Background
Methods
Guiding frameworks
Integrated model of condom use in sub-Saharan African youth Protogerou et al. [20] | Themes for Coding Framework | ||
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INDIVIDUAL LEVEL DETERMINANTS | |||
Intrapersonal Knowledge, attitudes, beliefs, skills and behaviours | Knowledge about SRH, where to obtain condoms | Sexual and Reproductive Health Knowledge | |
Attitudes (beliefs about the behaviour) | Attitudes (beliefs about the behaviour and positive planning) | Attitudes and beliefs about condom use | |
Barriers perceived e.g. stigma, lack of pleasure, lack of effectiveness, religious beliefs and actual e.g. access to condoms and partner refusal to use condoms | Barriers (perceived) e.g. myths, stigma, pleasure, effectiveness, religious beliefs, lack of consent, sexual coercion | Perceived barriers to condom use | |
Risk perception | Beliefs about consequences of unprotected sex (episodic future thinking; anticipated regret) | Risk perception and beliefs about consequences of not using condoms | |
Control (beliefs about self-efficacy and perceived behavioural control) | Beliefs about capabilities (perceived behavioural control & self-efficacy communicating to partners, peers, parents, and professionals) | Beliefs about ability to obtain and use condoms | |
Intentions | Intentions to avoid unprotected sex | Intentions to use condoms | |
Past condom use behaviour | Past condom use behaviour | ||
Age, gender, socioeconomic status, religiosity | Sociodemographic influences | ||
INTERPERSONAL LEVEL DETERMINANTS | |||
Interpersonal Social network and Relationships | Barriers (actual) e.g. partner refusal to use condoms | Social influences: Peers Parental values and beliefs Quality of parent-child communication | Interpersonal determinants |
STRUCTURAL LEVEL DETERMINANTS | |||
Organisational Relevant institutions | Barriers (actual) e.g. access to condoms | Organisational influences (school, church, health services) | Organisational determinants |
Community/Society Social norms and values | Norms | Social influences: Gender norms Social norms | Social norms and values relating to condom use |
Policy Local and national laws and policies | Political and economic determinants |
Criteria for study inclusion
Search strategy and screening methods
Data extraction
Quality appraisal
Data synthesis
Results
Search results
Characteristics of the selected studies
Author and year | Study design | Study aim | Country | Study population description | Female (n, %) | Male (n, %) | Total sample (n) at start of study | Age range |
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Baumgartner et al., 2010 [37] | Qualitative | To understand how Tanzanian adolescents think about and understand the concepts of faithfulness and partner reduction in the context of both HIV and pregnancy prevention | Tanzania | This study included 20 focus group discussions (FGDs) with 158 adolescents, aged 14 20 | 158 | 14–20 | ||
Bosmans et al., 2006 [38] | Qualitative | To explore adolescents’ access to condom information and supplies. | Democratic Republic of Congo | Focus group discussions were conducted with 11 groups of adolescents. Two interviews were conducted with programme officers of one SRH peer education programme. In addition they had an focus group with a group of 34 adolescent peer educators in Bukavu. | 60% | 40% | 117 | |
Butts et al., 2018 [39] | Qualitative | To identify sources of HIV prevention knowledge among young women aged 10–14 years and community-based strategies to enhance HIV prevention in Zambia. | Zambia | Focus group discussions were conducted with 114 young women in Zambian provinces with the highest rates (~ 20%) of HIV | 100% | 114 | 10–14 | |
Capurchande, et al., 2016 [40] | Qualitative | To explore adolescents and young adults’ experiences with contraception in Mozambique | Mozambique | Four focus group discussions, 16 in-depth interviews, four informal conversations, and observations were equally divided between two study sites. | 62 | 15–24 | ||
Casale,et al., 2010 [41] | Qualitative | To explore the complexities facing a faith based organization during its delivery of an HIV-prevention programme for adolescents. | South Africa | 11 focus group discussions: two groups with parents (n = 34), two with teachers (n = 16), four with learners (n = 48) and three with programme facilitators (n = 6). | 104 | |||
Cockcroft et al., 2010 [42] | Qualitative | To explore community views of inter-generational sex | Botswana, Namibia and Swaziland | The study included 12 focus group discussions with women aged 15–24 years | between 60 and 120 | 15–24 | ||
Groes-Green et al., [43] | Qualitative | To examine how class, gender and peer education affects safe sex in male youth and identifies the reasons behind condom use | Mozambique | 52 boys who qualified as consistent condom users between the ages of 18 and 23 | 52 | 18–23 | ||
