Incorrect condom programming in the primary health care setting : “ A prescription for a disaster ” ?

In the effort to stem the HIV pandemic, the promotion of the correct and consistent use of condoms has to be a priority in the primary health care sector. This study, con­ centrating on the southern Free State, sought to identify obstacles to condom usage and to develop strategies to encourage condom usage. Both primary health care work­ ers and their clients served as respondents in the study. The findings of this study indicate that the following as­ pects related to primary health care do not pose serious obstacles to clients’ attempts to obtain condoms: proxim ­ ity of clinics, staff attitudes and the behaviour of staff to­ wards clients. However, it does appear that primary health care workers neglect the counseling aspect o f condom dis­ tribution, a vital aspect considering the importance o f con­ sistent and correct condom usage. Although various fac­ tors may contribute to this problem, the findings of this study indicate that the workload of staff is the most signifi­ cant contributing factor. Regarding clients, the biggest problem related to condom use revealed in this study, is the significant percentage of clients that do not use condoms correctly and consistently. The authors recommend that client education should be made a priority and that a person should be appointed spe­ cifically to ensure that counseling programs are im ple­ mented. This person does not necessarily have to be a highly qualified primary health care worker, but someone who speaks and understands the clients’ “language” (in a broad cultural sense). The possibility of co-operation with non-government organisations should also be investigated. Opsomming In die poging om die HIV pandemie te kortw iek moet die bevordering van korrekte en konsekwente gebruik van k o n d o m e ‘n p r io r i te i t w ees in d ie p rim ê re gesondheidsorgsektor. Hierdie studie, wat op die SuidV ry s ta a t k o n se n tre e r , poog om v e rsp e rr in g s to t kondoom gebru ik te id en tif isee r en om strateg ieë te ontw ikkel om kondoom gebruik aan te moedig. Beide prim êre gesondheidsorgw erkers en hul kliënte het as respondente in hierdie studie gedien. Die bev ind inge van h ierd ie studie toon aan dat die volgende aspekte van primêre gesondheidsorg nie emstige problem e skep vir kliënte wat kondome wil bekom nie: afstand vanaf klinieke en die houding en die gedrag van personeel teenoor die kliënt. Dit wil egter voorkom asof primêre gesondheidsorgwerkers die voorligtingsaspek van kondoom verspreiding verwaarloos ‘n belangrike aspek gegewe die belang van die konsekwente en die korrekte gebruik van kondome. Alhoewel verskillende faktore mag bydra tot die probleem wil dit voorkom asof die werkslading van die personeel die belangrikste bydraende faktor is. Betreffende die kliënte, toon hierdie studie aan dat die grootste versperring tot effektiewe kondoom gebruik die beduidende persentasie van kliënte is wat die kondome nie korrek en konsekwent gebruik nie. Die outeurs beveel aan dat kliëntevoorligting as ‘n prioriteit gestel moet word en dat ’n persoon aangestel moet word w at spesifiek verantwoordelikheid moet aanvaar vir die implementering van voorligtingsprogram me. Die persoon hoef nie noodwendig ‘n hoogs gekwalifiseerde gesondheidsorgwerker te wees nie, maar moet iemand wees wat die “taal” (in ‘n breë kultuurverband) praat en verstaan. Die moontlikheid van samewerking met nie-regeringsorganisasies moet ook ondersoek word. Introduction The importance of the use of condom s has increased in the light of the current HIV pandemic facing South Africa. Con­ doms are increasingly becoming a way of not only preventing an unwanted pregnancy, but also a method of preventing the transm ission of sexually transmitted infections (STI’s). Vari­ ous studies regarding condom usage have found that con­

Regarding clients, the biggest problem related to condom use revealed in this study, is the significant percentage of clients that do not use condom s correctly and consistently. The authors recom m end that client education should be m ade a priority and that a person should be appointed spe cifically to ensure that counseling program s are im ple m ented. This person does not necessarily have to be a highly qualified prim ary health care worker, but som eone who speaks and understands the clients' "language" (in a broad cultural sense). The possibility o f co-operation with non-governm ent organisations should also be investigated.

