Adolescents aged 15–19 who have seen a demonstration about using condoms are up to five times as likely as their peers who have not seen such a demonstration to know key facts about how to use a condom correctly, according to nationally representative surveys of youth in four countries in Sub-Saharan Africa.1 In addition, male adolescents who are older, have had sex education, have at least a secondary education, are middle class or listen to the radio regularly have elevated levels of condom knowledge in at least two of the four countries. However, levels of consistent condom use itself remain far below the ideal: Among sexually active males aged 15–19 who had had sex at least twice in the past three months, only 20–47% had used a condom consistently, and 32–50% had not used condoms at all.
The data come from the 2004 National Survey of Adolescents, in which more than 19,000 youth in Burkino Faso, Ghana, Malawi and Uganda participated in extensive face-to-face interviews. Respondents were selected via a two-stage stratified sample design: After private households were randomly selected, all eligible 12–19-year-olds in each household were invited to participate. The overall response rates were 87–95%.
Respondents were asked about background characteristics, reproductive experiences, pregnancy knowledge, exposure to sex education, contraceptive knowledge and use, sexual activity, substance use and other topics. The measures of sexual activity and contraceptive (including condom) use were based on questions used in Demographic and Health Surveys. Knowledge of condom use was based on adolescents' responses (agree, disagree or don't know) to three statements: "A condom should always be put on before sexual intercourse starts," "A condom should be put on the penis only if the penis is fully erect or stiff" and "A condom can be used more than once." Young men were classified as consistent condom users if they had had vaginal intercourse at least twice in the past three months and had used a condom every time. In addition to calculating descriptive data on sexual activity and on knowledge and use of condoms, the researchers used ordered logistic regression models to identify factors associated with higher levels of condom knowledge and with consistent condom use. In the latter analysis, data from Burkina Faso, Malawi and Uganda were pooled (Ghana was excluded because very few young men had had sex at least twice in the past three months); in the remaining analyses, results were calculated by country.
Because relatively few younger adolescents had ever had sex, only 15–19-year-olds (N=10,690) were included in the analyses. Two-thirds of these respondents were aged 15–17, and most lived in rural areas. In Ghana, Malawi and Uganda, at least half of respondents were attending school; in Burkina Faso, however, slightly more than half had never attended school. Exposure to television, radio and print media varied by country but was generally limited: Only 9–30% of females and 12–39% of males reported regularly using all three types of media.
The proportion of 15–19-year-olds who had ever had sex ranged from 29% to 48% among females and from 15% to 60% among males. Current sexual activity was somewhat lower, as 21–39% of young women and 10–38% of young men had had sex in the past year. Lifetime and current sexual activity were lower in Ghana than elsewhere; Malawi was the only country in which levels of sexual activity were higher among males than among females.
Although most 15–19-year-olds (83–95% of females and 90–98% of males) were aware of condoms, at best half (32–48% of females and 46–53% of males) had ever used one. Most responses to the three statements about condoms were correct, as 75–81% of females and 84–89% of males knew that condoms should be put on before intercourse starts, 52–72% of females and 76–91% of males knew that a condom should be put on only if the penis is stiff or erect, and 50–74% of females and 68–84% of males knew that condoms should be used only once. However, just 26–50% of females and 50–68% of males responded correctly to all three statements.
In multivariate analyses, the factors associated with knowledge of correct condom use differed by country, and no factor was associated with such knowledge in all four of the countries. Having ever seen a condom demonstration was strongly associated with condom knowledge among both men and women in Burkina Faso, Ghana and Uganda (odds ratios, 2.0–4.6) but not in Malawi. Among men, five factors were positively associated with condom knowledge in two of the four countries: being aged 18–19, having at least a secondary education, listening to the radio regularly, having had sex education and being middle class (rather than poor). Among women, 18–19-year-olds in three countries had higher levels of condom knowledge than younger adolescents, and in two countries urban residents and those who had attended school were more knowledgeable than their rural and unschooled peers.
Most sexually active young men did not use condoms consistently. Among 15–19-year-old males who had had sex at least twice in the previous three months, the proportion who had used condoms every time ranged from 20% in Malawi to 47% in Ghana; up to half (32–50%) had not used a condom at all in the past three months. In multivariate analyses, the strongest predictor of consistent condom use was having a partner who was 0–4 years older (odds ratio, 2.5); the likelihood of condom use was also elevated for urban residents (2.2), those who had at least a secondary education (1.9), those who lived with their biological mother but not their biological father (1.7) and those who regularly listened to the radio (1.8) or read newspapers and magazines (1.8).
Although the results indicate that adolescents in the four countries generally lack detailed knowledge about condoms and do not use them consistently, they also indicate that youth who receive sex education—especially those who see a condom demonstration—are more likely than their peers to know key details about condom use. Thus, the authors recommend that "age-appropriate sex education" be introduced in schools "so that young people can receive relevant instructions before they are sexually active." In addition, they suggest that "programs that aim at promoting condom use…include condom use demonstrations as a way of promoting correct use of the method."—P. Doskoch
1. Bankole A et al., Knowledge of correct condom use and consistency of use among adolescents in four countries in Sub-Saharan Africa, African Journal of Reproductive Health, 2007, 11(3):197–220.