Klinger & Ramin, 2017 [44] | Qualitative | Evaluate perceptions, attitudes, and misconceptions regarding STIs and contraception among female and male adolescents | Madagascar | Data was collected from female and male adolescents ages 15–19 years (n = 43) in Northern Madagascar in 2014 using focus group discussions | 53% | 47% | 43 | 15–19 |
Lusey,et al., 2014 [45] | Qualitative | To explore discourses of young churchgoers from deprived areas of Kinshasa regarding masculinity and sexuality in the era of HIV. | Congo | This study included 16 semi-structured interviews with unmarried young churchgoers | 16 | 16 | 15–24 (mean 19.6) | |
MacPhail & Campbell, 2001 [46] | Qualitative | To increase our understandings of the influences on adolescent sexuality within a broader interest in HIV-prevention in Southern Africa. | South Africa | Study informants comprised 44 young women and men in the 13–25 year age group. | 50% | 50% | 44 | 13–25 |
Manuel, 2005 [47] | Qualitative | To explore how urban youth in Mozambique perceive their sexual behaviour and identifies the factors that hinder them from having safer sex in the context of HIV/AIDS, with special emphasis on the condom use. | Mozambique | Data was collected from high school students in Maputo, Mozambique. Using a combination of focus group discussions, interviews and informal conversations | Not reported | 16–18 | ||
Mavhu et al., [48] | Qualitative | Follow on to a quantitative survey that sought to characterize male sexual partners and sexual behaviours of sexually active HIV positive AGYW in Zimbabwe. | Zimbabwe | In-depth interviews were conducted with purposively sampled 28 adolescent girls and young women (16–24 years). | 100% | 28 | 16–24 | |
McCleary-Sills, et al., 2013 [49] | Qualitative | To examine Gendered norms, sexual exploitation and adolescent pregnancy in rural Tanzania | Tanzania | A participatory research and action project (Vitu Newala) conducted formative research in a rural district on the dynamics of sexual risk and agency among 82 girls aged 12–17. | 100% | 82 | 12–17 | |
McHome et al., 2015 [50] | Qualitative scripted scenarios | To examine staff perceptions of adolescent sexual health and reproductive services in Tanzania | Tanzania | Health service staff from 33 health care facilities | Between 41 and 48 | 18–19 | ||
Meekers et al., 2001 [51] | Qualitative | To understand constraints to adolescent condom procurement. Including condom use negotiation, consistency of condom use, and condom distribution amongst adolescents. | Botswana | Eight focus groups were conducted which included four to six participants per group (male and female) between the ages of 14–20. | Between 32 and 48 | 14–20 | ||
Moyo & Rusinga, 2017 [52] | Qualitative | To understand the importance of reproductive health education to contraceptive use among adolescents | Zimbabwe | A total of 185 adolescents aged 15–19 years were sampled. | 96 | 89 | 185 | 15–19 (mean 17) |
Mulumeoderhwa, 2018 [53] | Qualitative | To investigate young men’s perspectives about condom use, concurrent sexual partnerships and sex in the context of HIV/AIDS. | Democratic Republic of Congo | 28 boys aged 16–20 from two urban and two urban high schools in South Kivu provinces. | 100% | 28 | 16–20 | |
Mwalabu et al., 2017 [54] | Qualitative | To explore the sex and relationship experiences of young women growing up with perinatally-acquired HIV in order to understand how to improve SRH care and associated outcomes | Malawi | Data was collected for 14 cases through in-depth interviews (i.e. a total of 42 participants) | 100% | 42 | 15–19 | |
Nash et al., 2019 [55] | Qualitative | To understand how and what sexual and reproductive health information is shared with girls, in Malawi, and perceptions of such information among key informants | Malawi | Forty semi-structured interviews were conducted with three participant groups: adolescent girls (n = 18), mothers/female guardians of adolescent girls (n = 12), and leaders of initiation rites (n = 10). | 40 | 10–18 | ||
Self et al., 2018 [56] | Qualitative | To explore the perspectives of youth and adults about the drivers and barriers to youth accessing family planning in Malawi and their ideas to improve services | Malawi | 34 focus groups were conducted with youth 34 FGDs with 255 youth and 40 parent/guardian participants. | 255 | 15–24 | ||
Sommer et al., 2015 [57] | Qualitative | To explored the masculinity norms shaping pubescent boys perceptions of and engagement in (unsafe) sexual behaviours | Tanzania | In-depth interviews with adolescent boys in and out of school, key informant interviews (e.g. parents, teachers, religious leaders), focus groups with teachers, and participatory activities with adolescent boys in and out of school (n = 160) | 100% | 160 | 16–19 | |
