Despite South Africa experiencing one of the largest HIV epidemics in the world, condom use has decreased since 2008. However, condoms are the only low-cost HIV prevention technology widely available in South Africa. This study aims to explore a South African community’s perceptions of condoms, recent condom use decrease, and suggestions for increasing condom use. In 2014, we conducted seven focus groups (n = 40 men) and 20 in-depth interviews (n = 9 men, n = 11 women) with participants aged ≥ 18 years recruited from four urban settlement health clinics in Cape Town, South Africa. Data were collected, coded, and analysed using a general inductive approach. Participants perceived government-provided condoms negatively, with themes including “disgust” for condom physical properties, concerns with social status associated with free condoms, and performance concerns. There was an intersection of themes surrounding masculinity, condom use, and sexual pleasure. Solutions to increase condom use included improving the quality and variety of free condoms and rebranding free condoms. Participants suggested that condoms are distributed with novel attributes (e.g., more colors, smells/flavors, sizes, and in-demand brands) and that government programs should consider offering all brands of condoms at no or low cost. This study suggests a substantial rethinking of condom branding for government-provided condoms. Our findings suggest that condom dissemination and promotion programs should proactively address public concerns regarding condoms. Existing societal and structural norms such as hegemonic masculinity must also be addressed using gender-transformative interventions. We also strongly suggest the creation of a Male Condom Acceptability Scale to understand condom users’ needs.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Abdool, S. K., Abdool, Q. K., Preston-Whyte, E., & Sankar, N. (1992). Reasons for lack of condom use among high school students. South African Medical Journal, 82(2), 107–110.
Adam, B. D., Husbands, W., Murray, J., & Maxwell, J. (2005). AIDS optimism, condom fatigue, or self-esteem? Explaining unsafe sex among gay and bisexual men. Journal of Sex Research, 42(3), 238–248. https://doi.org/10.1080/00224490509552278.
Ajzen, I., Albarracin, D., & Hornik, R. (2012). Prediction and change of health behavior: Applying the reasoned action approach. London: Psychology Press. https://doi.org/10.4324/9780203937082.
Ashmore, J., & Henwood, R. (2015). Choice or no choice? The need for better branded public sector condoms in South Africa. Southern African Journal of HIV Medicine, 16(1), 353. https://doi.org/10.4102/sajhivmed.v16i1.353.
Ayala, G., Makofane, K., Santos, G., Beck, J., Do, T., Hebert, P., … Arreola, S. (2013). Access to basic HIV-related services and PrEP acceptability among men who have sex with men worldwide: Barriers, facilitators, and implications for combination prevention. Journal of Sexually Transmitted Diseases. https://doi.org/10.1155/2013/953123.
Baker, H., Fried, A., Cloete, A., Sigel, C., Miranda, D., Guillen, J., … Siegler, A. (2018). “Give what the people want”: A situational analysis of condom distribution and a feasibility study of user-friendly condoms in Cape Town, South Africa. Journal of the Association of Nurses in AIDS Care, 29(6), 887–901. https://doi.org/10.1016/j.jana.2018.04.002.
Baker, H., Guillen, J., Miranda, D., Sigel, C., & Cloete, A. (2014). Assessing the feasibility of fitted male condoms as a sexual health intervention in Cape Town, South Africa: Perspectives from condom education and distribution staff [Poster presentation]. GHI Scholars Symposium, Atlanta, GA. Retrieved November 11, 2017, from http://www.hsrc.ac.za/en/research-outputs/view/6703.
Beksinska, M. E., Smit, J. A., & Mantell, J. E. (2012). Progress and challenges to male and female condom use in South Africa. Sexual Health, 9(1), 51–58. https://doi.org/10.1071/sh11011.
Bosompra, K. (2001). Determinants of condom use intentions of university students in Ghana: An application of the theory of reasoned action. Social Science and Medicine, 52(7), 1057–1069. https://doi.org/10.1016/s0277-9536(00)00213-6.
Champion, V. L., & Skinner, C. S. (2008). The health belief model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 45–66). San Francisco: Jossey-Bass.
