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Exploring the condom gap: is supply or demand the limiting factor - condom access and use in an urban and a rural setting in Kilifi district, Kenya.
Global Health Sciences Literature Digest
Published April 11, 2011
Journal Article

Papo JK, Bauni EK, Sanders EJ, Brocklehurst P, Jaffe HW. Exploring the condom gap: is supply or demand the limiting factor - condom access and use in an urban and a rural setting in Kilifi district, Kenya. AIDS. 2011; 25:2, 247-55.

Objective

To evaluate the extend of the “condom gap,” meaning relative roles of the ‘supply-side’ vs. the ‘demand side’ in determining condom use

Setting

An urban (Kilifi Town) with high physical access to condoms, and a rural site (Sokoke) with low physical access to condoms were selected for study in Kilifi District (Coastal Province), Kenya. This is a resource-limited setting with a 5% HIV prevalence among antenatal clinics (ANC) in 2005. Kilifi is located on a main highway, has a high population density, small area (9 square kilometers), and numerous potential condom outlets. Sokoke is located inland, with limited road accessibility, low population density over 62 square kilometers and few condom outlets.

Study Design

Cross sectional study including GPS mapping of condom outlets and population based survey.

Population

Potential condom outlets were identified and surveyed, including public and private health facilities, shops/kiosk, chemists, bars, discos, hotels and guesthouses. (Schools, barbers/hair-salons, small restaurants, video-shows/mini cinemas were not considered condom outlets). 2) Population-based random sample of equal numbers of men and women aged 15–49

Main Outcome Measures

Condom use. Supply-side barriers to condoms: self-reported time to nearest health facility with free condoms, ability to pay $0.15 US for a three-pack of condoms. Demand-side barriers: embarrassment at getting a condom, difficulty asking partner to use a condom, negative/ambivalent attitude towards condoms, religion as influence on attitude towards condoms, never having been exposed to condoms. Felt unmet need: wanting to use a condom but unable to access or to do so. Attitudes towards condoms: obtained through open-ended questions

Methods

A list of potential condom outlets was obtained from the local government, and each study area was visited on foot/by vehicle to identify other potential outlets. A total 281 sites (248 Kilifi Town, 33 Sokoke) were identified and surveyed to determine if they stocked condoms; geographical coordinates were collected using GPS hand-held device. A questionnaire on barriers to condom use, felt unmet need, and attitudes towards condoms was administered to 630 of the 990 persons (68%) identified in the Demographic Surveillance System (EPI-DSS) sample (322 Kilifi Town, 308 Sokoke) using individual interviews. Straight-line distances from persons households to the nearest free and commercial condom outlets were calculated. Open-ended comments about attitudes towards condoms were grouped by theme

Results

Only 42% (119/281; 107 in Kilifi Town, and 12 in Sokoke) of potential condom outlets usually provided condoms, and 10% of these were temporarily out of stock. There was a greater range of type of outlets in Kilifi Town. The median straight-line distance from households to nearest free outlet was 18 times longer in the rural site (4.45 km vs. 0.25km in Kilifi Town), but distance to commercial outlets was less (0.13Km in Kilifi Town, and 0.98 km in Sokoke). Most (97%) of outlets provided the condom socially marketed by Population Services International. At outlets not providing condoms, 60% claimed personal choice for not doing so; only 1% of outlets provided female condoms.

Survey participants were evenly distributed by gender and location, by design (Kilifi Town: 172 males out of 322 total; Sokoke: 152 males out of 308 total). The mean age was 27.2, mostly of one tribe; more than two-thirds lived on less than $1 US per day. The sites differed in terms of education, poverty level, ethnic and religious makeup, marital status and HIV testing. Among those who had ever had sex 73% of total (48% in Kilifi and 34% in Sokoke, p=0.002) had ever used a condom; only 28% and 17% (p=0.014) had used a condom in the last 12 months, in the two towns respectively; only 1-2% used condoms most of the time with their martial/cohabitating partner; 40% used condoms with a non-marital partner in the last 12 months.

