Community Norms About Youth Condom Use in Western Kenya: Is Transition Occurring?

Abstract

Most HIV prevention strategies for African youth have been ineffective in changing key behaviors like condom use, partly because community antagonism and structural barriers have rarely been addressed. Through qualitative research in rural Western Kenya, we sought to describe the attitudes of different segments of society towards youth condom use and to identify where transitions may be occurring. We found that about half of community members strongly opposed youth condom use, with many advocating punishment such as beatings and expulsion. Our research revealed significant differences in attitudes by gender, with females generally more opposed to youth condom use. Health providers, teachers and male students seemed to be transitioning to more permissive attitudes. They also had more accurate knowledge about the condom. Building on these transitional views, we would recommend that schools eliminate sanctions for students found with condoms and that clinics discourage providers from interrogating youths about their reasons for wanting condoms. Furthermore, we believe that health campaigns should portray condoms as "disaster preparedness" devices for responsible youths, and more efforts should be made to dispel myths about condoms' efficacy.

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Tavrow et al. Community norms youth condom Kenya
African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
241
ORIGINAL RESEARCH ARTICLE
Community Norms About Youth Condom Use in Western Kenya:
Is Transition Occurring?
Paula Tavrow*
1
, Eunice Muthengi Karei
2
, Albert Obbuyi
3
and Vidalyne Omollo
3
1
Department of Community Health Sciences, School of Public Health, University of California at Los Angeles, 650 Charles E.
Young Drive South, Los Angeles,California 90095-1772, USA;
2
California Center for Population Research, University of
California at Los Angeles, 337 Charles E. Young Drive East, Los Angeles, California 90095, USA;
3
Youth for Youth Program,
P.O. Box 20, Bungoma, Kenya
*For correspondence: Email: ptavrow@ucla.edu, Tel: +1-310-794-4302
Abstract
Most HIV prevention strategies for African youth have been ineffective in changing key behaviors like condom use,
partly because community antagonism and structural barriers have rarely been addressed. Through qualitative
research in rural Western Kenya, we sought to describe the attitudes of different segments of society towards youth
condom use and to identify where transitions may be occurring. We found that about half of community members
strongly opposed youth condom use, with many advocating punishment such as beatings and expulsion. Our
research revealed significant differences in attitudes by gender, with females generally more opposed to youth
condom use. Health providers, teachers and male students seemed to be transitioning to more permissive attitudes.
They also had more accurate knowledge about the condom. Building on these transitional views, we would
recommend that schools eliminate sanctions for students found with condoms and that clinics discourage providers
from interrogating youths about their reasons for wanting condoms. Furthermore, we believe that health campaigns
should portray condoms as “disaster preparedness” devices for responsible youths, and more efforts should be made
to dispel myths about condoms’ efficacy (Afr J Reprod Health 2012 (Special Edition); 16[2]: 241-252).
Résumé
La plupart des stratégies pour la prévention du VIH à l’égard de la jeunesse africaine n’ont pas été efficaces quant
aux modifications des comportements clé comme l’utilisation des préservatifs, dû en partie au fait qu’on a à peine
abordé l’antagonisme communautaire et les obstacles structuraux. A partir d’une étude qualitative au Kenya de
l’Ouest rural, nous avons essayé de décrire les attitudes des secteurs différents de la société envers l’utilisation des
préservatifs et d’identifier là où peut-être se produisent les transitions. Nous avons découvert qu’à peu près une
moitié des membres de la communauté s’opposaient fermement à l’utilisation des préservatifs, beaucoup d’entre
eux préconisant la punition telles la correction et l’expulsion. Notre étude a révélé de différences significatives dans
les attitudes basées sur les sexes, les femmes étant en général les plus opposées à l’utilisation des préservatifs par la
jeunesse. Les dispensateurs de soins, les enseignants et les étudiants mâles semblaient être en mesure de passer vers
des attitudes plus permissives. Ils a avaient une connaissance plus précises des préservatifs. En nous basant sur les
opinions traditionnelles, nous recommandons que les écoles éliminent les sanctions pour les étudiants qui ont des
préservatifs en leur possession et que les cliniques découragent les dispensateurs d’interroger les jeunes gens pour
savoir pourquoi ils ont besoin des préservatifs. De plus, nous sommes convaincus que les campagnes sanitaires
doivent présenter les préservatifs comme des dispositions à « combattre le désastre » pour les jeunes gens
responsables et il faut faire encore d’effort pour dissiper les mythes autour de l’efficacité des préservatifs (Afr J
Reprod Health 2012 (Special Edition); 16[2]: 241-252).
