance to ask the why behind the what of a research problem with the former however adding explanation and context to quantitative findings of a study. Providing a rich array of data, the focus group offers insight into the perceptions, attitudes and beliefs of subjects as there is an opportunity to hear from participants. Its major strength in the current study was that it helped in soliciting more personalized sentiments in an open and free atmosphere. The discussion focused more on the attitudes that adolescents hold on condom use.

Upon completion of the data collection exercise in all the participating schools, the structured items in the respondents’ questionnaire were coded and analysed using the Statistical Package for the Social Sciences [SPSS] data entry software. Frequency distributions as well as cross tabulations were conducted and the initial results were checked for consistency before a data file was obtained. The unstructured items were analysed through thematic and narrative analysis with stories being drawn and generated from the various established themes. The focus group discussion recordings were transcribed to obtain an accurate representation of the discussion. Coding was then conducted to identify consistent themes with several themes being identified and finally synthesized resulting in subsequent interpretation. Bearing in mind the sensitive nature of the study, sexuality being considered a taboo in the Malawian society, the study had problems in data collection because some respondents were not so keen to offer information. However the rest of the respondents were relatively open on issues of sexuality possibly due to the current preponderance of information on HIV/AIDS, condom use and Sexually Transmitted Infections [STIs] in Malawi.

RESULTS AND DISCUSSION

The results of the study indicate that 65.5% of the entire respondent sample who affirmed having indulged in heterosexual vaginal intercourse across all research sites refuted having used the condom in their sexual debuts, whether first or otherwise. This was the case irrespective of the remarkable overall higher rating on knowledge concerning HIV/AIDS among the respondents. This justifies the findings documented by research (Ruto, 2000; Varga, 2004; Khaloko, 2000; Caldwell, 1992; Ngugi, Roth and Fujita, 2000; UNAIDS/WHO, 2004) that perception of risk and high knowledge about HIV/AIDS do not necessarily translate to risk-reduction or behavior change. In other words there is a pronounced misfit between knowledge of HIV transmission dynamics and sexual behavioral change exemplified in the framework of the study by condom use.

The current findings also concur with those by Maluwa-Banda (1999) that 50% of the sexually active girls in a study conducted in the same research setting as the current one did not use condoms during their first sexual encounter. Several factors were highlighted by respondents concerning this disdain towards the protective device. First, there are diverse pervasive myths surrounding the condom. These myths include the fact that one cannot enjoy sex to its climax if a condom is used; that condoms have some tiny pores through which the HIV virus can pass; that condoms cause itching and rashes; that condoms can cause cancer and that if a condom bursts and gets stuck in the vagina, this may culminate in uterus infection.

These findings tally with Caldwell (2001) that there are strong feelings against condom use among Africans in general. The argument being that it has become almost de rigueur to ascribe this disdain to prejudice.  Chibatamoto and Marangwanda (2001) as cited by Caldwell (2001) referencing intervention and advocacy groups rather than anthropological researchers, summarizes that:

      ‘Some people have a negative view of condoms because of personal experiences with them, but more often the problem is bad reputation, false rumors and myths.’

Another related finding warranting some attention relative to the designing of intervention programs among adolescents is the issue pertaining the reliability of the protective device. That 95.5% of the sampled respondents in the current study affirmed that condoms are not 100% effective in protecting one against HIV/AIDS is a fatal implication for any program geared at stemming the pandemic. Compounded by myths, misconceptions, apathy and rumors, it is apparent that even if a steady supply could be guaranteed; cultural stigma against the condom hitherto associated with prostitution and promiscuity, is particularly strong among African cultures in general.

The association of condoms with less sexual gratification is evident in the exponential affirmation by one respondent in the focus group discussion that, ‘condoms reduce sexual pleasure’. The statement tallies with McPhail and Campbell (2001) where statements akin to the misgivings are highlighted:

   ‘One does not take a shower in a coat’ or ‘one does not eat a sweet with the wrapper.’

Respondents in the current study suggested that condoms compromise sexual pleasure and this reflects the misgiving that, ‘using a condom is like bathing with your socks on or having a shower with your clothes on.’ (Mwamwenda, 1999; Forster and Furley, 1989). Gulure (2003) also concurs with the ideal of ascribing myth to condom use. He contends that different actions would be expedited if such myths reign supreme among adolescents:

·        First those using condoms would stop using them since condoms would not be seen to protect them from HIV infection.

·        Second those students who have never used a condom would see no need to start using them.

·        Third those who may have used condoms would live in fear of having indulged themselves in unsafe sex.

Such fatalistic attitudes and cognition unequivocally breed a recipe for risky sexual endeavors and a statement in the focus group discussion that ‘since a condom is not 100% effective one could rather do without it’, might be a product of such resigned attitudes. It is worthy pointing out however that, if condoms are regularly, correctly and consistently used, they largely negate all other risk factors (Ngugi et al, 2000). The paradox needless to say is that while condom use is one of the cheapest and most effective HIV/AIDS interventions, building an effective condom program means overcoming enormous logistic, cultural and biological barriers.

