Arch Sex Behav DOI 10.1007/s10508-014-0307-1

ORIGINAL PAPER

The Association Between Ethnic Identity and Condom Use Among Young Men in the Eastern Cape Province, South Africa Anam Nyembezi • Ken Resnicow • Robert A. C. Ruiter • Bart van den Borne Sibusiso Sifunda • Itumeleng Funani • Priscilla Reddy



Received: 14 March 2012 / Revised: 6 December 2013 / Accepted: 1 February 2014 Ó Springer Science+Business Media New York 2014

Abstract This article reports on the association between ethnic identity and condom use among Black African men in the rural areasoftheEasternCapeProvince,South Africa. Individual face-to-face structured interviews were conducted by trained community research assistants among 1,656 men who had undergone traditional initiation and male circumcision. Logistic regression analyses were used to explore the association between two components of ethnic identity (cultural affiliation and cultural alienation) and condom use. Overall, 49.2 % of the participants reported using condoms consistently and, of these users, 66.4 % used them correctly. Logisticregression adjustingforage, employment status, education level, and nation of origin showed

that participants who expressed high as opposed to low cultural affiliation were significantly more likely to use condoms consistently and correctly when having sex, especially if they reportedto havemorethan onesexual partner.Cultural alienation was negatively related with consistent condom use, whereas its association with correct use was unclear. The findings of this study suggest that positively emphasizing the ethnic identity of African black men may promote condom use. Keywords Ethnic identity  Condom use  Traditional male initiation  Circumcision  Rural  South Africa

Introduction A. Nyembezi (&)  P. Reddy Population Health, Health Systems and Innovation, Human Sciences Research Council, Private Bag X9182, Cape Town 8000, South Africa e-mail: [email protected] K. Resnicow Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA R. A. C. Ruiter Department of Work & Social Psychology, Maastricht University, Maastricht, The Netherlands B. van den Borne Department of Health Education & Health Promotion, Maastricht University, Maastricht, The Netherlands S. Sifunda HIV/AIDS, STIs and TB, Human Sciences Research Council, Cape Town, South Africa I. Funani Health Promotion Research and Development Unit, Medical Research Council of South Africa, Cape Town, South Africa

HIV infection rates among South Africans are among the highest in the world. In 2008, approximately 5.2 million people in South Africa were HIV positive, with an infection rate of 6.6 % among people aged between 15 and 24 years old in the Eastern Cape Province (Shisana et al., 2009). Unprotected heterosexual intercourse combined with concurrent multiple sexual partners (engaging in two or more sexual relationships at the same time) are the main contributors to the spread of the HIV epidemic (UNAIDS, 2010). In heterosexual relationships, consistent and correct use of male condoms is currently the most effective and common means of preventing sexually transmitted infections (STIs), including the human immunodeficiency virus (HIV) among sexually active people (Centers for Disease Control and Prevention [CDC], 2003). Therefore, it is important to understand factors that are associated with condom use among young adults, particularly of individuals who are sexually active and admit to having multiple sexual partners. An extensive body of research has identified predictors of condom use among young people in South Africa. These include