Keywords: Sexuality, young people, HIV/AIDS, gender, condoms, norms

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African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
242
Introduction
Preventing HIV transmission to African
adolescents continues to be a major challenge. Of
the estimated 5.4 million young people infected
with HIV worldwide, more than half reside in sub-
Saharan Africa
1
. HIV prevention programs
targeting African youths generally appear to have
had little effect on behavior change, although
some have improved knowledge and attitudes
2-5
.
To reduce HIV incidence among African
adolescents, it is important to identify community
norms that may be impeding behavior change.
Over the past two decades, the dominant
prevention strategy in Africa, including Kenya,
has been to promote people’s adherence to the
“ABCs”: abstain from sex (or delay debut), be
faithful to one partner (or reduce number of
partners), and use condoms correctly and
consistently. For African youths, however, the
abstinence message has been emphasized.
Opposition to youth sexuality and condom use has
obstructed young people’s access to condoms in
much of East Africa
6-9
. As the gate-keepers for
condom information and supplies, adult attitudes
can undermine youths’ efforts to protect
themselves
10
. For example, most nurse-midwives
in Kenya and Zambia reported that if unmarried
adolescents requested contraceptives, they would
recommend instead that the youths abstain
11
. Less
than half would encourage condom use for out-of-
school youths. Similarly, a study in South Africa
identified adult attitudes towards condoms and sex
as the main barriers to youth condom use
12
.
In Kenya, condom use at first sex among
young people aged 15-24 has doubled in the past
decade, from 12.5% in 2003 to 25% in 2009
13
.
However, a rural/urban divide has emerged: only
21% of rural young women used condoms as
compared to 32% of urban. A study in Nakuru
District in Kenya found that most youths believed
condoms are ineffective, likely to spread HIV,
physically harmful and immoral
7
. Even when
youths viewed condoms positively, they often
were reluctant to try to obtain condoms because of
the shame associated with being found with them
9
.
Social norms antagonistic to youth condom
use are likely to have a greater impact in
communal societies such as Kenya, where
individual self-actualization is rare and
confidentiality is often violated
14-15
. Yet to date
little is known about how various segments of
rural society—including trained peer educators—
regard youths who use condoms and if gender
differences exist. In this paper, we analyzed
qualitative data to determine how different
categories of adults and students in Western Kenya
view adolescent condom use and whether they
would penalize boys found with condoms. We
also identified conditions or situations where
youth condom use may be acceptable. Finally, we
made recommendations for encouraging a
transformation in condom attitudes to set the stage
for more effective youth HIV prevention programs
in rural Kenya.
Methods
Background
The study was based on focus group discussions
(FGDs) conducted as part of an interim evaluation
of the Youth for Youth program (Y4Y). The Y4Y
program was launched in September 2003 in
thirteen schools and three health centers in
Bungoma District, Western Kenya. The purpose
of the program was to test a peer education and
service model to improve rural African youth’s
reproductive health knowledge and to reduce risky
sexual behaviors
16
. In the participating schools,
any secondary student in Forms 2 or 3 who wished
to become a peer educator was asked to self-
nominate. Elections were then held among the
student body of each school to select the peer
educators. In mixed schools, students voted
separately for male and female peer educators to
ensure adequate representation by gender.
Afterwards, the Y4Y program staff directly trained
the elected students to serve as peer reproductive
health educators in high schools, and as mentor
educators in primary schools. The training
consisted of ten modules, including: setting
personal goals, building self-esteem and resisting
peer pressure, gender roles, puberty, relationships,
contraception, sexually transmitted diseases,
dating violence, communicating with parents and
adolescent rights. The top peer educators received
additional training to enable them to provide
counseling in health clinics to youths seeking

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African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
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information about specific contraceptive methods.
A taskforce of representatives from the Ministries
of Health and Education in Bungoma town
provided oversight to the Y4Y program. The
University of California at Los Angeles (UCLA)
Institutional Review Board and the Kenya Medical
Research Institute approved the study.
Procedures
FGD participants were recruited between June and
August 2005, through convenience sampling from
schools, churches, health centers and
neighborhoods in three sub-locations of Webuye
Division where Y4Y had been operational. The
participants consisted of primary school students
in Classes 7-8 (aged 13-15), secondary school
students in Forms 2-4 (aged 16-19), peer
educators, primary and secondary school teachers,
parents, church leaders, health providers, and Y4Y
taskforce officials. For each target group (except
the Y4Y taskforce), one FGD was conducted in
each of three sub-locations. This resulted in 31
FGDs, with 7 to 12 participants in each group. All
focus groups were of mixed gender, except those
involving students which were mixed. Altogether,
310 people participated (Table I). All FGDs were
conducted in English by the same male Y4Y staff
member (a middle-aged Kenyan). All participants
were told that they could use Kiswahili if they
preferred, but all seemed to be comfortable in
English. His female assistant obtained informed
consent from all participants prior to each FGD,
tape- recorded the session, and transcribed it for
subsequent analysis. The FGDs were conducted in
empty classrooms, health center conference rooms,
church halls, and a Ministry of Education office.
