Keywords
Condom acceptability; HIV/ AIDS; Condom demand; Adolescent health
Abstract
Background: Immense literature reports that condoms’ demand, distribution, and actual utilization are often constrained by social-cultural, psychological and supply factors. This article reports a qualitative study of the experiences, perceptions and attitudes of religious leaders and parents in relation to condom promotion in Tanzania.
Methodology: In-Depth Interviews (IDIs) with religions leaders and Focus Group Discussions (FGDs) with parents were conducted in Mpwapwa and Mbeya Rural districts between November 2011 and June 2012. FGD and IDI were tape recorded for later transcription verbatim. Transcribed reports supplemented with handwritten f ield notes were analyzed both manually and with help of NVIVO software.
Results: Mixed opinions were obtained from IDIs and FGDs on about the issue of condom promotion through mass media and school health programs. A few religious leaders and majority of non-Catholic parents partly supported the existing condom promotion strategies, contrary to Catholic and Islamic faith leaders who strongly opposed. All IDI and FGD participants seemed to appreciate that young children were already aware of what sex is and therefore like adults children have the right to information concerning HIV prevention including the issue of condom use. However, the majority were not in favor of health education targeting young children on condom use campaigns on ground that doing so exposes and tempts young and virgin children to premature sexual behaviors. Meanwhile, encouraging adult people to use condoms also was perceived as promoting promiscuity behaviors.
Conclusion: Condom advocates should maintain dialogue with religious leaders and faith adherents if they expect to overcome the challenge of dogmas prohibiting condom usage during sex by arriving at a mutual understanding of the benefits of condom use.
Background
Scientists have confirmed that condoms if appropriately and effectively used are health products highly needed for the prevention of people from Sexually Transmitted Diseases/Infections (STDs/ STIs). Unfortunately, reports continue indicating that the acceptability and utilization of such products remain low in many developing countries. Among the factors reported to contribute to the low usage of condoms is the presence of a considerable proportion of people believing that condoms are preferred by people who are dishonest in their marital relationships; adulterous, promiscuous or homosexuals, leave alone those who use condoms for preventing unwanted pregnancies [1]. Thus, condom marketers worldwide in general have been facing criticisms and opposition from different stakeholders including community groups and authorities in some government departments [2]. Targeting the messages associated with condom promotion through mass media, for example, without affecting the untargeted ones is one of the major challenges faced by the condom promoters [3]. Health behavioral change experts contend that a positive communication between parents and children about risky health behaviors helps children to be sensitive, establish individual values and make decisions with positive impact on their health. That said, the communication about the issue of condom usage is worthwhile to result into positive condom usage practices [4]. However,
reports from different countries reveal that parents and other groups of adult persons are often driven by their religious faiths to develop negative perceptions against condoms. These groups have been complaining against condom adverts through mass media, school health programs, and other open spaces and attempts of supplying condoms to young children in school settings. They maintain that promoting and supplying condoms in children prompt them to enter into heterosexual activities prematurely and sustain illegal or socially unacceptable sexual practices [5,6]. In Tanzania, religion plays an important role on shaping the mindsets and lives of people, including how people believe about certain health problems/issues and how they respond to such problems. For instance, early and more recent studies in this country found some missed opportunities when Faith-Based Organizations (FBOs) seem failing to support programs aiming to help the people living with HIV/AIDS as expected and particularly when the issue of condom promotion and mass distribution is one of the program packages [7].
Guided by immense information found in the literature regarding the prevailing debate about condom promotion under HIV/AIDS control programs, we designed and conducted a study with the aim of looking at the factors affecting the acceptability of, and demand for condoms among populations including parents and religious leaders representing different FBOs in Tanzania. We focused on, among other things and study population groups, the experiences, perceptions and attitudes of religious leaders and parents in relation to condom promotion. The rationale that built the foundation stone for this study getting funding was based on the suggestion given by past researchers that as religion shapes the beliefs and activities of many people, it is vital, in the context of HIV/ AIDS, for the world to understand how religions and their growing number of adherents either facilitate or undermine efforts made to fight stigma in relation to HIV/AIDS control [8].