123

Arch Sex Behav

age, gender, level of education, socioeconomic status, number of sexual partners, sexual relationship characteristics (e.g., casual or main partner), knowledge of HIV status, and psychosocial factor, such as attitudes, subjective norms, perceived behavioral control, and self-efficacy (e.g., Chimbindi, McGrath, Herbst, Tint, & Newell, 2010; Hargreaves et al., 2009; Jama Shai, Jewkes, Levin, Dunkle, & Nduna, 2010; Jemmott et al., 2007; Moyo, Levandowski, MacPhail, Rees, & Pettifor, 2008; Reddy, Meyer-Weitz, van den Borne, & Kok, 2000). This study examined the association between ethnic identity and condom use among Black African men in the rural areas of theEasternCapeProvince,SouthAfrica.Ethnicidentityhasbeen described as the degree to which a person identifies with and is involved socially, politically, emotionally, behaviorally or spiritually in cultural beliefs and practices of one’s racial/ethnic group (Langford et al., 2010; Saylor & Aries, 1999). An individual’s ethnic identity can be characterized by the stage or status of his or her exploration. Those who have given little thought or exploration of their ethnic identity are said to be in an unexamined stage and may hold a negative view of their ethnic group. Those who have gone through a stage of searching and have developed a clear meaning of and appreciation for their ethnic background are described as being in an achieved or integrated stage (Phinney, 1990). Among the factors that shape an individual’s ethnic identity are demographic characteristics such as race, age, gender, region of residence, and birthplace (Herd & Grube, 1996). The development of an ethnic identity, regardless of one’s ethnicity, is an essential human need because it provides the individual with a sense of belonging and historical continuity based on a common cultural heritage. Some studies presented ethnic identity as a safeguard against practicing behaviors that place people at risk for unhealthy sexual behaviors. For example, a study conducted among African American heterosexual females demonstrated differences in risky sexual acts in the previous 4 months, depending on the level of ethnic identity. It was reported that those females with higher levels of ethnic identity had lower levels of risky sexual behaviors compared to those with lower ethnic identity levels (Beadnell et al., 2003). In a study conducted among African American girls, ethnic identity was inversely associated with risky sexual attitudes (Belgrave, van oss Marin, & Chambers, 2000). A study conducted among U.S. adolescent girls reported that positive self-conceptualization (which consisted of self-esteem, ethnic identity, and body image) was associated with increased refusal of unprotected sex (Salazar et al., 2004). In another study conducted among African American, Latino American, and European American first year college students, ethnic identity was a protective factor against risky attitudes regardless of ethnicity (Espinosa-Hernandez & Lefkowitz, 2009). No studies have examined the association of ethnic identity and condom use in Africa. However, one study reported on the association of ethnic identity and sexual coercion in South Africa and found fewer reports of personal acts of sexual coercion among those that

123

expressed stronger positive ethnic identity (Nyembezi et al., 2012). We focused on recently circumcised young men because, in most African communities, male initiation and circumcision is a critical rite of passage from boyhood to manhood that contributes to the reinforcement of ethnic identity. Traditionally circumcised men are prepared for new roles as adults and are taught about sexual behaviors, essential duties to their families and community members through a traditional and culturally embedded process called male initiation (le Roux et al., 2007; Mbito & Malia, 2008). There have been concerns that beliefs about male circumcision protecting against HIV infection might decrease rates of STI prevention measures, such as consistent condom use (Bridges, Selck, Gray, McIntyre, & Martinson, 2011). A pilot study among recently traditional circumcised men in the Eastern Cape Province, South Africa reported that 7.9 % of the participants believed that circumcised men do not need to use condoms during sexual intercourse (Nyembezi et al., 2010). This article reports on data gathered from a quantitative study of young men who have undergone initiation and traditional male circumcision, which provided a unique opportunity to also explore the relationship between ethnic identity and condom use. We hypothesized that stronger positive ethnic identity, defined here as higher levels of cultural affiliation and lower levels of alienation would be associated with more consistent and correct condom use. Positive ethnic identity/cultural affiliation should be associated with stronger social bonding as well as, endorsement of traditional values, norms and teachings that encourage respect, discipline, and responsible manhood, which in turn would manifest with more consistent and correct condom use. In addition, strong ethnic identity provides motivation for men to resist risky sexual behaviors such as inconsistent and incorrect condom use that are harmful to their ethnic group. In contrast, cultural alienation would be associated with hopelessness, mistrust, social isolation and lower endorsement of traditional values, norms and teachings which would all increase risk taking behaviors.

Method Participants The study was conducted in five rural district municipalities of the Eastern Cape Province of South Africa among Black African men between 16 and 35 years old. The municipalities were purposively selected because they encompass the diverse nations or izizwe of people living there. Within the selected areas, the Eastern Cape House of Traditional Leaders referred us to 90 local chiefs. The findings discussed in this article have been drawn from a cross-sectional survey conducted among 2,337 men in 2010. Participants were eligible if they were isiXhosa or seSotho speaking, living in the rural area at any of the five districts, and