The facilitator ensured that the sessions were
private, and encouraged participants to speak
freely. He used a semi-structured moderator’s
guide that covered a range of topics such as youth
condom use, family planning use, and coerced sex.
Because participants in Bungoma district were not
familiar with the female condom, questions
concerned the male condom only. Each focus
group lasted 65 to 90 minutes. The questions used
for this study were:
(1) If a school finds a youth with condoms,
what should the school do? Why?
(2) If a boy who is about to become head boy
is found with condoms, should the school still
make him head boy? Why or why not?
(3) If a boy goes to a health center and asks
for condoms, should the nurse try to
discourage him from playing sex? Why or why
not?
Table 1: Focus group participants, by role and gender
Role No.
of
males
No. of
female
s
No. of
focus
groups
Primary students (aged
12-16)
a
34
34
6
Secondary students
(aged 15-20)
a
31
35
6
Peer educators
(secondary students,
aged 15-19)
18
19
3
Primary school
teachers 19 10 3
Secondary school
teachers
16
9
3
Parents 12 15 3
Church leaders 14 15 3
Health providers 8 14 3
Taskforce members 4 3 1
TOTAL (n=310) 156 154 31
a
The focus group discussions with students were
single gender.
The FGDs were entered into MAXQDA
qualitative software. Content analysis was used to
code the data and identify clusters. Codes were
developed independently by two investigators and
refined through an iterative process of discussing
themes and reviewing codes. Investigators used
the MAXQDA Code Matrix feature to compare
themes by role and gender.
Results
For about half of the focus group participants, a
youth found with condoms was considered to be
engaging in unacceptable or deviant behavior.
Nearly one quarter believed that youths discovered
with condoms at school should be actively
punished—e.g., expelled from school, beaten or
not allowed to become a head boy (a position of
honor). Those most inclined to punish youths

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244
found with condoms were female primary pupils,
female peer educators, parents and church leaders.
Surprisingly, peer educators, themselves
secondary students, were more antagonistic to
youth condom use than were other secondary
students. Peer educators views’ approximated
those of primary school teachers. A clear gender
gap was found in adolescent responses, with
female youths being considerably more
antagonistic to adolescent condom use. Among
adults, a similar gender difference was observed
for teachers only. The greatest gender disparities
were found among high school students and
teachers. Only a small minority, mostly health
providers, believed that condoms should be
promoted unconditionally to youths. In this section
we first present the main reasons for opposing
condom use by youths. Opposition was found
within all FGD categories. Then we examine the
main conditions by which some participants would
permit youths to have access to condoms, which
we label “transitional” views, since in rural
Kenyan society it has been normative to oppose
sexual activity and condom use by young people.
Condom use as deviant
Our research revealed that many participants
considered youth condom use as deviant and
deserving of punishment or censure. Deviance has
been defined as “departures from norms that draw
social disapproval and may elicit negative
sanctions”
17
. When a behavior is considered
deviant by society, most people avoid doing it.
Sociologists have determined that behaviors are
classified as deviant if society assesses negatively
the actors involved (their characteristics,
behaviors, and motivations), has concerns about
the object itself (in this case the condom), or has
misgivings about contextual issues (i.e., where the
behavior takes place). In this section, we used this
deviance framework—actors, object, context—to
categorize and describe community norms
regarding condoms.
a. Actor characteristics
The predominant reason participants opposed
youth condom use related to their perceptions of
the youths themselves. Many participants
considered youths “immature” and “too young” to
act responsibly about sex and condom use. Youths
were thought to be easily distracted by sex.
Having access to condoms would cause them to
pursue multiple “love affairs” and “forget about
their education.” Some participants expressed
concern that male youths would not use the
condoms properly because of their age. As one
female primary student noted, “The nurse should
not give him condoms, because he can read the
instructions badly and get HIV or any other
disease.” Several teachers worried that young
boys would re-use condoms or turn them into
balloons.
Those who believed youths should be
punished for having condoms focused on the
youths’ motivations and their influence on others.
Participants seemed more inclined to consider
youths immoral who “planned ahead” for sex.