Sommer et al., 2019 [58] | Qualitative | To explore structural and environmental factors influencing young people’s access to and use of alcohol, and subsequent engagement in safe or unsafe sexual behaviours, from their own perspectives | Tanzania | The study included 177 adolescent girls and boys in and out of school in four sites across Dar es Salaam, Tanzania. | 177 | 15–19 | ||
Winskell, et al., 2011 [59] | Qualitative | In order to inform education and communication efforts to increase condom use, we examined social representations of condoms among young people aged 10–24 in six African countries/regions with diverse HIV prevalence rates | Swaziland, Namibia, Kenya, South-East Nigeria, Burkina Faso, and Senegal | A unique data source was used, namely 11,354 creative ideas contributed from these countries to a continent-wide scriptwriting contest, held from 1st February to 15th April 2005, on the theme of HIV/AIDS. We stratified each country sample by the sex, age (10–14, 15–19, 20–24), and urban/rural location of the author and randomly selected up to 10 narratives for each of the 12 resulting strata, netting a total sample of 586 texts for the six countries. | Not clear (586 texts) | 10–24 |
Quality of included studies
Synthesis of the evidence
INDIVIDUAL LEVEL | ||
A Priori Themes/theoretical determinants | Key findings | Qualitative studies in the review citing influence of theoretical determinant |
Sexual and Reproductive Health Knowledge 10 studies indicated the relevance of adolescents’ knowledge about how to access and use condoms and the health risks and benefits of using condoms correctly and consistently. | Key Finding: Inadequate SRH knowledge among adolescents Key Finding: Adolescents who had adequate SRH knowledge had engaged in SRH programmes at school or in the community | |
Attitudes and beliefs about condom use 20 studies mentioned the relevance of attitudes (positive and negative) about condoms and condom use condoms. | Key finding: Negative attitudes about condom use were reported as a key determinant. These included attitudes that condom use reduces sexual pleasure for men, is morally inferior to abstinence, promotes sexual promiscuity and a lack of trust in committed relationships. Key finding: A minority of studies reported positive attitudes towards condom use as a facilitator of condom use. | - Twenty studies reported negative attitudes about condoms and condom use with the central attitudes being they are ineffective [38, 39, 41, 45, 52, 53, 57], cause disease [43, 51, 53, 56, 57], reduced sexual pleasure for men [39, 40, 42, 44, 45, 47, 53, 56, 57], are morally inferior to abstinence outside of marriage [41, 53, 59], and represent a lack of trust in committed and transactional relationships [37, 41, 42, 44, 46‐49, 54, 59]. |
Perceived barriers to condom use 20 studies reported links between adolescent perceptions that people do not use condoms because of various psychosocial factors. | Key Finding: Perceived barriers to condom use reported by adolescents included stigma, perceptions of reduced pleasure, not carrying condoms, beliefs about effectiveness, religious beliefs and the perceived impact of condom use on sexual relationships. | - Three studies reported male adolescent beliefs that girls who carry or use condoms are ‘easy’, untrustworthy and likely suffering from a STI [38, 42, 46]. Six studies reported adolescent girls fear of embarrassment or judgment if they sought to obtain, carried or requested to use condoms [44, 46, 48, 51‐53]. Three studies indicated that both males and females saw perceived stigma attached to adolescent sex as a barrier to obtaining condoms [51, 52, 59]. - Perceptions that condoms negatively impacted on pleasure or sexual satisfaction were noted in nine studies [39, 40, 42, 44, 45, 47, 53, 56, 57]. Although there were no reports from adolescent women regarding reduced pleasure, in one study young men claimed that their female partners complained that condoms bruise them [42]. - Two studies noted that a common barrier to condom use was that young people did not carry condoms with them and therefore did not have them readily available when they needed them [46, 57]. Both studies mentioned time and the space in which young people choose to have sex as relevant. - Seven studies reported that some adolescents did not use condoms because they believed they were ineffective in preventing HIV/STIs and pregnancy [38, 39, 41, 45, 52, 53, 57]. - Common negative beliefs were that condoms actually cause diseases such as cancer and other illnesses such as rashes, sores and stomach pains [43, 51, 53, 56, 57]. |
