Much variation in the reports of frequent condom use was found according to ethnic group. After adjustment for other factors, men from the Goun ethnic group in Cotonou and women from the Bemba ethnic group in Ndola were less likely to report frequent condom use. Men from Kisumu not belonging to one of the two main ethnic groups (Luo and Luhya) were more likely to report frequent condom use.
There was a significant increase in condom use by increasing educational status in all four sites in both men and women (Tables 1 and Table 2). In multivariate analysis, higher levels of education of at least one of the two partners in a given partnership were predictive of higher levels of condom use in all cities. In Yaoundé, the educational level of the male partner seemed to be more important: based on the answers from men, the respondent's educational level was associated with frequent condom use with an adjusted odds ratios (aOR) of 1.76. Answers from the women were consistent with these findings as the educational level of the partner of female respondents was associated with frequent condom use (aOR = 3.32).
The educational level of the female partner seemed to be more important in Cotonou and Kisumu: in Cotonou, the educational level of the female partner was associated with higher condom use based on reports from men (aOR = 2.36), and female respondents who were students were also more likely to report condom use (aOR = 3.25). In Kisumu, reports of men and women were consistent: the educational level of the female partner was associated with higher condom use, both when based on reports from men about their partners (aOR = 2.76) and on reports from women about themselves (aOR = 2.60). The results were not as consistent in Ndola where the respondent's own higher education level was associated with frequent condom use, for both men (aOR = 2.94) and women (aOR = 4.50), but after adjustment for other factors there was no association with the partner's education level for either men or women.
Men who did not know the educational level of their partner were more likely to report frequent condom use with that partner in Cotonou, Yaoundé and Kisumu, but in Yaoundé, women who did not know the educational level of their partner were less likely to report frequent condom use with that partner.
Type of partner
One-quarter of partners reported by men and one-tenth of partners reported by women were defined as not regular, and frequent condom use was more common with non-regular partners (Tables 1 and Table 2). After adjustment for other factors, the association between the type of partner and frequent condom use was significant for male respondents in Cotonou (aOR = 2.00) and female respondents in Yaoundé (aOR = 2.77). Frequent condom use was more likely to be reported by men for commercial partnerships in Yaoundé (aOR = 2.15).
Being a student was associated with reports of frequent condom use in several settings. When adjusted, including adjustment for educational level, being a student was still significantly associated with frequent condom use in Yaoundé according to reports from men (aOR = 2.02). In Cotonou, being a student was the only factor associated with frequent condom use based on reports from women (aOR = 3.25) and this was a better predictor than educational level. Male respondents with a professional, managerial or administrative occupation were much more likely to report frequent condom use in Ndola (aOR = 27).
Duration of the partnership
On the basis of reports from men, frequent condom use was significantly more likely in short-duration partnerships, with the highest probability of frequent condom use in partnerships of 1 day or less. In multivariate analysis, frequent condom use remained significantly more common within partnerships of 1 day or less in Kisumu (aOR = 2.48) and Ndola (aOR = 3.43) according to male respondents, and in Kisumu (aOR = 8.56) according to female respondents. In addition, an interval between the time when partners met and the time of the first sexual act of less than 1 day was strongly associated with frequent condom use among women in Kisumu, although only five women reported such partnerships.
When adjusted for other significant variables, alcohol consumption was not found to be associated with condom use for men. For women, having drunk alcohol more than once a week was associated with a decreased rate of frequent condom use in Yaoundé (aOR = 0.45).
In Ndola, Protestant men were less likely to report frequent condom use. An interaction was found between occupation and religion in men from Ndola: the association between being a professional and condom use was much stronger among non-protestant men. An interaction was also found between commercial partnerships and educational level of men in Yaoundé: if the female partner was a commercial sex worker, men with a lower educational level were more likely to have reported frequent condom use whereas if the female partner was not a commercial sex worker, men with a higher educational level were more likely to have reported frequent condom use. There were no significant associations after adjustment for other factors in any of the four cities between frequent condom use and place of birth, number of partners before marriage, number of lifetime partners, age at first sex, number of non-spousal partners in the last 12 months, sex during menstruation, dry sex practices or the marital status of the partner. No interactions were found with age or ethnic group.
