Factors Affecting Accessibility And Utilization Of - Condom (A Community Based Study) POLICY Project

 
Factors Affecting Accessibility And Utilization Of
                    Condom
          (A Community Based Study)

        The Futures Group International-Ethiopia

                   POLICY Project

                 (September, 2000)
Factor Affecting Accessibility And Utilization Of Condom                                                                                                  July, 2000

1     EXECUTIVE SUMMARY..................................................................................................1

1.1          Summary of major findings ......................................................................................................................1

Knowledge, Attitude and Practice related to HIV/AIDS and STDs ................................................................1

Level of awareness and source of information about condom ..........................................................................2

Availability, Accessibility and Utilization of condom..........................................................................................2

Attitude and socio-cultural factors affecting utilization of condom ................................................................2

2     INTRODUCTION AND BACKGROUND INFORMATION ...................................................4

2.1          The situation of HIV/AIDS in Ethiopia: ................................................................................................4

3     OBJECTIVE....................................................................................................................5

4     METHODOLOGY ............................................................................................................5

4.1          Study area: .....................................................................................................................................................5

4.2          Study population:.........................................................................................................................................5

4.3          Study design: .................................................................................................................................................5

4.4          Sampling: .......................................................................................................................................................5

4.5          Data collection: .............................................................................................................................................6

4.6          Data processing:...........................................................................................................................................6

4.7          Ethical considerations: ...............................................................................................................................6

5     DESCRIPTION OF THE STUDY AREAS ..........................................................................6

5.1          Addis Ababa:.................................................................................................................................................6

5.2          Debre-Berhan: ..............................................................................................................................................6

5.3          Arsi-Hitosa:....................................................................................................................................................7

6     RESULT..........................................................................................................................8

6.1          Socio-demographic characteristics of the study population.............................................................8

6.2          Knowledge, Attitude and Practice related to HIV/AIDS and STDs ..............................................9

6.3          Level of awareness and source of information about condoms .....................................................11

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6.4            Availability, Access and Utilization of Condom ................................................................................11

6.5            Attitude and socio cultural factors affecting utilization of condom: ............................................13

7      DISCUSSION AND CONCUSSIONS .............................................................................. 15

7.1            Level of awareness and attitude of the study population about STDs/HIV/AIDS ...................15

7.2       Awareness, Perception and Other Socio Cultural Factors Affecting acceptability and
Utilization of Condom: ...............................................................................................................................................16

8      RECOMMENDATIONS .................................................................................................. 18

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Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

1     Executive Summary

The need for condoms is growing as HIV/AIDS and other sexually transmitted infections (STIs)
spread; and this is true for countries like Ethiopia where heterosexual relation is the primary
mode of spread for HIV. Making condoms more accessible, lowering their cost, promoting them
extensively, and helping to overcome social and personal obstacles that limit their use, are some
of the widely advocated strategies that can be used to save lives lost due to HIV/AIDS.

Despite the recognition given to condom as a major mode of prevention for diseases that are
transmitted through sexual intercourse, much is not known about the factors that contribute for
current low condom use rate in Ethiopia.

This study has been conducted with the objective of narrowing the existing knowledge gap in the
area of condom accessibility and utilization among people residing in urban, semi-urban and rural
areas of Ethiopia. Summary of the major study findings are outlined below and practical
recommendations drown from the study findings are outlined at the end of the text.

1.1     Summary of major findings

Knowledge, Attitude and Practice related to HIV/AIDS and STDs

§     About 87% of the study population are aware of diseases transmitted by sexual intercourse
      and were able to mention the name of at least one STD

§     Syphilis (42%), HIV/AIDS (38%) and Gonorrhea (17%) are the three common and
      spontaneously mentioned STDs.

§     When prompted, about 97% of the study population indicated that they know about
      HIV/AIDS.

§     About 86% of the respondents believe that HIV/AIDS can be prevented (91% Addis Ababa
      and Debre Berhan and 71% Arsi/Hetosa).

§     Nearly two third of the respondents who know about HIV/AIDS do not perceive themselves
      as being susceptible to HIV/AIDS.

§     Remaining with one faithful partner (70%), using condoms (16%) and making sure injections
      are safe (3%) are the commonly stated mode of HIV prevention methods.

§     Major difference in proportion is observed in the level of awareness about AIDS and its
      prevention, the risk factors for HIV infection and perceived vulnerability between rural and
      urban residents and married and not married people. Almost in all cases, those who live in
      rural areas seem to be on disadvantage.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]          1
Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

Level of awareness and source of information about condom

§   Nearly 90% of those who know about AIDS also know about condoms.

§   About 76% of those who have heard about condoms have also seen condoms.

§   Radio is the main source of information for people from all the three study areas.

§   From the 728 respondents who have heard and seen condoms and volunteered to give
    information on availability of condoms at home or pocket 29% said that they have condoms
    at home/ pocket.

§   Out of the 1378 respondents 42% attended health education sessions on condoms and out of
    which 81% mentioned that the health education they attended included demonstration about
    condoms.

§   Nearly 72% of those people who have sexual partner(s) and used condom discusses condoms
    with their partners (49 Arsi/Hetosa, 72% Addis Ababa and 79 Debre Berhan)

Availability, Accessibility and Utilization of condom

§   About 33% of the respondents (38% Addis Ababa, 32% Debre Berhan and 20% Arsi/Hetosa)
    used condoms at least once in their life.

