Perceived social approval and condom use with casual partners among youth in urban Cameroon

Peer education is considered an effective technique for HIV prevention programs to reach and influence youth [1]. The basic idea is that the adoption of safer reproductive health behaviors is affected by the perceived normative environment and the individual's willingness to conform to that environment [2]. It is often assumed that for youths this normative environment is primarily shaped by other youth. This paper examines the effects of perceived social approval on condom use with casual partners among Cameroonian youth, and argues that peers may be less effective in bringing forth behavior change than is often assumed. Behavior change requires social approval, and peers may simply not be the most relevant reference group for youths.

Many Cameroonian youths engage in risky sexual behaviors, such as having sex with casual partners or having unprotected intercourse, which may lead to unplanned pregnancies and STIs, including AIDS [3–12]. Despite the risks, consistent condom use has remained fairly low [3, 7, 13]. Among unmarried youth in Yaoundé, only 24% of men and 16% of women reported frequently using condoms [14]. Another study estimated condom use among youths at 16% for women and 31% for men [15]. The Demographic and Health Surveys, however, show that condom use increased between 1991 and 2004 [16]. While in 1991 only 1.0% of sexually active women (ages 15-49) reported to currently use condoms, this increased to 3.5% in 1998 and 9.7% in 2004. For women aged 20-24 the proportion currently using condoms increased from 1.0% in 1991 to 6.2% in 1998 and 16.0% in 2004.

The 100% Jeune program, a social marketing program targeting youth aged 15-24 in Yaoundé and Douala, Cameroon's two major cities, was initiated and implemented by Programme de Marketing Social au Cameroon (PMSC) from 2000 onward [17, 18]. It aims to motivate urban youths to adopt safer reproductive health behaviors, including abstinence and condom use. A wide range of social marketing techniques are used, including mass media campaigns, education sessions and other peer education techniques [19–22]. Initially the program focused exclusively on youths, but subsequent phases of the program also sought to stimulate parent-youth communication [17].

Several theories of behavior change emphasize the importance of social learning [23]. However, most theories focus on the cognitive dimensions of the social environment. That is, it is assumed that youths are influenced by peers who act as role models and opinion leaders and that these influences will help create attitudinal and behavior change. However, within the African context such emphasis on peers is by no means self-evident. The presumed importance of the role of peers is based on the presumption that traditional authority systems, such as the family and the community, are declining due to modernization processes [2, 24–27]. It is assumed that as decisions about one's sexual behavior--such as whether to engage in intercourse or to use condoms-- become more individualized, peers become more important as opinion leaders. However, such arguments may underestimate the tenacity of traditional structures, which are integrated in the modernization process rather than being completely discarded. Hence, modernization does not necessarily imply the complete decline of traditional family and community structures [28]. Family and community structures can remain important frames of reference, even in the more modernized segments of these societies and therefore remain relevant contexts for decisions concerning reproductive health behavior. Furthermore, opinion leaders have a dual function; they not only disseminate information, but also express their approval/disapproval of various behaviors.

Social capital, social network and social control theories [29–31] conceptualize the social environment not only as a source of information, but also as a source of emotional support, practical support, identity, status, approval, and, perhaps even more importantly, social control. Behavior deemed inappropriate by others may be negatively sanctioned. These sanctions may vary from mild disapproval, over loss of social status and stigmatization, to social exclusion. Thus, reproductive health behavior needs cultural legitimation. Adopting safe sex practices may be difficult in the face of widespread social disapproval. For instance, Cameroonian women who carry condoms are stigmatized as sluts or prostitutes [32]. A supportive social environment, to the contrary, may facilitate the adoption of safe sex practices. Studies on Ghana, Zimbabwe, and Nigeria found a positive relationship between perceived social support and condom use [33–36]. A study among Cameroonian youths found that parental support increased the likelihood that youths had ever used condoms [17]. This suggests that family members and other adults may be more relevant than peers, when it comes to social approval of condom use.

Although peers may be important for the diffusion of new ideas, other actors, such as parents, other family members or religious leaders, may be more important for the acceptance of these ideas or the cultural legitimacy of such behavior [37]. In societies where the (extended) family is still an important principle of social organization and where social organization tends to be hierarchical, the opinion of family members or community leaders is likely to matter most. In many African societies, parents, family and community members still feature prominently in the everyday life of the adolescents. Because adolescents still depend on them financially, emotionally, socially as well as culturally, these actors continue to influence adolescent behavior through (anticipated) positive and negative sanctions. This study identifies actors whose opinions are valued by youths in urban Cameroon, and looks at the effect of their perceived social approval on condom attitudes and condom use with casual partners.