Materials and Methods
Study Design, population, areas and sampling strategies
The overall study was cross-sectional in design and adopted a combination of quantitative and qualitative data gathering and analysis techniques. Two districts were covered, namely - Mpwapwa that is located in Dodoma Region round central Tanzania and Mbeya Rural in Mbeya Region in the southern highlands of Tanzania. Selection of the latter districts was done randomly. This was done by picking only one district from each region out the list of the districts forming the respective region. The main criterion for selecting the said regions out of more than 20 regions in the country was the prevalence rates of HIV/AIDS when compared with the rest of the regions in mainland Tanzania. National statistical records showed Mbeya Region being one of the regions in mainland Tanzania with higher HIV/AIDS prevalence rates than regions like Dodoma with lower prevalence rates.
Additional details describing the two study districts with regard to HIV/AIDS status and socio-economic characteristics have been published recently elsewhere along with quantitative findings [9,10]. Parents and religious leaders representing different religious institutions were among the targeted study populations and actually the focus of the present paper. Inclusion of parents was based on the view that parents play a major role on advising their children on certain behavioral issues in their attempt to shape children’s moral conduct or behavior. Religious leaders were also included by considering their role on influencing their followers to develop (or stick to) certain beliefs in their attempt to keep them connected with religious law or principles.
From the beginning of the study design, a multistage sampling strategy was chosen to be adopted after selecting the study regions and districts and this was done as follows: identification of four wards randomly from the list of wards officially known in each district. Then from each ward, a purposeful section of at least one Christian leader and one Islamic leader was done and this was facilitated by approaching the administration of the existing churches or mosques. We ensured inclusion of representatives from different religious faiths/denominations. In each ward also, one village with a primary school was selected, our expectation being that among the parents approached were those caring school children.
Parents were purposefully mobilized to be met for a talk while in groups of 6-12 for collective discussions. In total, four groups of parents were mobilized in each district. As for religious leaders, 17 and 12 were covered in Mpwapwa and Mbeya (R) districts, respectively.
Data collection and Analysis methods
A multidiscipline team led by social scientists was involved in the study. Parents were asked to share their experiences and opinions through Focus Group Discussions (FGDs) while religious leaders participated in In-Depth Interviews (IDIs). The objective was to establish how parents and faith leaders viewed the issue of condoms promotion a strategy for controlling the spread of HIV infections in the community when such methods as school health education program and condom advertisements through mass media are employed. They were also investigated on the availability and accessibility of condoms, influence of politicians and commercial agencies on condom marketing and ultimate condom usage and their suggestions regarding what might be the appropriate message packaging if condoms were to continue being advocated and promoted for use as a HIV and AIDS prevention strategy in the community. Both the IDIs and FGDs were tape-recorded but were supplemented with handwritten notes. The study team met each day after data collection for debriefing based on the experience gained from the field and for discussing on data collected in as much as they seemed to answer the overall and specific objectives of the study.
Data analysis was performed as the data gathering process was completed each day and this helped the investigators to remember some of the events/points noted in the field that were not written down along with other notes [11,12]. Each of the research members had chance to go through the notes at their own time and come up with their interpretations of the study findings in relation to the study objectives. Record-taped FGD and IDIs were initially transcribed verbatim using a Microsoft Word processor. An NVIVO program was later employed to increase both the quality and reliability of the verbatim transcribed data. Final and comprehensive data analysis and interpretation were accomplished later after all the targeted data collection process has reached to an end.
