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Abstract

Background:

Although it is well known that low condom usage among fishers contributes to high HIV prevalence in fishing communities, little is known about the attitudes, beliefs, and behaviors of fishers when it comes to the use of condoms.

Design and methods:

This article is a follow-up to a cross-sectional study that used a mix-method design for data collection and analysis to examine the connection between mobility and the risk of contracting HIV among 385 fishers in the Elmina fishing community of Ghana. The Health Belief Model is utilized in the discussions to analyze attitudes and actions toward condom use among the fishers in Elmina.

Results:

Over 40% of respondents who said they had intercourse in the previous year did not use condoms. The results show that male fishers are more likely than female fishers to use condoms during sexual activity, and younger fishers are more likely to use condoms than older fishers. More condoms were used by educated fishers than by less educated or uneducated fishers. According to the study, female fishers use less condoms than male fishers since they are unable to convince their partners to use them when they refuse to. Additionally, the findings show that slightly more than one in 10 respondents did not use condoms because they believed their sexual partner to be attractive and unlikely to carry any sexual infection.

Conclusion:

There is a general low perception of HIV susceptibility and severity resulting in the low condom usage among the fisherfolks according to the results. The article urges civil society organizations in the study area to investigate ways to incorporate the provision of free condoms to fishers and at the numerous fishing destination sites along the coast of Elmina. The regular use of condoms in Elmina and the nearby fishing areas should also be emphasised through this outreach or mobile HIV service outlets.

Keywords

HIV and AIDS fishers mobility condoms use behavior Elmina Ghana

Introduction

Using condoms consistently in casual sexual relationships protects sexual partners from the risk of HIV transmission. Prior work on HIV indicates lower condoms use amongst mobile population groups such as truck drivers, mine workers, construction workers, traders, commercial sex workers, military personnel, and fishers.¹ These human population groups are described as a high risk of HIV transmission owing to their high mobility, engagement in multiple interactions with foreign and local populations, and sexual exchanges with itinerant traders and sex workers as they move from one destination to another doing their work.^1,2

Earlier fisheries studies around the world report low and inconsistent usage of condoms among fisherfolks resulting in their having high rates of HIV infection.^3,4 Prior studies in West Africa also describe fishers as a human population group that do not utilize condoms consistently.^4,5 In Ghana, similar findings of low condom use among artisanal fishers have also been reported in fishing destinations.^5,6 Prior works that have reported poor condom use among fisherfolks adduce barriers to condoms use to several reasons. In Kwena et al.,⁷ they mention that female fishers constitute a group that do not use condoms in sexual exchanges due to refusal to condoms by their partners. Some fishers also refuse to use condoms since they usually do not have any when they engage in sexual activity in the fishing locations where they engage in the act.⁶ Eleftheriou et al.⁸ also reports in an earlier work of fishers not using condoms because they trusted their partners to be disease free. These reports from earlier studies highlight unsafe sexual practices and consequences for HIV exposure in fishing locations due to low condom usage among fishers.

Although studies in developing countries in Africa, South and South-East Asia, and Central American fishing communities have indicated that fishers have poor attitudes toward condom use,^2–5,9 little is known about the circumstances in Ghanaian fishing communities. Therefore, the underlying assumption of this paper is that attitudes, behaviors, and barriers related to condom usage among Ghanaian fisheries workers are poorly documented and overlooked in literature and discourses concerning fisheries production and management. Underestimating the susceptibility, severity, and threat of HIV exposure because of fishers’ adverse attitudes and behaviors regarding condom use has negative implications on fishers’ health as well as the fishing industry. Therefore, it is critical to understand the dynamics of HIV threats, transmission, and prevention among fishers in relation to condom usage. The objective of this paper is to examine condom usage and perceived barriers to its use during sex among fishers in the Elmina fishing community. This work will fill a significant gap in the design, execution, and management of programs that are essential for decision-making processes directed toward HIV prevention among fisheries workers. The HBM has been used to analyze and explain fishers’ perception of condoms, and whether they view it as a method of assuring protected sex and lowering the risk of HIV in the study area.

HIV vulnerability and condom use among fishers

The first recorded usage of the condom was during the Roman era, when animal bladders were employed to stop the spread of sexually transmitted infections (STIs).¹⁰ The first mention was made public by Italian anatomist Gabriel Fallopio, who suggested using a linen sheath soaked with lotion to prevent syphilis in 1564.¹¹ Condoms are only particularly mentioned as a method of family planning to avoid conception in the 18th century. But when HIV spread, policymakers and program managers for reproductive health turned their emphasis on to strategies to prevent the disease, particularly condom use, which was promoted as a preventative measure and a contraceptive.¹⁰ Pinkerton and Abramson¹² explain that individuals who use condoms consistently are 10–20 times less likely to be infected with HIV than non-condom users. Inconsistent use of condoms in any non-regular sexual activity is regarded as unprotected sex which could expose an individual to STIs.