§   Out of the respondents who gave information about their current utilization of condoms, 59%
    mentioned that they used condoms during their recent (last) sexual encounter.

§   As compared to the illiterates and those with elementary education, the proportion of condom
    users is higher among people with high school and college level education (26% illiterates
    and 40% college education).

§   Out of the 432 respondents that have ever used condoms, 63% pointed out that they know
    about different types of condoms (74% Addis Ababa, 46% Debre-Berhn and 22% Arsi-
    Hetosa)

§   Of those people who stated their reasons for using condom, 97% pointed out that they are
    using condoms as protection from STD/HIV/AIDS while only 3% are using condoms as a
    contraceptive method.

Attitude and socio-cultural factors affecting utilization of condom

§   Nearly half the females believe that males are not willing to use condoms while about a third
    of males believe that females would not be willing to use condoms.

§   About third of the respondents (42% Iteya, 37% Addis Ababa and 30% Debre-Berhan)
    pointed out that male makes the final decision to use or not to use condom. While a quarter
    said it is the female (28% Addis Ababa, 22% Debre-Berhan and 16% Arsi-Hetosa) who
    decides whether to use condoms or not.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]          2
Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

§   Nearly a third indicated that faced with religious imposition to use condom.

§   About 69% of those who heard and seen condoms said their peers would approve their use of
    condom (79% Addis Ababa, 64% Debre Behran and 55% Iteya). Moreover, nearly half
    (48%) said that their families would approve their use of condoms.

§   From the respondents who have seen, heard of and used condom previously, but not using
    currently, 52% said they have no apparent reason for not using condom .

§   About 75% of the respondents recommend condoms to others, of which 29% recommend
    condom only for unmarried people.

§    Of those people who would not recommend condom use for others, about 23% believe
    condom will motivate people to be promiscuous.

§   According to the result of the qualitative study, false rumors, myths and reputations about
    condom like: "Condom is neither protective nor pleasant to use", "condom decreases sexual
    pleasure", " sex with condom is like eating candy with its cover"; " sex with condom is like
    wearing blanket on a hot day"," Sex with condom is equivalent to not doing sex at all " etc
    are quite common and widespread among the study population.

§   The qualitative study also reveled that some organized resistance to condom use. Nearly a
    third of the respondents of the study said that their religion has some imposition in their use
    of condom. Participants of the qualitative study indicated that religious leaders openly oppose
    the use of condoms associating it with immoral behaviors like promiscuity.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]          3
Factor Affecting Accessibility And Utilization Of Condom                                                            July, 2000

2        Introduction and background Information

2.1       The situation of HIV/AIDS in Ethiopia:
Ethiopia is one of the many sub-Saharan African countries that are strongly affected by the AIDS
pandemic. The national HIV prevalence estimate for mid-2000 showed that 2.6 million
Ethiopians are infected with HIV 1 The available information indicates that there is a marked
difference in HIV prevalence between urban and rural areas, and even among the different urban
sites within the country. The sero-prevalence surveys conducted in different parts of the country
in 19992 showed that the adult HIV prevalence for urban areas ranged from 3.0% in Metu town
(Illubabaor zone, South Western Ethiopia) to 20.8% in Bahir Dar town (the capital of the Amhara
National Regional State, North Western Ethiopia). In rural areas the adult prevalence ranged from
0.7% in Gambo (Arsi zone, Central Ethiopia) to 7% in Atat (West Shoa Zone, Southern
Ethiopia).

The need for condoms is growing as HIV/AIDS and other sexually transmitted infections (STIs)
spread and this is true for countries like Ethiopia where heterosexual relation is the primary mode
of spread for HIV. Making condoms more accessible, lowering their cost, promoting them
extensively, and helping to overcome social and personal obstacles that limit their use, are some
of the widely advocated strategies that can be used to save lives lost due to HIV/AIDS. These
condom use strategies also help to reduce the enormous consequences and costs of STIs and
unintended pregnancies3.

Educating the public on the proper use of condom and ensuring its distribution through all
possible outlets at affordable prices and on a continuous basses are among the general strategies
stipulated in the HIV/AIDS policy document of the Ethiopian Government4. Though there are
indications that the use of condoms is increasing among the various section of the population, the
results of recent surveys showed reasonably high discrepancy in the proportion of condom users
(ranging from 0% among female factory workers in Akaki to 77.2 % in sex workers in Addis
Ababa) 5,6 . This fact is a good indicator for the fact that still many people who are at risk of HIV
infection are not using condom and are involved in risky behaviors that could expose them to
HIV/AIDS. This is partly evident by the rapid spread of HIV/AIDS among urban and rural
communities.

According to the available literatures, many institution-based studies have been conducted on
knowledge, attitude and practice of different section of the community on condoms and their use.
However, there is a lack of community-based studies focused on identifying the factors affecting
the accessibility and utilization of condoms among the different urban and rural community
groups. This study has thus been conducted with the objective of narrowing the existing
knowledge gap in the area of condom accessibility and utilization among urban, semi urban and
rural areas of Ethiopia.
______________________
    1.   Estimating national HIV Prevalence in Ethiopia Using Sentinel Surveillance Data: Disease Prevention and control department,
         Ministry of health, June 2000
    2.   (Data Base on HIV/AIDS Non-Governmental organizations in Ethiopia, Joint United nations program on HIV/AIDS,
         UNAIDS-Ethiopia, February 1999)
    3.   Closing the condom gap. In Population Reports, Volume XXVII, Number 1 April 1999.
    4.   Policy on HIV/AIDS of the Federal Democratic Republic of Ethiopia, August 1998.
    5.   Sahlu T, Kassa E, Agonafer T et al. Sexual behaviors, perception of risk of HIV infection and factors associated with
         attending HIV post-test counseling in Ethiopia. AIDS 1999; 13:1263-1272
    6.   Aklilu M, Messele T, Biru T et al Factors associated with the with HIV infection among sex workers of Addis Ababa, 1998.
         First International Conference on HIV/AIDS in Ethiopia, Addis Ababa, November 1999. (Abstract)

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Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

3 Objective
The major objective of the study is to identify factors and determinants affecting the
accessibility and utilization of condoms in relation to HIV/AIDS prevention in urban,
semi urban and rural areas of Ethiopia.