Ethical considerations
Ethical clearance for this study was obtained from the Medical Research Coordinating Committee (MRCC) of Tanzania and was based on the research proposal submitted through its Secretariat under the National Institute for Medical Research (NIMR).Submission of the proposal to NIMR went hand in hand with communicating with Regional Health Management Teams (RHMT) for Mbeya and Dodoma as another crucial step for requesting for study permission to the authorities in the planned study localities as the same procedure was followed by the research team went further down to local government (e.g. ward and village) authorities in the respective study districts. Procedures for seeking informed consent – both oral and written from the targeted population groups were followed as reported elsewhere [9,10].
Results
Availability, Types and Sources of Information about the Condoms Promoted
Condom information sources: In both the IDIs and FGDs, participants acknowledged knowledge of various agencies dealing with condom promotion, distribution either for free or for sale that existed in their community areas. They also acknowledged the following sources of condom promotion through which they personally and other community members could know what programs wanted about condoms:
• Adverts posted on street billboards
• vans announcing condoms along the main highways, bus stations
• hearing/watching adverts in mass media such as radios, Televisions (TVs) and newspapers
• Part II poison shops • mobile condom vendors (including the commonly known as Wamachinga in Swahili)
• Retailers selling condoms along other consumer products at ordinary shops or kiosks or along roadways;
• Posters stamped at public offices including those found on the walls at the healthcare facilities and other business centers;
• Short messages written in simple take-away print outs such as brochures or leaflets normally given at various public meetings;
• Health education on family planning (child-spacing) and prevention of sexually transmitted infections including HIV/ AIDS and syphilis among women attending Reproductive And Child Health (RCH) clinics; and sometimes
• Hired musicians and drama groupsthat pass over communitiesto sing and give demonstration on HIV/AIDS prevention methods.
Condom types and availability: As for the supply of condoms, the experience of the parents was that occasionally, the retail sources were found with no condoms, and especially in remote places. At Bunila Village in Mpwapwa district, for example, it was revealed that some of the people originating from the same village but who were living in towns were surprised at finding no condoms at village shops/ kiosks after visiting their homes during holidays or when they are on leave. The majority of the parents and some religious leaders reported their experience with shortage (or unavailability) of female condoms as compared to male ones and to have rarely found female condoms being advertised for the public to know them as compared to male condoms.
Safety and HIV Protection
In both study districts, the majority of parents testified knowing the condom retailers who were selling expired condoms. As claimed, some of the traders were doing so knowingly and so the government authorities concerned were supposed to carry out surprise visits along with regular monitoring of condom traders’ misconducts like this at community level. As added, it is common to find people who after using the expired condoms and got side effects ends up complaining in the streets’. “You can be waiting for service at the kiosk or shop, and then suddenly comes a person asking the sellers openly, ‘Why do you give me this when it has already expired? You people will kill us because of your profit thirst; you just sell your things without looking at their expiry dates and yet they say they are protecting people from the virus infections” (a parent in a FGD, Mbeya ‘R’).
In Mpwapwa district, statements similar to the foregoing one were also obtained from parents in FGD sessions. Meanwhile, parents and religious leaders alike expressed their concern about the condom retailers who stocked the condoms in the same shelves as those used to stock other consumer products including foods and beverages.
Doing so was perceived to downgrade or lower the status of other consumer products meanwhile demoralized the customers coming to purchase such products. In Mpwapwa, reports from parents and religious leaders applauded an NGO called ‘Pamoja Tutangaze Ukimwi (PATUU), – meaning ‘Together, let us join forces to sensitize the public on HIV/ AIDS). As argued, PATUU had so far succeeded passing the message to a considerable number of community members (including teens, adolescents and youths). It employed drama groups and choirs that visit schools and colleges to pass information on HIV/AIDS through songs, poets, dances and plays.
These things attract young children both in schools and in the streets. As the parents put it, the packets of, used condoms are commonly found disposed off along the roadways and children see them on their way to and from school or elsewhere. Meanwhile, religious leaders were concerned about some NGOs dealing with the condom promotion business causing confusion and inconvenience to the public when the messages they attach to the condoms being promoted carry different contents relating to types of condoms with the most acceptable quality for meeting both maximum sexual satisfaction and infection prevention.