Arch Sex Behav

had undergone initiation and circumcision in the previous 12–24 months. We excluded 681 participants from the data analysis who reported never having had sex. This resulted in a sample of 1,656 participants. Procedure Data were collected by trained community research assistants (CRAs) who were identified by local chiefs. All CRAs were male who had undergone initiation and circumcision some time in their life and lived in the same community as the participants. All interviews were conducted in isiXhosa or seSotho, the first language of both the participants and the interviewers. CRAs were trained by the research team, informed about the objectives of the study, and taught how to recruit participants, obtain informed consent, administer the questionnaire, and record responses on the answering sheet. The interviews took place in the home of the participants or a place where they were comfortable. Detailed information about the content, procedures, and confidentiality were provided verbally before written consent was obtained. Ethical approval for the study was obtained from the South African Medical Association Ethics Committee. Measures The primary questionnaire was developed in isiXhosa to ensure face validity and then translated into English and seSotho. All questions were inspected for cultural relevance and appropriateness by community elders. The measures were piloted amongst 114 recently initiated and circumcised men (see Nyembezi et al., 2010). Sociodemographic questions elicited age, nation of origin (isizwe), whether they were currently in school (yes vs. no), highest grade passed (primary, secondary or post matric), employment status (yes vs. no), knowledge of local traditional leadership (yes vs. no), and registration with the local chief before undergoing the initiation processes (yes vs. no). Sexual behavior questions enquired about whether participants had a main sexual partner, other sexual partners next to their main partner, and ever had sex (0 = No, 1 = Yes). Open-ended questions asked about the number of current sexual partners, the number of women one had ever had sex within the past 6 months and the number of women one had ever had sex within the past 30 days. Consistent condom use was measured using the averaged scores of three items:‘‘When you have sex, how often do you use a condom?’’(1 = Never, 2 = Sometimes, 3 = Always),‘‘The last time you had sex did you use a condom?’’(0 = No, 1 = Yes), and ‘‘Did you use a condom when you had sex for the first time after initiation processes?’’ (0 = No, 1 = Yes). We decided to dichotomize the scores such that participants obtained consistent condom use (1 = Yes, 0 = No) if they reported to have always used condoms, used it at last sex, and after initiation processes (49.2 %). If participants failed to score positive on at least one of

the items, they were denoted as inconsistent condom users (44.9 %). Based on the premise that correct use of condoms is also an important component of preventing STIs/HIV, we also measured correct condom use. Correct condom use was assessed with five items each measured using a binary scale (1 = Yes, 0 = No; e.g., ‘‘In the past 3 months, did you start having sex with your sexual partner with the condom on and then took it off before sex was over?,’’‘‘In the past 3 months, did you start having sex with your sexual partner without the condom, then put the condom on later?,’’‘‘In the past 3 months, did the condom slip off the penis during sex?.’’Participants were classified as 1 = correct users vs. 0 = incorrect users. Correct use required a negative answer to all five items (66.4 %) and incorrect use at least one positive response (30.6 %). All social psychological measures were based on Likert-type items with five response options. For each measure, scores on items that showed sufficient internal consistency (Cronbach’s alpha [a][.60) were averaged into one single index. Higher scores reflect a stronger presence of the concerning variable. Scales were then inspected for deviations from assumed normal distribution. Strong deviations from normal distributions, predominantly characterized by the presence of bimodal distributions, were identified. In those cases, we decided to dichotomize the scores such that meaningful binary answering categories were created by differentiating those that scored positively on the variable of interest (i.e., scoring four and higher) from those that gave a neutral or negative response (i.e., scoring lower than four). It should also be noted that the binary scoring of the psychosocial measures fits the difficulties participants experienced with using multiple 5-point Likert scales to answer belief-based questions. For example, participants indicated difficulties with differentiating between scores such as 4 = agree vs. 5 = strongly agree as the native languages do not have good synonyms to differentiate between two positive (or negative) answers. In comparing different approaches to the data analysis (i.e., using continuous vs. binary measures of the study variables), the use of binary scales improved the information value of the data as expressed in more explainedvarianceandmorestraightforwardinterpretationofthe findings. Ethnic identity was assessed using 17 items adapted from the Adult Survey of Black Life and Adolescent Survey of Black Life (Resnicow & Ross-Gaddy, 1997; Resnicow, Soler, Braithwaite, Selassie, & Smith, 1999), with a 5-point Likert scale (1 = strongly agree, 5 = strongly disagree). Factor analysis suggested two subscales which were coded as cultural affiliation and cultural alienation. The subscale of cultural affiliation was measured by nine items (e.g.,‘‘I am proud of my cultural heritage,’’‘‘I am proud of being a Black African,’’‘‘It is important for me to respect the authority oftraditional leaders,’’‘‘Ifeel it isimportantformeto contribute positively in improving my community’’; a = .87). The subscale of cultural alienation was measured by seven items (e.g.,‘‘Being Black African makes it harder to succeed in South