Risk perception and beliefs about consequences of using/not using condoms 12 studies reported beliefs about the consequences of using/not using condoms as determinants of condom use | Key finding: Perceptions of risk of having to leave education and risk of contracting HIV from a casual partner were mentioned as a facilitator of condom use for some. Key finding: In this context, perceptions of risk of contracting condoms appeared to be moderated by perceptions that they were immune to catching HIV because of their choices or that they had become so used to HIV that they no longer feared it. Key finding: In age-disparate and transactional relationships risk perception appeared to be moderated by factors such as poverty and beliefs that condom use would result in a loss of the relationship. | - Six studies mentioned finishing school and the importance of education as a belief that encouraged condom use among adolescent boys and girls [37, 40, 43, 49, 56, 57]. - Two studies mentioned that the fear of HIV when relationships were of a casual nature was a facilitator of condom use [46, 47] and one noted that younger adolescents seemed to fear the consequences of unprotected sex more strongly [49]. - One study [47] noted that young people appeared to think they were immune to HIV/AIDS because their lifestyle was such that they would not have sex without a condom with anyone whom they deemed to have HIV. Similarly, one study [57] highlighted that the young men in their study had become so used to HIV that the fear of contracting the illness was as low to them as the fear of catching the flu. |
Beliefs about ability to obtain and use condoms (Perceived Behavioural Control) 7 studies reported a person’s confidence or lack of confidence in their ability to a) obtain condoms; b) negotiate their use with their partner; and c) use them correctly and consistently every time they have sex. | Key finding: Knowledge about where to obtain condoms, self-efficacy obtaining condoms, costs of condoms, self-efficacy in ability to use condoms correctly presented as common Key finding: Beliefs about ability to negotiate condom use presented as a challenge for females | - Adolescents in four studies reported that they did not know where to obtain condoms and others reported that, although they did know where to obtain them, they did not feel confident doing so [38, 44, 51, 57]. - Two studies reported low beliefs in ability to use condoms, an issue that was linked to a lack of comprehensive SRH education [44, 57]. - One study reported female adolescents’ low-self-efficacy to negotiate condom use with their partners, particularly older men [48] and another reported that high self-efficacy in ability to communicate with partners about condom use was a facilitator [59]. - One study highlighted that for some, lack of behavioural control was blamed on puberty [58]. |
Intentions to use condoms 12 studies presented findings relating to a person’s stated intention to use condoms when they have sexual intercourse. | Key Finding: There was evidence from two studies to suggest that female agency was related to high intentions to use condoms Key Finding: Several studies indicated negative intentions among adolescents in committed, age-disparate or transactional relationships | - Reports of intentions to use condoms generally related to female affirmations that regardless of possible barriers, they intended to use condoms any time they had sex [45, 46], intentions to use condoms whenever they had a sex with a new partner or a part who had not been tested for STIs [44], or intentions to use condoms in order to avoid future negative consequences for education, employment [37, 41, 42, 44, 46‐49, 54, 59]. |
Past Behaviour 1 study presented findings relating to person’s past as a determinant of condom use | Key finding: One study reported that past condom use behaviour could be a barrier or facilitator of condom use | One study [57] noted that intentions to use condoms is associated with past condom use “Once you start having sex without a condom, you cannot change to using a condom. Sometimes someone will try to use a condom and not use a condom to compare the difference. So then in that moment, they forget about HIV and pregnancy because the temptation is so high to not use a condom.” |
Sociodemographic determinants of condom use 10 studies reported sociodemographic factors as determinants of condom use | Key finding: Being male presented as a determinant of condom use, with negative impacts more pronounced for older adolescents Key finding: Middle class males in education more likely to use condoms Key finding: Poverty as a determinant of condom use for young women (especially those in transactional relationships with older men) Key finding: Marriage a determinant of condom use | - In general studies reported that male adolescents were less likely to use or want to use condoms than females [40, 49, 52, 57], although two studies reported that this was more common among older adolescents and older men, with younger boys and girls reported to be more likely to use condoms. - One study reported that young women assumed that it