Opsomming
In die poging om die HIV pandem ie te kortw iek m oet die bevordering van korrekte en konsekw ente gebruik van k o n d o m e 'n p r io r i te i t w e e s in d ie p rim ê re gesondheidsorgsektor. H ierdie studie, w at op die Suid-V ry s ta a t k o n s e n tre e r , p o o g o m v e r s p e r r in g s to t k o n d o o m g e b ru ik te id e n tifise e r en om strateg ie ë te ontw ikkel om kon d o o m g eb ru ik aan te m oedig. Beide p rim êre g eso n d h eid so rg w erk ers en hul kliën te het as respondente in hierdie studie gedien. D ie b e v in d in g e van h ie rd ie stu d ie to o n aan dat die volgende aspekte van prim êre gesondheidsorg nie em stige problem e skep vir kliënte w at kondom e wil bekom nie: afstand van af klinieke en die houding en die gedrag van personeel teenoor die kliënt. Dit wil egter voorkom asof prim êre gesondheidsorgw erkers die voorligtingsaspek van kondoom verspreiding verw aarloos -'n belangrike aspek gegew e die belang van die konsekw ente en die korrekte gebruik van kondom e. Alhoew el verskillende faktore mag bydra tot die probleem wil dit voorkom asof die werkslading van die personeel die belangrikste bydraende faktor is.

Introduction
The im portance o f the use o f condom s has increased in the light of the current HIV pandem ic facing South Africa. C on dom s are increasingly becom ing a way o f not only preventing an unw anted pregnancy, but also a m ethod o f preventing the transm ission o f sexually transm itted infections (ST I's). Vari ous studies regarding condom usage have found that co n dom s are not used correctly and consistently (W arren, 1997;Sankar & Karim, 1999;Pesa, Syre & Fu, 1999).
In South Africa, condom s are available at Prim ary H ealth Care (PHC) clinics and are therefore available to the majority o f South A fricans. However, it is im portant to realise that availability does not necessarily lead to the use or the effective use of condom s for that matter. The South A frican D em ographic and Health Survey conducted in 1998 found that only 22% o f women aged 15-49 who had sexual intercourse in the 12 m onths p re ceding the survey, had ever used condom . Looking at the total figure, ju st under 80% o f sexually active South A frican w omen are not practicing safe-sex (D epartm ent o f H ealth, 1998:17). O nly a third o f teenagers were protecting them selves, the other two thirds w ere having unprotected sex. It is therefore crucial to investigate w hat barriers exist in the PHC setting that pre vent the correct and consistent use o f condom s and w hat atti tudes or behaviour o f the clients them selves may pose a bar rier to the use o f condom s.

Setting
The study concentrated on Region B o f the Free State Prov ince. This region consists o f widely scattered sm all towns. Fifty three percent o f the population in this area is rural. R e gion B is also considered to be econom ically poor w ith a m onthly per capita incom e o f R892 (Health System s Trust and D epartment o f Health, 1996:22). The nearest large urban centre is B loem fontein (situated in Region A) w here tertiary public health care facilities are available at Pelonom i, N ational and U niversitas hospitals.

Problem statement
South Africa, like many other African countries, has a high rate o f sexually transm itted diseases (STIs). It has been estim ated that one quarter o f South A frica's sexually active population may have at least one STI (Key, De Noon & Boyles, 1997: 12). In Region B, prim ary health care w orkers (PH C w orkers) re ported an exceptionally high incidence o f STIs am ong their clients. Some PHC-w orkers reported treating as m any as fourty clients per w eek for STIs.
One o f the strategies to prevent STIs, HIV in particular, is the correct and consistent use of condom s. H ow ever, condom s are not alw ays used effectively and consistently (Joffe, 1993: 701). It is im portant that the specific attitudes, know ledge and b ehavioural patterns related to condom s and condom use should be studied and understood in order to plan effective condom usage cam paigns. In this regard researchers in Region B decided to launch a study focusing on condom usage.