Earlier studies on fishers in fishing communities in some developing countries in Africa, South and South-East Asia, and Central America have produced evidence that suggests high HIV infection rates among fishers and other people living in fishing communities.^2,5,9 Earlier works estimate rates of HIV prevalence in fishing communities to be five to ten times higher than those in the general population.^2,5,9,13 Some reason given for the high HIV rates in fishing communities is the high mobility of fishers, which contributes to changing sexual behaviors among them.^13–17 The low use of condoms by fishers in sexual exchanges at fishing destinations also accounts for their high HIV rates.³ Prior studies in Kenya, Zambia, and Uganda adduce fishers’ non-use of condoms to ignorance and poor knowledge about HIV prevention methods.^3,7,18 Kyei-Gyamfi⁶ describes the high mobility of fishers poses a challenge for many to participate in HIV education at fishing destinations, leading to their poor knowledge, and behavior regarding HIV transmission and protection.

Holvoet¹⁵ notes the state of living conditions in fishing communities favors promiscuous lifestyles, whilst Lungu and Hüsken³ also argue that inadequate accommodation for mobile fishers in fishing destinations leads to sexual relations and risky sexual engagements there. Lungu and Hüsken³ further elaborate that the inadequate accommodation facilities in the fishing communities facilitate fish traders cohabiting with single male fishers, which often leads to risky sexual engagements. According to Kyei-Gyamfi,¹⁹ some female fish traders travel to the fish markets with very little trading capital and often do not want to use their income for accommodation if they must spend a night at a fishing destination outside their homes. The fish traders, often out of desperation to get a comfortable place to sleep as well as to keep their trading capital intact, offer sex in exchange for accommodation and to secure their trading capital.³ Many of these women who have been given free lodging are frequently put in situations where they are unable to negotiate the usage of condoms because they are afraid of losing the offer when the men suggest having sex without them.³

Another reason for low condom usage among fishers is their HIV risk denial attitudes.^20,21 Fishing is generally regarded as a high-risk occupation in terms of livelihood insecurity, and physical danger.²² According to Allison and Seeley²⁰, fishing’s inherent risks and uncertainties encourage fishers to engage in hazardous sexual activity, abuse drugs and consume excessive alcohol. Lubega et al.²¹ found in a study in Kasensero of Uganda that lack of HIV-related fear among fishers was a determining factor in the high HIV transmission in the study area. Besides, they observe that in Kasensero many fishers have had experiences of seeing their colleagues dying at sea whilst fishing, and as a result, these fishers see this activity as a life-threatening and more dangerous undertaking than the fear of HIV infection. Owing to this, the decision to use condoms hardly occurs to fishers with an HIV-risk denial attitude and this works against HIV protection efforts in fishing communities.^15,20,21 According to Kwena et al.,⁷ some female fish traders engage in unprotected sex when their male partners refuse to use condoms out of fear of losing access to fish. Many of these women find it challenging to negotiate for protection during sex because they fear losing their fish supplies to other female fish traders who, if they refuse, may give in to the sexual demands of the male fishers. According to Kyei-Gyamfi,¹⁹ women in most fishing villages depend on their male counterparts either for fish or other economic gains, which exposes them to these sexual exploitations.

The health belief model (HBM)

The HBM is an important psychological model that emphasizes individual attitudes and beliefs to explain and predict health behaviors. It was developed in the 1950s by social psychologists working for the US Public Health Service and modified in the 1980s. It was developed to explain the lack of public participation in health screening and prevention initiatives. It is a tool that scientists use to try to predict health behaviors.^23,24 The HBM has since been adapted to examine a range of health behaviors, including sexual risk behaviors and the spread of HIV. The fundamental idea of the HBM, according to Hochbaum²⁴, is that individual beliefs or perceptions about a disease and the methods available to reduce its incidence influence health behavior. Therefore, the model which has six constructs sees “belief” as the key component in preventing a health condition. It has been used in this paper to explain attitudes and behaviors regarding the use of condoms among fishers.

Perceived susceptibility is the first HBM construct, and it reflects how susceptible a person feels to a certain health risk, such as their propensity to contract a virus like HIV. Therefore, a person must first believe they are at risk of contracting HIV before taking any action to prevent it. People are typically more driven to take action to avoid contracting an illness when they perceive they are at risk of becoming infected. In other words, people tend to engage in less healthy behaviors when they perceive they are not at risk or are at low risk. Previous studies on fishers have found that most of them believe they are invincible to HIV because they see themselves as physically fit people who regularly face and overcome various hazards while carrying out their regular fishing responsibilities.^20,21 Given that many fishers perceive the fishing occupation to be more dangerous than HIV, their belief about their susceptibility to HIV is very low, accounting for their unpreparedness to take precautions like wearing condoms during sex. In a previous study, Korankye and Dwomoh⁵ revealed that although fishers in Elmina, were aware of HIV, most of them did not see the disease as a concern. Many of them believed that HIV only affects others and not themselves, and therefore not view it as a dangerous condition that should be taken seriously. The chance of participating in behaviors to reduce risk increases with perceived risk.

The second construct on perceived severity refers to one’s perception of the gravity of a disease or other health condition. Medical outcomes, such as death or disability, or individual beliefs about how the illness would affect their life can both be used to determine severity. When people are unaware of how serious an illness is, as the HBM proposes, they are less likely to take preventive actions. This explains why people who do not consider HIV to be a severe virus never use condoms.¹⁵ Individuals are more inclined to act when they view their vulnerability and severity to be greater. The severity of HIV will be viewed differently by fishers if they are made aware of its threat.

