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Int J STD AIDS OnlineFirst, published on February 13, 2015 as doi:10.1177/0956462415571373
Original research article
Geospatial analysis of condom availability and accessibility in urban Malawi
International Journal of STD & AIDS 0(0) 1–7 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462415571373 std.sagepub.com
Enbal Shacham1, Rebecca Thornton2, Susan Godlonton3, Ryan Murphy1 and Jake Gilliland1
Summary An audit of condom availability conducted in urban Malawi identified limited access to this HIV prevention method. Barriers included cost, location in store, and few stores selling or distributing condoms. Background: Prevalence of HIV in sub-Saharan African countries persists at alarming rates. There are currently four promoted methods to prevent HIV infection: adherence to antiretroviral therapy, male circumcision, pre-exposure prophylaxis and use of condoms. This study aimed to assess the availability and accessibility of one of the prevention efforts, condoms, in Kawale, Lilongwe, Malawi. Methods: A total of 220 potential condom-selling establishments were surveyed in 2012. Data were collected with store owners or staff and locations were geocoded to assess store density. Descriptive analyses were conducted. Results: Of those audited, 96 stores sold condoms, 13 of which distributed free condoms. The stores were most often small shops and located in markets or trading centres. Condoms were most often found at the back of the store in an open space. There were approximately 1.2 stores per ¼ mile; 44% of the businesses in the study region carried condoms. Conclusion: This one method of prevention exhibited multiple barriers in this region: few stores sold condoms, high costs, condom locations within stores and limited availability. The limited accessibility is likely to influence social norms surrounding condom use. Future research should incorporate assessing norms and addressing barriers to uptake of HIV prevention efforts.
Keywords Condom, STD/STI prevention, accessibility and availability, geographic disparities, HIV/AIDS Date received: 28 October 2014; accepted: 12 January 2015
Introduction Despite tremendous advances in HIV care, including significant improvements in effectiveness and availability of combination antiretroviral therapies (cART), HIV incidence rates have not decreased dramatically and life expectancy continues to lag behind those who are uninfected.1,2 We now have four strategies for HIV prevention that are being promoted as methods to getting to ‘zero’ new HIV infections (1 – cART adherence, 2 – voluntary medical male circumcision, 3 – preexposure prophylaxis and 4 – condom use).3–9 Identifying individual- and structural-level barriers to the uptake any of these methods will help highlight opportunities for improving services and tailor intervention efforts. In Malawi, the national HIV prevalence rate is estimated at 17.4% in urban regions and 8.9% in rural regions.10 Malawi-based studies identified barriers to condom use which included reduced sensitivity, distrust
of the efficacy of the condoms, cultural reasons, family planning and partner mistrust.11–14 Recent HIV prevention efforts have been successful in increasing reported condom use through interventions that addressed: religious acceptability of condom use,15 social norms through communication campaigns,16 peer
1
College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA 2 Department of Economics, University of Michigan, Ann Arbor, MI, USA 3 Department of Economics, Williams College, Williamstown, MA, USA and International Food Policy Research Institute, Markets, Trade and Institution, Washington, DC, USA Corresponding author: Enbal Shacham, Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, 3545 Lafayette Avenue, Office 315, St. Louis, MO 63104, USA. Email: [email protected]
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interactions,17 and sexually transmitted infection (STI) testing and treatment.18 Understanding geographic disparities in availability and accessibility of HIV prevention methods in high HIV prevalence regions is important in order to guide the development and implementation of needed location-based and structural interventions. Namely, access to condoms is necessary to offer a cheap and effective method to reduce HIV cases, specifically responding to demands due to successful interventions. If ‘condom deserts’ exist in areas of high HIV prevalence, it does not seem plausible that reduction in HIV infections will be feasible. Previous condom availability research in sub-Saharan Africa found that efforts to increase condom availability have been successful, yet difficult to sustain.19–24 To date, the authors did not identify any studies that examined the geospatial distribution of condoms in Malawi. It is likely that the geographic disparities of HIV infection may be partially due to limited condom availability and accessibility. The notion of a ‘condom desert’ will not only influence the purchase and use of condoms, but also it is likely to influence social norms.25 Specifically, businesses that sell accessible condoms have them in visible locations, cheaper, have more variety in types of condoms and carry larger quantities will influence condom using norms. We hypothesise that this accessibility influences individual use as well as social norms surrounding condom use. This study aimed to (1) test the feasibility of conducting a condom availability and accessibility audit and (2) examine the availability and accessibility of one HIV prevention method, condoms, within Kawale (Area 7), an area in Lilongwe City, Malawi. These findings will identify additional opportunities to study geographic resources and which spatial patterns may exist.