Creese, A., Floyd, K., Alban, A., & Guinness, L. (2002). Cost-effectiveness of HIV/AIDS interventions in Africa: A systematic review of the evidence. Lancet, 359(9318), 1635–1642. https://doi.org/10.1016/s0140-6736(02)08595-1.
Dworkin, S. L., Hatcher, A. M., Colvin, C., & Peacock, D. (2013a). Impact of a gender-transformative HIV and antiviolence program on gender ideologies and masculinities in two rural, South African communities. Men and Masculinities, 16(2), 181–202. https://doi.org/10.1177/1097184X12469878.
Dworkin, S. L., Treves-Kagan, S., & Lippman, S. A. (2013b). Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: A review of the global evidence. AIDS and Behavior, 17(9), 2845–2863.
Gallo, M. F., Grimes, D. A., Lopez, L. M., & Schulz, K. F. (2006). Nonlatex versus latex male condoms for contraception. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd003550.pub2.
Glasier, A. (2010). Acceptability of contraception for men: A review. Contraception, 82(5), 453–456. https://doi.org/10.1016/j.contraception.2010.03.016.
Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18(1), 59–82. https://doi.org/10.1177/1525822x05279903.
Guest, G., Namey, E., & McKenna, K. (2016). How many focus groups are enough? Building an evidence base for nonprobability sample sizes. Field Methods, 29(1), 3–22. https://doi.org/10.1177/1525822x16639015.
Halcomb, E. J., & Davidson, P. M. (2006). Is verbatim transcription of interview data always necessary? Applied Nursing Research, 19(1), 38–42. https://doi.org/10.1016/j.apnr.2005.06.001.
Hatcher, A. M., Colvin, C. J., Ndlovu, N., & Dworkin, S. L. (2014). Intimate partner violence among rural South African men: Alcohol use, sexual decision-making, and partner communication. Culture, Health & Sexuality, 16(9), 1023–1039. https://doi.org/10.1080/13691058.2014.924558.
Holmes, K. K., Levine, R., & Weaver, M. (2004). Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization, 82, 454–461.
Human Sciences Research Council. (2018). The fifth South African national HIV prevalence, incidence, behaviour and communication survey, 2017: HIV impact assessment summary report. Retrieved July 31, 2018, from http://www.hsrc.ac.za/en/media-briefs/saph/sabssm-launch-2018v2.
Jain, A., & Ogden, J. (1999). General practitioners’ experiences of patients’ complaints: Qualitative study. British Medical Journal, 318(7198), 1596–1599. https://doi.org/10.1136/bmj.318.7198.1596.
Jewkes, R., & Morrell, R. (2010). Gender and sexuality: Emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. Journal of the International AIDS Society, 13(1), 6. https://doi.org/10.1186/1758-2652-13-6.
Jewkes, R., Sikweyiya, Y., Morrell, R., & Dunkle, K. (2011). Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: Findings of a cross-sectional study. PLoS ONE, 6(12), e29590. https://doi.org/10.1371/journal.pone.0029590.
Jewkes, R. K., Dunkle, K., Nduna, M., & Shai, N. (2010). Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: A cohort study. Lancet, 376(9734), 41–48. https://doi.org/10.1016/s0140-6736(10)60548-x.
Kalichman, S. C., Simbayi, L. C., Cain, D., & Jooste, S. (2009). Condom failure among men receiving sexually transmissible infection clinic services, Cape Town, South Africa. Sexual Health, 6(4), 300–304. https://doi.org/10.1071/sh09046.
Kalichman, S. C., Simbayi, L. C., Kaufman, M., Cain, D., Cherry, C., Jooste, S., & Mathiti, V. (2005). Gender attitudes, sexual violence, and HIV/AIDS risks among men and women in Cape Town, South Africa. Journal of Sex Research, 42(4), 299–305. https://doi.org/10.1080/00224490509552285.
Kuckartz, U. (2007). MAXQDA: Qualitative data analysis. https://maxqda.com.
