Young people's stories about condoms can help re-shape prevention messages

The themes and preoccupations of stories submitted by young people in six African countries should be looked at to inform HIV prevention programmes, researchers write in the journal Social Science and Medicine. With rates of condom use being low in these populations, programmes need to better understand barriers and facilitators of condom use, information needs and appropriate communication strategies.

Kate Winskell and colleagues used an innovative research methodology: the qualitative analysis of scripts submitted by young people for short films on the theme of HIV and AIDS. The Scenarios from Africa contest takes place annually and invites young people aged 10 to 24 to propose a creative idea that could be turned into a five minute educational film. For the 2005 contest, around 23,000 scenarios were submitted from 35 countries.

The researchers acknowledge that the young people taking part are not necessarily representative of the wider youth population: they are likely to be better educated, more knowledgeable about HIV, more motivated about HIV and more likely to live in urban areas. Nonetheless, the stories that they tell are likely to draw on cultural and social representations that are more widely shared. 

“Narratives are a source of insight into how people make sense of the world, and how they communicate those understandings to others,” the authors say. “They reveal the cultural resources available to young people… as they strive to make sense of the role of condoms in the response to HIV/AIDS.”

For this study, researchers analysed the themes of 586 texts submitted in 2005 from six countries: Senegal, Burkina Faso, Nigeria, Kenya, Namibia and Swaziland. The countries were selected on the basis of the diversity of their historic, religious, development and epidemiological profiles.

Just over a third of the narratives mention condoms. It is more common for characters to become infected because they failed to use condoms than for the stories to show that condoms prevent infection. When no reference to condoms is made, blame for infection is often seen to lie with the ‘immoral’ sexual behaviour of the characters.

A number of the narratives, especially from Nigeria, Kenya and Swaziland, question the efficacy, effectiveness and safety of condoms. Out of 120 Nigerian narratives that were analysed, only three represent the use of a condom during sex - and in each of these, the condom breaks. Other stories suggest that condoms are only partially effective and propose abstinence as an alternative. One Nigerian teenager concluded: “Many thinks condom is the true protector (LIES) but I tell you today that the true solution is self management.”

Several Kenyan stories argue for condoms to be made easily available but at the same time do not condone their use. Condoms are morally ambivalent. In one story a scene of condom distribution in a bar is brought to a close with the text written on the condom packet: “Think twice: unprotected sex is a risk but adultery and fornication is an illicit sex, a big sin and unsafe.”

On the other hand, most narratives from Burkina Faso, Swaziland and Namibia present condoms in a positive light, with a number debunking misinformation about them. A number of stories, often using humour and avoiding a moralising approach, show characters successfully using condoms.

Namibian writers tend to present condoms as a normal and taken-for-granted part of life. In one story a character learns that her rural cousin has two sexual partners. She is stunned that her cousin is not using ‘protection’. “Where have you been? People are dying like flies and you ask me ‘protection from what?’”

The contributors from Senegal tend to represent condoms in positive terms. However the researchers find it notable that in this relatively low-prevalence country, the stories focus on high-risk populations: sex workers, people with multiple partners, people living with HIV, foreigners and returning migrants. The researchers comment that this seems to present HIV as being morally or geographically distant, but threatening to come into people’s lives when there is an opportunity. One story involves a childhood friend who returns home sick from Europe, having been infected by a wealthy white woman. The narrator warns his audience to beware of AIDS and to use condoms, “the only medicine” for it.

The researchers note that PEPFAR-funded programmes target condoms for high-risk groups, promoting abstinence instead. Condoms are only provided to young people who “are identified as engaging in or at high risk for engaging in risky sexual behaviours”. They suggest that such policies are associated with the spread of misinformation about condom effectiveness, and that the association of condoms with sex workers and other stigmatised groups discourages others from using them.

Narratives from all countries consistently represent female characters as initiating condom negotiation, while male characters typically resist their use. Men’s barriers to condom use are overwhelmingly linked to their own beliefs and attitudes. A number of male characters insist on unprotected sex despite knowing that their partner has HIV, warnings from friends or the persuasion of their partner, and in several cases, end up acquiring HIV.

Within marriage, women who attempt to negotiate condom use are invariably met with their husbands’ resistance - which is often violent. Women who acquiesce to unprotected sex are shown to be doing so because of structural factors: poverty, an older partner, marriage, fear of losing their partner. Women who succeed in condom negotiation are represented as not being prepared to compromise and to have taken the trouble to educate their partner about HIV and AIDS.

The authors suggest that these stories indicate the need for education and communication programmes which promote alternative narratives, featuring male role models who insist on condom use or refuse to concede under pressure.

Moreover education and communication programmes need to respond to the specific themes encountered in different countries. “The data suggest a clear need for tailored condom-related programming,” they write. Where negative narratives proliferate - most obviously in Nigeria - there is a need for community-level dialogue to challenge and reshape these representations.

Winskell K et al. Making sense of condoms: social representations in young people’s HIV-related narratives from six African countries. Social Science & Medicine (online ahead of print), 2011. doi:10.1016/j.socscimed.2011.01.014