Table 3 A Priori Themes – Individual, interpersonal and structural level determinants of condom use among adolescents in Southern Africa

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

- Three studies reported that sexual and reproductive health knowledge was evident among the adolescents in their studies [37, 40, 50]. Adolescents who had adequate SRH knowledge noted that they had engaged in SRH programmes at school or in the community [40, 50].

- Seven studies reported that inadequate or inaccurate SRH knowledge was common [38, 39, 47, 48, 50, 55, 57], mainly because participants had not received comprehensive SRH education.

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, 46,47,48,49, 54, 59].

- Two studies did report positive attitudes to condoms (generally related to their value in preventing STIs and unintended pregnancy) [43, 49].

- Two studies reported perceptions that condom use indicated trust and respect in relationships [37, 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, 51,52,53]. 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].

- Adolescents in three studies [41, 53, 59] noted that their religious beliefs acted as a barrier to condom use.

- Six studies reported possible negative impacts on committed relationship dynamics as a barrier to condom use [37, 38, 40, 46, 47, 53] and five studies mentioned transactional relationships as barriers [41, 42, 44, 48, 59].

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.

- Although several studies highlighted that girls were aware of the risks of having sex with older men, this seem to be overpowered by their belief that not using condoms would result in negative consequences for them [41, 42, 44, 48, 59].

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, 46,47,48,49, 54, 59].

- Nine studies that indicated that adolescents (particularly males and females in relationships with older men) did not intend to use condoms, especially in committed or transactional relationships [37, 41, 42, 44, 46,47,48,49, 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].

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].

- One study noted that early fatherhood acted a facilitator of condom use among some young men [40] and two others reported agency on the part of young women [45, 46].

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.

The studies indicated a lack of communication between parents and adolescents about SRH, parental discomfort discussing sexual matters and adolescent perceptions that parents would disapprove of condom use [40, 46, 51, 57].

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].

- Two studies reported the facilitative effect of positive attitudes about condom use from health professionals [50, 51].

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].

- One study indicated that health professionals reported a conflict between promoting sexual wellbeing and conforming to religious norms [54] while another found that acceptance of religious norms had influenced the provision of SRH [38].

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].

- Discomfort among teachers was noted by one study [57] as a possible reason for a lack of provision and a lack of SRH resources for teachers was noted in another study [52].

- Adolescents reported learning about SRH primarily from peers and initiation ceremonies [39, 55].

- One study noted the provision of condoms in schools as a facilitator of condom use [46] and another mentioned the provision of SRH programmes in schools as a facilitator [40].

Other community Organisations

Key findings: The availability of condoms in organisations in the community was reported as a facilitator of condom use

- Five studies found that organisations within communities acted as facilitators of condom use with bars [38, 52], guesthouses [58], and shops [44, 46, 52] often mentioned as places where young people had access to condoms.

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, 45,46,47,48,49, 51,52,53, 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, 46,47,48,49, 51,52,53], and it was also evident that restrictive masculinities were a negative determinant of condom use among men [40, 46, 52, 53].

- Six studies noted that men played the central role in making sexual decisions [40, 46,47,48, 53, 59].

-Two studies reported female as a positive determinant of condom use [45, 46] and in two other studies young men reported that they viewed using condoms as a sign of respect for their partners [37, 59].

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].

- Six studies mentioned that there was a desire for communities to retain their traditional culture and methods of avoiding HIV and pregnancy (which generally involves avoiding sex outside of marriage) rather than embracing contemporary ‘Western’ methods [38, 43, 44, 53, 54, 59].

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].

- Five studies reported the negative impact of poverty on young women’s decisions to use condoms in age-disparate and transactional relationships [41, 42, 44, 48, 52, 59].

- Conversely, six studies reported that higher socioeconomic status and future orientation were positive determinants of condom use [37, 40, 43, 49, 56, 57].