The third construct is known as perceived benefits, and it refers to an individual’s assessment of the worth or usefulness of a new behavior in lowering the risk of contracting a disease. When people think their new action may lower their risk of contracting an illness, they are more likely to adopt healthy habits. Individuals frequently wonder what gains or losses they would experience if they altered their behavior. Likewise, they will not perceive the need to modify their bad behaviors if they do not understand the advantages of changing their behavior. For example, female fishers in fish-for-sex (FFS) relationships have reported in previous studies that their male sexual partners have refused to use condoms during their encounters.^22,25 Incidentally, the women are either afraid to insist on their partners using condom or are unconcerned about the risk of a STI, since using condoms would mean losing access to fish or other financial gain from their male fisher partners. Not using condoms during sex puts the women and their partners at risk of contracting STI, but they stand to benefit by getting easy and regular access to fish supply. These female fishers have always had unprotected sex with their FFS partners, so it is a challenge convincing them to change a behavior knowing that they stand to lose access to fish supplies or a kind of financial benefit. The HBM espouses that many people will not give up something they enjoy if they will not get something in return. People need to have faith in the change’s ability to produce beneficial outcomes to make it.

A person’s perception of the barriers to behavior change is known as perceived barriers. Barriers might be tangible or intangible. For instance, in fishing communities, tangible barriers may include a lack of funding, poor condom access, and a dearth of HIV education initiatives owing to the remote nature of fishing communities. Intangible obstacles are usually psychological or emotional in nature such as people being afraid to insist on the use of condoms, or ashamed to buy condoms, or are intimidated to seek help for a health condition. According to the HBM, for a person to adopt a new behavior, they must perceive that the advantages of the new behavior outweigh the consequences of retaining the old behavior. Sometimes people need assistance in figuring out how to get beyond obstacles. A hurdle to identifying a behavior change in condom usage among the female fishers involved in FFS in Elmina is the anxiety of asking male fishers to use condoms during sex. A fisher who wants to use condom and cannot get one to buy due to lack of access in a remote fishing village may serve as a barrier to having safe and protective sex. Perceived barriers are the HBM construct that has the greatest impact on behavior change, according to Janz and Becker.²⁶ Change is not something that comes easily, but it is likely to occur once the individual is able to overcome the barriers.

The HBM contends that in addition to the four beliefs or perceptions and moderating factors, cues to action also have an impact on behavior. The fifth construct relates to internal and external cues for action which constitute the circumstances that lead to risky or protective behavior. These are strategies used to encourage people to take initiative by boosting individual or collective readiness. These may include programs that encourage people to make specific decisions, such as those that provide information, raise awareness, and serve as reminders about HIV and AIDS. In other words, a person’s risky or protective behaviors depend on how well HIV and AIDS education initiatives inform the public about the infection and disease. Incidentally, fishing communities are described in the fisheries literature as hard-to-reach areas with HIV and AIDS education programs.^6,14,27 In addition to the difficulty of reaching fishers to sensitize them, many of them lack the time or are uninterested in participating in such programs because of the mobile nature of their work.¹⁴ These factors account for poor knowledge, attitude and behaviors regarding HIV and AIDS among fisher groups.

The perceived self-efficacy, also known as personal competence or capability, of the individual to engage in protective behaviors, is the sixth construct of the HBM. Self-efficacy is the assurance that a person has in their capacity to act or carry out a specific behavior. People usually do not attempt to acquire new behaviors unless they have confidence in their ability to do so. A person who believes changing their conduct would be beneficial but is skeptical of their ability to do so is unlikely to try changing their way of life. For example, in a very divisive fishing community where a lot of women are marginalized and largely dependent on male fishers for sustenance, the capacity and tenacity of women to bargain for the use of condoms in sexual encounters is very low. According to Kwena,²⁸ most sexual encounters in fishing communities take place in unprotected circumstances with very little condom use since many women are unable to bargain for the use of condoms out of fear of being denied access to fish. In such circumstances, it becomes impossible to carry out a suggested course of action, such as negotiating condom use. The HBM, however argues that with support, training, and other encouragement, self-efficacy can be strengthened.

The HBM has been criticized for failing to pay enough attention to environmental and economic factors that frequently have an impact on health behaviors.^29,30 It ignores for instance, gender-based economic disparities between men and women, which have a significant impact on how much control men and women have when making decisions about their sex lives. This is typical of fishing communities where many women depend on men for fish or for financial support. Men have a lot of power to manipulate decisions about having sexual encounters because women rely on them for these supports. For instance, some women are afraid of losing a favor they are asking of their male partner if they try to negotiate the use of a condom during a sexual encounter where a man insists on not using one. The model is also critiqued for being individualistic and failing to sufficiently account for how peer pressure and societal norms affect people’s choices in terms of their health-related behaviors. It is also possible that some cultural influences are out of a person’s control. When young individuals are away from home, peer pressure and peer modeling effects have a stronger influence on the choices they make about their sexual behavior. Young mobile employees, like fishers, who are frequently away from their homes and lose familial ties, are susceptible to this. The model, according to critics, also focuses more on describing health behaviors than it does on demonstrating how to alter them.²³

Despite its limitations, the HBM is effective in the current paper’s explanations of the hazardous and protective behaviors of fishers. The model explains why some people would choose to wear condoms during sex and why other people might not. The model also describes advances in reducing HIV risk behaviors that can be realized when efforts are placed toward improving knowledge, attitudes, and perceptions through the construct on the cues for action. In the same way it forecasts individual sexual behaviors, it enables the development of appropriate interventions for increasing safe sex in fishing communities. The use of the HBM in this paper is very suitable in explaining attitudes and behaviors regarding the use of condoms by fishers in fishing communities.