Abstaining from pre-marital sex was viewed as the
moral ideal for both sexes. A youth who carried a
condom, even if he had not yet had sexual
intercourse, was “plotting” for sex and therefore a
“bad” person. As one female primary student
explained, “The youth [with condoms] should be
beaten and the teachers should send him home to
call the parent, because youths are supposed to
abstain from sex until they are married.” This was
not merely a theoretical assertion. One man told
his fellow participants:
When my son was in… Boys High School, he
was found with condoms and I was called. We
agreed with the teachers and we beat the boy.
We have never seen him with them again.
Even the teachers are saying he has now
changed. (Male health provider)
These participants believed that a boy’s chief
motivation for wanting condoms was to enable
him to become promiscuous. Permitting boys to
have condoms was tantamount to encouraging
them to engage in sex, which could have serious
consequences for girls:
They [boys with condoms] may start raping
girls because they know that they have
protected themselves. (Male primary student)

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African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
245
The nurse should not give [condoms], because
if he is given he will continue having sex even
more and will spoil so many people. (Female
secondary student)
Because many participants believed that a male
youth found with condoms was immoral, they
would oppose making him the head boy at his
secondary school. Head boys are expected to set
an example for others and to assist the teachers
and school administration. Participants generally
felt that a head boy with condoms would be a poor
role model, would influence other students to
engage in sex, and would lower school standards.
A school head boy should be a good leader
and a role model to the others. If he is the one
found with condoms, then we as teachers will
look at him as an immoral person and even the
students will not respect him. So he should not
be made the head boy if he is found with
condoms. (Female secondary teacher)
A boy [found with condoms] should not be
made the head boy, because the school will
think that this is encouraging sex. Other
students will also follow his footsteps and the
whole school will be in a mess. (Male
secondary student)
b. Object attributes
The condom itself seemed to represent deviance to
many focus group participants. Some participants
perceived the condom as causing youths to feel
reckless and disinhibited from abstaining. They
felt that access to condoms conveys the message
that boys can have sex without suffering negative
consequences, which is sufficient to motivate
youths to have sex.
Participants who opposed youth condom use
often harbored misconceptions about condoms’
efficacy. The vast majority of adults (including a
few health providers) and about half the youths
(including some peer educators) had serious
misgivings about condoms, even though the latter
had been participating in the Y4Y program which
provided accurate condom information. The most
prevalent myth was that condoms have holes
which permit the HIV virus to pass through.
Numerous participants mentioned hearing that
condom have tiny holes that can only be seen
under a microscope. Apparently, some participants
had attended AIDS education sessions where
misinformation was given.
I attended a seminar on HIV and the doctor
was saying that there is very little chance that
they can prevent [transmission], even if you
put on sixteen condoms. They have micro
holes and the virus can still pass, so it is not
safe. (Male secondary teacher)
Another common belief was that condoms can
cause infections because they are “very light and
weak,” which makes them burst easily during sex.
As one male primary teacher described, “Condoms
are recommended to stay within a given
temperature. If a man is having sex the body
temperature goes very high, beyond the required
temperature for the condoms.” A female primary
teacher argued that since condoms existed prior to
AIDS and were meant for family planning, they
would need to be modified to prevent the AIDS
virus from passing through. Others noted that
people who use condoms still get HIV. Many
have misinterpreted the AIDS prevention message
that condoms are “not 100% safe” to mean that
condoms are dangerous and should be avoided.
c. Contextual issues
To virtually all participants, school premises and
condoms were considered antithetical. Many
maintained that allowing students to bring
condoms to school would harm the academic
enterprise and undermine a school’s ability to
maintain dignity and order. Some female
secondary students averred that having condoms in
their pockets would interfere with youths’ studies,
leading them not to be able to concentrate in class.
This would in turn reduce the school’s
performance and affect its academic standing.
It was often noted that allowing condoms on
campus directly conflicted with existing school
regulations. For co-educational schools, “love
affairs” among students generally are prohibited.

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African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
246
To reinforce the rules against relationships, some
participants advocated that students found with
condoms be punished or even expelled. Several
male participants thought that a solution could be
to educate youth about the right time and place for
condoms. Others, mostly females, felt strongly that
students should concentrate exclusively on their
academic work.
Youths should be discouraged completely not
to use the condoms and be encouraged to
serve one master at a go. When they are still
in school they should focus on their studies.