Methods Data collection took place in all enumeration areas within Kawale during a four-day period in February 2012. Kawale comprises 29 census enumeration areas as defined by the Malawi National Statistics office for the 2008 Malawi Population and Housing Census. An enumeration area comprises of approximately 235 households. As the capital city, Lilongwe is a highly populated area, with nearly 1.1 million residents. Kawale accounts for one area in Lilongwe, with an estimated 40,000 residents, approximately 50% over the age of 18 years. At the country level, the physician workforce is estimated at 0.2/10,000 residents and the total health expenditure as percent of gross domestic product is 9.2%. We aimed to study the feasibility of conducting a condom availability and accessibility audit in one region of a capital city to reveal geographic disparities.
A total of four Malawian research team members collected these data. We identified a wide range of establishments as potential selling points (or free availability) of condoms, as were previously identified as potential condom distribution locations.26,27 The studied establishments included: small shops, bars, clinics, youth centres and rest houses (short-term accommodations). For analyses, we categorised the types of businesses into small shops vs. all other businesses. Small shops are typically small grocery stores. These businesses included those that may distribute condoms for free. We had no information regarding whether they sold condoms prior to the audit.
Store audits Any potential establishment was automatically recruited in order to assess whether they sell condoms. For establishments that were closed, neighbours were asked whether the closure was temporary or permanent. In cases where it was a temporary closure, team members revisited the establishments later during the day or another day. The research team started in the South West corner (enumeration areas 28) and moved across completing the audit in the North East corner (enumeration area 18). In each establishment, one representative was asked to complete the audit. Most shops were owned by families, thus, any family member aged 18 or above was asked to complete the questionnaire on behalf of the establishment. For establishments that were not family-owned, the research team spoke with the manager, or whomever was identified as being ‘in charge’ at the premises. In cases where the establishments identified that they did not offer condoms free or for sale, the interview was terminated. Where condoms were available, the entire audit was administered.
Audit The audit included the following items: business hours, type of business, condom selling/free distribution, cost of a package of three condoms, where the business gets the condoms, number of brands, the placement of the condoms in the store and geocoded location of the store.
Data analyses First, descriptive analyses of the audit responses were assessed to describe condom availability and accessibility and then, bivariate comparisons were conducted in order to identify differences in accessibility factors. Store type was recoded as small shop or other to allow for identifying differences in business types.
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The research team carried GPS units with them and were able to document the GIS data points, longitude and latitude, for each business visited. ArcGIS 10.1 (esri, 2014) was used to conduct geospatial analyses. We conducted density analyses to assess whether there were areas with high and low condom availability in the study region. The spatial distribution of condom vendors was analysed to provide insight into how condom availability is distributed as expressed as a density. The density analysis was performed on the point patterns of condom vendors based on a 100 m radius (bandwidth) using a kernel density function. The kernel density fits a smooth surface over each point based on the population of points. The highest density values are at point location and diminish with distance (a distance decay effect). Kernel densities are useful for preserving shapes that point data may adhere to such as road networks. The numeric values generated are the number of condom vendors per 100 m where higher numbers represent a higher density, thus a greater availability.28 Figure 1 depicts the actual data with the high density areas, and Figure 2 indicates the potential density if all businesses audited sold condoms.