Methodology
The research presented in this article form ed part o f the Pri mary H ealth Care Info Project w hich is part o f an overall strat egy in the Free State to develop an effective inform ation sys tem intended to guide prim ary health care policy planning and form ulation, and the m anagem ent thereof. The objective o f the Info-project was to establish a research culture and capacity am ong PHC w orkers and related professions in the Free State. A m ulti-disciplinary approach w as follow ed in this project, w here prim ary health care w orkers participated in a research m ethodology-training program in order to develop research skills. They were selected in such as way as to be representa tive of the PHC clinics in the region. The Deutsche Gesellschaft fur Technische Z usam m enarbeit (GTZ), the H ealth System s Trust, and the Free State D epartm ent o f H ealth sponsored the project. The project was im plem ented and co-ordinated by the Centre for H ealth System s Research and D evelopm ent of the U niversity of the Free State.
Both quantitative and qualitative m ethods o f data collection w ere em ployed during this study. Q ualitative data was col lected by means of a focus group. The focus group consisted o f the PHC w orkers that participated in the above-m entioned training program and centred on the problem s related to the provision o f condom s to clients and the use o f condom s by the clients, as a means o f preventing STIs. T his focus group served a dual purpose, as apart from collecting the relevant inform ation, PH C -w orkers w ere also exposed to focus group facilitation techniques.
A questionnaire was designed and used to collect quantitative data from clients visiting the PH C clinics. For the survey, the unit o f analysis was the p a tien t who reported to the prim ary health care clinic fo r treatm ent o f a sexually transm itted in fection, as well as those who visited the clinic to obtain con dom s. In this w ay the target population (sexually active cli ents) was reached. Focus groups w ere not used in this in stance due to the sensitive nature o f the topic, notw ithstand ing the logistic difficulties o f conducting a focus group.
As a result o f the sensitive nature and difficulties associated with researching this issue, a convenience sam ple was selected. It m ust therefore be borne in m ind that the data, due to the convenient nature o f the sam ple, cannot sim ply be used to m ake inferences to the population. However, even though the inform ation is not generalisable, it may contribute to the un derstanding o f condom usage and could thus be valuable to the design of condom distribution program m es.
Each of the clinics in R egion B received twenty questionnaires. Ten questionnaires had to be com pleted with clients who vis ited the clinics for the treatm ent o f sexually transm itted infec tions. The rem aining ten questionnaires had to be com pleted with clients visiting the clinic for free condom s. The profes sional nurses at the various prim ary health care clinics acted as interviewers.
The nature of the questions in the interview was consistent with the general assessm ent and historical outline w hich, as a rule, has to be com pleted with the client who presents with a STI. The questionnaire consisted o f three parts. Part I, focussed on service delivery and contained questions related to geo graphical accessibility, clinic hours, cost to reach the clinic and aspects related to service d elivery (eg: "D o you trust the staff?"). Part ii, was related to sexual behaviour and condom usage and was introduced as follow s: "The fo llo w in g ques tions are o f a m ore p ersonal nature and are related to sexual practices and habits. The researchers will appreciate i f you answ er the questions honestly, but please rem em ber that you are answ ering these questions voluntarily a nd that you are under no obligation to answ er questions that you do not want to answ er". Part iii, collected biographical inform ation as por trayed in table 1. In an effort to ensure reliability and validity, the questionnaire was critically evaluated and scrutinised by research m ethodologists and experts in the field o f condom research who were affiliated to the Centre for H ealth System s Research and D evelopm ent. It w as also thoroughly analised and criticised by the researchers involved in the training pro gram (PHC workers).
The qualitative data was analysed using a them atic approach where themes were identified from the transcriptions. The quan titative data was analysed using the SPSS statistical analysis programme. Since the study involved the collection o f sensitive inform a tion, careful attention was paid to ethical aspects. N either the respondent's name, nor tow n was indicated on the q u estion naire. All inform ation was handled as highly confidential and the inform ation was collected by professional nurses only, who are bound to a code o f professional ethics w hich stipulates the confidential handling of all inform ation entrusted to them in the course o f their duties.
The client was fully inform ed about the nature o f the study and the inform ation that was required. It was em phasised that their participation w as strictly voluntary and that they w ere free to w ithdraw from the interview at any stage. C lients w ere thus inform ed that they w ere under no com pul sion w hatsoever to answ er any o f the ques tions. D uring the interview, before the m ore sensitive questions were asked, the client was once again given the choice to com plete or term inate the interview.