was less risky to have unprotected sex with younger than older men [42]. - Two studies noted that middle-class male adolescents and older adolescents still in education were more likely to express positive attitudes towards condom use [43]. -Several other studies noted that poverty was a barrier to condom use if free condoms were not provided [46] or in instances when young women agreed to sex with men in return for material goods [48, 49, 54, 59]. - One study mentioned that secondary school boys availed of free condoms because they feared getting their partner pregnant and had no money for an abortion [49]. - One study mentioned that unmarried adolescent women were more likely to mention condom use than married women [60]. |
INTERPERSONAL LEVEL | ||
A Priori Themes/theoretical determinants | Key findings | Qualitative studies in the review citing influence of theoretical determinant |
Interpersonal determinants of condom use 14 studies described the barriers and facilitators of condom use at the interpersonal level. These related to relationship dynamics with sexual partners, peers and parents. | Sexual Partners: Key Finding: Condom-use in casual relationships more widely accepted than condom-use in monogamous, transactional and age-disparate relationships Key Finding: There were some indications of a shift in sexual relationship dynamics | - Six studies reported that for those in monogamous relationships, not using condoms appeared to represent trust, faithfulness and respect [37, 38, 40, 46, 47, 53]. - Two studies reported that those who requested condoms were assumed to be ‘sick’ or untrustworthy, especially women [42, 48] - Five studies noted that condom use was less acceptable in age-disparate and transactional relationships [41, 42, 44, 48, 59]. - One study reported that condom use was seen as a sign of respect for some [37]. |
Peers Key finding: Peer relationships can exert positive or negative influence on condom use | - Two studies noted that negative peer norms relating to condom use acted as a barrier, particularly for young men [46, 47]. - One study reported peers acting as facilitators of condom use by sharing their condoms with friends [51]. | |
Parents/Primary Caregivers Key finding: A lack of communication and guidance from parents/primary caregivers in relation to SRH was indicated as a possible barrier to condom use. | ||
STRUCTURAL LEVEL | ||
A Priori Themes/theoretical determinants | Key findings | Qualitative studies in the review citing influence of theoretical determinant |
Organisational determinants of condom use 18 studies described the determinants of condom use at the organisational or institutional level. These included SRH providers or clinics; religious organisations, schools and other organisations in the community including private enterprises such as guesthouses, bars and pharmacies | Sexual and Reproductive Health providers or clinics Key finding: Some adolescents, particularly young women, report negative experiences with professionals and a lack of provision of easily accessible, privately available condoms at SRH clinics Key finding: Some SRH professionals report not wanting to distribute condoms because it might encourage ‘promiscuity’ Key finding: Positive experiences reported with youth-friendly services | - Three studies reported that staff did not distribute free condoms to adolescents because they did not want to encourage sexual activity [38, 54, 55] and three other studies reported negative experiences at clinics, which included being shouted at and judged by healthcare staff, particularly by young women [46, 51, 52]. |
Religious organisations and their representatives Key finding: Acceptance of religious norms by adolescents and other community members can act as a barrier to condom use among adolescents | Six studies reported that religious leaders encouraged abstinence and monogamy and condoned or discouraged condom use [38, 41, 43, 45, 53, 54]. - One study reported that an Archbishop had alleged that condoms had been infected by Western countries in order to ‘finish the African people’ [43]. | |
Schools Key finding: Absence of or inadequate SRH education in schools was reported as a barrier to condoms use among adolescents Key finding: Some studies note that inaccurate information to young people Key finding: Learning about SRH from peers or initiation ceremonies was common Key finding: Provision of condoms and SRH programmes in schools was noted as a facilitator | Six studies mentioned the absence of sex education in schools as an organisational determinant of condom use, which often resulted in inaccurate knowledge and harmful sexual practices [39, 46, 47, 52, 55, 57]. - Two studies noted that information provided by existing SRH programmes was inaccurate, for example providing young people with false statistics relating to the efficacy of condoms [41, 59]. | |