Methods

This paper is based on an earlier cross-sectional study conducted between July 2017 and August 2017 in the Elmina fishing community in the Komenda Edina Eguafo Abrem (KEEA) Municipality in the Central region of Ghana. For data collection and processing, it used convergent parallel mixed research methods. The goal of the study was to ascertain whether fishers’ mobility and susceptibility to HIV infection were related. For interpreting the findings, it integrated a survey with key informant interviews (KIIs), focus group discussions (FGDs), observation, secondary data from both published and unpublished works, and the Internet. The main research population consisted of artisanal marine fishers who were 18 years or older and were involved in any type of fishing activity in the study area, including actual fishing, fish porterage, boat (canoe) repairs, and the sale of fishing gear, and fish trading.

Owing to budget constraints, the time allocated to administer the questionnaires, and the unknown population size of fishers in the study area for the main study, the author derived the sample size by computing the minimum sample size required for accuracy in estimating proportions. To arrive at an estimated sample size of 385 respondents for the survey, he considered a standard normal deviation at a 95% confidence level (1.96), the percentage choosing a choice or response (50% = 0.5), and confidence interval (0.05 = 5).

The 30 participants in the KII were chosen using a purposeful sampling criterion. Selected key KEEA officials, as well as influential members of the community such as the fish queen, chief fisherman, and other traders of fishing accessories, participated in the KIIs. The purpose of the KIIs was to learn about their opinions on fishing activity and problems relating to fishers’ sexual behavior. Male and female fishers participated in two FGDs. Ten people made up each group, chosen based on their age, place of residence, membership of fisher associations, and ability to offer in-depth information that would help answer the research questions. Several trips were made to the landing beach to see the offshore activity. The observations allowed for a first-hand evaluation of the fishing conditions in Elmina, including settlement patterns, the level of social infrastructure and services, sleeping and living arrangements, repair, molding, and production of fishing gear, and general experience. Regarding quantitative analysis, both descriptive (frequencies, percentages) and inferential (Chi-square test) statistics have been used in the analysis to draw conclusions from the quantitative data. Bivariate analysis was done by cross tabulating the variables of interest to determine the association between independent and dependent variables.

Thematic analysis was also used to analyze the qualitative data. The KIIs and FGDS data were transcribed with an audio recorder to produce a report. After transcribing the KIIs and FGDs, the author thoroughly examined the data to become acquainted with the results, and assigned codes to the various themes, which emerged from the interactions. The next stage was to organize the data from the KIIs and FGDs by arranging them under the codes (themes). Writing a report on the findings was the last step. Narrative descriptions have also been made to explain relationships in the data presented, with statements by participants of the FGDs and KIIs also presented as quotes in some portions to enrich the analysis.

Results

Socio-demographic background of fishers

The socio-demographic characteristics of the 385 participants in the survey have been analyzed by sex, age, mobility status, education, religion, marital status, and type of fishing engagement (see Table 1). The results indicate more females (51.4%) than males (48.6%) participated in the survey. Table 1, again, indicates participants aged 34–44 constitute the majority (29.9%) of the sample, followed by the 25–34-year group (24.2%) and those below 25 years (22.3%). The participants reporting being 65 years and above, formed the least (3.6%) group. Results in Table 1 show that 76.4% of the participants were below 35 years. The results in Table 1 also indicate that more than half (54.3%) of the study participants were mobile fishers. Mobile fishers constitute those reporting to have traveled from Elmina to other fishing communities to engage in any fishing activity in the last 12 months before the study.

Table 1.

Socio-demographic characteristics of respondents.

	Frequency	Percent
Sex
Male	187	48.6
Female	198	51.4
Age
<25	86	22.3
25–34	93	24.2
35–44	115	29.9
45–54	50	13.0
55–64	27	7.0
65+	14	3.6
Mobility status
Mobile fisher	209	54.3
Non-mobile fisher	176	45.7
Education
No education	129	33.5
Middle/JHS education	207	53.8
Secondary/vocational and higher	49	12.7
Religion
Islam	21	5.5
African traditionalist	19	4.9
No religion	29	7.5
Christianity	316	82.1
Marital status
Never married	112	29.1
Cohabiting/Informal/Consensual	34	8.8
Married	180	46.8
Divorced/separated/widowed	59	15.3
Type of fishing occupation
Fish catch group	98	25.5
Post-harvest group	149	38.7
Maintenance and repair group	55	14.3
Porters and errand group	83	21.5

Source: Fieldwork, July–August 2017.

In terms of education, Table 1 further indicates that 53.8% of respondents had attained Middle/JHS education level, almost a third with no education, and 12.7% reporting to have secondary/vocational school and higher education. The majority of the participants were Christians (82.1%). Regarding marital status, 46.8% reported being married, whilst the remaining 53.2% were not in any form of marital union. More than one-third (38.7%) of participants reported being engaged in post-harvest activities. The rest of the participants engaged in actual fishing (25.5%), fish porterage (21.6%), and boat repair and/or maintenance (14.3%).

