Adolescent condom use in Southern Africa: narrative systematic review and conceptual model of multilevel barriers and facilitators

In sub-Saharan Africa, consistent use of condoms among adolescents is low [1]. This is likely a contributory factor for the high prevalence of sexually transmitted infections (STIs), including HIV, and adolescent pregnancy in the region [1‐4], which has persisted despite more than two decades of research and programming. As many as 20% of women in sub-Saharan Africa have their first child by the age of 19 [5], and around half of these pregnancies are unintended [6]. In 2017, adolescent girls accounted for 25% of all new global HIV infections, despite comprising only 10% of the population [7]. Further, in the Southern African region in particular, there are stark gender disparities in relation to HIV risk: risk among adolescent girls aged 15–19 is six times higher than among their male counterparts [8]. Further, a recent systematic review has identified persistent perceived and experienced barriers to STI services for adolescents [9].

Much research has attempted to uncover determinants of condom use among adolescents that might be targeted by sexual and reproductive health (SRH) programmes. A complex array of individual-, interpersonal- and structural-level influences are at play [10‐14], including lack of desire to use condoms, lack of local access to condoms, gender inequalities and social norms restricting condom use, and age-disparate and transactional sexual relationships [2, 15‐18]. These factors, taken together, may help explain why SRH programmes that focus only on individual determinants of condom use and ignore wider interpersonal and structural determinants have had limited impact [19]. One recent meta-analysis [20] found individual-level social-cognitive determinants accounted for only 15–30% of the variance in adolescent condom use intentions and behaviours. These findings indicate that interpersonal and social dynamics, plus context-dependent cultural and structural conditions, are key factors associated with condom use that must be explored further both theoretically and empirically [20]. In order to craft more effective condom use interventions for adolescents, programme developers must adopt a multilevel approach, including a combination of structural and behavioural interventions that target both males and females [7, 13]. Systematic reviews can aid this process by examining multilevel barriers and facilitators of condom use in particular geographic regions. Results of such work would be better positioned to guide future intervention planning and empirical work on this important subject. Qualitative studies from Southern Africa are particularly important for deriving deeper and more nuanced understandings of the barriers to condom use, and can assist researchers and practitioners develop, adapt, or scale-up interventions in the region [13, 21].

This review aims to describe the individual-, interpersonal- and structural-level determinants of condom use among male and female adolescents in Southern Africa and then develop an integrated conceptual framework. The findings provide clear recommendations for future research aiming to test causal pathways explaining condom use among adolescents, and for SRH programme development and adaptation in the Southern African region.

The synthesis reported here is part of a larger research study to adapt an SRH intervention for adolescents in Southern Africa [22]. The project includes two linked reviews that used a common preregistered protocol [23] but reviewed qualitative and quantitative literature separately. In this paper we include qualitative studies only, in order to promote a deep exploration of salient individual and interpersonal barriers and facilitators of condom use among adolescents, as well as broader social, cultural and structural dynamics. Findings from a review of quantitative studies are reported elsewhere [24].

For the present review, the ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) [25] guidelines informed reporting of the analysis. This review aimed to answer the following research questions: 1) What are the individual-, interpersonal- and structural-level barriers and facilitators of condom use among adolescents in Southern Africa? 2) How can these multilevel barriers and facilitators be conceptualised within an integrated framework?

This review aimed to synthesise qualitative evidence relating to the individual-, interpersonal- and structural-level barriers and facilitators of condom use among adolescents in Southern Africa. We identified and mapped relevant qualitative literature onto an a priori framework incorporating three theoretical models – the social ecological model [31, 32]; an integrated model of condom use among young people in sub-Saharan Africa [20]; and the If Were Jack theory of change [28‐30] – and then used inductive thematic analysis to identify the key barriers and facilitators of condom use which we incorporated into a new conceptual model (Fig. 2).

The findings provided evidence to support all 12 a priori themes in the original ‘best-fit’ model depicting the multi-level determinants of condom use among adolescents in Southern Africa. The combined three-model framework was able to capture more determinants than any one of the models could accurately achieve on its own, thus suggesting that a multilevel conceptual model as outlined in Fig. 2 may be more appropriate.