[If] one has condoms then he will not be
focused [on school]. (Female parent)
Transitional views on condoms
While about half of the participants opposed youth
condom use, the remainder believed that condoms
should be made available to youths, although
usually with conditions. Male students, male
secondary teachers and health providers of both
sexes were the most likely to favor youths’ access
to condoms. We consider these views
“transitional” because they represent a more
liberal attitude than historically, and may be
attributable to AIDS educational efforts in Kenya
and the Y4Y program, which several participants
mentioned. Male peer educators were more
conflicted about condoms, even though they taught
youths about proper condom use. They usually
recommended that students found with condoms
be “guided” (counseled) as a gentle way to
discourage condom use, which implies that youths
could continue using condoms if they had a good
reason. Teachers and female secondary students
generally shared this view. However, female peer
educators were mostly antagonistic to youth
condom use, despite having the highest condom
knowledge.
a. Actor characteristics
Just as those who opposed youths’ access to
condoms often justified their position based on
characteristics of the youths themselves, so did
those who favored youth’s access to condoms.
They argued that it was misguided to deny a youth
condoms if he were “already mature.” This
designation did not necessarily relate to a youth’s
chronological age, although one participant stated
specifically that only youths 18 and above should
be permitted condoms. Participants seemed to
assess a youth’s maturity based on how he
presented himself to a nurse and if he were already
having sex. Being forthright and persistent with
nurses in his demands for condoms suggested that
a boy was sexually active. Since being denied
condoms would not deter him from having sex,
some participants felt it would be pointless and
even wrongheaded for a nurse to turn him away or
interrogate him.
[If the boy comes for condoms and]the nurse
doesn’t give, the boy may go ahead and have
unprotected sex, because this boy already has
food on the plate and can eat it if he is not
allowed to wash his hand. That is the same
with having sex without a condom. The nurse
should counsel him and also give him the
condoms. (Male primary teacher)
The nurse should give unconditionally because
he/she [needs to adhere to] professional
ethics. If the boy comes and is denied the
condoms, he will still go and have sex, and
later come back to the nurse with an STI and
the nurse will have to treat him. Yet it is the
nurse to blame, because the boy came for the
condoms and he/she refused to give. So the
nurse has to give without any question. (Male
secondary teacher)
These participants—mostly male—felt that it was
futile to try to prevent boys from being sexual.
Abstinence, while morally desirable, was not
considered realistic for all youths. As one female
peer educator noted, “The nurse should give
[condoms to those who ask for them,] because not
all boys can control their feelings.” Others readily
acknowledged that boys in and out of school were
having sex. Trying to insist that all boys act the
same seemed unreasonable. A male peer educator
explained that “all of us have different sexual
feelings and we behave differently from each
other.” The more male youths were likened to
adults, the less inclined participants were to deny

Tavrow et al. Community norms youth condom Kenya
African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
247
them condoms or to penalize them if found with
condoms.
While youths’ maturity was the most
commonly cited reason to permit them access to
condoms, the other major reason was nearly the
opposite: boys could be potential victims needing
protection. These participants considered boys as
fairly passive players in a dangerous world due to
AIDS. They argued that boys at times were
subject to peer pressure about sex, which may be
difficult to resist. Alternatively, a boy might “find
himself” in a situation where he needed
“protection.” As one female primary teacher
explained, “The nurse should just give [condoms]
because the boy [needs to be] prepared for
disaster.” Male participants were much more
likely than female participants to believe that boys
might land in a predicament not of their own
choosing, where the condom could serve as an
emergency protective measure:
[A youth found with condoms] should not be
punished, because there are those people who
are HIV positive and they can force one into
sex. If the boy is caught in such a situation,
then he can just put on that condom and use it.
Then he is not infected. (Male primary
student)
No action should be taken [against a head boy
found with condoms], because even if you are
saved, you may have bad company, which may
influence you to have sex. Therefore you
should use a condom for protection. (Male
primary student)
b. Object attributes
In contrast to those participants (mainly female)
who believed that the condom itself induced
youths to engage in sexually promiscuous and
aggressive behavior, some male participants were
inclined to consider the condom a benign object
that should no longer stigmatized. One male
secondary teacher argued that it was “high time
[the condom] be taken just like anything else, like
a textbook.” Participants acknowledged that the
condom is still difficult for many to accept
because of its association with sexuality, but felt
that youths should have a right to something that
could protect their health.
The manufacturers and some other cultures do
not see anything wrong with the use and
giving out of condoms, but for us here even
mentioning this word is just a taboo. But since
the condoms have been introduced, let the
youths have them in order to save their lives.