In four cities of sub-Saharan Africa, of a large number of factors examined, education was found to be the most consistent determinant of condom use in non-spousal partnerships. Two surveys in Tanzania also identified educational level as a determinant of condom use. In both Arusha region, and Dar-es-Salaam the proportion of respondents who had ever used condoms increased with educational level [10,12]. Occupation as a marker of economic status has been suggested as a predictor of condom use . Economic status may partly explain the link we found with education, but inclusion of occupation in the multivariate models did not affect the association between frequent condom use and educational level.
There was some evidence that people adapt their condom use to the type of partner and the duration of the partnership. Similarly, in rural Tanzania use of condoms was higher when the partner was casual or non-regular , and among commercial sex workers in the Gambia condom use decreased with regular clients . This adaptation to the type of the partner has also been found in studies outside sub-Saharan Africa [6,7,19–21].
Alcohol use has been reported to reduce condom use in all types of partnership in urban minority youth in the USA . This could be due to alcohol causing a loss of control over behaviour but alcohol consumption could also be part of an overall risk-taking lifestyle, including lack of condom use. The association of alcohol consumption with lack of condom use was found in our study only among women in Yaoundé. We did not find risk behaviour – in terms of number of partners – to be a predictor of condom use, although that has been found in other studies [10,12,14]. Recent papers have pointed out the different rates of condom use between migrants and non-migrants in sub-Saharan Africa [12,14]. Having travelled outside the city in the last 12 months was not significantly associated with increased use of condoms in our study when adjusted for other factors.
Variation in the reports of frequent condom use was seen according to ethnic group. Although it was beyond the scope of this study to explore the cultural reasons for this, these will be important for planning prevention programmes.
The validity of reports on sexual behaviour, including condom use, is always a concern. In all sites men reported more partnerships than women, and a higher proportion of short duration partnerships. This could suggest misreporting, with women under-reporting partnerships, especially those of short duration, and over-reporting the duration of partnerships, or men under-reporting the duration and over-reporting the number, but it could also be explained by men having sex with a population not included in the sample, such as commercial sex workers . Social desirability towards interviewers who are known to work on a project centred on AIDS and its prevention could have led to over-reporting of condom use. If this over-reporting had been more frequent among the well-educated, this could partly explain the observed effect of education on condom use.
We published elsewhere a study of validity of reports of condom use based on the same data set . We assessed internal consistency of reports using a question on condom use during the last sexual intercourse with each non-spousal partner. For each non-spousal partnership, the proportion in which last intercourse was protected increased with reported overall frequency (`always', ‘most of the time', ‘rarely’ and ‘never') of condom use for male and female respondents in all four cities. All trends were highly significant. Inconsistent answers (i.e. reports of ‘always’ use and unprotected last sexual intercourse; or ‘never’ use and protected last sexual intercourse) were rare, (0 to 2.4 per 100 partnerships). However, the proportion who used a condom during the last contact was not much higher in those reporting use ‘most of the time’ than in those reporting ‘rarely’ among men from Cotonou and Ndola and among men and women from Kisumu. There is a large gap between ‘rarely’ and ‘most of the time’ and those who would have answered ‘sometimes’ may have veered towards ‘most of the time'. It is difficult to predict whether this potential misclassification could be linked with the education level of respondents. If not, it would only tend to dilute any association with condom use. We also assessed reliability of condom use reports among married couples where both were interviewed. Concordance between spouses in reported frequency of condom use within spousal partnerships (as measured by the kappa index) was good in Yaoundé (0.65) and Cotonou (0.63) but relatively low in Kisumu (0.28) and Ndola (0.17). However, reporting of condom use in spousal and non-spousal partnerships may differ.