The literature has identified other factors that also affect condom use. For instance, self-efficacy is a central concept in both social learning theory and the theory of planned behavior [38, 39], and is known to increase the likelihood of condom use [17, 33, 40–42].

Youths' attitudes toward condoms, the perceived effectiveness of condoms for family planning and STI prevention, and the perceived advantages and disadvantages of condom use are also important determinants of condom use. Youths who have positive attitudes toward condom use are more likely to use them, while those who have negative attitudes or perceptions are less likely to do so [17, 43, 44, 44].

Risk perception is another factor affecting condom use. Increased awareness of the severity of the AIDS epidemic leads to increased condom use [17, 45]. Youths who consider themselves at high risk for HIV infection are also more likely to adopt protective behaviors [17, 33, 34, 42, 46, 47].

However, condom use is also dependent on the community context. For instance, condom availability (ease of access) is known to facilitate condom use [17, 37, 48–51]. The cultural acceptance of condom use and the community attitude and openness toward reproductive health issues also affect use. In communities where reproductive health issues can be discussed freely and where condom use is condoned or approved of, individuals are more likely to actually use them [37, 52].

Our data show that condom use with casual partners increased rapidly among youth in urban Cameroon over the course of the study period. This finding is consistent with the results from the Demographic and Health Surveys [16] that reported increased condom use among married women and sexually active unmarried women. At the same time there were also significant, but less impressive, changes in attitudes towards condom use and perceived social approval of condom use.

The results show that perceived support for condom use from the respondent's most valued person has a positive effect on the frequency of condom use with casual partners. This finding is consistent with the literature on the importance of the social environment and on social support for condom use [17, 33–35, 37]. Information about condom use, or a favorable attitude toward it, is not sufficient to use them. The perception that condom use is approved of by people whose opinion one values is a crucial link in the process of adopting condom use.

Although the perception that MVPs support condom use only had a small effect, it is noteworthy that youths rarely named a peer as someone whose opinion mattered much to them. The overwhelming majority named their parents or other relatives as MVPs. This emphasizes the importance of vertical over horizontal relations, and of traditional authority relations. Peers may be important for knowledge and such, but in the end it is still the approval of parents and relatives that matters. AIDS prevention programs, therefore, should pay more attention to these traditional authority structures as any widespread behavior change requires support of both important adults and peers. Recognizing the importance of these authority structures, the 100% Jeune program increased their focus on parent-youth communication. Rather than focusing on specific target groups, such as youth and other high risk groups, AIDS programs should be more encompassing and include the entire community. Whenever possible, traditional authority systems should be mobilized to promote and support behavior change. The finding that the negative effect of the MVP's opinion on the respondents' condom attitudes disappeared by the end of the study period suggests that this approach may be having success. Improved communication, especially with parents, creates an environment that facilitates the adoption of reproductive health behaviors, in which youths feel support for their decisions.

Because people prefer to associate with others who are similar, homophily is a major organizing principle in human relations. Hence, many public health programs assume that peers are the relevant reference group for adolescents. However, the homophily principle applies only to voluntary relationships when there are few structural constraints on one's relationships. Relationships with family and the community are ascribed, not achieved. While peers may influence one's beliefs and knowledge, it is the non-voluntary relationships with family and community members that exert social control over the behaviors of adolescents. This, however, does not suggest that peers are irrelevant for the adoption of condoms or that peer education programs should be abandoned. Peers remain a very important reference group for adolescents. The study does suggest, however, that although peers may be a source of social approval and support, their support is insufficient for the adoption of condom use. Other actors, primarily parents and other family members, play a crucial role in this respect. This suggests a two-pronged approach: a traditional program oriented towards adolescents, and a second program that targets the community with special attention to opinion leaders in the community. The role of these opinion leaders is twofold: disseminating information about safe sex behaviors, and providing moral approval for such behaviors. As there is no reason to belief that these findings are unique to these Cameroonian youth [see e.g. reference [36]] such two-pronged approach may be applicable in many more communities worldwide.

This study also has its limitations, several of which are related to the question about the MVP. Respondents were only allowed to name a single MVP, while social approval is an environmental process involving multiple persons. The results therefore confirm the importance of parents and family, but they do not necessarily prove that peers are unimportant. It is quite possible that if more choices were allowed, peers would have been mentioned as second or third choice. Second, the question asked respondents to identify someone whose opinion they valued; it did not specifically ask whose opinion they valued with respect to reproductive health issues or condom use. Had they been asked whose opinion they values for reproductive health issues, they may have named a different person. Nevertheless, we did observe that the perception that the person named as MVP approved condom use had a significant effect on condom use. If our measure of perceived social approval was invalid, either because it either did not include all relevant persons or was too general, then one would expect to find no effect of this variable on the outcome. Although social approval is a community process, not everyone is equally important. Social approval is linked to the stratification within the community and the status of individuals. Because youths tend to have lower status they may be less important for social approval. Furthermore, because of its link to the stratification system, the social approval system also tends to be more general rather than issue-specific.