Acceptability of Methods Used in the Condom Promotion and Distribution Program
Data indicated somewhat inter-group and intra-group differences in the views expressed in both districts regarding acceptability of the approaches used to promote condoms. In both study districts, it was frequently mentioned by some of the FGD members that to the individual or family members who had experienced at least an adult relative suffering from AIDS before, the issue of condom promotion or distribution was highly appreciated. These groups of participants commonly added that in general the public was already highly sensitized on HIV and AIDS. Interestingly, participants from Mbeya claimed that their region was known by many residents as being among the top five regions that are highly affected with HIV/AIDS in mainland Tanzania as per official reports regularly given through mass media and AIDS control agencies operating at district and grass root levels.
The second reason is that only a few people had never seen a person suffering from AIDS. To the surprise, still a considerable proportion of the public members had not changed behavior of practicing unsafe sex despite the existing strong campaigns for condom usage. The issue of open adverts of condoms through mass media was criticized mainly on moral grounds. As argued, messages displayed in TV or newspapers are sometimes accompanied by pictures that are too-eye-catchy and tempting people including young children to develop sexual desires prematurely. This outcry was heard from both the parents and religious leaders. The sense of parental humiliation by the messages displayed was also reported to prevail among the parents and religious leaders in both districts, especially if the messages are given on TV screens while parents are sitting with their young children watching.
In Mpwapwa, leaders during an interview at community level had the following to argue against condom adverts in the open public sites: “There are mobile vans passing in the streets and carrying girls who appear in short and tight dresses including skin-tights or bikinis while dancing to promote condoms in a sexy manner. Therefore, people watching them among whom are young children get stimulated to think of and actually do sex. That is why it is difficult to prevent new HIV infections in the community” (Imam, of one Mosque, Mpwapwa district).
Social Stigma Associated with Open Discussion about Sex and Condom use Issues
In both districts, a number of parents and religious leaders were indifferent when discussing on whether or not it is appropriate for parents to discuss condom issues with children. As generally argued parents discussing sex issues with their children only is uncommon, and it actually sounds as culturally shameful and almost a taboo.
This point was strongly criticized by one religious leader in Mpwapwa who reported experience with parents who were advising their children to use condoms in case they were forced by their sexual desires or could not tolerate abstinence. Some parents also did not deny experiencing the same from other parents, although they seemed to be surprised. Moreover, both the parents and religious leaders reported to have seen the children who shied away to be seen by their parents or other elders while buying or holding condoms. These views were opposed by the FGD participants in one village in Mbeya (R) as reflected by the following statement that was strongly supported by other FGD members in the same district: “First of all, seeing your son or daughter keeping a condom makes you as a parent happy since you know that the child is now well informed about safe sexual practice and methods for preventing HIV infections. In this village, it is not strange to find an adult person asking loudly about condoms from a retailer in the presence of other people including young children” (a female participant).
Throughout all the interviews conducted in both districts, the R.C Church and Imams of mosques strongly opposed the programs encouraging open discussions in the public on condom usage. They emphasized that their views express the stances of their religious institutions, and on behalf of others, one leader had the following to comment: “If the government has a slogan of campaigning against malaria by stating that malaria is unacceptable, we religious leaders also say that condoms are unacceptable” (a representative of Moslem Mosque, Mpwapwa).
Perceived Protective Ability and Other Qualities of Condoms for HIV/AIDS Infections
Doubts about condoms’ ability to prevent STIs and the courage of school children to use them as recommended while performing sexual intercourses were noted among the IDI and FGD members in both districts. Supporting their claims, reasons for the expressed doubts were as shown in Table 1.
Table 1: Views regarding condom’s protective efficacy as expressed by study participants.