123

Arch Sex Behav

Africa,’’‘‘Nowadays, Black African males are more disadvantaged and face more complex challenges than in the past,’’ ‘‘Things are getting worse for Black people in this country’’; a = .89). All items were coded so that higher values indicated more cultural affiliation or more cultural alienation. Because of strongly negative skewed distributions, both subscales were dichotomized into a binary variable, using the sample median to distinguish between those with low cultural affiliation or cultural alienation and those with high scores on these measures. Data Analysis The statistical software SPSS Version 18 was used for all analyses. Frequencies, means, and SD were calculated for sociodemographics and sexual behaviors. Multiple logistic regression models were conducted to examine the independent association between condom use variables and ethnic identity constructs, while controlling for the influence of age, employment, education level, and nation of origin. In addition, we tested two-way interactions between each of the two ethnic identity constructs and number of sexual partners (dichotomized as one sexual partner and more than one sexual partner) as well as the three way interaction among the two ethnic identity scales and number of sexual partners. When interaction terms were significant, we report results separately by the moderator variable (simple effect analysis). Because of the low number of participants in some of the 11 categories of nations (see Table 1) and the stratification of the data analyses along the number of sexual partners (1 vs. more than 1), we dichotomized the measure of nation into 1 = amaXhosa nation (45 %) vs. 0 = all other nations (55 %) for all regression analyses. A significance level of p\.05 was used in the analyses.

Table 1 Sociodemographic profile of participants (N = 1,656) Variables

Sociodemographics The sociodemographic characteristics of the sample are shown in Table 1. The mean age of participants was 21.4 years with a range of 15–36. The majority (45.4 %) belonged to the amaXhosa nation. A total of 38.3 % of the participants were currently in school and 13.9 % were currently working. Of the participants, 91.1 % were able to identify their traditional leader by name and 66.5 % reported that they registered with their traditional leader prior to the proceedings of initiation and circumcision processes. Sexual Behaviors Atotalof72.3 %oftheparticipantsreportedhavingamainsexual partner and, of those, 44.9 % indicated currently having other sexual partners as well. The mean number of female partners participants had sex with in the past 6 months and past 30 days

123

Percentage

Nation (isizwe) abaThembu

36

2.2

amaMpondo

250

15.1

amaHlubi

192

11.6

amaZizi

36

2.2

amaXhosa

751

45.4

abeSotho

64

3.9

amaBhaca

68

4.1

amaMpondomise

79

4.8

amaBhele

62

3.7

amaXesibe Other

47 71

2.8 4.3

634

38.3

1,022

61.7

Currently in school Yes No Highest grade passed Primary Secondary Post-matric

349

21.1

1,047

63.2

260

15.7

Currently working Yes No

230

13.9

1,426

86.1

Have children Yes No

260

15.7

1,396

84.3

1,508 148

91.0 9.0

Know your chief Yes No

Registered with the chief before initiation Yes

Results

Frequencies

No

1,101

66.5

555

33.5

was 1.63 (SD = 1.27) and 1.32 (SD = 1.13), respectively. With respect to condom use, 49.2 % of the participants reported using condoms consistently and 66.4 % used them correctly. Correlates of Condom Use The omnibus logistic regression analysis on the measure of consistent condom use revealed no significant support for the 3-wayinteractionbetweencultural alienation, cultural affiliation, and number of sexual partners, Wald (1) = 0.79, which was therefore removed from the significant regression model, v2(11, N = 1,395) = 180.85, p\.001. However, a significant regression model including the two-way interactions, v2(10, N = 1,395) = 180.07, p\.001, showed significant contributions for the interactions between cultural alienation and cultural affiliation, Wald (1) = 16.22, p\.001, cultural alienation and number of sexual partners, Wald (1) = 45.06, p\.001, and cultural