Factors identified to be significantly associated with condom use in the last 12 months, using multivariable logistic regression analysis, included: being in Kilifi Town (aOR 3.2 [95% CI 1.6-6.5]), being male (aOR 2.3, CI [1.2-4 )], not having a religious affiliation (aOR 2.4, CI [1.2-4.8]), being unmarried/non-cohabitating (aOR 6.2, CI [3.2-12.1). Age, economic status, and education were not associated with using a condom. Additional factors associated with12 month condom use were: being less than minutes from a free condom facility (aOR 2.3, CI [1.2-4.5]); being able to afford to buy a pack (aOR 4.2, CI [1.1-15.6]); not having any supply side barriers (aOR 3.0, CI [1.4-6.3]); not being embarrassed to get a condom (aOR 2.4, CI [1.2-4.8]); no difficulty in asking a partner to use a condom(aOR 27.8, CI [3.8-217.5]); no influence of religion on attitude towards condoms (aOR 2.6, CI [1.4-5.1]); lack of exposure to condoms (given/shown/event) (aOR 2.5. CI [1.3-4.8]; having no demand-side barriers (aOR 3.8 CI [1.8-7.9]).

Women (39% vs. 21% of men), and those in Sokoke (53% vs. 13% of those in Kilifi) were more likely to have one or more supply-side barriers (both p>0.001). Women were also more likely to experience demand-side barriers (88% vs. 73% of men), although persons in Kilifi were more likely to experience at least one demand side barrier than those in Sokoke (89% vs. 70%), both p<0.001. The total amount of reported unmet need was 7%, and higher in Kilifi than Sokoke (10% vs. 5%, p<0.05); unmet need was higher among men compared to women (11% vs. 4%, p<0.-5).

Open ended comments indicated that 83% have negative or ambivalent attitudes towards condoms such as not seeing the need to use them, or disliking them (30%); 21% distrusted the product as having 'pores' or likely to tear; 16% had religious and/or moralistic reasons against condoms (sin and promiscuity).

Conclusions

The authors state that despite a generalized HIV epidemic in this area (5% HIV prevalence in ANC), condom use was low and mainly due to prevalent demand-side barriers and low levels of felt need. The authors conclude that this indicates the need to renewed condom promotion to build need as well as to improving physical access.

Quality Rating

This was a good quality cross-sectional study, although with a somewhat high non-response rate (32%). Although population based sampling was employed, Kilifi district differs from the results of Kenya based on its high levels of poverty, low education and employment, and its greater religious diversity.

In Context

Despite more than two decades of condom promotion, persistently low levels of condom use still exist(1) with only modest improvements over time in sub-Saharan Africa.(2,3) In 2000, the estimated public sector provision of condoms was only 4.6 condoms per male aged 15-59, and remained 4/male in 2008.(4,5) In Kenya in 2003, condom use was less than 50% at last sex with non-marital partner and <2% with martial partners(6) in 2003. Other studies have shown a relationship between condom access and distance, cost, embarrassment at accessing condoms, and conservative religious affiliations. Condom use here was markedly lower with marital partners and is consistent with past studies.(1,6,8)

Programmatic Implications

In general, the potential for condoms as a public health tool for prevention of HIV/STIS is poorly realized. Given that heterosexual sex between regular partners was estimated to be the leading cause of new infections (44%) in 2006 in Kenya, these findings are concerning. In addition, approximately 6% of couples in Kenya are estimated to HIV discordant, with up to 80% of them being unaware of their partner’s HIV status.(8) This indicates that better methods of making condoms available and in demand are still needed. Programs should think creatively about making condoms more easily available and promoting their use–within care and treatment centers, and offering couples testing and counseling with condom provision.

References

  1. Agha S, Kusanthan T, Longfield K, Klein M, Berman J. Reasons for nonuse of condoms in eight countries in sub-Saharan Africa. PSI Research Division Working Paper No. 49. Washington DC: Population Services International (PSI); 2002.
  2. Adair T. Men’s condom use in higher-risk sex: trends in five sub- Saharan African countries. J Popul Res. 2008; 25:51–62.
  3. Cleland J, Ali MM. Sexual abstinence, contraception, and condom use by young African women: a secondary analysis of survey data. Lancet. 2006; 368:1788–1793.
  4. Shelton JD, Johnston B. Condom gap in Africa: evidence from donor agencies and key informants. 2008 Dec 15;49(5):523-31.
  5. UNAIDS. Letter to partners. Antiretroviral therapy for HIV-1-infected children in Haiti. Geneva, Switzerland: UNAIDS, 2010.
  6. Central Bureau of Statistics (CBS), Ministry of Health (MoH), and ORC Macro. Kenya demographic and health survey 2003. Calverton, MD: CBS, MoH, and ORC Macro, 2004.
  7. Agha S, Hutchinson P, Kusanthan T. The effects of religious affiliation on sexual initiation and condom use in Zambia . J Adolesc Health. 2006; 38:550–555.
  8. National AIDS and STI Control Programme (NASCOP), Ministry of Health, Kenya. Kenya AIDS indicator survey 2007: full report. Nairobi, Kenya: NASCOP; 2009.