Thus, both religious leaders and parents were of the opinion that the condom messages normally presented by the AIDS Control Programs are either ignored by the target audience if they seem to add no value or are misinterpreted contrary to expectations. However, it was lamented that people generally tend to ignore or undervalue health experts’ advice on proper health behaviors because of being accustomed to particular lifestyles associated with personal or social beliefs. The reported shying away of women to persuade their male partners to use condoms was due to their attempt to avoid being seen as prostitutes or sexually dishonest women because of having multiple male sexual partners. As for point number 2 in Table 1 above, the following testimony was given by one FGD member in Mbeya (R) who amused everybody: “Youths, especially boys are ones causing trouble by confusing us. They can share and use a condom by interacting with several women…..mhh….They tear the condom at the top and pretend to wear it for sexual action. They play the same game to both us and our daughters. And it is sometimes difficult for us parents to discover that the same guys are sharing with us and our daughters” (a lady in her early 30’s, Mbeya Rural).
Table 2: Selected statements directly quoted to reflect religious leaders’ personal or institutions’ position on the issue of engaging children in condom campaign endeavors.
Insisting on their stance, some parents in during FGDs in villages, especially in Mbeya claimed that sensitizing the community (including children) about condoms was crucial since honesty in sexual relationship between people (married ones and single alike) has generally disappeared; and at the same time people who are already suspecting themselves or who have confirmed to be HIV positive rudely persuade and tempt young girls to enter into sexual intercourse with them without using condoms. This is confirmed by the prevailing reports about or a continued experience with the number of girls who get pregnancy and when they are tested they are found being HIV positive. These views were validated by fellow participants in Mpwapwa district who condemned religious leaders seeming conservative to encourage their adherents to use condoms.
Discussion
Acceptability of condoms in the context of social and cultural values
The present study confirms that the acceptability and utilization of condoms for their potential to protect people from contracting HIV causing AIDS through sexual intercourse remains impeded by social factors including religious beliefs and social stigma to discuss on condoms with children in Tanzania [10,13-17]. Reports from several countries show the conservative religious organizations pushing against condom promotion. This has created ideological conflict between government and commercial sector agencies dealing with condom promotion and distribution campaigns on one side and the FBOs and their adherents on the other side [18,19]. Behavioral studies conducted mainly by behavioral (and mostly social) scientists have established that humans are influenced by their thoughts to develop certain behaviors, and such thoughts may be partly or largely rooted from the social environment where the individual concerned interacts with other people, information and other things [20,21]. If a person believes that using a condom is risky to the woman during sex, or if they believe that sexual satisfaction is not possible if a condom is used, as we have heard from the present study and as we read in the immense literature, it is obvious that one will challenge the campaign for condom use.
We have seen from the present study that in recognition of the fact that some teens and adolescents already are in heterosexual relations, there are parents and religious leaders who dared to advise them to use condoms should they be stimulated to participating in sexual intercourse and were unhappy with the religious leaders and parents opposing the condom use campaigns as part of a comprehensive strategy for AIDS control. While it appears that some study participants suggested that condoms may still be promoted by repackaging the information and reviewing the mechanisms for passing the message to the target audiences, the main challenge could be how to accomplish that in the midst of criticisms from the religious clergy and without contravening certain Biblical and Q’uranic verses. Changing the mindset of conservative leaders is not easy because of the doctrines they were brought up with and the positions they hold as defendants of faith before the general public. Evidence indicates that most persons in Islamic communities tend to believe that all HIV infections are transmitted through immoral sexual behaviors. Such people are not aware of possible inadvertent infections through mother-to-child, accidental pricking of skin and contact with contaminated blood or an innocent spouse getting infected through her/his marital partner [22].
Nevertheless, a recent report from the neighboring country of Kenya, particularly the North Eastern province shows that the leaders had agreed to actively preach against the use and public promotion of condoms as a strategy to contain the pandemic, prevent pregnancy and discourage promotion of immoral behavior. They also agreed to oppose the distribution of condoms in villages and educational institutions across the northeast [23]. Similar experiences are reported from Alambra State in Nigeria as in other Islamic communities around the world [24].