In line with previous reviews [14, 62, 63], the findings indicate that young people in Southern Africa face a range of barriers to condom use operating at all levels of their social ecological milieu. Results also highlight complex interactions among six key themes and illustrate that both positive and negative influences are reinforced at different levels. In line with the UN Sustainable Development Goals and their focus on multilevel determinants of health, this review offers understanding and insights into how common themes such as gender inequality and poverty exert their influence on condom use across social ecological levels.

The findings of our review are consistent with other studies [14, 18, 62‐64] whose authors have identified a need to move beyond individual-level behaviour change frameworks and programmes by incorporating broader understandings of the structural-level barriers and facilitators of condom use among young people in Southern Africa. We advance previous findings by offering a conceptual framework of the key barriers and facilitators at society, community, interpersonal and individual levels that might act as a guide for decision-makers, programme developers and researchers wishing to optimise intervention impact. We are also optimistic about the fact that we have uncovered positive findings relating to shifts in unequal gendered norms, with key messages relating to female agency in sexual decision-making emerging as key.

The findings suggest that valuable and limited resources should be best used in coordinated effort to increase condom use by implementing multilevel interventions at all levels of the social ecological system. This could be informed by emerging broad-based guidance for improving uptake and access to contraception [64]. Programming efforts should, at the very least, ensure efforts are made to start addressing the widespread influence of gender inequalities and restrictive gendered and social norms that appear to operate at all levels of the social ecological system. While this approach is not a panacea—especially in challenging political and economic climates which are characterised, at times, by a lack of policy or policy implementation relating to gender equality —it might help shift attitudes and initiate change slowly across the community, organisational, interpersonal and individual levels [21].

The findings of this study indicate the need for easily accessible and free condoms, especially in resource-poor and rural settings. Importantly, they equally emphasise the need for evidence-based adolescent SRH strategies that provide health professionals and educators training and resources needed to provide youth-friendly SRH services and education. The findings also highlight the influence of social norms reflecting negative perceptions of adolescent sexuality, and non-traditional sex education and methods of avoiding HIV, STIs and unintended pregnancy. The strength of these prevailing norms suggest that programme developers need to involve local stakeholders in co-design and co-production processes. Interventions that can engage wider community members where these negative norms are played out are also critical. Community mobilisation interventions have shown positive impacts in relation to other SRH interventions, particularly those that involve comprehensive SRH education and positive role modelling by community members such as community elders, religious leaders, healthcare professionals and educators [65‐67]. Coupled with this approach is the need for individual-level interventions targeting health professionals, educators and community members that promote youth-friendly, evidence-based comprehensive SRH education and practice [68]. Decision-makers should also be lobbied to support such interventions with policy-led adolescent SRH strategies and to provide resources for their implementation with youth [69‐71].

Centrally, comprehensive sex education delivered to adolescents in school and community settings should include gender transformative components; directly challenge stigma and myths surrounding condoms and condom use; and harness the facilitating effects of promoting female agency in sexual decision-making [21, 72]. These curricula should prioritise key issues such as male roles and responsibilities in relation to avoiding HIV and unintended pregnancy; sexual pleasure (particularly gender disparities in relation to expectations of pleasure and the contradictions relating to pleasure in committed versus casual relationships); and negotiating condom use (particularly in age-disparate and transactional relationships). Programmes that promote the roles and responsibilities of sexual partners, peers and parents/caregivers as key interpersonal influences will also be necessary [70].

Our findings suggest that programmes should address the wider structural influences through both individual- and structural-level interventions, in addition to targeting individual-level socio-cognitive factors. It is especially important to understand the key barriers and facilitators of condom use that act as moderators on the pathway towards consistent condom use among adolescents. In Southern Africa, as in many other regions of the world, these barriers include unequal gender norms and restrictive masculinities that stigmatise adolescent girls; social norms that restrict positive sexualities among adolescents and perpetuate negative perceptions of condoms and condom use; and the pervasive impact of poverty on access to condoms, SRH education and the power to negotiate condom use freely. SRH programming targeting barriers and facilitators of condom use at multiple levels is urgently needed in Southern Africa. Such programmes should pay particular attention to the key gaps in knowledge and evidence-based interventions highlighted by this review, for example: promotion of female agency in SRH decision-making; increasing positive parent-child communication about SRH; increasing accessible youth-friendly SRH services; and encouraging the widespread adoption and implementation of strategies to improve SRH.