4     Methodology

4.1    Study area:
The study areas (sites) are selected to represent major socioeconomic, ethnic and cultural
gradients in the country. Accordingly, Addis Ababa, Debre Berhan, and Arsi-Hetosa were
chosen. Addis Ababa is both a national and regional capital (urban), whereas Arsi-Hetosa is a
predominantly rural district in Arsi Zone. Debre Berhan, on the other hand, is a zonal capital and
was intended to represent an intermediate picture between the two urban and rural settings.
Selection of the study areas also took account of logistic feasibility in undertaking the field data
collection within a limited period of time.

4.2    Study population:
The source population for the quantitative part of the study was drawn from the general adult
population in the reproductive age group 15 – 49 years of age. In the qualitative part of the study
special focus was made to include the ‘high-risk groups’ such as commercial sex-workers.
Accordingly, five internally homogenous groups were identified and targeted for focus-group-
discussions (FGD) from each of the three study sites. The groups were composed of; (1)
unmarried young males, (2) unmarried young females, (3) married men, (4) married women, and
(5) commercial sex workers.

4.3    Study design:
The study had a cross-sectional descriptive design, allowing internal comparison across the three
study sites. Both qualitative and quantitative study methods were employed. Hence, FGDs were
made to enrich or supplement the information generated through the quantitative data collection
methods. A review of the literature was also made to summarize relevant information from
different published and unpublished works in the country.

4.4 Sampling:
Households were used as sampling unit, while individuals in the age group 15 - 49 years
were the actual study population for the quantitative part of the study. A multi- stage
cluster sampling technique was applied to identify households that were to be enrolled in
the study. All individuals, including guests, in the specified age group and available at
home during the household visit were interviewed. A second visit during the same day
was arranged for otherwise eligible individuals who were not available at home during
the visit.

The sample size was determined in accordance with the guideline for determination of
single proportion, but also taking into account logistic feasibility for undertaking the filed
data collection. It was also attempted to maintain a reasonable proportion between the
three study sites.

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Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

4.5    Data collection:
High school graduates were trained to serve as enumerators and supervisors for the quantitative
data collection. Public health experts with substantial training and expertise in qualitative
research methods collected the qualitative data. A structured questionnaire, standardized and pre-
tested, was used for quantitative data collection, and an FGD guide was developed and used for
the qualitative data collection.

4.6    Data processing:
Quantitative data were processed and analyzed using the EPI INFO version 6.03 statistical
software. The qualitative information was compiled and summarized manually.

4.7    Ethical considerations:
Appropriate ethical conduct was maintained throughout the study. Informed consent was sought
from the study population during the field data collection. Confidentiality of information was
ensured, and the study subjects were not identified by name on the questionnaire.

5     Description of the study areas

5.1    Addis Ababa:
Addis Ababa is the political and economic center of Ethiopia, and the seat for many regional and
international organizations. It has an estimated population of 2.4 million people. In Addis Ababa,
there are 13 hospitals, 20 health centers, 25 health stations, 312 private clinics and 184
pharmacies and drug vending shops with potential health service coverage of about 139 %.

The big health facilities, particularly hospitals and other privately owned health units in Addis are
mainly involved in providing curative health services. However, preventive health service
activities like HIV/AIDS and STD prevention and control are mainly carried out by health centers
and other smaller health units owned by NGO's and church agencies

Most hospitals and the four health centers (HIV sentinel surveillance sites) in Addis Ababa
provide HIV testing and pre and post counseling services. Furthermore, recently some few private
clinics in Addis Ababa have started providing HIV testing services.

There are 35 HIV/AIDS NGOs operating in Addis Ababa (including 15 that are operating
exclusively in Addis Ababa). Most of the NGOs are working in the area of IEC and target the
general population. Some work on STD control projects, providing counseling services while
others are directly involved in service provision to AIDS patients, AIDS orphans and their
families. A few NGOs also work on condom programming projects.

5.2    Debre-Berhan:
Debre-Berhane is the capital for the North Shoa zone of the Amahra regional state and it is
located 145 kilometers North East of Addis Ababa. Administratively, Debre-Berhan town is
divided in to nine Kebeles and has an estimated population of 42,384. The people are
predominantly Amharas by Ethnicity and followers of the Orthodox Christian faith.

In Debre-Berhan, there is one hospital, one health center, four private clinics and four
pharmacies. The health center and the hospital provide both curative and preventive health
services. Health education on HIV/AIDS/ STDs and condom promotion are among the
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Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

preventive health services that are undertaken by the hospital and the health center. Furthermore,
the zonal health department active ly coordinates the HIV/AIDS related activities like,
strengthening Anti-AIDS clubs in schools, condom promotion, organizing, coordination and
implementing HIV/AIDS training for teachers, anti-AIDS club members, opinion leaders and
priests.