Objectives
The general aim o f this study was to identify the obstacles to condom usage by clients in R egion B and to develop strategies to en courage effective condom usage.
T he specific objectives o f this study w ere to determine • w hether clinics are accessible to cli ents -since inaccessible clinics may have a negative im pact on condom use.
• clien ts' perceptions w ith regard to prim ary health care w orkers' attitudes tow ards them as clients -as this may im pact on w illingness o f clients to discuss sensitive sexual issues w ith the PHC worker.
• whether clients use condom s correctly and consistently.
• w hat patterns o f condom use exists so that existing counseling pro gram m es can be reevaluated and pos sibly improved.

Problems related to condom usage
The findings will be discussed in two sections: Firstly the prob lem s related to service factors will be discussed and secondly problem s that stem from the behaviour and attitudes o f the client them selves.

Factors related to service provision
T he follow ing factors related to the service rendered to the client by the PH C clinic and staff with regards to condom use, w ere investigated.

• Staff's attitudes towards clients
In the health care setting the attitude o f staff tow ards the client is o f the utm ost im portance. This is particu -larly true w hen things o f a sensitive nature are dealt with. Regarding the issue o f STI, it is obvious that the staff m ust evoke feelings o f trust from the client and that the client m ust be at ease w ith the staff member. If the behaviour o f the staff o f the PH C clinics is nega tive, it m ight constitute an obstacle to effective con-and 7.2% that staff m em bers were not helpful. The types of incidents that were identified here included w here staff made the client feel uncom fortable or unim portant, w ere unhelpful, or failed to provide proper counseling.
W hat was encouraging is that a relationship o f trust appears to exist betw een clinic staff and clients as respondents indi cated that they perceive the staff as trustw orthy. To the ques tion "why they trust s ta f f ', 28.6% o f the respondents indi cated that it was because clinic staff w ere helpful, and 17.5% that they were trained.
Im portantly, it also appears that the clinic staff generally un derstood w hat the respondents w anted o f them w ith 69   T he accessibility o f clinics w as also investigated. If clinics are inaccessible (for w hatever reason) it stands to reason that con dom s that are distributed at clinics will be out o f the reach of clients. However, in this study for m ost o f the respondents, reaching the clinic poses no problem s as was indicated by 82.8%. The vast m ajority o f the respondents (85.7% ; N = 70) indicated that there were no costs involved in reaching the clinic. In addition to being easy to reach, clinic hours also seem to suit the respondents o f this study as indicated by 94.3% . Only distribution. T he overw helm ing m ajority o f respondents felt the clinic was the m ost appropriate place to obtain condom s.

Most appropriate place for distribution
According to Crichton (1997: 38) there are three main players in the distribution o f condom s: the governm ent, non-govem m ental organisations and com m ercial m anufacturers (see table 3).  On the grounds of the above-m entioned findings, it may be concluded that problem s w ith regard to transport to and the accessibility o f clinics do not present m ajor obstacles to cli ents attem pting to obtain condom s. It appears that clinics are relatively accessible. This ties in with the next factor -the m ost appropriate place for T he focus o f this study is the condom s that are m ade available at clinics and that are provided by the governm ent. As m en tioned earlier, the respondents regard clinics as the m ost ap propriate place to obtain condom s.
A lthough condom s are available free o f charge at clinics, it has often been suggested that they should also be m ade available free o f charge at other places, such as dance clubs and bars. In term s o f the results in table 3, how ever, it appears that re spondents believe that the clinic is the best place to obtain condom s.

Curationis May 2002
In this study more than half o f the respondents (59% , N = 64) indicated that they w ould not feel em barrassed to buy co n dom s at a shop. Forty-seven (N=64) of the respondents did not believe that condom s bought at a shop are o f a better quality than those obtainable from the clinic; 44% o f the re spondents were, however, not sure about this issue.