Condoms usage during sexual intercourse

The results regarding participants reporting to have had sex with the use of condoms within the previous 12 months of the study are shown in Table 2. According to Table 2, 56.6% of the respondents admitted to using condoms during sexual activity. According to the findings, a little more than four in ten of the respondents who had intercourse during the period did not use a condom. Table 2 also shows that 34.8% of women and 54.0% of men who responded to the survey used condoms during their most recent intercourse.

Table 2.

Condom usage in the last 12 months by background characteristics.

Background characteristics	Used condom (%)	Did not use condom (%)	p<value
Sex			0.000
Male	101 (54.0)	86 (46.0)
Female	69 (34.8)	129 (65.2)
Age			0.000
<25	53 (61.6)	33 (38.4)
25–34	51 (54.8)	42 (45.2)
35–44	35 (30.4)	80 (69.6)
45–54	20 (40.0)	30 (60.0)
55–64	8 (29.6)	19 (70.4)
65+	3 (21.4)	11 (78.6)
Mobility status			0.118
Mobile fisher	100 (47.6)	110 53.4)
Non-mobile fisher	69 (39.7)	105 (60.3)
Education			0.025
No education	50 (38.8)	79 (61.2)
Middle/JHS education	90 (43.5)	117 (56.5)
Secondary/vocational and higher	30 (61.2)	19 (38.8)
Religion			0.140
Islam	7 (33.3)	14 (66.7)
African Traditionalist	12 (63.2)	7 (36.8)
No religion	16 (55.2)	13 (44.8)
Christianity	135 (42.7)	181 (57.3)
Marital status			0.000
Never married	66 (58.9)	46 (41.1)
Cohabiting/Consensual	23 (67.6)	11 (32.4)
Currently married	58 (32.2)	122 (67.8)
Divorced/Separated/Widowed	23 (39.0)	36 (61.0)
Type of fishing activity			0.000
Fish catch group	49 (50.0)	49 (50.0)
Post-harvest group	45 (30.2)	104 (69.8)
Maintenance and repair group.	29 (52.7)	26 (47.3)
Porters and errand group	47 (56.6)	36 (43.4)
Total	170 (44.2)	215 (55.8)

Source: Fieldwork, July–August 2017.

Additionally, Table 2 shows a statistically significant association between age and condom use (p-value = 0.000). With increasing age, the respondents’ usage of a condom during the previous 12 months declines. According to Table 2, younger respondents use condoms more frequently than older respondents. Regarding mobility, compared to those who were not mobile (39.7%), mobile fishers (47.6%) were more likely to report using condoms during sexual activity in the previous 12 months. Further, it was gathered during the male FGD that mobile fishers carry condoms when they travel to protect themselves from sexual infections and unprepared pregnancies with other sexual partners. This is corroborated by one of FGD participants as follows:

I don’t use condoms when I have sex with my wife back in the Volta Region, but I do so here in Elmina to avoid contracting a disease or getting another woman pregnant. Every time I go on a lengthy fishing exhibition, I always have condoms with me. It might be challenging to get condoms while you are in other areas, so having them with you always is useful. (FGD 1)

A positive correlation exists between condom use and educational level. As seen in Table 2, respondents with higher education use condoms substantially more frequently (p = 0.025). The findings suggest that educated people use condoms more frequently than those with little or no education because they tend to know more about them. In terms of religion, respondents who claimed to use condoms were more likely to be African Traditionalists (63.2%) or Atheists (55.2%), in contrast to Christians (42.7%) and Islam followers (33.3%), who reported lower condom usage rates.

Regarding marital status, condom usage is more prevalent among people who have never been married, are cohabiting, or are in consensual partnerships, while it is least prevalent among those who are already married. In the male FGD, it was discovered that many married people avoid using condoms with their partners out of fear of being thought to be having an extramarital affair, particularly after having recently returned from a trip to another fishing community. The statement below was expressed during the male FGD:

Even when you want to use a condom, you are sometimes afraid to ask because your wife will think you cheated while you were away on your travels. This is one of the main reasons most of us married can’t even suggest to other partners to use condoms. (FGD 2)

Analysis of the female FGD shows similar views that seem to indicate that married individuals may not use a condom if the male partner is against its use. The following was expressed by a participant in the female FGD:

I am aware that my husband has several sexual partners, but I am unable to suggest that he uses condoms because they are often reserved for prostitutes and girlfriends. In addition, using condoms is a choice made by males. Even worse, he could end up divorcing me because I asked him to use condoms. Because of this, I find it challenging to even advise that my spouse wear condoms. (FGD 3).

According to the claims, even among married persons, some respondents are unwilling to negotiate the use of condoms because they are afraid of being accused of cheating on their spouse or upsetting them. According to the study, even when married couples are aware that their husbands have an affair with other individuals, they decide not to act because they are concerned that doing so might lead their relationships to fall apart or become strained. Table 2 also reveals that, among occupations associated with fishing, usage of condoms during sexual activity in the previous 12 months was most common in the porters and errand (56.6%) group and least common in the post-harvest group (30.2%). This was to be expected because the post-harvest group, which is mostly made up of women, is less likely to use condoms than the maintenance and repair group, which is dominated by men.