Lambert, S. D., & Loiselle, C. G. (2008). Combining individual interviews and focus groups to enhance data richness. Journal of Advanced Nursing, 62(2), 228–237. https://doi.org/10.1111/j.1365-2648.2007.04559.x.
Leddy, A., Chakravarty, D., Dladla, S., de Bruyn, G., & Darbes, L. (2016). Sexual communication self-efficacy, hegemonic masculine norms and condom use among heterosexual couples in South Africa. AIDS Care, 28(2), 228–233. https://doi.org/10.1080/09540121.2015.1080792.
Manhart, L. E., & Koutsky, L. A. (2002). Do condoms prevent genital HPV infection, external genital warts, or cervical neoplasia?: A meta-analysis. Sexually Transmitted Diseases, 29(11), 725–735. https://doi.org/10.1097/00007435-200211000-00018.
Mash, R., Mash, B., & De Villiers, P. (2010). ‘Why don’t you just use a condom?’: Understanding the motivational tensions in the minds of South African women. African Journal of Primary Health Care and Family Medicine, 2(1), 1–4. https://doi.org/10.4102/phcfm.v2i1.79.
Miller, J., & Glassner, B. (1997). The “inside” and the “outside”: Finding realities in interviews. In D. Silverman (Ed.), Qualitative research: Theory, method and practice (pp. 99–112). Thousand Oaks, CA: Sage Publications.
Montano, D. E., & Kasprzyk, D. (2015). Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior: Theory, research, and practice (pp. 95–124). San Francisco: Jossey-Bass.
Morgan, D., & Krueger, R. (1993). When to use focus groups and why. Successful focus groups: Advancing the state of the art. Thousand Oaks, CA: Sage Publications. https://doi.org/10.4135/9781483349008.n1.
Morrell, R., Jewkes, R., Lindegger, G., & Hamlall, V. (2013). Hegemonic masculinity: Reviewing the gendered analysis of men’s power in South Africa. South African Review of Sociology, 44(1), 3–21. https://doi.org/10.1080/21528586.2013.784445.
Mulwo, A. K., Tomaselli, K. G., & Dalrymple, L. (2009). Condom brands, perceptions of condom efficacy and HIV prevention among university students in KwaZulu-Natal, South Africa. African Journal of AIDS Research, 8(3), 311–320. https://doi.org/10.2989/ajar.2009.8.3.7.928.
National Department of Health. (2014). National department of health annual report 2012/13 [Annual Report 2012/13]. South African Department of Health. Retrieved July 31, 2018, from https://africacheck.org/wp-content/uploads/2014/02/131016dohrreport.pdf.
Osuafor, G. N., Maputle, S., Ayiga, N., & Mturi, A. J. (2018). Condom use among married and cohabiting women and its implications for HIV infection in Mahikeng, South Africa. Journal of Population Research, 35(1), 41–65. https://doi.org/10.1007/s12546-017-9195-2.
Pallin, S., Meekers, D., Lupu, O., & Longfield, K. (2013). South Africa: A total market approach for male condoms. Retrieved July 31, 2018, from https://www.psi.org/publication/total-market-approach-south-africa/.
Pettifor, A. E., Measham, D. M., Rees, H. V., & Padian, N. S. (2004). Sexual power and HIV risk, South Africa. Emerging Infectious Diseases, 10(11), 1996–2004. https://doi.org/10.3201/eid1011.040252.
Pretorius, C., Stover, J., Bollinger, L., Bacaër, N., & Williams, B. (2010). Evaluating the cost-effectiveness of pre-exposure prophylaxis (PrEP) and its impact on HIV-1 transmission in South Africa. PLoS ONE, 5(11), e13646. https://doi.org/10.1371/journal.pone.0013646.
Randolph, M. E., Pinkerton, S. D., Bogart, L. M., Cecil, H., & Abramson, P. R. (2007). Sexual pleasure and condom use. Archives of Sexual Behavior, 36(6), 844–848. https://doi.org/10.1007/s10508-007-9213-0.
Reddy, P., Meyer-Weitz, A., Van Den Borne, B., & Kok, G. (1999). STD-related knowledge, beliefs and attitudes of Xhosa-speaking patients attending STD primary health-care clinics in South Africa. International Journal of STD and AIDS, 10(6), 392–400. https://doi.org/10.1177/095646249901000607.