Other community Organisations Key findings: The availability of condoms in organisations in the community was reported as a facilitator of condom use | ||
Society and community level determinants of condom use 17 studies described the barriers and facilitators of condom use relating to social norms at level of community and society. These included gender norms and social norms. | Gender Norms Key finding: The stigmatisation of condom use among adolescents in general, and young women in particular, is a key negative determinant condom use Key finding: Unequal gendered norms relating to sexual decision-making and responsibility, favouring men, is a determinant of condom use Key finding: Some studies reported a shift in thinking and disregard for unequal gendered norms among adolescents which acted as a positive determinant of condom use | - Thirteen studies mentioned the influence of gender norms as determinants of condom use [37, 38, 40, 42, 45‐49, 51‐53, 59], with most highlighting that unequal gender norms impacted negatively on young people’s condom use. - Ten studies found that condom use among adolescent women was highly stigmatised [38, 40, 42, 46‐49, 51‐53], and it was also evident that restrictive masculinities were a negative determinant of condom use among men [40, 46, 52, 53]. |
Other Social Norms Key finding: Some studies reported that social norms which favour traditional methods of SRH education (including initiation ceremonies) and family planning acted as negative determinants of condom use | - One study noted that young people received a lot of information about sex from traditional ‘initiation ceremonies’, which often led to inaccurate knowledge [39]. | |
Political and economic barriers and facilitators of condom use 13 studies described the determinants of condom use at the political and economic levels. | Political and Economic: Key finding: There were indications that provision of free condoms and that national mass media campaigns to promote condom use was an important determinant. Key finding: Lack of an adolescent SRH strategy was identified as a barrier for educators wishing to incorporate RSE into their curriculum. Key finding: The availability of free condoms was noted as important, particularly in resource poor and rural settings. | - One study [52] identified media advertisements as important in promoting condom use but also found that the lack of an adolescent sexual and reproductive health strategy as a barrier for educators wishing to incorporate RSE into their curriculum. - One study [46] highlighted the facilitating effects of government provision of free condoms, particularly in resource poor settings. One study highlighted that condoms were not available in some rural villages [44]. |
Themes and sub-themes | Studies presenting evidence for theme | Examples of evidence for theme |
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1. Unequal Gender norms and Restrictive Masculinities: Pervasive unequal gender norms and restrictive masculinities are barriers to condom use Sub-themes: - Women that use condoms are ‘up to no good’ - ‘Real’ men don’t wear condoms - Sexual pleasure and decision-making a privilege of men - Female agency to change gendered norms | 15/23 studies | Social norms encroach on the extent to which young women are prepared to carry condoms with them. Participants mentioned that gossip is a constant source of conflict in the township and that women carrying condoms risked being labelled a ‘bitch’ or promiscuous [46]. Some girls also showed agency in refusing unprotected sex in cases where partners did not use a condom. In such cases, boyfriends would be requested to buy one; otherwise sex would not take place [45]. |
2. Other social norms: Social norms reflecting negative perceptions of non-traditional sexual and reproductive health education, non-traditional family planning, and adolescent sexuality are barriers to condom use Sub-themes: -Traditional methods of family planning and education are best - Adolescent sexuality is taboo - Social norms are possible moderators of risk perception | 20/23 studies | “Malagasy tradition says that condoms are not good in some communities. I think Malagasy people think, ‘why should we change what we’ve been doing when it has been working? My ancestors weren’t sick with STIs so why should we have any problem?’” [44] “The fact of selling condoms encourages the widespread [sic] of sexual violence. It is as if people are conveying a message saying: ‘have sex and satisfy your sexual urge’. This can discourage men to hold their sexual urge until they get married, because they know that they cannot get diseases.” [53] “[Young people] know everything [about HIV] and may pass people in the street and even say ‘so and so is infected’. But the boys say, why are you afraid of HIV and not flu? They have become unafraid because it’s so normal.” [57] |