Another concern is that details were only recorded on a maximum of eight non-spousal partners, and respondents did not always give partner characteristics for the full number of partners they did report when it was less than eight (1% of men in Yaoundé, 1.5% in Ndola and < 1% in the other cities omitted to give any details for some partners). The combined effect of limiting the detailed data to eight partners, and of men omitting to give the data for some partners means that some of the reported partnerships of the last 12 months were not included in the analysis. For men, these account for 4% of the non-spousal partnerships in Cotonou, 8% in Yaoundé, 0.5% in Kisumu and 15% in Ndola. For women the loss of information was negligible.
Across the four cities, education was found to be the most consistent determinant of condom use. An association of condom use with education could reflect increased exposure to condom prevention campaigns, increased receptiveness to these campaigns or greater skills in negotiating condom use. Several studies have shown that educated people are more exposed to media, discuss AIDS more often, have a better knowledge of modes of transmission of HIV, fewer misconceptions about AIDS, more favourable opinions about condoms, and have a better perception of their personal sexual risk [23–25].
The main result is a considerable challenge for African countries where a very large proportion of the population achieves no or low levels of education. Nonetheless, our findings suggest that there is a communication and a targeting problem with condom promotion and that special efforts are needed to reach men and women with low educational attainment. An analogy could be made with child survival in Africa, which has been shown to depend on mother's education. Our findings emphasize the need for a better educational system as part of the overall public health strategy to combat the AIDS and STDs epidemics. However, even among the more educated condom use is still too low, with many unprotected high risk partnerships reported.
We are indebted to Alice Guéguen and Jean-Pierre Nakache for their invaluable help in statistical analysis and to Alfred Spira for useful comments throughout the preparation of this manuscript.
1. Plummer F, Simonsen J, Cameron D. et al
. Cofactors in male–female sexual transmission of Human Immunodeficiency Virus Type 1. J Infect Dis 1991, 163: 233–239.
2. de Vincenzi I, for the European Study Group on Heterosexual Transmission of HIV. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. N Engl J Med 1994, 331: 341–346.
3. Lagarde E, Auvert B, Chege J, et al
. Condom use and association with HIV/STDs in four urban communities of sub-Saharan Africa.AIDS
2001, 15(Suppl 4)
: (in press).
4. Catania J, Coates T, Kegeles S. et al
. Condom use in multi-ethnic neighborhoods of San Francisco: the population-based AMEN (AIDS in Multi-Ethnic Neighborhoods) study. Am J Public Health 1991, 81: 284–287.
5. Wingood G, DiClemente R. The effect of an abusive primary partner on the condom use and sexual negociation practices of African-American women. Am J Public Health 1997, 87: 1016–1018.
6. Macaluso M, Demand M, Lynn M, Hook III E. Partner type and condom use. AIDS 2000, 14: 537–546.
7. Morris M, Pramualratana A, Podhisita C, Wawer M. The relational determinants of condom use with commercial sex partners in Thailand. AIDS 1995, 5: 507–515.
8. Ford K, Wirawan D, Fajans P. AIDS Knowledge, risk behaviors, and condom use among four groups of female sex workers in Bali, Indonesia. J Acquir Immune Defic Syndr Hum Retrovirol 1995, 10: 569–576.
9. Ford K, Norris A. Alcohol use, perception of the effects of alcohol use, and condom use in urban minority youth. J Acquir Immune Defic Syndr Hum Retrovirol 1998, 17: 269–274.
10. Kapiga S, Lwihula G, Shao J, Hunter D. Predictors of AIDS knowledge, condom use and high-risk sexual behaviour among women in Dar-es-Salaam, Tanzania. Int J STD AIDS 1995, 6: 175–183.
11. Abdool Karim S, Abdool Karim Q, Preston-Whyte E, Sankar N. Reasons for lack of condom use among high school students. S Afr Med J 1992, 82: 107–110.
12. Mnyika K, Klepp K, Kvale G, Ole-King'ori N. Determinant of high-risk sexual behaviour and condom use among adults in the Arusha region, Tanzania. Int J STD AIDS 1997, 8: 176–183.
