In rural Malawi, residents who belong to religious congregations whose leaders frequently talk publicly or privately about sexual behavior are more likely than their peers in other congregations to be faithful and to use a condom—two of the pillars of AIDS prevention.¹ Findings from a longitudinal study that examined respondents' sexual and religious behavior, as well as the characteristics of their congregations, revealed that belonging to a church or mosque whose leader privately advised members not to be promiscuous was associated with an elevated likelihood of fidelity among married adults (coefficient, 0.50). Similarly, among sexually active respondents, condom use was associated with belonging to a congregation whose leader privately advised members to use condoms (0.38).

The analysis used data from the third (2004) wave of the Malawi Diffusion and Ideational Change Project, and from its sister study, the Malawi Religion Project. In the first wave of the ideational change study, conducted in 1999, researchers used cluster sampling in three of the country's 28 districts to choose 145 villages, from which they randomly selected 1,500 ever-married women aged 15–49 and, if available, their husbands; although the resulting sample was not nationally representative, participants' characteristics generally resembled those of the country's rural population. For the 2004 wave, roughly 1,200 married or unmarried young adults aged 15–29 were added to the study, yielding a total sample of 3,386 respondents. In interviews, participants provided information on age, education, wealth (classified according to ownership of a mattress, radio, bicycle and pit latrine), lifetime number of partners and whether they felt that premarital sex and condom use with a spouse are acceptable. They also provided information on their adherence to the familiar ABCs of AIDS prevention: abstinence (whether they had ever had sex), being faithful (whether they had had a nonmarital partner in the past year) and condom use (whether they had ever used a condom with any of their last three partners in the past year). Respondents' attendance at religious services was classified according to the last time they had gone to a church or mosque: in the past week, in the past month or more than a month ago.

In the sister study, conducted in 2005, religious leaders from each of the 187 congregations to which participants in the main study belonged provided information about the characteristics of their congregation, their views on AIDS and the impact of the disease on their congregation. They also reported whether they discussed morality and AIDS with congregation members frequently (weekly or "almost every week") or infrequently, and whether they ever privately advised members to be faithful to one partner or to use condoms. Responses were linked with data from the ideational change study to create multivariate models assessing the relationship between the ABC variables and congregation characteristics (e.g., having a leader who advised members about condom use or monogamy). For each model, the analytic sample was restricted to the appropriate subsample—never-married young adults for abstinence, married respondents for being faithful and sexually active respondents for condom use—and omitted respondents with missing information on key variables.

The mean age of the 615 never-married young adults was 18; 61% were male, 24% had completed secondary school and 57% had never had sex. The 2,486 married respondents were older (mean age, 38); most were female (67%) and had had no extramarital partners in the past year (91%). Nine percent had completed secondary school. Similarly, the majority of the 2,883 sexually active respondents (mean age, 35) were female (56%) and had been faithful (91%), and 11% had completed secondary school. Only 22% had used a condom with any of their last three partners of the past year, and only 1% reported consistent condom use.

In all three groups, most respondents were Muslim (24–26%), traditional mission Pro- testant (20–28%) or Catholic (18–22%); the remainder belonged to another denomination (26–36%) or no church (1%). At least three-fifths opposed premarital sex (60–72%). Never-married young adults were more likely than respondents in the other two groups to say that condom use among married persons is acceptable (63% vs. 34–38%).

Most of the religious leaders reported that they frequently discussed morality (88%), sexual morality (73%) and AIDS (72%) in their services. The vast majority had privately advised members to stop being promiscuous (95%), though only half reported doing so on a weekly basis (52%). About a quarter (27%) had ever privately advised members to use condoms.

In multivariate models of never-married young adults, male respondents were less likely than females to report having been abstinent (coefficient, –0.90), and Muslims were less likely than Catholics to have abstained (–0.67). In addition, abstinence was positively associated with greater wealth (0.20 for each additional household possession) and negatively associated with completion of secondary school (–0.73). However, it was unrelated to attendance at religious services or to the frequency of congregation leaders' messages about AIDS, sexual morality or condom use.

Among married adults, males were less likely than females to report having been faithful to their spouses (coefficient, –1.03). Fidelity was positively associated with opposition to premarital sex (0.80), and respondents belonging to congregations whose leaders frequently advised members not to be promiscuous were more likely to be faithful than were respondents who did not belong to such congregations (0.50). Fidelity was not associated with leaders' messages about AIDS or condom use, nor with denomination or frequency of service attendance.

Predictors of condom use among sexually active respondents included being male (coefficient, 0.49), having switched congregations in the past five years (0.29) and having had a nonmarital partner (1.23). Moreover, condom use was negatively associated with opposition to premarital sex (–0.31), and positively associated with wealth (0.17 per household item) and acceptance of condom use (0.62). Finally, respondents belonging to congregations whose leaders privately recommended condom use were more likely to use condoms than were respondents who did not belong to such congregations (0.38). Denomination and frequency of service attendance were unrelated to condom use.

A final analysis stratified respondents by service attendance. Among respondents who had attended a service in the past week, abstinence was associated with belonging to a congregation whose leader frequently preached about AIDS (coefficient, 1.36) and privately advised members to use condoms (0.78); faithfulness was associated with belonging to a congregation whose leader privately advised against promiscuity (0.45); and condom use was associated with belonging to a congregation whose leader privately advised members to use condoms (0.42). In each case, the comparison group was individuals who did not belong to such congregations.

The author cautions that these findings do not establish causality and are subject to the limitations inherent in all self-reports of sexual behavior. Nonetheless, the results suggest that studies that focus on the relationship among religious attendance, denomination and sexual behavior in Malawi (and possibly elsewhere in Sub-Saharan Africa) should take into account what religious leaders say and do about sexual behavior. "Most religious leaders in rural Malawi are actively engaged in promoting sexual behavior change in their communities," the investigator notes, and these interventions "matter for the AIDS- related behaviors of their members." While such leaders commonly promote fidelity to a single partner—"a critical method of curbing the spread of HIV"—they are less likely to endorse condom use; flexibility on this issue on the part of religious leaders may be "crucial for improving uptake in a region where their use remains low."—P. Doskoch

REFERENCE

1. Trinitapoli J, Religious teachings and influences on the ABCs of HIV prevention in Malawi, Social Science & Medicine, 2009, 69(2):199–209.