Perceived barriers to condom use with a sexual partner

The study also reports on perceived barriers to condom use in the last sexual encounter by respondents who had sex in the last 12 months. In Table 3, the individuals’ justifications for not using condoms are listed. Partner objection accounted for 35.2% of those who did not use condoms during their most recent sex act. According to the qualitative findings, partner opposition to condom use is caused by the fact that men typically have more economic power than their female counterparts. As a result, many women are in a weaker position to negotiate for the use of condoms because they typically rely on men for support. This is summed up in the following statement by a participant in the female FGD:

Most of the local ladies I am familiar with prefer to have safe sex by using condoms. By the way, many of us rely either on the males for our financial security or the availability of fish. Most of us are concerned that if we disagree with our partner’s objection to wearing a condom, they may become upset and cease providing us with financial assistance or fish supplies. (FGD 4).

Table 3.

Reasons for non-use of condoms in last sexual encounter by sex.

Reason	Sex		Total
Reason	Male (%)	Female (%)
Partner objected	24 (26.7)	55 (41.1)	77 (35.2)
Condom not available	21 (23.3)	38 (29.5)	59 (26.9)
Trust partner not to have any sexual infection	21 (23.3)	38 (29.5)	59 (26.9)
Partner very attractive and not likely to carry any sexual infection	24 (26.7)	0 (0.0)	24 (11.0)

Source: Fieldwork, July–August 2017.

More than one in four (26.9%) of the respondents indicated they did not use condoms because they felt safe having intercourse with their partners and thought they were clean of STIs. A condom was not accessible at the time of the sexual contact, according to the same percentage (26.9%) who claimed they did not use one. The remaining 11% said they did not wear a condom because they did not think they needed to because their partner was exceptionally beautiful and unlikely to have any STIs. The reasons given by respondents for not using condoms point to some respondents’ low-risk perception and lack of awareness. The reasons cited by respondents for not using condoms appear to reflect sex differences.

Females (41.1%) were more likely than males (26.7%) to report partner opposition as a result of not using a condom during their most recent sex. Due to assertions of confidence in their partners, whom they felt were disease-free, more females (29.5%) than males (23.3%) reported not wearing a condom. Additionally, a somewhat larger percentage of female respondents (29.5%) than men (23.3%) failed to wear a condom because one was not easily accessible during the sexual act. Therefore, sex is conducted without the use of a condom when the male partner does not have one at the time of sexual contact. Only male respondents from Table 3 stated that they did not use condoms during their most recent sexual activity since their partners were very attractive and unlikely to have any sexually transmitted diseases.

Discussion

This paper examined factors affecting condom usage and perceived barriers among the respondents in the last 12 months before the survey. The study had a higher percentage of female participants (51.4%) than male participants (48.6%). Regarding age, participants aged 34–44 constitute the majority (29.9%) of the sample, and those reporting being 65 years and above formed the least (3.6%) group. Almost eight in ten (76.4%) of all participants were under the age of 35, indicating that younger people fish in the study area. Mobile fishers made up the majority of research respondents (54.3%). More than half (53.8%) of respondents had completed middle or junior high school, and about a third had no formal schooling. The findings, which are consistent with Duwal et al.,¹⁴ point to a significant percentage of illiteracy among fishers in the research area. Christians made up the majority of the participants (82.1%). In terms of marital status, 46.8% of respondents said they were married, while 53.2% said they were not married. While the remaining participants engaged in actual fishing (25.5%), fish porterage (21.6%), and boat repair and/or maintenance, 38.7% of participants reported engaging in post-harvest activities (14.3%).

The results show that more than four in ten of the respondents who reported having sex in the past year did not use condoms. Thus, the findings of this study on respondents’ poor condom usage are in line with those of other studies.^13,31 Additionally, the findings show that condom usage varies by gender, with more males than females reporting using them. According to earlier research,^32–34 men are more likely than women to use condoms because they are more likely to engage in sex with casual sex partners, which may necessitate the use of condoms for prevention against pregnancy or STIs. The qualitative findings show that one factor in the low reporting of condom use among the female fishers is the inability of some women to negotiate the use of condoms when their male partners refuse to do so. The sixth construct of the HBM describes inability to make a health decision as a person’s lack of confidence or ability to take an important action to protect themselves from a health-related condition, such as the female fishers’ reported inability to insist on condom use in the current results.

In line with past research, the study also discovered a relationship between the respondents’ ages and condom use, with younger respondents using condoms more frequently than older respondents.³³ The HBM’s fifth construct on the internal and external cues for action, which indicates that people with more access to information are likely to take HIV transmission and prevention measures seriously is supported by this study. The external cues to action espoused in the HBM serve as reminders to people to take precautions against health conditions such as HIV infection. A high percentage of condom usage among younger fishers may be a big help to program managers in the campaign to consistently use condoms as a preventive means against HIV and other STIs in the study area since younger individuals are more sexually active.

Furthermore, condom usage was prevalent among mobile fishers than non-mobile ones. This finding is in line with those of research conducted by Lagarde et al.³⁵ and Mnyika et al.³⁶, which discovered that mobile workers carry condoms to help prevent STIs. In the male FGD, participants indicated that mobile fishers carry condoms with them so they may use them when they have sex while traveling. According to the findings, this is not the case with non-mobile fishers, who frequently work with their spouses at the home landing site and hardly ever use condoms when having sex with their partners. Since condoms will prevent them from STIs while they engage in sexual activity while traveling, it is encouraging to observe that mobile fishers are using them more often. Although the results show that mobile fishers are more likely to use condoms than non-mobile fishers, it is worrying to learn that non-mobile fishers refuse to do so, claiming that since their partners have not been mobile, it is safe to have sex with them even if no condoms are used. Perceived susceptibility is a crucial factor in addressing a health issue, as claimed by the first HBM construct. This is true when people believe they are immune to a particular health risk, as in the instance of the non-mobile fishers in the current study.