13. Pickering H, Quigley M, Hayes R, Todd J, Wilkins A. Determinants of condom use in 24 000 prostitute/client contacts in the Gambia. AIDS 1993, 7: 1093–1098.
14. Morris M, Wawer M, Makumbi F, Zavisca J, Sewankambo N. Condom acceptance is higher among travelers in Uganda. AIDS 2000, 14: 733–741.
15. Buvé A, Caraël M, Hayes R, et al
. The multicentre study on factors determining the differential spread of HIV in four African towns: summary and conclusions.AIDS15(Supply 4)
: in press.
16. Morison L, Weiss HA, Buvé A, et al
. Commercial sex and the spread of HIV in four cities in sub-Saharan Africa.AIDS
2001, 15(Suppl 4)
: (in press).
17. Liang KZS. Longitudinal data analysis using generalized linear models. Biometrika 1986, 73: 13–22.
18. Munguti K, Grosskurth H, Newell J. et al
. Patterns of sexual behaviour in a rural population in north-western Tanzania. Soc Sci Med 1997, 44: 1553–1561.
19. Lansky ATJ, Earp J. Partner-specific sexual behaviours among persons with both main and other partners. Fam Plann Perspect 1998, 30: 39–96.
20. Castilla J, Barrio G, de la Fuente L, Belza M. Sexual behaviour and condom use in the general population of Spain.1996.
AIDS Care 1998, 10: 667–676.
21. Dubois-Arber F, Jeannin A, Konings E, Paccaud F. Increased condom use and sex without other major changes insexual behavior among the general population in Switzerland. Am J Public Health 1997, 87: 558–566.
22. Buvé A, Lagarde E, Caraël M, et al
. Interpreting sexual behaviour data: validity issues in the multicentre study on factors determining the differential spread of HIV in four African cities.AIDS
2001, 15(Suppl 4)
: (in press).
23. Ingham R. AIDS: knowledge, awareness and attitudes.
In:Sexual Behaviour and AIDS in the Developing World
. Edited by Cleland J, Ferry B. London: Taylor & Francis; 1995: 43–74.
24. Mehryar A. Condoms: awarness, attitudes and use.
In:Sexual Behaviour and AIDS in the Developing World
. Edited by Cleland J, Ferry B. London: Taylor & Francis; 1995: 126–156.
25. Blanc A. The Relationship Between Sexual Behaviour and Level of Education in Developing Countries.
UNAIDS report: key document. Geneva: UNAIDS; 2000.
Members of the Study Group on Heterogeneity of HIV Epidemics in African Cities: A. Buvé (co-ordinator), M. Laga, E. Van Dyck, W. Janssens, L. Heyndricks (Institute of Tropical Medicine, Belgium); S. Anagonou (Programme National de Lutte contre le SIDA, Benin); M. Laourou (Institut National de Statistiques et d'Analyses Economiques, Benin); L. Kanhonou (Centre de Recherche en Reproduction Humaine et en Démographie, Benin); E. Akam, M. de Loenzien (Institut de Formation et de Recherche Démographiques, Cameroon); S.-C. Abega (Université Catholique d'Afrique Centrale, Cameroon); L. Zekeng (Programme de Lutte contre le Sida, Cameroon); J. Chege (The Population Council, Kenya), V Kimani, J. Olenja (University of Nairobi, Kenya); M. Kahindo (National AIDS/STD control programme, Kenya); F. Kaona, R. Musonda, T. Sukwa (Tropical Diseases Research Centre, Zambia); N. Rutenberg (The Population Council, USA); B. Auvert, E. Lagarde (INSERM U88, France); B. Ferry, N. Lydié (Centre français sur la Population et le Développement/ Institut de Recherche pour le Développement, France); R. Hayes, L. Morison, H. Weiss, J. R. Glynn (London School of Hygiene & Tropical Medicine, UK); N. J. Robinson (Glaxo Wellcome R&D, UK, formerly INSERM U88); M. Caraël (UNAIDS, Switzerland).
Keywords:© 2001 Lippincott Williams & Wilkins, Inc.
Education; HIV; Africa; condom