Arch Sex Behav

affiliation and number of sexual partners, Wald (1) = 7.96, p\.01. Forcorrect condom use,asignificant regression model,v2 (11, N = 1,427) = 201.94, p\.001, showed a significant contribution of the 3-way interaction between cultural affiliation, cultural alienation and number of sexual partner, Wald (1) = 2.95, p\.05. Further analyses to explore the relationships between ethnic identity measures and condom use measures were therefore conducted separately for those with one sexual partner and those with more than one sexual partner. All the multivariate analyses adjusted for differences in age, working status, education, and nation of origin. Consistent Condom Use In Table 2, we show the correlates of consistent condom use stratified by participants with one sexual partner and those with more than one sexual partner. For men with one sexual partner, we found a significant interaction between cultural affiliation and cultural alienation, Wald (1) = 4.34, p\.05, in a significant regression model, v2(8, N = 713) = 114.79, p\.001. However, simpleeffect analysesshowedno significant association between cultural affiliation and consistent condom use for those who reported a low level of cultural alienation (OR 0.61, 95 % CI 0.34–1.09), nor for those reporting a high level of cultural alienation (OR 0.91, 95 % CI 0.58–1.43). Testing the simple effects of cultural alienation for those who reported low versus high cultural affiliation, we found also no significant association between cultural alienation and consistent condom use in those reporting low (OR 0.68, 95 % CI 0.42–1.01) or high levels of cultural affiliation (OR 1.27, 95 % CI 0.73–2.19). In sum, no significant associations were found between both ethnic identity

Table 2 Multivariate logistic regression with consistent condom use as a dependent variable One sexual partner (N = 713)

Multiple sexual partners (N = 655)

Odds ratios (95 % CI)

Odds ratios (95 % CI)

p

p

Cultural affiliation

0.44 (0.26–0.75) .02

0.87 (0.53–1.42) ns

Cultural alienation Age

0.66 (0.41–1.06) .08 0.90 (0.83–0.98) .01

0.24 (0.15–0.40) .001 1.04 (0.97–1.12) ns

Working

1.01 (0.61–1.65) ns

0.63 (0.39–1.00) .05

Primary

1

1

Secondary

4.22 (2.32–7.66) .001 1.34 (0.78–2.32) ns

Post-matric

4.06 (2.44–7.74) .001 1.44 (0.89–2.32) ns

Nations (Xhosa vs. rest)

1.94 (1.35–2.77) .001 1.61 (1.14–2.30) .01

Cultural 2.09 (1.05–4.20) .04 affiliation 9 cultural alienation

2.31 (1.19–4.48) .01

measures and consistent condom use for men who reported to have only one sexual partner. For those with more than one sexual partner, a significant regression model, v2(8, N = 655) = 51.43, p\.001, revealed a significant interaction effect between cultural alienation and cultural affiliation, Wald (1) = 6.15, p = .01. Simple effects showed that for those with low levels of cultural alienation, no significant association was found between cultural affiliation and consistent condom use (OR 0.95, 95 % CI 0.56–1.60). However, a significant positive association between cultural affiliation and consistent condom use was found for those reporting a high level of cultural alienation (OR 1.90, 95 % CI 1.18–3.07). Vice versa, testing the simple effect of cultural alienation under low and high levels of cultural affiliation, we found negative associations between cultural alienation and consistent condom use for those reporting low levels of cultural affiliation (OR 0.25, 95 % CI 0.15–0.41) and also (but less strong) for those reporting high levels of cultural affiliation (OR 0.56, 95 % CI 0.35–0.90). In sum, for those with more than one sexual partner, the findings suggest that strengthening cultural affiliation may promote consistent condom use, especially in those that feel that Black Africans have a harder time in current South Africa (high cultural alienation); whereas feelings of alienation in themselves negatively relate to consistent condom use.

Correct Condom Use In Table 3, we show the correlates of correct condom use stratified by those participants with one sexual partner and those with multiple sexual partners. For men with one sexual partner, we found no significant support for the interaction term of cultural affiliation and cultural alienation, Wald (1) = 2.44. We therefore repeated the analysis without the interaction term in the model. In a significant regression model, v2(N = 729) = 123.27, p\.001, we found a positive association between cultural affiliation and correct condom use (OR 3.64, 95 % CI 2.37–5.59), suggesting that feeling more proud of the own ethnic identity is associated with more correct condom use. The association of cultural alienation with correct condom use was also positive but smaller (OR 1.50, 95 % CI 1.02–2.22), suggesting that more cultural alienation is also resulting in more correct condom use. For men with multiple sexual partners, the interaction effect between cultural affiliation and cultural alienation did also not approach significance, Wald (1) = 0.12. Repeating the analyses with only the main effects of both ethnic identity measures revealed in a significant regression model, v2(df = 7, N = 670) = 63.78, p\.001, a positive contribution of cultural affiliation in the prediction of correct condom use (OR 2.21, 95 % CI 1.56–3.14), whereas the contribution of cultural alienation was not significant (OR 0.93,95 % CI0.66–1.31).In sum, the findings for the relation between ethnic identity measures and correct condom use thus suggest that cultural affiliation is a strong