(Male primary teacher)
Participants with transitional views often referred
approvingly to training seminars or media
advertisements that extolled the condom as a
protective device. They seemed to trust that the
government would not promote a product that was
harmful or defective, so long as it were used
properly and not expired. As one male peer
educator noted, “The reason why these condoms
were made is to protect people from contracting
STIs, instead of dying.” Probably due to their
repeated exposure to AIDS refresher training, not
a single health provider averred that condoms had
holes in them. These participants often expressed
confidence that condoms would confer protection,
and were skeptical about claims to the contrary.
[Condoms do not have holes] unless the
person using it is not careful and does not
follow instructions, because these condoms
are fully tested and found effective for people
to use. If they could be having holes, they
could not be recommended for people to use.
(Male secondary student)
I don’t think they have holes because I have
attended so many seminars. I think these are
just myths that condoms do have holes and I
also think it is a polite way of promoting
abstinence. (Male secondary teacher)
c. Contextual issues
A consistent theme across all participants was their
opposition to sexual activity on school grounds.
However, for those who felt it was unrealistic to
expect all boys to remain abstinent, the anticipated
context of condom use made a difference. Mixed
and urban schools were considered more

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African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
248
acceptable venues than single-sex or rural schools
for youths to be found with condoms. Whereas
participants who opposed condoms often
presumed that a boy found with condoms would
engage in sex on the school premises, those with
transitional views generally believed that boys
were planning to engage in sex elsewhere, so it
was acceptable for the boy to be found with
condoms at school.
If the boy is in a day school then maybe he
always meets his girlfriends on his way home.
Then he just has to carry them [condoms] to
school, so that he can use them after school on
his way home. (Male health official)
The youth [found with condoms at school]
should be helped. He [should be] told that the
condoms are not supposed to be used in
school, but at home in their free time. (Male
secondary student)
A few participants praised the youth found with
condoms and definitely felt that he should be made
head boy. One female health provider would not
only make the youth a head boy, but “would even
use him to campaign for safer sex and to educate
others.” These participants believed that a head
boy who used condoms could even be a positive
influence on teachers who did not see the value of
condoms for AIDS prevention. While these
opinions were rare, considerably more participants
felt that youths have a “right” to condoms and the
nurse should “just give.” Yet for a student
discovered with condoms to be made head boy,
most believed that he should be able to articulate
morally acceptable reasons for needing condoms.
[If a youth is found with condoms] the school
should find out where he got them from and
why he is having them. After you have known
the purpose of having the condom, maybe he is
using them for protection and to maintain his
good health. Then he can still be made the
head boy. (Male primary teacher)
Although the question was not posed directly,
even participants with transitional views seemed
averse to condom distribution on school campuses.
As one male peer educator declared, “To me the
nurse giving out condoms [to youths] is not an
offence. It depends on the situation: as long as it is
not in the school but…in the health center.” A
number of participants were disinclined to allow
current students to have access to condoms but felt
they should be available to boys not in school.
Many parents felt that nurses should provide
condoms and “not ask questions” of ordinary boys,
but should actively discourage boys wearing
school uniforms.
Discussion
This study found that about half of participants in
a rural community in Western Kenya felt that
youth condom use was deviant, even though an
after-school youth reproductive health program
with condom demonstrations had been in
operation for two years. Parents, primary school
teachers, church leaders, female peer educators
and female primary students were the most
antagonistic to youth condom use, and many
maintained that punitive measures should be taken
if male students were found with condoms. Only
among health providers and male secondary
students who were not peer educators did a
majority believe that youths should be given
condoms unconditionally.
A clear gender divide in viewpoints emerged,
with females considerably more oppositional to
male youth condom use than males, perhaps
because males were more likely to identify with
young men wishing to use condoms or to have
used condoms themselves. Male participants were
more inclined to believe that youths could use
condoms responsibly to protect themselves from
HIV, that condom use prevented HIV, and that
boys would have sex regardless of whether they
obtained condoms. The gender division was most
pronounced among young people. A study in
Tanzania similarly found that boys were
significantly more likely than girls to approve of
adolescent condom use
18
. This may reflect female
youths’ greater distrust of a male youth’s
motivations and actions, possibly because of
previous firsthand experience of being sexually
harassed or seduced by male youths
12
. Girls also
might be less inclined to support youth condom
use because the male condom is not within their

Tavrow et al. Community norms youth condom Kenya
African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
249
locus of control, so girls may see it as another way
for boys to dominate sexual decision-making. On
their part, boys may consider condom use by male
peers or by themselves to represent responsible
sexual behavior.