The findings show that respondents with higher levels of education used condoms far more frequently, demonstrating that educated people are more likely to comprehend the seriousness of HIV and value the use of condoms during sexual encounters than those with little to no education. This finding is in line with research by Sharma and Nam³⁷ and Magnani et al.³⁸ indicating persons with higher levels of education are more likely than those with lower or no levels of education to use condoms during sexual activity. The results are consistent with the second HBM construct, which explains why people who perceive HIV to be a severe and dangerous virus are more likely to take care to avoid getting infected than those who do not.

According to the results, condom use among followers of Islam and Christians were low compared to the other religious sub-groups. This is not surprising considering that some Islamic and Christian groups view the use of condoms and other forms of birth control as immoral behaviors. According to Roudi-Fahimi,³⁹ birth control methods are acceptable in Islam if they are carried out in accordance with what the Quran permits. However, some Muslim communities in countries with strict religious laws have been told by clerics that the Quran commands women to continue having children until they reach their reproductive capacity. The message of the clerics is that contraception is usually haram, or forbidden, or immoral. The numerous misinterpretations of Islamic teaching on contraception from certain Islamic groups undoubtedly affect people’s decisions about using contraception.⁴⁰ The low prevalence of condom usage recorded by Christians and Islamic followers may be attributed to a commitment to religious principles to avoid going against them.^40–42 This is one of the areas of weakness of HBM model as it fails to recognize social influences such as religious doctrines and beliefs. According to the current results, religion has a strong influence in shaping the decisions of its members. Thus, if the stance of religion affects a certain health condition, members of such religious group are likely to be susceptible to that health condition, such as the Catholics and some Islamic groups’ stand on contraception.

The study further demonstrate that married respondents use the fewest condoms. This finding can be related to a couple’s trust in one another, their fear of being accused of adultery, or their worry that doing so would be disrespectful to their spouse. This finding was previously reported in research which explains why condoms usage is low among married couples^37,43 because they are afraid of straining or ending their relationships, even when they suspect adultery.³² The low condom use among married couples raises concerns about the threat married couples may be exposed to if they decide not to use condoms because of fear of causing mistrust in their marriages. In the event of one or both partners ever having unprotected extramarital sex with a casual sex partner, married couples may be in danger of contracting HIV. According to other research, the low condom use among married persons is also due to the widespread belief that condoms are only appropriate for use during extramarital relationships and not during marriage. Due to this belief, some couples choose not to use condoms, even when they are aware that their partner is a promiscuous person.^37,43 Due to this, married persons may have few alternatives for negotiating safe sex with their potential partners who may participate in unsafe sexual conduct, which may increase their risk of contracting HIV. The finding from the current study urges program administrators to step up communication about condom usage among married persons.

More than three in ten of the respondents mentioned partner opposition as the reason they did not use condoms during their most recent sexual experience, with males more likely than females to do so. The qualitative findings support earlier findings that most African men have the attitude of objecting to condom use during sex.³²

Another study by Chamratrithirong and Kaiser³³ also reports that some males often oppose the use of condoms due to the idea that they lessen the enjoyment of sexual contact. A little more than a quarter of all respondents who had intercourse in the previous 12 months did not wear a condom because they believed their partners were free of any sexually transmitted diseases. Due to assertions of confidence in their partners, whom they felt were disease-free, more females (29.5%) than males (23.3%) reported not wearing a condom. Similar findings from other research, like those of Higgins et al.,⁴⁴ imply that women’s willingness to engage in sex without the use of a condom is influenced by how much they trust their male sexual partners. The same percentage of respondents admitted they did not wear a condom since one was not accessible during the sexual interaction. The objection to the use of condoms raises issues of whether the male fishers perceive HIV to be a threat and whether they are susceptible to its infection. The result of male fishers objecting the use of condoms is a clear manifestation of many male fishers discounting the severity and threat of HIV in the study area.

The results indicate that a little more than one in ten of the respondents did not use a condom because they found their sexual partner attractive and unlikely to carry any sexual infection. Notably, all the respondents who cited this justification were males. This conclusion has been drawn from prior research, which stresses that males are less likely to use condoms than females, particularly when they think their partner is attractive.^8,45 The issue of not using condoms because of the perception that good-looking people are STI-free is borne out of ignorance, suggesting that the person is unaware that a person may be HIV-positive and still appear quite beautiful or handsome. According to the HBM, a person lacking this essential knowledge might choose not to wear a condom in a sexual activity because a sexual partner is attractive. Therefore, there is a need to educate individuals in the study area to stop presuming that attractive people are STI-free.