123

Arch Sex Behav Table 3 Multivariate logistic regression with correct condom use as a dependent variable

Cultural affiliation

One sexual partner (N = 729)

Multiple sexual partners (N = 670)

Odds ratios (95 % CI)

Odds ratios (95 % CI)

p

p

3.64 (2.37–5.59) .001 2.21 (1.56–3.14) .001

Cultural alienation

1.50 (1.01–2.22) .04

0.93 (0.66–1.31) ns

Age

0.95 (0.86–1.04) ns

1.06 (0.98–1.15) ns

Working

0.45 (0.28–0.72) .001 0.45 (0.29–0.71) .001

Primary

1

1

Secondary

0.77 (0.36–1.68) ns

Post-matric

0.41 (0.21–0.78) .007 1.54 (0.97–2.48) .07

2.73 (1.55–4.82) .001

Nation (Xhosa vs. rest)

0.71 (0.48–1.07) .10

0.59 (0.41–0.83) .003

positive predictor of correct condom use, whereas this is not (or less) the case for the measure of cultural alienation.

Discussion This study was one of the first to explore the association of ethnic identity and condom use among young men who have been traditionally initiated and circumcised in South Africa. Our participants were an important cohort to study in the context of HIV transmission within heterosexual relationships that are often characterized by risky sexual behaviors such as unprotected sex (Bridges et al., 2011; Nyembezi et al., 2010). Our sample was at increased risk for STIs/HIV infection because 44.9 % were in concurrent sexual relationships, more than half reported inconsistent condom use, and 66.4 % incorrectly used condoms. Given that the mean age was 21 years, the participants represent a group that is regarded as highly susceptible to HIV infection and to spread the virus to their female sexual partners. Our findings highlight the need for STI/HIV prevention strategies that continue to encourage sexually active circumcised men to consistently and correctly use condom, as every sexual act that is protected by a condom reduces the risk of infection. Furthermore, they should be provided with the essential skills to negotiate with their sexual partners to always use condoms correctly (Jemmott et al., 2007; Reddy et al., 2000; Saleh-Onoya et al., 2009). Our findings were consistent with other studies that have shown ethnic identity as a protective factor for risky sexual behaviors, including unprotected sex (Belgrave et al., 2000; Espinosa-Hernandez & Lefkowitz, 2009; Salazar et al., 2004). Higher levels of cultural affiliation were significantly associated with consistent and correct condom use, especially among those who reported having multiple sexual partners. This positive association may well be explained by participants’ realization of their risky sexual behaviors, such as engaging in concurrent multiple sexual relationships. In addition, from a cultural

123

perspective, unmarried men among the investigated nations are still largely expected to pay damages of impregnation (which is commonly known as inhlawulo); hence, using condoms consistently and correctly when having sex is necessary. It could be contended that cultural affiliation was protective as participants’ responsible behavior might have been informed by the cognition to their personal benefits, their community and nation, while maintaining the values and norms that are rooted in their own culture, including healthy sexual practices. Therefore, traditional male initiation could also serve as an intervention setting to further strengthen circumcised men’s commitment to cultural values and thus reduce aversive sexual practices and promote safe sexual practices. Somewhat counterintuitive was the negative relation between higher levels of cultural affiliation and consistent condom use among those men who had one sexual partner. This is understandable because during the right of passage, which is regarded as part of ethnic identity, men are encouraged to have one sexual partner and think about marrying. Therefore, it could be contended that those who reported having one sexual partner used condoms inconsistently to prevent unwanted pregnancy which is normally perceived as a more immediate threat than STI/HIV. However, there is a need for culturally tailored health education interventions aimed to encourage traditionally initiated and circumcised unmarried men to use condoms consistently. In contrast, higher levels of cultural alienation were associated with inconsistent condom use among those men who had multiple sexual partners. A possible explanation could be that those participants who felt culturally alienated may have been more concerned about immediate sexual pleasure than the long-term negativeoutcomesofinconsistentcondomuseandbehaviorsthat can be risky to the members of the community. It could also be contended that this association was based on the perception that circumcised men do not need to use condoms during sexual intercourse (Nyembezi et al., 2010). The findings among men who had multiple sexual partners suggest that more work is needed to highlight the role played by multiple sexual partnerships in exacerbating the spread of STI/ HIV infection. For example, HIV prevention interventions for traditionally initiated men should include components aimed to discourage any attitudes that promote multiple sexual partners. They should be embedded into the cultural and social meaning of traditional male circumcision, which motivates men to have one sexual partner and marriage (Vincent, 2008). The current investigation had several limitations that should be considered for future research. The interpretation of the results was limited to the population in which the research was done and further research should be extended to Black African men of different populations and settings. In addition, further research is needed to understand the difference of risky sexual behaviors across nations that practice initiation and traditional male circumcision in the Eastern Cape Province. In the current study, we controlled for nation membership but a closerlook at the data (not