• Excessive demands on primary health care services
A problem that becam e evident from the focus group discus sions is the negative im pact that heavy w orkloads have on condom program m es. It was argued that as a result o f heavy workloads and understaffing in PHC clinics, it is often not pos sible to provide detailed counseling regarding condom usage. It appears that the provision o f inform ation to the client with regard to condom use is not high on the priority list o f the PHC worker.
The above state o f affairs is unfortunate, as it is crucial that the correct use o f condom s m ust be conveyed effectively and in positive term s to the client in order to encourage correct and consistent use. M oreover, in m ost cases dem onstrations of the correct use o f condom s are not included in the counseling process. The giving o f the necessary verbal feedback and test ing o f the client to determ ine w hether adequate reinforcem ent has taken place are processes that are seldom perform ed. L an guage differences may also create a problem because inform a tion is often conveyed to the client in a language other than his/her m other tongue.
According to the participants o f the focus group, raising aw are ness o f effective condom use by the PHC w orker in the client, is often absent. Therefore, an unconscious choice is forced on the client not to use condom s or may result in the incorrect use o f condom s w hich renders them ineffective.

• Socio-cultural convictions of the primary health care-worker and fear of stigmatisation
PHC w orkers participating in the focus groups also m entioned the possibility that the socio-cultural convictions o f the pri mary health care w orker m ay contribute to a situation where he/she m ight be unw illing to m ake condom s freely available.
T here is a possibility that som e PHC w orkers w ho hold the b elief that condom s encourage prom iscuity are guilty o f stig m atising clients w ho ask for condom s through their reactions or behaviour. In this way, they discourage condom use. PHC w orkers may also, due to their fear o f being stigm atised by their community, be hesitant to make condom s freely available, and may even discourage their use. A local church council has for example, censured the staff of a particular PHC clinic in the region because they allegedly approve o f and encourage pro m iscuity by encouraging the use o f condom s and by making condom s available free o f charge.
M em bers o f the focus group stated that there is still a stigm a attached to the use o f condom s and that some m oralists in the com m unity believe that encouraging the use of condom s, en courages sexual promiscuity. This has an impact on the mindset o f the PH C w orkers and thus ultim ately on the condom usage o f clients.

• Attractiveness
A ccording to the PHC w orkers who participated in the focus group, condom s available at clinics, are unattractive in com parison w ith the condom s that are available in the market.
In response to the increasing interest in condom use, com m er cial m anufacturers have begun to m anufacture condom s in a variety o f sizes, shapes, textures and colours. PHC w orkers suggest that if various kinds o f condom s, in term s o f colour and im proved packaging, are m ade available at clinics, it can possibly stimulate the clients' attention, and the item will "sell" itself. PHC workers also com plained that packaging material is not available at clinics, and the client m ust bring his own paper or plastic bag for this purpose. This, they said, creates the im pression of unprofessional service.
Focus group participants also m entioned a batch o f particu larly poor quality condom s once received: not only did the lubricant ooze from the packaging, but they also had an un pleasant odour and the packaging had a unattractive brown colour. O ne primary health care w orker described the batch as "utterly repulsive" and questioned the quality o f the product. In a study am ongst prim ary health care w orkers in the Free State clinics by Crichton (1997: 84), as m any as 30 per cent of the respondents (N = 84) were dissatisfied with the condom s supplied to their clinics.

Factors related to the client
The first section touched on factors related to the PHC setting that may discourage the use o f condom s. In this section fac tors related to the clients them selves such as: the nature of sexual relationships that clients develop with their partners; condom usage within these relationships and other general issues regarding the use o f condom s, are investigated.

• The nature of sexual relationships
A relatively high percentage o f respondents had more than one sex partner during the previous month, w hich is possibly an explanation for the reported high incidence o f sexually trans m itted infections. Sixty per cent o f respondents had only one sex partner during the preceding m onth, w hile the rem aining 40% have had two or m ore sex partners. Twenty four per cent indicate having two partners, 7.7% had three partners and 7.7% four. These findings have to be interpreted in the light o f the biographical inform ation where 67% o f the respondents are single, 17.6% are cohabiting and only 14.7% are in a marital (legal or traditional) relationships.
In term s o f the nature o f the reported sexual relationships re spondents were engaged in, 66.7% o f the relationships were with the steady partner, but a significant proportion (33.3% )

9
Curationis May 2002 w ith a "casual" partner with w hom no steady relationship was established or a "new " partner. O f the respondents, 31 (49.2 %) indicated that they had used condom s during the previous month, w hile 32 (50.8% ) indicated that they did not use con doms.