Quality and affordability of Condoms as determinants of condom acceptability
We have noted the participants in the present study expressing concern about the traders allegedly selling expired condoms in the community. If this is true, more danger or risk falls to residents of rural settings where people have no wider room to choose between condom varieties due to reported supply shortages. According to Jafar and Chapman [18], the supply side of condom is an essential consideration when it comes to quality of the condom promoted. The author depicts that most donors and implementing agencies have been procuring condoms from manufacturers whose factories are pre-qualified by WHO, although from time to time, reports of poor condom quality often difficult to substantiate seem to surface and indicate a possibility of rapidly undermining condom promotion programs.
Moreover, the experience of the parents from the two districts surveyed in this study shows that even when the information is available regarding the HIV risk and ways to protect HIV infection using quality condoms, yet a significant number of people neglect the message and decide to take risk of not using condoms for example for safe sex. The explanation for this happening can be comprehended by referring to behavioral theories in relation to STIs including HIV prevention and treatment. Jafar and Chapman [18], for example, also maintain that the risk compensation model suggests that when an effective prevention or treatment intervention (or one perceived to be effective) is available, an individual’s perception of transmission risk may be reduced, and this may in turn lead to increased risk-taking.
How fair are the stances of parents and religious leaders against condoms?
Religious leaders and parents remain respected by governments and program officers involved in designing policies and enforcing their implementation towards effective communicable disease control, including the prevention and treatment of HIV/AIDS. This is important as the present study demonstrates, as the fact remains that religious leaders and parents hold a pivotal position when it comes to influencing their followers/dependents including children on certain behavioral issues such as those touching on faith. The main problem with religiosity in the fight against HIV/AIDS is rooted from the prevailing myths about condoms and conservative nature of one’s faith [25,26]. It is not uncommon to find opinions of religious leaders differing from those of parents or governmental and NGOs participating in the anti-HIV campaigns [27].
Respecting one’s faithbased stance is one thing, but learning from experience about the best practices is another important thing. Examples of some of the best practices in relation to religious leaders’ participation in the condom promotion campaigns for HIV infection/transmission prevention come from Uganda, South Africa and Zimbabwe. In Uganda, the Church has been coopted as an integral stakeholder in the campaign against HIV/AIDS and this includes participation in such activities as prevention, counseling and testing, and distribution and utilization of ARVs [8]. Even in Islam dominated communities, participation by religious leaders in the programs sensitizing people to prevent HIV/ AIDS infections even through means other than condom use has indicated encouraging results such as increase in number of condom users, reduction in HIV infections, sufferings and deaths [28,29].
Acknowledgement
Funds for carrying out this study were obtained from the Global for Fighting AIDS, Tuberculosis and Malaria (GFTAM) under the auspices of the Ministry of Health and Social Welfare, Tanzania through coordination by the Tanzania Commission for AIDS (TACAIDS). Invaluable support was obtained from study population, religious authorities, regional and district government authorities and study enumerators. Prof. Kato J. Njunwa of Kigali Health Institute under the University of Kigali in Rwanda and former Director of Amani Medical Research Centre in Tanzania reviewed the paper and commented to improve it. The study was officially ethically cleared at national level by the MRCC
References
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22. Hasnain M. Cultural approach to HIV/AIDS harm reduction in Muslim countries. Harm Reduct J. 2005; 2: 23.
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Citation
Mubyazi GM, Exavery A, Malebo HM, Makundi EA, Malekia SE, Wiketye V, et al. Experiences, Perceptions and Attitudes of Religious Leaders and Parents Regarding Condom Promotion for HIV Infection Prevention: A Qualitative Study from Tanzania. SM J Public Health Epidemiol. 2016; 2(1):1024.