Rogers, E. M. (2010). Diffusion of innovations. New York: Simon and Schuster.
Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403.
Shai, N. J., Jewkes, R., Nduna, M., & Dunkle, K. (2012). Masculinities and condom use patterns among young rural South Africa men: A cross-sectional baseline survey. BMC Public Health, 12(1), 462. https://doi.org/10.1186/1471-2458-12-462.
Shisana, O., Rehle, T., Simbayi, L., Zuma, K., Jooste, S., Pillay-van-Wyk, P, … The SABSSM III Implementation Team. (2009). South African national HIV prevalence incidence behaviour and communication survey 2008: A turning tide among teenagers? Human Sciences Research Council Press. Retrieved August 7, 2018, from https://www.hsrcpress.ac.za/books/south-african-national-hiv-prevalence-incidence-behaviour-and-communication-survey-2008.
Shisana, O., Rehle, T., Simbayi, L. C., Zuma, K., Jooste, S., Zungu, N., … Onoya, D. (2014). South African national HIV prevalence, incidence and behaviour survey, 2012. Human Sciences Research Council Press. Retrieved August 7, 2018, from http://ecommons.hsrc.ac.za/bitstream/handle/20.500.11910/2490/8162.pdf?sequence=1&isAllowed=y.
Shisana, O., Simbayi, L., Rehle, T., Zungu, N., Zuma, K., Ngogo, N., … SABSSM III Implementation Team. (2010). South African national HIV prevalence, incidence, behaviour and communication survey, 2008: The health of our children. Cape Town, South Africa: Human Sciences Research Council Press.
Siegler, A., Rosenthal, E., Sullivan, P., Ahlschlager, L., Kelley, C., Mehta, C., … Cecil, M. (2019a). Double-blind, single-center, randomized three-way crossover trial of fitted, thin, and standard condoms for vaginal and anal sex: C-PLEASURE study protocol and baseline data. JMIR Research Protocols, 8(4), e12205. https://doi.org/10.2196/12205.
Siegler, A., Rosenthal, E., Sullivan, P., Mehta, C., Moore, R., Ahlschlager, L., … Cecil, M. P. (2019b). Levels of clinical condom failure for anal sex: A randomized cross-over trial. EClinicalMedicine, 17, 100199. https://doi.org/10.1016/j.eclinm.2019.10.012.
Siegler, A. J., Boos, E., Rosenberg, E. S., Cecil, M. P., & Sullivan, P. S. (2018). Validation of an Event-Level, Male Sexual Pleasure Scale (EMSEXpleasure) among condom-using men in the U.S. Archives of Sexual Behavior, 47, 1745–1754. https://doi.org/10.1007/s10508-017-1103-5.
Siegler, A. J., Mbwambo, J. K., McCarty, F. A., & DiClemente, R. J. (2012). Condoms “contain worms” and “cause HIV” in Tanzania: Negative condom beliefs scale development and implications for HIV prevention. Social Science and Medicine, 75(9), 1685–1691. https://doi.org/10.1016/j.socscimed.2012.07.010.
South African Government. (2019). President Cyril Ramaphosa: Address to the nation on public and gender-based violence. Retrieved January 11, 2020, from https://www.gov.za/speeches/president-cyril-ramaphosa-address-nation-public-and-gender-based-violence-5-sep-2019-0000.
Spruyt, A., Steiner, M. J., Joanis, C., Glover, L. H., Piedrahita, C., Alvarado, G., … Cordero, M. (1998). Identifying condom users at risk for breakage and slippage: Findings from three international sites. American Journal of Public Health, 88(2), 239–244. https://doi.org/10.2105/ajph.88.2.239.
Stover, J., Rosen, J. E., Carvalho, M. N., Korenromp, E. L., Friedman, H. S., Cogan, M., & Deperthes, B. (2017). The case for investing in the male condom. PLoS ONE, 12(5), e0177108–e0177108. https://doi.org/10.1371/journal.pone.0177108.