Results A total of 220 potential condom vendors or distributors were audited in Kawale. Of those stores, 96 stores (43.6%) sold or distributed condoms. The majority of the stores that sold condoms were classified as a small shop (n ¼ 58; 60.4%); most of the businesses were located in a market area or trading center (n ¼ 72; 75.0%). Of the types of stores included, there was one identified clinic, one HIV non-governmental organisation and one youth centre. The youth centre served as voluntary counselling and testing site. Some reported reasons consumers may have frequented businesses primarily included loitering, listening to music, watching television or playing indoor games. The mean amount of time that stores were open during the weekdays and weekends was 13.6 and 13.5 hours, respectively; approximately 06:00 until 21:00. Small shops were more likely to be opened earlier in the day than other businesses (p < 0.001). Men and women reportedly were equally likely to frequent the businesses audited. Table 1 includes store characteristics. Condoms were stored in the back of the store in an open space in most of the stores (n ¼ 66; 68.8%). Only 13 (13.5%) stores provided free condoms. When auditing the number of different brands of condoms sold per business, most often the stores reported that they usually sold two brands of condoms (n ¼ 49); while one store usually sold five different kinds. The audit specifically assessed what was currently available as well as what was typically sold. Fewer stores currently were
carrying two different types of condoms (n ¼ 34). The average cost of a three-condom pack was 44.0 Malawian Kawacha (equivalent to US$0.02). The cost of condoms was higher in stores that sold alcohol (p < 0.05). Of all the stores audited, there is an 8.2% chance of walking in the store and finding condoms visible in the front of the store. Only 43.6% of businesses sold condoms within the study area. There were approximately 1.2 stores per ¼ mile; 44% of the businesses in the region carried condoms. Figure 1 depicts the density of condom availability in the study area. Had all the businesses in the study region sold condoms, there would be an increase of 37.2% of condom spatial distribution (Figure 2).
Discussion This was an initial study of condom availability and accessibility as a feasible HIV prevention method. This study was able to identify a methodology that was effective in collecting data regarding these factors. Condoms had low availability and accessibility in businesses, which likely serves as a significant limitation for the uptake of this HIV prevention approach. While much of the effort of rolling out and scaling up HIV prevention methods have focused on cART throughout low resource areas, it seems that condom availability may now be overlooked as a viable prevention option. The study results suggest that there are patterns of an existing ‘condom desert’ and thus, community members do not have high accessibility to condoms, which in turn, serves as a significant barrier to use with their sex partners. While hours of the businesses differed by type of establishment, they offered many open hours for potential condom purchases. Moreover, the average cost of a three-condom pack was 44.0 Malawian Kawacha (equivalent to US$0.02) and to contextualise, the GDP per capita is $800 and thus, prioritising the condom costs is likely to be difficult. Additionally, there were limited choices in condom brands. Furthermore, accessibility was low with less than 10% of the condom selling stores having condoms visible when a community member entered the store. Lastly, the geospatial distribution of condoms was analysed to provide an accurate depiction of how residents may be exposed to condoms in their neighborhood. There was a 44% chance of finding a store that sells condoms in the Kawale area, while there could be 81% chance of finding a store that sells condoms if all of the stores audited sold condoms. These findings suggest that it is unrealistic to expect condom use to be consistent, specifically due to cost and limited accessibility. While residents may be accustomed to travelling to retrieve condoms,
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Figure 1. Condom vendor geographic densities, Kawale, Lilongwe, Malawi.
this study posits that proximity matters in influencing condom use norms. This study surmises that this region existed within a context that may be denoted as a ‘condom desert,’ which suggests that limited availability and accessibility are likely to have a larger influence than difficulty in
getting condoms. Social norms may be influenced by this lack of access, and community members may assume that others do not use them, since they do not see condoms where they shop. Additionally, previous research in Malawi, both urban and rural, suggests that with varied intervention approaches, condom use
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Figure 2. Difference in condom densities: potential less current vendors.