Although the use of structural equation models allowed us to both include a non-recursive element in the model and to compare regression coefficients across the three survey waves, it only estimates linear regression equations. For the ordinal variables in the model we therefore had to use polychoric correlations. As the polychoric correlation assumes an underlying normal distribution of the variable, the extent to which this assumption does not hold might affect the estimated coefficients.

Further, this study uses a series of cross-sectional surveys rather than longitudinal data which means we cannot assess individual behavioral change or measure the role of social approval in the change process. Because our study only includes youths who reported having casual partners in the past 12 months, our findings may not apply to those who only have regular partners. The role of MVPs and perceived social approval may be different in these groups as decision making takes place in different contexts.

Although there is little data on the frequency of condom use in Cameroon, the DHS data indicate that condom use has increased substantially since the mid-nineties. Our study falls in the middle of this period and provides additional evidence for such a change. Not only did condom use become much more frequent from 2000 to 2003, but attitudes shifted to being more favorable towards condoms as well, and MVPs were reported to be more supportive of condom use. The changes in attitudes, however, are fairly small compared to changes in behavior. When support for condom use becomes widespread, one can, paradoxically, expect social support to become a less important factor regarding condom use. In this study, however, no such shift in the effect of social support was yet observed. This implies that for the time being programs should keep focusing on building widespread support for condom use in the general population, and not simply focus on groups-at-risk.

Items included in condom attitude scale.

#      Item

1   Seriez-vous gêné d'acheter des condoms dans une boutique à côté de votre domicile? (Would you be embarrassed to buy condoms in a shop near your residence?)

2   Seriez-vous gêné de discuter de l'utilisation des condoms avec vos amis? (Would you be embarrassed to discuss the use of condoms with your friends?)

3   Croyez-vous que les femmes qui ne sont pas mariées devraient toujours être en mesure d'acheter des condoms? (Do you believe that non-married women should always be able to buy condoms?)

4   Les condoms sont-ils efficaces dans la prévention des maladies sexuellement transmissibles? (Are condoms effective for the prevention of sexually transmitted diseases?)

5   Les condoms sont-ils efficaces pour prévenir le VIH/SIDA? (Are condoms effective for the prevention of HIV/AIDS?)

6   Pensez-vous que les condoms se rompent facilement? (Do you think condoms rip easily?)

7   Pensez-vous qu'il est difficile d'utiliser le condom avec une personne avec qui vous ne l'avez jamais utilisé avant? (Do you think it is difficult to use a condom with someone with whom you never used one before?)

8   Pensez-vous qu'il est facile d'introduire les condoms en disant qu'il est pour la prévention des grossesses non désires? (Do you think it is easy to introduce condoms by stating it is for the prevention of unwanted pregnancies?)

9   Pensez-vous que les condoms sont difficiles à obtenir? (Do you think condoms are difficult to obtain?)

10   Une femme peut-elle demander qu'un homme utilise le condom pour une raison quelconque? (Can a woman ask a man to use a condom for whatever reason?)

11   Pensez-vous que l'utilisation du condom diminue le plaisir sexuel pour l'homme? (Do you think that using a condom reduces the sexual pleasure of the man?)

12   Pensez-vous que l'utilisation du condom diminue le plaisir sexuel pour la femme? (Do you think that using a condom reduces the sexual pleasure of the woman?)

13   Pensez-vous que le condom peut resté dans le vagin de la femme au cours de son utilisation? (Do you think a condom may remain in a woman's vagina after use?)

14   Pensez-vous que le condom peut irriter ou blesser le vagin de la femme au cours de son utilisation? (Do you think a condom may irritate or hurt a woman's vagina during use?)

15   Pensez-vous qu'on ne devrait pas faire confiance à un partenaire qui suggère le port du condom? (Do you think one cannot trust a partner who suggest the use of a condom?)

16   Une femme peut-elle se protéger contre une MST si son mari en est déjà atteint? (Can a woman protect herself against a STI when her husband is already infected?)

Each item was scored 0: no, 1: yes and 0.5: do not know/no opinion. All items were (re-)scored such that a higher total score reflect a more positive attitude towards condom use.