Arch Sex Behav

reported here) suggest that particular men who belong to amaMpondo, amaHlubi, amaZizi, amaBhaca, abeSotho and amaBhele nations reported behaviors such as multiple sexual partners, inconsistent and incorrect condom use, that are known to enhance transmission of STIs (including HIV) and unwanted pregnancies.Theuseofself-reportedmeasurestoassesssensitive and complex information about condom use leaves room for misreporting. In addition, this study generated new measures and constructs on this topic, but the use of Likert scales also showed significant limitations when applied in a non-English language context, more especially when translated in isiXhosa and seSotho languages. Our participants indicated difficulties to assess the distinctioninthese languages betweenscores,such as‘‘agree’’and ‘‘strongly agree’’and‘‘disagree’’and‘‘strongly disagree.’’Hence, most of the measures were dichotomized for analysis. These measures could nevertheless be used as a stepping point for further measurement development. These limitations notwithstanding, our results highlight the need to explore the role of traditional male initiation practices and ethnic identity commitment in the STI/HIV prevention strategies. The findings of this article can inform the development of culturally appropriate health promotion interventions, which can be integrated into the initiation practices and sexual behavior education programs. Acknowledgments The authors wish to thank Eastern Cape House of Traditional Leaders, CRAs, and the study participants for their support and cooperation in this project.

References Beadnell, B., Stielstra, S., Baker, S., Morrison, D. M., Knox, K., Gutierrez, L., et al. (2003). Ethnic identity and sexual risk-taking among AfricanAmerican women enrolled in an HIV/STD prevention intervention. Psychology, Health & Medicine, 8, 187–198. Belgrave, F. Z., van oss Marin, B., & Chambers, D. B. (2000). Cultural, contextual, and intrapersonal predictors of risky sexual attitudes among urban African American girls in early adolescence. Cultural Diversity & Ethnic Minority Psychology, 6, 309–322. Bridges,J.F.P.,Selck,F.W.,Gray,G.E.,McIntyre,J.A.,&Martinson,N.A. (2011). Condom avoidance and determinants of demand for male circumcision in Johannesburg, South Africa. Health Policy and Planning, 26, 298–306. CDC. (2003). Male latex condoms and sexually transmitted diseases. Retrieved June 10, 2011, from http://www.cdc.gov/nchstp/od/cond oms.pdf. Chimbindi, N. Z., McGrath, N., Herbst, K., Tint, K. S., & Newell, M. L. (2010). Socio-demographic determinants of condom use among sexual active young adults in rural KwaZulu-Natal, South Africa. The Open AIDS Journal, 4, 88–95. Espinosa-Hernandez, G., & Lefkowitz, E. S. (2009). Sexual behaviors and attitudes and ethnic identity during college. Journal of Sex Research, 46, 471–482. Hargreaves, J. R., Morison, L. A., Kim, J. C., Busza, J., Phetla, G., Porter, J. D., et al. (2009). Characteristics of sexual partnerships, not just of individuals,areassociatedwithcondom use andrecent HIVinfectionin rural South Africa. AIDS Care, 21, 1058–1070.