improves.11,14,15,17,18,24 This lack of condom access is detrimental to health outcomes. As this study was an initial assessment of the feasibility and efficacy of this audit method and condom availability and accessibility, there are limitations to this study. This was conducted in one small area of
the capital city in Malawi. Based on the differences in responses for what types of condoms were usually carried and what was currently available, there is likely to be fluctuation in inventory, which may be difficult to predict. Additionally, data were not collected about the stores that did not carry condoms; in future research,
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Table 1. Description of condom selling establishments, Kawale, Lilongwe, Malawi. n Number of businesses audited Number of businesses sold condoms Location of business Market area/trading centre Residential area Main road Near place that serves alcohol Type of establishment Stand or stall Small shop Large shop Other Reasons to frequent store Sell alcohol Dance Music Video/TV Loitering Indoor games Hours of business Opening hours: weekdays (n ¼ 92) Closing hours: weekdays (n ¼ 96) Duration of day: weekdays (n ¼ 92) Opening hours on Saturday (n ¼ 94) Closing hours on Saturday (n ¼ 94) Duration of day on Saturday (n ¼ 94) Opening hours on Sunday (n ¼ 82) Closing hours on Sunday (n ¼ 82) Duration of day on Sunday (n ¼ 82) Mean number of male visitors on busiest days Mean number of female visitors on busiest days
%
220 96 72 24 6 11
10.9
5 58 12 21
5.2 60.4 5.5 9.5
32 13 42 33 47 20 Mean 6.894 20.67 13.63 6.46 19.97 13.51 7.17 20.72 13.56 54 48.6 n
Location of condoms in business In front above the counter In front under the counter At the back of the store in an open space At the back of the store in a hidden space At the reception In the house outside the shop On a table where everyone can see and take when they want Number of businesses offering free condoms
43.6
33.3% 13.5% 43.8% 34.4% 49.0% 20.8% SD 2.73 3.11 3.58 2.6 3.92 4.66 3.33 3 4.42 96 84
Table 1. Continued. n Number of condom brands usually carry One Two Three Five Number of condom brands currently carry Zero One Two Five
%
1 49 4 1 5 15 34 1
additional characteristics of location types and barriers businesses may experience in carrying condoms should be collected. Previous studies have not incorporated social norms in the context of availability and accessibility. This study was conducted as the initial phase of testing the method of collecting these data as well as identifying if ‘condom deserts’ exist in this context. The next phases will need to include larger regions and assessments of condom use norms. Furthermore, this study examined the availability and accessibility of only one of the HIV prevention methods. This question has begun to be addressed in the context of scale up efforts for wide implementation of HIV prevention methods.29–31 While infrastructure development is time- and resource-consuming, it is imperative in order to meet the goal of no new HIV infections. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
%
Funding 11 7 66
11.5% 7.3% 68.8%
8
8.3%
2 1 1
2.1% 1.0% 1.0%
13
13.5% (continued)
The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Palella FJJ, Baker RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. JAIDS J Acquir Immune Def Syndr 2006; 43: 27–34. 2. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493–505. 3. Bailey R, Moses S, Parker C, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643–656.
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4. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 657–666. 5. Auvert B, Sobngwi-Tambekou J, Cutler E, et al. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis 2009; 199: 14–19. 6. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493–505. 7. Bessinger R, Katende C and Gupta N. Multi-media campaign exposure effects on knowledge and use of condoms for STI and HIV/AIDS prevention in Uganda. Eval Program Plann 2004; 27: 397–407. 8. Charania M, Crepaz N, Guenther-Gray C, et al. Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998– 2007. AIDS Behav 2011; 15: 1283–1297. 9. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010; 363: 2587–2599. 10. Demographic and Health Survey. HIV prevalence: data from the 2010 Malawi Demographic and Health Survey 2010. Available at: http://dhsprogram.com/pubs/pdf/ HF34/HF34.pdf (accessed 22 October 2012). 11. Versteeg M and Murray M. Condom use as part of the wider HIV prevention strategy: experiences from communities in the North West Province, South Africa. SAHARA J: J Soc Asp HIV/AIDS Res Alliance/ SAHARA, Hum Sci Res Council 2008; 5: 83–93. 12. Maharaj P and Cleland J. Risk perception and condom use among married or cohabiting couples in KwaZuluNatal, South Africa. Int Fam Plann Perspect 2005; 31: 24–29. 13. Anglewicz P and Clark S. The effect of marriage and HIV risks on condom use acceptability in rural Malawi. Soc Sci Med 2013; 97: 29–40. 14. Muula AS, Thomas JC, Pettifor AE, et al. Religion, condom use acceptability and use within marriage among rural women in Malawi. World Health Popul 2011; 12: 35–47. 15. Willms DG, Arratia MI and Makondesa P. Can interfaith research partnerships develop new paradigms for condom use and HIV prevention? The implementation of conceptual events in Malawi results in a ‘spiritualised condom’. Sex Transm Infect 2011; 87: 611–615. 16. Kaufman MR, Rimal RN, Carrasco M, et al. Using social and behavior change communication to increase HIV testing and condom use: the Malawi BRIDGE Project. AIDS Care 2014; 26(Supp 1): S46–S49.
