Table 4 Synthesis themes and sub-themes

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

[38,39,40, 42, 44,45,46,47,48,49, 51,52,53, 57, 59] presented evidence for this theme.

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

[37,38,39, 41,42,43,44,45,46,47,48,49,50, 52,53,54,55, 57,58,59] presented evidence for this theme.

Six of these studies mentioned that there was a desire for communities to retain their traditional methods of family planning [38, 43, 44, 53, 54, 59].

“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

[37, 40,41,42,43,44, 46, 48, 49, 52, 54, 56, 57, 59] presented evidence for this theme.

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

18/23 studies [38,39,40,41, 43,44,45,46,47, 50,51,52,53,54,55, 57,58,59] presented evidence for this theme.

“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

[37, 38, 40,41,42, 44, 46,47,48, 51, 53, 54, 59] presented evidence for this theme.

“….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

14/23 studies [38,39,40,41,42,43,44,45, 47, 51,52,53, 56, 57] presented evidence for this theme.

“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]