An important finding was that both male and
female peer educators’ opinions more closely
paralleled teachers’ views than those of other
secondary students of the same gender. More than
half of peer educators felt that youths should not
be allowed access to condoms, despite being
trained in the Y4Y curriculum which spelled out
youths’ rights to condoms and the effectiveness of
proper condom use. It is possible that the peer
educators’ special training and status led them to
identify more with teachers, and to distance
themselves from their peers to show moral
superiority. Alternatively, peer educators might
have gravitated towards their teachers’ views in
order to avoid appearing too provocative and
risking censure. In South Africa, Campbell and
MacPhail noted that HIV peer educators who
“disrespected” teachers might have their programs
shut down
19
. A study in the United States found
that HIV peer educators in schools assume
altruistic role identities and hold themselves to a
higher standard concerning risk behaviors
20
.
Further research is needed to determine if student
educators in Africa generally become more
ambivalent about youths’ access to condoms,
because this could have important programmatic
implications.
The results from this study suggest that
community perceptions about male youths’
intrinsic characteristics and motivations, the nature
and viability of condoms, and the sanctity of the
school campus can explain their antipathy for
youth condom use. Regarding their perceptions
of male youths, opinions seemed polarized.
Among those who believed youth condom use to
be deviant, youths were likely to be characterized
as young and immature. They often were
constructed as rogues who needed to be strictly
policed to prevent them from inflicting sexual
harm. These views correspond to traditional
parenting norms in much of Africa, where
authoritarian and punitive approaches to child-
raising still hold sway
21
. In contrast, participants
with transitional views were inclined to perceive
boys desiring condoms as mature and responsible,
who had a right to protection. Rather than being
the sexual aggressor, these participants constructed
boys as potential victims who could become
infected if they did not take precautions.
However, even participants with transitional
views were reluctant to permit a student found
with condoms to become a head boy unless he was
counseled to avoid sex and be a moral role model.
The head boy is a potent symbol: an upstanding
young person who is the teachers’ alter-ego. Very
few participants could envision a male youth using
condoms (and therefore having sex) as an
acceptable role model, since the official line in
Kenya is that students should be abstaining
22
.
Only if he were using condoms for “educational
purposes” would some consider him eligible for
head boy. Important exceptions to this general
norm were health providers, in contrast to the
findings of an earlier study of provider attitudes in
Kenya
11
. Perhaps youth-friendly training and
exposure to forthright boys permitted health
providers in this study to consider a head boy with
condoms as a potential ally.
For many participants, their stance on youth
condom use appeared to color their perceptions of
the condom (or possibly vice versa). Except for
female peer educators, those who considered
condom use deviant were considerably more
suspicious about condoms’ properties and
efficacy. These participants framed the condom as
a device that could “destroy” the school because it
would motivate boys to become promiscuous,
since they would no longer fear HIV. Yet these
same participants also usually contended that
condoms were weak and contained holes large
enough for the HIV virus to pass, a common
misconception in rural East Africa
23-24
. A few
female adults acknowledged that they had never
seen a condom, yet they still voiced concerns
about condoms’ durability. No participant seemed
aware of this apparent contradiction between
characterizing the condom as a catalyst for
adolescent sex because it shields youths from
disease, yet considering it too flimsy to prevent
HIV transmission. Perceptions about condoms’
efficacy are important because they seem directly
linked to youths’ actual use of condoms
18, 25
.
However, greater familiarity with condoms may

Tavrow et al. Community norms youth condom Kenya
African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
250
increase reports that condoms break, possibly
because of incorrect use
26
.
The school campus was almost always
considered off-limits for condoms. As noted
elsewhere, romantic relationships among African
youths are considered to be intensely distracting
and hence discouraged, rather than accepted as a
natural part of adolescence
5
. Since many believe
that the condom spurs youths to be more sexual, it
is considered an impediment to youths’ ability to
concentrate on academics. Second, many people
consider students as too young and immature to
use condoms. The school is heralded as a pristine
environment where children’s innocence can be
maintained if it is not sullied with sexuality
education and condoms
8, 22, 27
. Lastly, schools in
Western Kenya often have a religious sponsor,
however nominal. Church leaders in this study
were among those most oppositional, believing
that condoms violated the sanctity of the school
grounds and tempted youths to be immoral. Some
teachers and school administrators invoked a
school’s religious sponsorship for why a student
found with condoms should be expelled.
Participants were most divided about whether
male youths should be entitled to obtain condoms
at a health center. If a boy were in a school
uniform, many participants seemed uneasy about
allowing him access to condoms without at least
some effort of the nurse to discourage him.