17. Kaponda CP, Norr KF, Crittenden KS, et al. Outcomes of an HIV prevention peer group intervention for rural adults in Malawi. Health Educ Behav [the official publication of the Society for Public Health Education] 2011; 38: 159–170. 18. Paz-Soldan VA, Hoffman I, deGraft JJ, et al. Sexually transmitted infection (STI) screening, case and contact treatment, and condom promotion resulting in STI reduction two years later in rural Malawi. Malawi Med J: J Med Assoc Malawi 2012; 24: 8–13. 19. Agha S and Kusanthan T. Equity in access to condoms in urban Zambia. Health Policy Plann 2003; 18: 299–305. 20. Agha S and Meekers D. The availability of socially marketed condoms in urban Tanzania, 1997–99. J Biosoc Sci 2004; 36: 127–140. 21. Barnes JR. The impact of social marketing on HIV/ AIDS. AIDS Anal Afr 1999; 10: 8–10. 22. Benefo KD. Determinants of condom use in Zambia: a multilevel analysis. Studies Fam Plann 2010; 41: 19–30. 23. Gilmour E, Karim SSA and Fourie HJ. Availability of condoms in urban and rural areas of KwaZulu-Natal, South Africa. Sex Transm Dis 2000; 27: 353–357. 24. Metcalfe D. A negative association between condom availability and incidence of urethral discharge in a closed Malawian community. Int J STD AIDS 2007; 18: 559–562. 25. Glanz K, Rimer BK and Viswanath K. Health behavior and health education: theory, research, and practice. New York: John Wiley & Sons, 2008. 26. Ross MW and Williams ML. Effective targeted and community HIV/STD prevention programs. J Sex Res 2002; 39: 58. 27. Reece M, Herbenick D, Schick V, et al. Condom use rates in a national probability sample of males and females ages 14 to 94 in the United States. J Sex Med 2010 2010; 7(suppl 5): 266–276. 28. Silverman BW. Density estimation for statistics and data analysis. Boca Raton, FL: Hall/CRC, 1986. 29. Johnson DC, Feldacker C, Tweya H, et al. Factors associated with timely initiation of antiretroviral therapy in two HIV clinics in Lilongwe, Malawi. Int J STD AIDS 2013; 24: 42–49. 30. Feldacker C, Ennett ST and Speizer I. It’s not just who you are but where you live: an exploration of community influences on individual HIV status in rural Malawi. Soc Sci Med 2011; 72: 717–725. 31. Feldacker C, Emch M and Ennett S. The who and where of HIV in rural Malawi: exploring the effects of person and place on individual HIV status. Health Place 2010; 16: 996–1006.
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Int J STD AIDS OnlineFirst, published on February 13, 2015 as doi:10.1177/0956462415571373
Original research article
Geospatial analysis of condom availability and accessibility in urban Malawi
International Journal of STD & AIDS 0(0) 1–7 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462415571373 std.sagepub.com
Enbal Shacham1, Rebecca Thornton2, Susan Godlonton3, Ryan Murphy1 and Jake Gilliland1
Summary An audit of condom availability conducted in urban Malawi identified limited access to this HIV prevention method. Barriers included cost, location in store, and few stores selling or distributing condoms. Background: Prevalence of HIV in sub-Saharan African countries persists at alarming rates. There are currently four promoted methods to prevent HIV infection: adherence to antiretroviral therapy, male circumcision, pre-exposure prophylaxis and use of condoms. This study aimed to assess the availability and accessibility of one of the prevention efforts, condoms, in Kawale, Lilongwe, Malawi. Methods: A total of 220 potential condom-selling establishments were surveyed in 2012. Data were collected with store owners or staff and locations were geocoded to assess store density. Descriptive analyses were conducted. Results: Of those audited, 96 stores sold condoms, 13 of which distributed free condoms. The stores were most often small shops and located in markets or trading centres. Condoms were most often found at the back of the store in an open space. There were approximately 1.2 stores per ¼ mile; 44% of the businesses in the study region carried condoms. Conclusion: This one method of prevention exhibited multiple barriers in this region: few stores sold condoms, high costs, condom locations within stores and limited availability. The limited accessibility is likely to influence social norms surrounding condom use. Future research should incorporate assessing norms and addressing barriers to uptake of HIV prevention efforts.