Currently there are four NGOs that assist the zonal health department with HIV/AIDS prevention
and control programs. This is being implemented directly by HIV/AIDS control programs like
straightening schools anti AIDS clubs, condom promotion, health education and other IEC
activities on HIVAIDS and providing financial assistance to the zonal health department.

Since 1994, Debre-Berhan hospital has been providing HIV testing and pre and post-test
counseling services for progressively increasing patients suspected of being HIV positive.

All the twelve schools in Debre-Berhan town had organized school-Anti-AIDS clubs that are
active in the areas of HIV/AIDS prevention and control.

5.3    Arsi-Hitosa:
Hitosa is one of the 20 districts in Arsi Administrative Zone. It is divided into 42 administrative
units, of which 37 area rural kebeles (peasant associations), and the rest are urban kebeles. Iteya
is the capital city of the district. The 1996 population of Hetosa district in 1996 was estimated at
187,566 of which 12.7% was urban population.

Health services are rendered through six government owned health stations and through other
private clinics in Huruta and Iteya towns. The government owned health stations are involved in
routine health education activities, which also include topics such as STD and HIV/AIDS.
Occasionally, they are also invited by Anti-AIDS clubs to provide health education at schools.

The health stations also try to deliver health education messages during public gatherings and
meetings. Otherwise, there are no regular IEC programs or condom promotion in the area. There
are no outreach intervention activities to the rural kebeles. There are no any organized programs
targeting CSWs or any other vulnerable section of the population.

Health workers in the area believe that the youth have better awareness about HIV/AIDS and that
the prevalence of STDs is decreasing compared to recent years. In Itayyaa, Health Station, for
instance, STDs were not in the list of top ten diagnoses made during 1999/2000. However, they
also noted that during the harvesting seasons a more risky sexual behavior is observed among the
youth, which is the result of increased consumption of alcoholic drinks.

More and more people are aware that HIV infection can be transmitted through unclean
injections, hence they often request for disposable needles and syringes. However, there are
complaints that the private clinics are reuse disposable needles and syringes. Because the clinics
are not adequately staffed, there are rumors about unqualified personnel like cleaners and guards
being involved in providing injections.

The local health officials also blame local (traditional) practitioners for using contaminated blades
and other sharp instruments during tooth extraction, uvula cutting and similar harmful traditional
surgical practices.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]          7
Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

6     Result

6.1      Socio-demographic characteristics of the study population
One thousand eight hundred and fifty six, people in the age group 15-49 are included in the study
of which 55% are from Addis Ababa (an urban area), 24.4% from Arsi-Hitosa (an exclusively
rural area) and the remaining 21% are from Debre-Berhane (semi urban area). Females' account
for 56% of the study population and 57% are single (never married). About 85% are Christians
and 14% are Muslims. Results of the basic socio demographic characteristics of the population is
presented in table 1

Table 1. Socio- demographic characteristics of the study population in urban, semi urban and
rural areas of Ethiopia, July 2000

                                             STUDY AREAS
                           Addis Ababa         Debre -Berahn        Arsi-Hitosa        Total
                      ______N=1019___        ____N=385_____        ___N=452____        ___1856____
VARIABLES                  % of total           % of total          % of total             %

Sex
Male                       42                         40                50                44
Female                     58                         60                50                56

Age
15-24                      57                         49                51                54
25-49                      43                         51                49                46
Mean age                   25                         27                27                26
SD                         7.7                         8.8               9                 8

Marital statue
Married 1                  34                         54                47                44
Never married              66                         46                43                56

Education status
Unable to read and write   6                          5                 26                11
Able to read and           3                          7                  6                 5
write (non formal)
Elementary school          12                         17                39                20
High school                68                         65                28                58
College education          11                          6                 1                 7

Availability of radio, TV
and VCR
Have radio                50                       64               57   54
Have only TV               2                        2               .2    2
Have TV and radio         22                       18                5   16
Have radio, TV and VCR 15                           5                0    9
Do not have all           10                       12               42   18
______________________________________________________________________________________
1:       Includes those who are married, widowed, divorced and separated

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6.2     Knowledge, Attitude and Practice related to HIV/AIDS and STDs
When respondents in the three areas were asked whether or not they heard about diseases that are
transmitted through sexual relation, 87% answered "yes" (94% in Debre-Berhan, 92% Addis
Ababa and 69% in Arsi-Hitosa). Syphilis (42%), HIV/AIDS (38%) and Gonorrhea (17%) are the
three STDs mentioned by the respondents. When exclusively asked about AIDS, 97% indicated
that they heard about it (ranging from 98% in Debre-Berahn to 93% in Arsi-Hitosa). Table 2

Table 2: Knowledge of HIV/AIDS, STDs and Condom among the study population in urban,
          Semi urban and rural areas in Ethiopia, July 2000

                      Knowledge of STDs A            Knowledge of AIDS B         Knowledge of condom B
                     ___________________         ___________________             ___________________
Study areas              N( %)                          N ( %)                          N(% )

Addis Ababa                924 (92)                    990(98)                            947(95)

Debre Berahne              349(94)                     379(98)                            352(93)

Arsi-Hitosa                307(69)                     416(93)                            307(69)

Total                   1580(87.0)                     1785(97)                           1606(88)

______________________________________________________________________________________

A        Spontaneous knowledge
B        Prompted

About 41% (71% Debre-Berhan, 40% Arsi-Hitosa and 30% Addis Ababa) indicated promiscuity
and/or sex with commercial sex workers as the leading risk factors for HIV infection. And, about
86% of the respondents believe that HIV/AIDS could be prevented (91% in Addis and Debre-
Berahne and 71% Arsi-Hitosa) table 3.