Conclusions

The use of the HBM in this paper was to analyze and explain the attitudes and behaviors regarding the use of condoms and the consequences of the exposure of fishers to HIV infection in fishing communities. Overall, the results show poor condom usage among the participants, indicating that many fisherfolks in the research community do not view themselves as susceptible to HIV, do not contemplate its severity, and are vulnerable to HIV infection. The HBM propounds that people’s risky or protective behaviors depend on how well initiatives are designed to inform them about the susceptibility and severity of a health condition such as HIV and AIDS, and the measures to be taken to avoid infection. On this basis, there is the need to enhance knowledge of fishers on regular use of condoms in the sexual interactions, through constant engagements by HIV and AIDS program managers. HIV education programs of groups such as the KEEA Assembly, Municipal Health Administration, and Non-governmental agencies in Elmina should also explore ways of including the supply of free condoms, and distribution of Information Education and Communication (IE&C) materials to fishers and at the various fishing destination points along the coast of Elmina.

According to the findings, younger fishers are more likely to use condoms than older fishers during sexual activity. Males are more likely to use condoms than females during sexual activity. Once more, according to the results, fishers with higher education reported using more condoms than those with lower or no education. The findings also show that unmarried fishers are more likely to use condoms than married people, who are less likely to do so. In terms of religion, Christians and Islamic followers reported the lowest condom usage compared to other religious groups. Regarding the type of fishing activity performed by the fishers, more condom usage is recorded among the younger fishers who served as porters and errand workers, while lower condom usage is observed among the post-harvest group, which is predominately female. The difference across the subgroups suggests that people’s demographic traits have impact on their condom use. Designing appropriate strategies for improving knowledge, attitudes, and behaviors, according to the HBM, are crucial components for encouraging people to take action to prevent HIV infection. The HBM also posits messages that effectively address perceived barriers, benefits, self-efficacy, and threats will result in the best behavior change. As a result, while developing IE&C messaging for the fisherfolk in Elmina and other nearby fishing towns in the study area, educational programs must take into consideration the existing subgroup variances.

The qualitative results which reveal that some female fishers are afraid of losing financial support or access to fish supplies by merely insisting on condom usage during sex with their partners indicates the unequal economic power, which allows some men to dictate and exploit women during sex. The HBM claims that support and encouragement can boost self-efficacy. On this basis, it is necessary to look for measures to empower women and protect them against unfair exploitation by their male counterparts. Female petty traders need to be provided easy access to financial capital for their fish trade. If the female fishers have access to capital, then the male fishers will have very little basis to exploit them over sex matters.

Considering devout followers would always adhere to the instructions and teachings of their faith, the results of religious groups like Christians and Islam influencing health decisions based on religious practices are concerning. Similar worries are raised about the threat married couples are likely to face if they choose not to use condoms due to the fear of fostering marital distrust. These are areas program managers could consider in their community education interventions in sensitizing people not to discount the severity, susceptibility, and threat of HIV, but consider things they can do to make healthier choices to avoid being infected. Since the HBM’s cues to action include any strategy that encourages people to make a health behavior change, it is imperative to seek out and use any approach suitable for reducing ignorance and increasing perceptions about the severity and threats of HIV among the fishers.

In sum, increasing perceived severity, perceived susceptibility, perceived benefits, self-efficacy, and cues to action while decreasing perceived barriers are actions required to encourage the fishers adopt positive change in sexual behaviors.

Footnotes

Acknowledgements

The author would like to express appreciation to Zita Kyei-Gyamfi, Bernard Amoh, Patience Hayford, Joseph Kwatsenu, Amanda Kyei-Gyamfi, Frank Kyei-Gyamfi, and Lisa Kyei-Gyamfi for reading sections of the work and providing insightful comments. Finally, the author would like to thank the anonymous reviewers whose comments helped to improve the paper. An earlier version of the paper is in preprint entitled “Asking to use a condom with your wife is an admission of cheating while you were away on your fishing expedition” and can be accessed at

Consent

During data collection, oral consent was obtained from all participants for the survey, KIIs and FGDs. For each of the sessions, the researcher expressed appreciation to the participants for agreeing to participate, gave a brief introduction about himself, the reason for carrying out the research, and why they were taking part. They were also briefed about the processes involved and he during of the sessions, assured that any information provided was to be treated confidential and used solely for he purposes of he research. They were also informed that they could skip any questions they felt uncomfortable answering and could stop the interaction process anytime they felt to do so. The interviews of the survey, KIIs, and interactions in the FGDs only commenced after the participants had given the go-ahead. All interviews were held at the convenience of the participants to ensure privacy and confidentiality.

Data availability statement

The material for the current paper was derived from the author’s Doctoral thesis obtained from the Centre for Migration Studies of the University of Ghana. The full thesis can be accessed at . The dataset is also available and can be made available upon request.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics statement

To adhere to ethical principles and conduct the research in a responsible and accountable manner, ethical clearance was sought. In view of this, ethical clearance was sought from the Ethics Committee for the Humanities (ECH) at the University of Ghana and approval was granted by the Committee in April 2017 to commence fieldwork.

ORCID iD

Sylvester Kyei-Gyamfi

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Factors affecting condom use among fishers in Elmina fishing community in Ghana

Abstract

Background:

Design and methods:

Results:

Conclusion:

Keywords

Introduction

HIV vulnerability and condom use among fishers

The health belief model (HBM)

Methods

Results

Socio-demographic background of fishers

Condoms usage during sexual intercourse

Perceived barriers to condom use with a sexual partner

Discussion

Conclusions

Footnotes

Acknowledgements

Consent

Data availability statement

Declaration of conflicting interests

Funding

Ethics statement

ORCID iD

References