Keywords Condom, STD/STI prevention, accessibility and availability, geographic disparities, HIV/AIDS Date received: 28 October 2014; accepted: 12 January 2015
Introduction Despite tremendous advances in HIV care, including significant improvements in effectiveness and availability of combination antiretroviral therapies (cART), HIV incidence rates have not decreased dramatically and life expectancy continues to lag behind those who are uninfected.1,2 We now have four strategies for HIV prevention that are being promoted as methods to getting to ‘zero’ new HIV infections (1 – cART adherence, 2 – voluntary medical male circumcision, 3 – preexposure prophylaxis and 4 – condom use).3–9 Identifying individual- and structural-level barriers to the uptake any of these methods will help highlight opportunities for improving services and tailor intervention efforts. In Malawi, the national HIV prevalence rate is estimated at 17.4% in urban regions and 8.9% in rural regions.10 Malawi-based studies identified barriers to condom use which included reduced sensitivity, distrust
of the efficacy of the condoms, cultural reasons, family planning and partner mistrust.11–14 Recent HIV prevention efforts have been successful in increasing reported condom use through interventions that addressed: religious acceptability of condom use,15 social norms through communication campaigns,16 peer
1
College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA 2 Department of Economics, University of Michigan, Ann Arbor, MI, USA 3 Department of Economics, Williams College, Williamstown, MA, USA and International Food Policy Research Institute, Markets, Trade and Institution, Washington, DC, USA Corresponding author: Enbal Shacham, Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, 3545 Lafayette Avenue, Office 315, St. Louis, MO 63104, USA. Email: [email protected]
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interactions,17 and sexually transmitted infection (STI) testing and treatment.18 Understanding geographic disparities in availability and accessibility of HIV prevention methods in high HIV prevalence regions is important in order to guide the development and implementation of needed location-based and structural interventions. Namely, access to condoms is necessary to offer a cheap and effective method to reduce HIV cases, specifically responding to demands due to successful interventions. If ‘condom deserts’ exist in areas of high HIV prevalence, it does not seem plausible that reduction in HIV infections will be feasible. Previous condom availability research in sub-Saharan Africa found that efforts to increase condom availability have been successful, yet difficult to sustain.19–24 To date, the authors did not identify any studies that examined the geospatial distribution of condoms in Malawi. It is likely that the geographic disparities of HIV infection may be partially due to limited condom availability and accessibility. The notion of a ‘condom desert’ will not only influence the purchase and use of condoms, but also it is likely to influence social norms.25 Specifically, businesses that sell accessible condoms have them in visible locations, cheaper, have more variety in types of condoms and carry larger quantities will influence condom using norms. We hypothesise that this accessibility influences individual use as well as social norms surrounding condom use. This study aimed to (1) test the feasibility of conducting a condom availability and accessibility audit and (2) examine the availability and accessibility of one HIV prevention method, condoms, within Kawale (Area 7), an area in Lilongwe City, Malawi. These findings will identify additional opportunities to study geographic resources and which spatial patterns may exist.
Methods Data collection took place in all enumeration areas within Kawale during a four-day period in February 2012. Kawale comprises 29 census enumeration areas as defined by the Malawi National Statistics office for the 2008 Malawi Population and Housing Census. An enumeration area comprises of approximately 235 households. As the capital city, Lilongwe is a highly populated area, with nearly 1.1 million residents. Kawale accounts for one area in Lilongwe, with an estimated 40,000 residents, approximately 50% over the age of 18 years. At the country level, the physician workforce is estimated at 0.2/10,000 residents and the total health expenditure as percent of gross domestic product is 9.2%. We aimed to study the feasibility of conducting a condom availability and accessibility audit in one region of a capital city to reveal geographic disparities.
A total of four Malawian research team members collected these data. We identified a wide range of establishments as potential selling points (or free availability) of condoms, as were previously identified as potential condom distribution locations.26,27 The studied establishments included: small shops, bars, clinics, youth centres and rest houses (short-term accommodations). For analyses, we categorised the types of businesses into small shops vs. all other businesses. Small shops are typically small grocery stores. These businesses included those that may distribute condoms for free. We had no information regarding whether they sold condoms prior to the audit.