Regarding the perceived level of vulnerability and measures taken to protect self from
HIV/AIDS, 65% said, they do not feel vulnerable to HIV/AIDS (67% Addis Ababa, 68% Debre-
Berhan and 58% Arsi-Hitosa). While about 75% (82% Addis, 77% Debre berhane and 55% Arsi-
Hitosa) and 78% never married and 70% married people indicated that currently are taking some
measures to avoid the risk of HIV infection and in all study areas around 90% started taking
action for more than year duration, table 3. When asked to mention the measures they taken to
avoid the risk of HIV infection, 36% said limited with one trusted partner, 11% avoided sharing
sharp objects, 10% abstained from sex and 8% started using condoms.

Remaining with one faithful sexual partner 70%, using condom 16% (15% Addis Ababa, 24%
Debre berhan and 12% Arsi-Hitosa) and making sure injection are safe (3%) are the commonly
stated perceived mode of HIV prevention methods, table 3.

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Factor Affecting Accessibility And Utilization Of Condom                                        July, 2000

Table 3. Perceived level of vulnerability and measures taken to avoid risk of HIV infection in
         urban, semi urban and rural areas of Ethiopia, July 2000

                                                      STUDY AREAS
                                    Addis Ababa        Debre Berahn               Arsi-Hitosa        Total
                                    % of total           % of total              % of total          %
Variables

Perceived factors that
increase HIV transmission         N=         985               377               415                 1777
Sex with commercial sex workers
and/or promiscuity                           30                71                40                  41
Premarital sex                               23                11                13                  18
Extramarital sex                             11                3                 13                  10
Sharing needle and blades                    13                6                 4                   9
Sex with person with the AIDS virus          8                 6                 14                  9
Living with AIDS patients                    0                 0                 5                   1
Shaking hands with AIDS patients             0                 0                 3                   1
Others                                       15                3                 2                   11

Perceived susceptibility
to HIV infection                    N=       985               377               415                 1777
Not vulnerable                               67                68                58                  65
Vulnerable                                   21                16                14                  19
Do not know                                  11                16                28                  16

Believe people could be protected
from HIV                 Number              985               377               415                 1777
Yes                                          91                91                71                  86

Measures taken to avoid
HIV infection                       N=       985               377               415                 1777
Yes                                          82                77                55                  75

Duration since taking
measures                            N=       807               290               228                 1325
More than a year                             91                90                95                  92
Less than a year                              9                 10                5                   9

Perceived mode of HIV
prevention                   N=     977           375            409           1761
Remain with one
faithful partner                    71            70             69            70
Use condom during
sexual intercourse                  15            24             12            16
Make sure injections
are safe                             3             2              2             3
Avoid touching AIDS patients         0             0              4             1
Prevent mosquito bit                 1             0              2             1
Others                              10             4              1             9
______________________________________________________________________________________

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Factor Affecting Accessibility And Utilization Of Condom                                          July, 2000

6.3     Level of awareness and source of information about condoms

Table 4. Knowledge and utilization of condom among men and women in urban, semi urban and
        rural areas of Ethiopia, July 2000
                                                                          A
                       Ever heard of condoms           Ever seen condom       Ever used condom B
                           ___________                   _____________           _______________
                             Male      Female            Male       Female      Male     Female
STUDY Areas                  N (%)     N (%)             N (%)     N (%)         N (%)     N (%)

Addis Ababa                  410(96) 537(94)             407(96)    463(80)      197(51) 187(24)

Debre Berahne                142(93) 210(92)             139(91)    175(76)       48(35)    51(30)

Arsi-Hitosa                  183(83) 121(57)             143(65)     68(31)       39(27)     3(5)

Total                       735(92) 871(86)              689(86)    706(69)      284(43) 153(24)

____________________________________________________________________________________
A:       Those who have heard and seen condoms
B:       Those who have heard, seen and used condoms

About 88% of the respondents have heard about condoms (95% Addis Ababa, 93% Debre-
Berhan and 70 % Iteya). Out of the 1596 respondents who have heard about condom 76% (87%
Addis Ababa, 82% Debre Berhan and 48% Arsi-Hitosa) also have seen condom.

Out of those people who have had information about condoms, sixty seven percent first heard the
information from the radio. Similarly for 34% radio is indicated to be the main source of regular
information, while for 16% newspaper is the regular source of information

Out of 728 respondents who have heard about and seen condom and volunteered to answer the
question: "Do you have condom at home or in pocket?" 29% said that they currently had condom
at home/pocket.

Out of the thousand fifty nine respondents who were asked the question about the presence of an
incidence where they wanted but could not use condom, 10% said that there were times when
they wanted but could not used condom and the reasons for this was stated as, non- availability of
condoms (40% Arsi-Hitosa, 30% Addis Ababa and 25% Debre Berhan), 17% refusal of partner
and for 16% of them, the condom they had was finished.