• Reasons for condom use or non-use and negotiating the issue
In this section, the follow ing issues were investigated: • the reasons respondents give for using or not using condom s; • who the person in the relationships was that w anted to use condom s; • factors that prevent respondents from obtaining con doms; • practices related to correct condom use and • personal perceptions regarding condom use.
W hen reasons for condom usage w ere investigated the fol low ing becam e evident: 40% (10 o f 25 respondents) indicated condom s because they trust their partners im plies that con dom usage m ay be associated with mistrust.
It m ay be deduced from the results in table 6 that more discu s sion about condom usage exists in steady relationships: 48,4% o f respondents in steady relationships stated that they w anted to use condom s, w hile 41.9% o f them stated that both partners w anted to use condom s. W hen "casual" relationships are in volved, only 2 o f the 11 respondents in the category "single casual p a r tn e r" indicated that both w anted to (that is 18.2%). O f the respondents, 72.7% w ho responded here indicated that they desired to use condom s. Therefore, it appears as if the encouragem ent to use condom s has to be accom panied by the encouragem ent to have a single sex partner in a steady rela tionship. It is in a steady relationship w here it is likely that greater openness and discussion occurs betw een partners, and this appears to encourage the use o f condom s.

• Condom use
A ccording to Crichton (1997: 50) the correct use o f condom s cannot be overem phasized as the correct use reduces the con- A ccording to the data presented in table 5, the m ost im portant reason offered by respondents w hy they do n o t use condom s, is that they trust their partner (12 out o f 21; 57.1% ). It som e tim es also happens that the partner refuses to use a condom (3 out o f 21 respondents; 14.3%). M oreover, some respondents stated that they w anted direct contact (2 out o f 21; 9.5%), and that they were unfam iliar with the use of condom s (2 out o f 21; 9.5%). T he fact that 58 per cent indicated that they do not use d om 's failure rate and consequently increases its protective qualities.
From the results presented in table 7, it is deducted that the broad and sim ple principles o f condom use are indeed being follow ed during sexual intercourse. H ow ever, the finer points are often neglected, for exam ple, sexual contact takes place before the condom is placed over the penis; the penis is not always w ithdraw n w hile it is still erect, nor is the penis (and condom ) consistently held tight at the base w hen it is w ith drawn. This m ay explain why sexually transm itted infections are som etim es m anifested, even when clients report that they do, in fact, use condom s. These findings confirm the earlier

Concluding comments
It was postulated initially in this study that ineffective condom use m ight be related to a variety o f factors. This study, how ever, showed that the accessibility and proxim ity o f clinics in the area o f study were not significant problem s to respondents who were involved in the study. It also seems that PHC w ork ers attitudes and behaviour tow ards clients in the specific area were not factors that discouraged clients from using condom s as, in general, respondents had a positive perception o f clinic staff's behaviour tow ards them and show ed a high level trust in them.
The biggest problem identified by this study is that a signifi cant percentage o f clients did not use condom s consistently in the correct way. The data collected confirm s that although cli ents do not have difficulties in obtaining condom s, they are often used incorrectly and clients do not consistently follow the correct procedures so that safe sexual intercourse are al ways ensured. G iven that a high percentage o f the investigated group had m ore than one sex partner in the preceding month, it is o f im portance not only that condom s are made available free of charge, but also that the availability o f condom s has to be accom panied by an effective and thorough counselling pro gramm e. It therefore a concern that PHC w orkers reported that as a result o f enorm ous dem ands made on them, (in terms o f course attendance and client overload), they spend too little tim e in clinics and with their patients. In fact m any o f the PHC workers w ho were requested to com plete the questionnaire with their clients for the purposes o f this study, com plained that they did not have enough tim e. This is disconcerting, since most o f the questions that were posed in the client questinnaire, were questions that had to be dealt with any client presenting with a STI.

Recommendations
The first recom m endation is that the w orkload o f the PHC has to be specifically tasked to perform this kind o f w ork on a full-time basis. In addition to the above, the authors recom m end that any co n dom education program m e should not only provide counsel ling related to the effective and correct use o f condom s, but