Respondents in the current study also highlighted the fact that resistance to condom use especially among adolescent males lies also in the association of condoms with multiple partners and prostitution. As such, requesting the use of one in any affair other than prostitution can be interpreted as evidence that one has acquired HIV or is unfaithful or thinks the partner is involved in other sexual liaisons. Another reason for the disdain towards the condom as revealed by the study is the extraordinary stoicism towards death in African cultures. This has been widely documented (Caldwell, 2001; Orubuloye and Oguntinehin, 2004; Awusabo-Asare, 2003; Amuyunzu-Nyamongo, 1999; Varga, 2004). This streak of stubbornness and fatalistic resignation was reflected through a focus group sentiment at one of the study sites that:

   ‘Death is inevitable, I can as well die from an accident or any other unprecedented cause’.

This brave but stoic attitude towards death has been depicted as being very far from dominating decision making about life choices, least of which being self-efficacy towards the condom. It is widely thought that death is preordained or predestined and the surest way to death therefore is through worrying about it and devoting too much anxiety to its avoidance (Caldwell, 2001). Amuyuzu-Nyamongo (1999), summarizes the East African philosophy for instance as, ‘Everyone will die anyway?’ This ideal that death occurs from multiple causes invalidates the idea that a person could die from a simple virus. It is unequivocal that the rise in mortality rates occasioned by AIDS in sub-Saharan Africa, Malawi inclusive might have culminated in more resignation to death and more carelessness about life. Ayiga (1998) however argues conversely that, the higher mortality rate should in the final analysis have made the societies more sensitive to the perils around them, this being particularly the case among the educated. That this may indeed be the case is given support by the reported decline in HIV incidence and prevalence in Uganda.

It is possible also that those exposed longest to the world religions are more focused on the significance of death. The important point about the African AIDS epidemic is not that the message about the risk of death from AIDS has not had sufficient impact, but that the message about the high priority that should be given to all deaths has not reached a sufficiently receptive audience. Suffice it to say, any programs aimed at abating and stemming the tide of HIV/AIDS should first and foremost instill realistic attitudes towards life and death as the current mentality paves way to more devastating repercussions than are currently evident.

Other reasons documented by the current study for the adamancy towards condom use in the research setting include such factors as; adolescents’ feeling that they cannot enjoy sex to its climax if they use the condom, not knowing a partner’s serostatus, endeavoring to show the partner that one loves and trusts him or her, as a matter of choice, that girls feel good to have sperms ejaculated into their vagina, for maximum sensation, just for fun, and the stigmatization typical of service providers in institutions that offer advice on reproductive health to adolescents. These findings are concomitant with Ngugi et.al’s (2000) results revealing that demanding condom use in anything but the most commercial relationship is regarded as an admission either of risky behavior elsewhere or of knowing one is seropositive.

Studies also highlight as the findings have aptly documented that many adolescents do not know where to get condoms or are apprehensive of approaching service providers due to discriminatory and stigmatic mindsets thereof (Awusabo-Asare, 2003). Further adolescents do not seek such services for other reasons other than the specified ones as; inconvenient schedules and locations, lack of privacy and confidentiality, judgmental attitudes of service providers, and unaffordable fees (UNAIDS/WHO, 2004). It is perhaps not surprising therefore that there are particularly low levels of health promoting or seeking behaviors among young people with related difficulty accessing contraception and condoms.

Further girls cannot provide the condom since such action would suggest to the boy an unwillingness for intimacy and a suspicion of promiscuity even though the scale of costs and benefits of condom use weigh more to the detriment of the girl being not only the subsequent victim of HIV-infection but also pregnancy (Awasabo-Asare, 2003). Unprotected sex is also construed as a sign of young love, and accordingly boys as well as girls find it difficult to negotiate safer sex. Anticipated pleasure loss together with other factors perpetrating disdain towards the condom may therefore not be associated with adaptive cognition (Abrams and Seagal, 1994).

The trends and patterns unveiled seem to suggest that the social costs and benefits of condom use are more important than anticipated inconvenience or loss of sensation in adolescent coping appraisals (Boyd and Henderson, 1991). If this is the case efforts to make condoms more interesting and exciting as is the case with ‘Manyuchi’ in Malawi, may have little effects unless their use is seen to be socially acceptable and isolated from skepticism, myth, rumors, misconceptions and apathy. It may therefore be especially important to publicize findings indicating that young people in general intend to use condoms and are unlikely to be offended if their partner suggests using one (Abrahams and Seagal, 1994).

CONCLUSION

The current study has aptly revealed that perception of risk together with knowledge of HIV/AIDS transmission dynamics do not necessarily translate into behavior change typified in part by condom use. Imbued by apathy, misconceptions, skepticism, myth, rumors and other such factors; it is rather unfortunate to note that even though empirical evidence seems to be forthcoming that condom use could at least negate the devastating repercussions of HIV/AIDS; the preventive device is yet to be embraced among sexually active adolescents in the study area. The dilemma still remains that far as adolescents are engaging in unprotected sexual debuts measures to put into place to salvage them from contracting the HIV are yet elusive. The findings documented will have policy implications that will help government and key stakeholders in formulating policies that will improve sexual behavior among young people in Malawi.

                                         

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