6.4     Availability, Access and Utilization of Condom

Nearly 90% of those who know about AIDS also know about condoms. While from the 1311
respondents who know about AIDS and volunteered to give answers about their current and past
experience in the utilization of condom only 33% said that, used condom at least once in their
life- time (38% Addis Ababa, 32% Debre Berhan and 20% Arsi-Hitosa) table 5.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]         11
Factor Affecting Accessibility And Utilization Of Condom                                                    July, 2000

Out of the 391 who gave information on their current utilization of condom, 59% mentioned that
they used condom during their recent (last) sexual encounter (60% Addis Ababa, 53% Debre
Berahn and 65% Arsi-Hitosa).

Table 5. Knowledge about and utilization of condom among married and never married people
in urban, semi urban and rural areas of Ethiopia, July 2000

                             Ever heard of condoms          Ever seen condom A              Ever used condom B
                                 % of total                      % of total                     % of total
Study area                   Married1 Not married2          Married Not married             Married Not married
                       N(%)           N(%) N(%)            N(%) N(%)             N(%)
         _____________________________________________________________________________

Addis Ababa                  258(92)          679(96)       223(80)           639( 90)      75(34)               221(39)

                   Total            937(95)                            862(87)                        296(38)
         ______________________________________________________________________________

Debre Berahn                 152(92)          196(94)        135(82)          175(83)       42(31)               56(33)

                   Total                348(93)                        310(82)                        98(32)
         ______________________________________________________________________________
Arsi-Hitosa            152(68)     155(75)    93(42)     118(56) 15(16)         27(23)

                   Total                307(71)                        211(48)                        42(20)

______________________________________________________________________________________
A:       Those who have heard and seen condoms B:             Those who have heard, seen and used condoms
1:       Married refers to the currently married individuals
2:       Not married includes never married/widowed divorced and separated.

Table 6: Awareness about and accessibility of condoms among the study population in urban,
semi urban and rural areas of Ethiopia, July 2000

                                                            Study Areas
                                    Addis Ababa          Debre Berhan         Arsi-Hitosa             Total

         Variables                      N(%)                N( %)                N( %)                N( %)

Ever get information about
condom and its use                      669(77)             216(69)              95(45)                980(70)

Ever attended health
education on condom                     361(42)             142(45)              76(36)                579(42)

Ever attended demonstration
On how to use condoms                   315(84)             101(68)              54(72)                470(81)

Know places where condoms
are distributed for free                398(46)             166(53)              28(14)               592(43)

_____________________________________________________________________________________

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]                    12
Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

As opposed to the illiterates and those with elementary level education, the proportion of condom
users is found to be higher among people with a high school and college education (26%
illiterate, verses 25% elementary, 34% high school and 49% college education).

Out of the1378 respondents, 42% attended health education sessions on condom and out of which
81% mentioned that the health education they attended included demonstration about condoms
table 6. Of the 437 respondents that ever used condoms, 63% pointed out that they know about
different types of condoms (74% Addis Ababa, 46% Debre Berhan and 22% Arsi-Hitosa). When
asked to list the type of condoms they know, respondents came up with 24 different names; Out
of which 50% mentioned brand (Hiowt Trust, Durex, Sensation etc.), 33% identified the condoms
they know with color of the packets (white, yellow, green etc.), 12% identified the condom with
the country of production (USA, Korea, Germany etc) and the remaining 5% identified with
thickness of the condom (thick and thin). Hiwot trust is the preferred condom for about 66% of
the 176 respondents who stated their condom of preference

Those who have sexual partner/s and used condoms previous ly were asked, whether they ever
discussed condom use with their partner/s and 72% said that they did. However, a marked
difference in proportion is observed, between respondents from the rural, semi urban and urban
areas (49% rural 72% urban and 79% Semi urban area). The 'yes' answer for the same question by
respondents who have sexual partners but not ever used condom is only 45%. A similar pattern of
difference in proportion is also observed between respondents from urban and rural settings (49%
Addis Ababa and Debre- Berhan and 24% Arsi-Hitosa).

Out of the 209 people who stated their prime reasons for using condom, 97% pointed out that
they are using condoms as protection from STD/HIV/AIDS, while the remaining 3% are using
condoms as a contraceptive method.

When people who have heard and seen condom were asked about how often they would accept
the request from their partners to use condom, 367(37%) said that they would always accept
request to use condoms from their partner (43% Addis Ababa, 33% Debre Berahn and 22% Arsi-
Hitsosa) and 28% said that they would never accept such a request from their partners (22%
Addis Ababa, 29% Debre Berahn and 44% Arsi-Hitsoa). Further analysis showed that 156 (54%)
of male respondents indicated that they would always accept such a request but only 95(32%) of
the female respondents gave similar answer. On the contrary 88(29%) of the female respondents
said that they would never accept such a request while only 14% had similar answer.

6.5    Attitude and socio cultural factors affecting utilization of condom:

When females who heard about and seen condom were asked to give their view about the
willingness of males to use condom, 28% said that men would be willing to use condoms.
However, nearly half the respondents said that men would not be willing to use condoms. On the
contrary, for similar question posed to men, 42% said that women would be willing to use
condoms, while 36% believe that women would not be willing to use condoms.

Concerning the attitude of the respondents about who makes the final decision on the use of
condom, 37% (42% Arsi-Hitosa, 37% Addis Ababa and 30% Debre Berhan) said, the male makes
the final decision. While 25% said it is the female (28% Addis Ababa, 22% Debre-Berhan and
16% Arsi-Hitosa) who decides whether to use condoms or not.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]      13
Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

When asked about whether there is religious imposition on condom, 46% of the respondents said
that their religion have no imposition on the use of condom, whereas about 29% indicated that
they are faced with religious imposition to use condoms.