Store audits Any potential establishment was automatically recruited in order to assess whether they sell condoms. For establishments that were closed, neighbours were asked whether the closure was temporary or permanent. In cases where it was a temporary closure, team members revisited the establishments later during the day or another day. The research team started in the South West corner (enumeration areas 28) and moved across completing the audit in the North East corner (enumeration area 18). In each establishment, one representative was asked to complete the audit. Most shops were owned by families, thus, any family member aged 18 or above was asked to complete the questionnaire on behalf of the establishment. For establishments that were not family-owned, the research team spoke with the manager, or whomever was identified as being ‘in charge’ at the premises. In cases where the establishments identified that they did not offer condoms free or for sale, the interview was terminated. Where condoms were available, the entire audit was administered.
Audit The audit included the following items: business hours, type of business, condom selling/free distribution, cost of a package of three condoms, where the business gets the condoms, number of brands, the placement of the condoms in the store and geocoded location of the store.
Data analyses First, descriptive analyses of the audit responses were assessed to describe condom availability and accessibility and then, bivariate comparisons were conducted in order to identify differences in accessibility factors. Store type was recoded as small shop or other to allow for identifying differences in business types.
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The research team carried GPS units with them and were able to document the GIS data points, longitude and latitude, for each business visited. ArcGIS 10.1 (esri, 2014) was used to conduct geospatial analyses. We conducted density analyses to assess whether there were areas with high and low condom availability in the study region. The spatial distribution of condom vendors was analysed to provide insight into how condom availability is distributed as expressed as a density. The density analysis was performed on the point patterns of condom vendors based on a 100 m radius (bandwidth) using a kernel density function. The kernel density fits a smooth surface over each point based on the population of points. The highest density values are at point location and diminish with distance (a distance decay effect). Kernel densities are useful for preserving shapes that point data may adhere to such as road networks. The numeric values generated are the number of condom vendors per 100 m where higher numbers represent a higher density, thus a greater availability.28 Figure 1 depicts the actual data with the high density areas, and Figure 2 indicates the potential density if all businesses audited sold condoms.
Results A total of 220 potential condom vendors or distributors were audited in Kawale. Of those stores, 96 stores (43.6%) sold or distributed condoms. The majority of the stores that sold condoms were classified as a small shop (n ¼ 58; 60.4%); most of the businesses were located in a market area or trading center (n ¼ 72; 75.0%). Of the types of stores included, there was one identified clinic, one HIV non-governmental organisation and one youth centre. The youth centre served as voluntary counselling and testing site. Some reported reasons consumers may have frequented businesses primarily included loitering, listening to music, watching television or playing indoor games. The mean amount of time that stores were open during the weekdays and weekends was 13.6 and 13.5 hours, respectively; approximately 06:00 until 21:00. Small shops were more likely to be opened earlier in the day than other businesses (p < 0.001). Men and women reportedly were equally likely to frequent the businesses audited. Table 1 includes store characteristics. Condoms were stored in the back of the store in an open space in most of the stores (n ¼ 66; 68.8%). Only 13 (13.5%) stores provided free condoms. When auditing the number of different brands of condoms sold per business, most often the stores reported that they usually sold two brands of condoms (n ¼ 49); while one store usually sold five different kinds. The audit specifically assessed what was currently available as well as what was typically sold. Fewer stores currently were
carrying two different types of condoms (n ¼ 34). The average cost of a three-condom pack was 44.0 Malawian Kawacha (equivalent to US$0.02). The cost of condoms was higher in stores that sold alcohol (p < 0.05). Of all the stores audited, there is an 8.2% chance of walking in the store and finding condoms visible in the front of the store. Only 43.6% of businesses sold condoms within the study area. There were approximately 1.2 stores per ¼ mile; 44% of the businesses in the region carried condoms. Figure 1 depicts the density of condom availability in the study area. Had all the businesses in the study region sold condoms, there would be an increase of 37.2% of condom spatial distribution (Figure 2).