However, for youths out of school or not in school
uniform, most participants would not deny them
condoms. The teachers felt that the boundaries of
their authority did not extend beyond the school
grounds; the youths believed that what they did in
their personal lives away from school was their
own concern. Only parents and church leaders
seemed to oppose youths’ access to condoms in
these circumstances. In fact, a significant number
of participants invoked the language of “rights”
and “professional ethics” in declaring that nurses
at health centers should not withhold condoms
from students, particularly in view of the AIDS
epidemic. The notion that young people have
rights to condoms may derive from repeated
exposure to “rights of the child” discourse of
international organizations operating in Kenya,
such as UNICEF, as well as to constant media
coverage about AIDS. Bhana suggested that the
intrinsic appeal of children’s rights could be
exploited to expand and enhance sexuality
education in schools in sub-Saharan Africa
28
.
Limitations
Because this study was limited to a single rural
locality, its generalizability is not known. An
added complication was that many focus group
participants had received training through the
Youth for Youth program, which gave detailed
information about sexuality and condoms.
Furthermore, the facilitator of the focus groups
was the local Y4Y manager, which may have
biased some participants to speak more favorably
about youth condom use. Hence, it is possible that
rural residents elsewhere would be more
conservative. To reduce courtesy bias or the
repetition of Y4Y messages, the focus group
questions were intentionally framed to evoke
normative responses.
The use of English as the language of
discussion may have hindered some participants in
articulating their views, particularly parents and
church leaders who do not use English regularly.
However, no one objected to using English, and
the facilitator was conversant in both Luhya (the
predominant language of the district) and Swahili.
The advantage to conducting the focus groups in
English was that participants’ words could be
reproduced verbatim, without losing nuance from
translation.
Conclusions
Overall, the results of our study indicate that
opposition to youth condom use in rural Kenya is
still entrenched. Even after participating in or
being within the vicinity of an adolescent
reproductive health program that attempted to
demystify the condom, about half of community
members (including youths themselves, especially
girls) considered male youths with condoms to be
engaging in deviant behaviors, and a sizeable
minority would actively punish them. Peer
educators also tended to oppose youth condom
use, more so than members of their same-sex age
sets. This means that a male student in rural
Kenya who followed ABC prevention messages

Tavrow et al. Community norms youth condom Kenya
African Journal of Reproductive Health June 2012 (Special Edition); 16(2):
251
and chose to use condoms could risk
stigmatization, loss of status, beatings, and
expulsion from school.
On the other hand, a transition did seem to be
occurring. Health providers were nearly all
supportive of youth condom use and a few even
portrayed male youths with condoms as role
models. Nearly half of participants, particularly
male students and teachers, would permit youths’
access to condoms in certain circumstances. Some
felt that youths have rights to condoms and were
critical of nurses who interrogated boys or denied
them condoms.
Since community labeling of adolescent
condom use as deviant is likely to be hindering
youths from using condoms effectively, the
Kenyan government and media may need to be
more pro-active in dispelling myths about
condoms’ efficacy and properties. Although
Kenya introduced Life Skills education into the
primary and secondary curricula in 2008, a recent
situational analysis conducted by the Network of
Adolescents and Youth of Africa (NAYA-Kenya)
found that comprehensive sexuality education still
is not being taught
29
. Given that our study
revealed that both teachers and students have
considerable misunderstandings about the condom,
the Ministry of Education may wish to consider
augmenting its Life Skills curricula with factual
information about condoms and other
contraceptives, as well as sensitizing teachers to
the efficacy of condoms for HIV and pregnancy
prevention.
Regarding health care providers, the
government needs to reinforce its policy that all
Kenyans be given full access to condoms with no
questions asked. Demanding to know a youth’s
purpose for requesting condoms is counter-
productive. Demonstrations of condoms’
durability in the mass media and through outreach
by health providers—such as pouring water into
them and showing they do not leak—could also
help to confront directly the notion that condoms
have small holes and break easily.
Lastly, the results of our study indicate that
communities may be receptive to portraying
condoms as “disaster preparedness” devices for
responsible people, instead of as instruments to
help people have safer sex with whomever they
please. Delinking condoms in the popular
imagination from casual sex and promiscuity
seems to have been done with some success
elsewhere in Africa
30-31
. Rather than showing the
condom user as a hip young man who keeps a
condom in his back jeans pockets (as occurred in a
recent social marketing campaign in Kenya),
depicting the condom user as a mature,
responsible, clean-cut and intelligent young man
might be more effective. The condom might be
best shown as banal and sanitary (like soap), not as
a flashy accessory for a disco-hopping youth.
Until all condom users are re-framed as
responsible, non-deviant people, sexually-active
youths will have difficulty accessing condoms and
using them consistently.
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