Respondents were asked to give their view on what would be the attitude of their friends and
families if they found that the respondents uses condoms; and 69% of those who had heard and
seen condom said that their friends would appr ove their use of condom (79% Addis Ababa, 64%
Debre Behran and 55% Arsi-Hitosa). And, nearly half (48%) said families would approve their
use of condom.

Those people who have seen, heard and used condom previously, but not using currently, were
asked about their prime reason for not using condom and 329 (37%) said that they do not use
condom because they have a steady single partner, 42(5%) want to have child, 29(3%) partner/s
refuses to use condom, 17(2.0%) said condom reduce satisfaction. However, nearly half (52%) of
the respondents indicated that they have no reason for not currently using condom.

For the question do you recommend condom for others? 1016(75%) of the respondents gave a yes
answer, and of which 29% said that they shall recommend condom only for unmarried people,
while 37% recommend for both married and unmarried.

Out of the 920 respondents who further gave their reasons for recommending condoms for others
63% said that they want others protected from HIV/AIDS/STDs, and 28% said that they want
others to be protected from HIV/AIDS/STDs and unwanted pregnancy. While 4% said,
recommend condom only to those who have multiple sexual partners.

On the contrary people out of the 326 people who did not recommend condoms to others and
further gave their reasons 23% said they believed condom will motivate people to be promiscuous
and 11% said that they believed condoms have the AIDS virus in it. Furthermore, 10% said that
they themselves were not using condoms and 4% said their religion would not allow them to
advise others to use condom.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]      14
Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

7     Discussion and Concussions

7.1    Level of awareness and attitude of the study population about
       STDs/HIV/AIDS

The study reveled that, a large proportion of the study population (87%) know about and were
able to mention the name of at least one sexually transmitted disease. When prompted, almost all
(97%) indicated that they are aware of HIV/AIDS, and nearly a tenth also mention that they have
a friend or relative affected by HIV/AIDS. However, about half the respondents from the rural
area believed that a person living with HIV always shows symptoms, and the substantial
proportion of respondents from the other two study sites also have similar opinion. Nearly half
pointed out that promiscuity and/or having sex with commercial sex workers, premarital sex,
extramarital sex and sharing sharp objects like needles and blades are among the major risk
factors for HIV transmission. The above listed points are the clear indications of the fact that,
though people are aware of HIV/AIDS, it looks that many do not have adequate information
about the mode of transmission of the virus and signs and symptoms related to AIDS.

Virtually all the participants in the qualitative studies in the three study sites have indicated that
AIDS is among the leading health problems in their respective locality; and unprotected sex is the
major risk factor for the transmission of HIV/AIDS and other STDs. Furthermore, all of them
indicated that young people, particularly those that take alcohol and abus ive substances and
drugs, are among the major risk group for HIV/AIDS and STDs.

The majority of the people who know about HIV/AIDS have pointed out that AIDS is a
preventable disease. However, only a fifth of them have perceived themselves as being
vulnerable to HIV infection. Despite the low perception of vulnerability, the majority (75%), both
married and unmarried people have reported change in their sexual behavior and started taking
measures to avoid AIDS. Limiting oneself with one trusted partner, avoiding sharing sharp
objects, abstaining from sex and use of condom are among the measures that have been taken to
avoid the risk of HIV infection.

The above data indicates that the general awareness level of the study population about
HIV/AIDS, its mode of transmission and associated risk factors is reasonably high. However,
major difference in proportion is observed in the level of awareness about AIDS and its
preventability, the risk factors for HIV infection and perceived vulnerability between rural and
urban residents and married and not married people. Almost in all cases, those who live in rural
areas are lacking in knowledge and information. Many of those who are perceived to be at risk,
are not still taking measures to protect themselves and their partners from HIV. This could be an
indication of the low level of HIV/AIDS related intervention activities that are taking place in the
rural areas and a relatively lesser involvement of married people in risky behaviors.

Both the descriptive and qualitative studies have reveled that many people perceive the youth,
unmarried people, those who take alcohol and addictive substances like "chat" as well as
commercial sex workers are among the major risk groups for HIV/AIDS. Many attributed this to
the involvement of those people in risky behaviors like unprotect sexual relations.

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Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

7.2    Awareness, Perception and Other Socio Cultural Factors Affecting
       acceptability and Utilization of Condom:

Regarding the level of awareness about and utilization of condom, the survey results showed that
most people (88%) know about condom, however, only a third reported ever used it. Some
marked differences in awareness and utilization of condoms is observed between the study
population from the rural and urban areas, among married and not married and between males
and females. In all the three study sites the proportion of males and not married people that know
and used condom is higher than females and married people. The proportion of those who know
and used condom also showed a uniform and declining pattern between the three study sites. In
all cases awareness and use of condom are high in urban areas (Addis Ababa) and low in the rural
area (Arsi-Hitosa). A better level of awareness and use of condom among males, unmarried
people and those from urban areas is a justifiable finding from studies like this conducted in
societies, where male dominance is accepted as culture, sex before marriage is widely practiced
and the urban residents have a better access to information related condom and HIV/AIDS.

Further analysis on condom use among people with different educational background, reveled
that, as compared to the illiterate and those with elementary education, the proportion of people
reported ever used condom is higher among those with high school and collage level education.
Mostly, those people with better education will have a relatively better access to different
information sources; hence this finding justifies the fact that better level of education to be one of
the factors that would increase people's access to information related to condom and its use.