Thomas, D. R. (2006). A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation, 27(2), 237–246. https://doi.org/10.1177/1098214005283748.
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042.
UNAIDS. (2010). Report on the global AIDS epidemic [Global report]. UNAIDS. Retrieved January 11, 2020, from https://www.unaids.org/en/resources/documents/2010/20101123_globalreport.
UNAIDS. (2019). Country: South Africa [Country report]. UNAIDS. Retrieved January 11, 2020, from https://www.unaids.org/en/regionscountries/countries/southafrica.
United Nations Population Fund. (2016). MAX condom launched in South Africa with UNFPA support. Retrieved August 20, 2018, from UNFPA South Africa. http://southafrica.unfpa.org/news/max-condom-launched-south-africa-unfpa-support#sthash.q958doDx.dpuf.
Volk, J. E., & Koopman, C. (2001). Factors associated with condom use in Kenya: A test of the health belief model. AIDS Education and Prevention, 13(6), 495–508. https://doi.org/10.1521/aeap.13.6.495.21438.
Weaver, M. A., Joanis, C., Toroitich-Ruto, C., Parker, W., Gyamenah, N. A., Rinaldi, A., … Steiner, M. J. (2011). The effects of condom choice on self-reported condom use among men in Ghana, Kenya and South Africa: A randomized trial. Contraception, 84(3), 291–298. https://doi.org/10.1016/j.contraception.2011.01.010.
Western Cape Government. (2016). Choice condoms go to the Max. Western Cape Government. Retrieved August 20, 2018, from https://www.westerncape.gov.za/general-publication/choice-condoms-go-max.
Zuma, K., Shisana, O., Rehle, T. M., Simbayi, L. C., Jooste, S., Zungu, N., … Moyo, S. (2016). New insights into HIV epidemic in South Africa: Key findings from the National HIV Prevalence, Incidence and Behaviour Survey 2012. African Journal of AIDS Research, 15(1), 67–75. https://doi.org/10.2989/16085906.2016.1153491.
We would like to thank the Human Sciences Research Council for their guidance through the design and implementation of this study. We would also like to thank Drs. Leickness Simbayi and Allanise Cloete for their invaluable mentorship and guidance during the conduct of this research project. We would also like to thank all of our community partners in South Africa, including Nati and the many community health workers for their tireless dedication towards the eradication of HIV and their support of our research. Further, we would like to thank our participants, community members of Cape Town, for sharing their narratives with us. We would also like to thank Dr. Sara St. George for her guidance on qualitative methods.
This work was supported by the Emory University Global Health Initiative, Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund, National Institute on Drug Abuse (awards #K99DA041494, #R00DA041494), the National Institute on Mental Health (award #R01MH100021), and the Emory University Center for AIDS Research Adelante.
Conflict of interest
The authors disclose they have no financial interest or benefit that has arisen from the direct applications of our research.
The Emory University Institutional Review Board (Study No.: IRB IRB00066402) and the Human Sciences Research Council Research Ethics Committee (ID 10350) provided ethical review and clearance to conduct the study. The City of Cape Town granted further permission to conduct research at four City of Cape Town public health clinics—additional information can be found above and elsewhere (Baker et al., 2018). The authors wrote this publication in accordance with the COnsolidated Criteria for REporting Qualitative research (COREQ) checklist, to report important aspects of the study (Tong, Sainsbury, & Craig, 2007). All procedures performed in studies involving human participants were in accordance with the ethical standards of Emory University Institutional Review Board, the Human Sciences Research Council Research Ethics Committee, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed written and verbal consent was obtained from all individual participants included in the study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Shrader, CH., Peters Jefferson, K., Kanamori, M. et al. “I’d Rather Use a Refuse Bag:” A Qualitative Exploration of a South African Community’s Perceptions of Government-Provided Condoms and Participant-Preferred Solutions. Arch Sex Behav 50, 615–627 (2021). https://doi.org/10.1007/s10508-020-01701-2
- HIV prevention
- South Africa
- Condom use
- Global health
- Qualitative research