Herd, D., & Grube, J. (1996). Black identity and drinking in the US: A national study. Addiction, 91, 845–857. Jama Shai, N., Jewkes, R., Levin, J., Dunkle, K., & Nduna, M. (2010). Factors associated with consistent condom use among rural young women in South Africa. AIDS Care, 22, 1379–1385. Jemmott, J. B., Heeren, G. A., Ngwane, Z., Hewitt, N., Jemmott, L. S., Shell, R., et al. (2007). Theory of planned behaviour predictors of intention to use condoms among Xhosa adolescents in South Africa. AIDS Care, 19, 677–684. Langford, A. T., Resnicow, K., Davis, R. E., Alexander, G. L., Calvi, J., Weise, C., et al. (2010). Ethnic identity predicts loss-to-follow-up in health promotion trial. Contemporary Clinic Trials, 31, 414–418. le Roux, R., Niehaus, D. J., Koen, L., Seller, C., Lochner, C., & Emsley, R. A. (2007). Initiation rites as a perceived stressor for IsiXhosa males with schizophrenia. Transcultural Psychiatry, 44, 292–299. Mbito, M. N., & Malia, J. A. (2008). Transfer of the Kenyan Kikuyu male circumcision ritual to future generations living in the United States. Journal of Adolescence, 32, 39–53. Moyo, W., Levandowski, B. A., MacPhail, C., Rees, H., & Pettifor, A. (2008). Consistent condom use in South African youth’s most recent sexual relationships. AIDS and Behavior, 12, 431–440. Nyembezi, A., Resnicow, K., James, S., Funani, I., Sifunda, S., Ruiter, R. A. C., et al. (2012). The association between ethnic identity and sexual coercion among young men in the Eastern Cape Province, South Africa. Journal of Health Psychology, 17, 1089–1094. Nyembezi, A., Sifunda, S., Funani, I., Ruiter, R. A., van den Borne, B., & Reddy, P. S. (2010). Correlates of risky sexual behaviors in recently traditionally circumcised men from initiation lodges in the Eastern Cape, South Africa. International Quarterly Community Health Education, 30, 97–114. Phinney, J. S. (1990). Ethnic identity in adolescents and adults: Review of research. Psychological Bulletin, 108, 499–514. Reddy, P., Meyer-Weitz, A., van den Borne, B., & Kok, G. (2000). Determinants of condom-use behaviour among STD clinic attenders in South Africa. International Journal of STD and AIDS, 11, 521–530. Resnicow, K., & Ross-Gaddy, D. (1997). Development of a racial identity questionnaire for low-income African Americans. Journal of Black Studies, 28, 239–254. Resnicow, K., Soler, R. E., Braithwaite, R. L., Selassie, M. B., & Smith, M. (1999). Development of racial and ethnic identity scale for African American adolescents: The survey of Black life. Journal of Black Psychology, 25, 171–188. Salazar,L.F.,DiClemente,R.J., Wingood, G.M.,Crosby,R.A.,Harrington, K., Davies, S., et al. (2004). Self-concept and adolescent’s refusal of unprotected sex: A test of mediating mechanisms among African American girls. Prevention Science, 5, 137–149. Saleh-Onoya,D.,Reddy,P.S.,Ruiter,R.A.,Sifunda,S.,Wingood,G.,& van den Borne, B. (2009). Condom use promotion among isiXhosa speaking women living with HIV in the Western Cape Province, South Africa: A pilot study. AIDS Care, 21, 817–825. Saylor, E. S., & Aries, E. (1999). Ethnic identity and change in social context. Journal of Social Psychology, 139, 549–566. Shisana, O., Rehle, T., Simbayi, L. C., Zuma, K., Jooste, S., Pillay-van-Wyk, V., et al. (2009). South African national HIV prevalence, incidence, behavior and communication survey 2008: A turning tide among teenagers?. Cape Town: HSRC Press. UN Joint Programme on HIV/AIDS, Global Report. (2010). UNAIDS report on the global AIDS epidemic. Retrieved August 12, 2011, from http:// www.unhcr.org/refworld/docid/4cfca9c62.html. Vincent, L. (2008). ‘Boys will be boys’: Traditional Xhosa male circumcision, HIV and sexual socialisation in contemporary South Africa. Culture, Health & Sexuality, 10, 431–446.

123

The association between ethnic identity and condom use among young men in the Eastern Cape Province, South Africa.

This article reports on the association between ethnic identity and condom use among Black African men in the rural areas of the Eastern Cape Province...
221KB Sizes 1 Downloads 3 Views