Many people, who know about condom, first heard the information on the radio and similarly for
a considerable proportion of the study subjects radio and newspaper are the main and regular
source of information about condom and its use. Added to this many people living both in rural
and urban areas declared having radios. Hence radios could be taken as the means of
communications where by education about condom and HIV/AIDS and other related issues could
easily be disseminated to people living in different settings.

Though, the cost for a pack of condoms differs from place to place and during day and night time,
many of the respondents that were involved in the survey and the qualitative study considered the
cost for a pack of condom to be cheap ("not expensive") and pointed out that they faced with little
problem in getting condom. Similarly almost all of the people who saw and used condoms were
able to mention sites from where they can get condoms. This is an indication of the positive
perception most people have regarding the cost as well as about a fair economic and physical
acceptability of condoms to the study population.

However, the fact that only a quarter of the respondents ever used condoms, a tenth of condom
users faced with problems of using condoms due to the factors related to access and attitude of
partners, and the involvement of many in risky behavior, would still cast a shadow of doubt about
the wide acceptance of condom as HIV/AIDS/STDs prevention method by the study population.

More males believed that females are willing to use condoms; on the contrary more females
believed that males are not willing to use condoms. The above findings could be a refle ction of
the fact that traditional cultural norms where men are accepted as decision makers in key family
issues and therefore more males believe that females would accept their request for condom use
but females believed the reverse.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]      16
Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

Most of the respondents (about 75%) would recommend condoms to others, however, nearly a
quarter would recommend only to unmarried people. Prevention from HIV/AIDS and STDs is the
major reason for the recommendation of condom to others. However, most who did not
recommend condoms to others stated that they believe condom will encourage promiscuity and
spread of the AIDS virus. People's recommendation of condom for HIV/AIDS/STD prevention
and for unmarried people can be taken as an indirect indication of the positive perception people
have about condom in preventing HIV/AIDS/STD and its role in minimizing the risk of HIV and
STDs to the perceived at risk group "unmarried people".

The recognition given to condom as a widely accepted mode for HIV/STD prevention by the
studied community is reveled with the fact that protection of self and partners from STDs and
HIV/AIDS is the main reasons for condom use and discussion about condoms is common among
partners, especially among people who have previously used condoms. This is often a case in
urban areas where a better access to condoms and related information exists. However, the results
of the qualitative study pointed out that discussion about condom is uncommon among member
of the family in both urban and rural. This could possibly explain the cultural barrier and sex
related taboo that hinder the discussion of sex and related issues with members of the family.

False rumors, myths and reputations about condom are quite common and widespread among the
study population. Similarly there are indications that condom has faced with an image problem.
Some people are frequently heard saying; "Condom is neither protective nor pleasant to use", in
fact, many youth and some adults believe that condom itself is the source of HIV. Similarly many
people incriminate condom for the fast spread of AIDS (people associate the fast spread of
HIV/AIDS with the increased use of condom). Many people also expressed their distrust for
condom with sayings like, " sex with condom is like eating candy with its cover"; " condom
decrease sexual pleasure", " sex with condom is like wearing blanket in a hot day"," Sex with
condom is equivalent to not doing sex at all ". People often associate condoms with promiscuity,
extramarital sexual affair.

The study also reveled some organized resistance to condom use. Nearly a third of the
respondents of the study implicated that their religion have some imposition in their use of
condom. Participants of the qualitative study indicated that that religious leaders openly oppose
the use of condoms associating it with immoral behaviors like promiscuity. This together with the
widespread rumors and inadequacy of information about condom have resulted in serious
imposition on the use of condom for the prevention of HIV/AIDS (as observed from the low
prevalence of condom use among the study population)

People's perception about the effectiveness of condom in preventing HIV infection has been
found to be diverse. Most people believe that if properly used condom is effective in protecting
from HIV infection. Contrary to this, a considerable proportion of people particularly those that
were involved in the qualitative study present convincing argument for doubting the effectiveness
of condom like: problems in properly wearing condoms, tear and breakage of condom during use.
Similarly, the survey result indicated that only a third of those who attended health education
session about condoms came across with information on how to use condoms. This is a clear
indication on how lack of awareness about condoms affects people perception and its utilization.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]      17
Factor Affecting Accessibility And Utilization Of Condom                                       July, 2000

8    Recommendations

§   A good level of awareness about HIV/AIDS, its mode of transmission, prevention and the use
    of condom is identified among the study population. However, there is still a need to
    maximize the level of awareness of the rural community, married people and those with low
    level of education about HIV/AIDS, condom and its use.

§   To fill the identified gap in the awareness of the community regarding condom and its use,
    IEC activ ities that include demonstration on condom targeting the widely prevalent wrong
    belief and rumors related to condoms and their use should be widely promoted.

§   The radio is an important source of information on condoms and HIV/AIDS. Hence in order
    to reach the various section of the community with the necessary information there is a need
    to improve the coverage and quality of health messages about condom and HIV/AIDS
    conveyed through the radio.

§   The contribution of health institutions regarding raising the awareness of the community
    about condoms and HIV/AIDS through the promotion of behavioral changes aimed at risk
    reduction should be given adequate emphasis.

§   Religious as well as social organizations that have enormous acceptances by the society
    should be encouraged to play a pivotal role in teaching about HIV/AIDS and condoms.

The Futures Groups International, Ethiopia, POLICY Project. By United Management Consultants [UMC]      18
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