Discussion This was an initial study of condom availability and accessibility as a feasible HIV prevention method. This study was able to identify a methodology that was effective in collecting data regarding these factors. Condoms had low availability and accessibility in businesses, which likely serves as a significant limitation for the uptake of this HIV prevention approach. While much of the effort of rolling out and scaling up HIV prevention methods have focused on cART throughout low resource areas, it seems that condom availability may now be overlooked as a viable prevention option. The study results suggest that there are patterns of an existing ‘condom desert’ and thus, community members do not have high accessibility to condoms, which in turn, serves as a significant barrier to use with their sex partners. While hours of the businesses differed by type of establishment, they offered many open hours for potential condom purchases. Moreover, the average cost of a three-condom pack was 44.0 Malawian Kawacha (equivalent to US$0.02) and to contextualise, the GDP per capita is $800 and thus, prioritising the condom costs is likely to be difficult. Additionally, there were limited choices in condom brands. Furthermore, accessibility was low with less than 10% of the condom selling stores having condoms visible when a community member entered the store. Lastly, the geospatial distribution of condoms was analysed to provide an accurate depiction of how residents may be exposed to condoms in their neighborhood. There was a 44% chance of finding a store that sells condoms in the Kawale area, while there could be 81% chance of finding a store that sells condoms if all of the stores audited sold condoms. These findings suggest that it is unrealistic to expect condom use to be consistent, specifically due to cost and limited accessibility. While residents may be accustomed to travelling to retrieve condoms,
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Figure 1. Condom vendor geographic densities, Kawale, Lilongwe, Malawi.
this study posits that proximity matters in influencing condom use norms. This study surmises that this region existed within a context that may be denoted as a ‘condom desert,’ which suggests that limited availability and accessibility are likely to have a larger influence than difficulty in
getting condoms. Social norms may be influenced by this lack of access, and community members may assume that others do not use them, since they do not see condoms where they shop. Additionally, previous research in Malawi, both urban and rural, suggests that with varied intervention approaches, condom use
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Figure 2. Difference in condom densities: potential less current vendors.
improves.11,14,15,17,18,24 This lack of condom access is detrimental to health outcomes. As this study was an initial assessment of the feasibility and efficacy of this audit method and condom availability and accessibility, there are limitations to this study. This was conducted in one small area of
the capital city in Malawi. Based on the differences in responses for what types of condoms were usually carried and what was currently available, there is likely to be fluctuation in inventory, which may be difficult to predict. Additionally, data were not collected about the stores that did not carry condoms; in future research,
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Table 1. Description of condom selling establishments, Kawale, Lilongwe, Malawi. n Number of businesses audited Number of businesses sold condoms Location of business Market area/trading centre Residential area Main road Near place that serves alcohol Type of establishment Stand or stall Small shop Large shop Other Reasons to frequent store Sell alcohol Dance Music Video/TV Loitering Indoor games Hours of business Opening hours: weekdays (n ¼ 92) Closing hours: weekdays (n ¼ 96) Duration of day: weekdays (n ¼ 92) Opening hours on Saturday (n ¼ 94) Closing hours on Saturday (n ¼ 94) Duration of day on Saturday (n ¼ 94) Opening hours on Sunday (n ¼ 82) Closing hours on Sunday (n ¼ 82) Duration of day on Sunday (n ¼ 82) Mean number of male visitors on busiest days Mean number of female visitors on busiest days
%
220 96 72 24 6 11
10.9
5 58 12 21
5.2 60.4 5.5 9.5
32 13 42 33 47 20 Mean 6.894 20.67 13.63 6.46 19.97 13.51 7.17 20.72 13.56 54 48.6 n
Location of condoms in business In front above the counter In front under the counter At the back of the store in an open space At the back of the store in a hidden space At the reception In the house outside the shop On a table where everyone can see and take when they want Number of businesses offering free condoms
43.6
33.3% 13.5% 43.8% 34.4% 49.0% 20.8% SD 2.73 3.11 3.58 2.6 3.92 4.66 3.33 3 4.42 96 84
Table 1. Continued. n Number of condom brands usually carry One Two Three Five Number of condom brands currently carry Zero One Two Five
%
1 49 4 1 5 15 34 1
additional characteristics of location types and barriers businesses may experience in carrying condoms should be collected. Previous studies have not incorporated social norms in the context of availability and accessibility. This study was conducted as the initial phase of testing the method of collecting these data as well as identifying if ‘condom deserts’ exist in this context. The next phases will need to include larger regions and assessments of condom use norms. Furthermore, this study examined the availability and accessibility of only one of the HIV prevention methods. This question has begun to be addressed in the context of scale up efforts for wide implementation of HIV prevention methods.29–31 While infrastructure development is time- and resource-consuming, it is imperative in order to meet the goal of no new HIV infections. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
%
Funding 11 7 66
11.5% 7.3% 68.8%
8
8.3%
2 1 1
2.1% 1.0% 1.0%
13
13.5% (continued)
The authors received no financial support for the research, authorship, and/or publication of this article.
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