3. Political and Economic Climate: The political and economic climate are barriers and facilitators of condom use Sub-themes: -Policy-led promotion and resourcing of adolescent SRH and condom use - Poverty and socioeconomic status | 14/23 studies | There is still no policy or law that specifically caters for the reproductive health needs of adolescents in Zimbabwe. Consequently, this has made it difficult (…) for the Ministry of Education to develop comprehensive national adolescent reproductive health syllabi for the respective grades [52]. “Diseases will not end if they sell condoms to us. People here are very poor; if someone gets five rand they spend it on bread and candles, not condoms.” [46] “That’s what is happening with these schoolgirls we have. They’re financially dependent on these taxi drivers and all, because they are coming from poor backgrounds. There is no money at home. They need to buy cell phones and all these [sic] stuff. So in order to get that, she tells herself — Let me fall in love with the taxi driver, he’s going to provide all that for me. And if the taxi driver says — no condom.” [41] “[…] Such statements were common in middle class youth’s rationalisations of condom use and safe sex. Hence, the planning of sexual and reproductive behaviour was part of a broader view of life and future where the risk of HIV infection and pregnancy are lumped together as threats on the way towards fulling ones dreams and careers.” [43] |
4. Community-based resources and influences: Community-based organisations, facilities and spaces are barriers and facilitators of adolescent condom use Sub-themes: -Accessible adolescent SRH services - Sex education in schools and communities - Religious Influences - Access to condoms and spaces for sex in communities | “If you take any contraception at the clinic, you should know that before sunset everyone (including your parents and church members) in the community will be aware that you have taken some contraceptives at the clinic. This will be definitely the hot selling news of the day. The news will spread like a wild fire accompanied by a mighty wind.” [52] “We promote the natural method for doing family planning... this method is the one proposed by the Catholic Church because the artificial methods do not conform with the will of God.” [38] | |
5. Interpersonal Influences: Interpersonal relationship dynamics are barriers and facilitators of condom use Sub-themes: - Trust and Transactions in Sexual Relationships - Peer Influences - Parent/Caregiver Communication | 13/23 studies | “….he has been supporting me since I was 10 years old. I felt like paying back in kind (exchanging his kindness with sex); how about transmitting the virus to him? How could I suggest condom use? If he knew my [HIV] status, I felt like losing my SACCO (Savings and Credit Cooperative – a money lending agency in Malawi); I conceived…he married me.” [54] “If you’re unsure of your husband, you need to buy condoms.” [59] Many of the [male] participants stated that they had been accused of being stupid [and jeered at by their friends] after using condoms and had decided that they would not use them again [46]. Teenagers don’t want to be seen obtaining condoms because they don’t want their parents to know that they are sexually active (even though adolescent sexual activity is the norm) [51]. |
6. Adolescent attitudes about condoms: Negative views of condoms and condom use among adolescents as barriers to condom use Sub-themes: -Male pleasure and performance -Condom myths | “Young men socially construct their ideal of true love in unprotected or ‘flesh-to-flesh’ sex. Nowadays’ youth often say: ‘you cannot eat a candy in a wrapper’” [53]. “I realized that even if you use thousand condoms at once, the way that they are built can cause cancer. You can get sicknesses or pregnancy though you wear them, they can prevent absolutely nothing.” [53] |
Barriers and facilitators of condom use among adolescents in southern Africa
Unequal gender norms as a barrier to condom use were also evident in widespread reporting of sexual pleasure as a privilege of men [39, 40, 42, 44, 45, 47, 56, 57, 61]. A contradiction in this regard is highlighted in a Mozambican study: although young men believed condoms reduced pleasure, they would still use condoms with sex workers because of the perceived heightened risk of HIV. The author notes ‘Condoms only appear to interrupt pleasure in close and steady relationships, and not with people considered more likely to be HIV infected’ [47].‘Girls have to decide for themselves if they will take the responsibility for carrying condoms. In doing so, they can avoid risk-behaviour and lessen the male’s sense of duty. At the same time, girls have to face embarrassment when the initiative of carrying condoms comes from the female partner.’ [40]