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

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.

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https://doi.org/10.1177/22799036231191035
Journal of Public Health Research
2023, Vol. 12(3), 1 –12
© The Author(s) 2023
DOI: 10.1177/22799036231191035
journals.sagepub.com/home/phj
Journal o
f
Public Health Research
Original Article
1191035PHJXXX10.1177/22799036231191035Journal of Public Health ResearchKyei-Gyamfi
research-article20232023
Factors affecting condom use among
fishers in Elmina fishing community in
Ghana
Sylvester Kyei-Gyamfi
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
Date received: 6 March 2023; accepted: 13 July 2023
Department of Children, Ministry of Gender, Children and Social
Protection, Accra, Greater Accra Region, Ghana
Corresponding author:
Sylvester Kyei-Gyamfi, Department of Children, Ministry of Gender,
Children and Social Protection, Ministries Accra Ghana, Accra, Greater
Accra Region 233, Ghana.
Emails: sylvesterr_kyeigyamfi@yahoo.com; sylvester.kyei-gyamfi@
mogcsp.gov.gh
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 work-
ers 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 arti-
sanal fishers have also been reported in fishing destina-
tions.5,6 Prior works that have reported poor condom use
among fisherfolks adduce barriers to condoms use to

2 Journal of Public Health Research
several reasons. In Kwena et al.,7 they mention that female
fishers constitute a group that do not use condoms in sex-
ual 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 atti-
tudes toward condom use,2–5,9 little is known about the cir-
cumstances 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 fisher-
ies production and management. Underestimating the sus-
ceptibility, 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’ per-
ception 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 par-
ticularly mentioned as a method of family planning to
avoid conception in the 18th century. But when HIV
spread, policymakers and program managers for reproduc-
tive 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 unpro-
tected 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 com-
munities 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 accommoda-
tion 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 mar-
kets 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 encour-
age 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 experi-
ences of seeing their colleagues dying at sea whilst fishing,

Kyei-Gyamfi 3
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 con-
doms hardly occurs to fishers with an HIV-risk denial atti-
tude 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 chal-
lenging 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 con-
structs 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 sus-
ceptibility to HIV is very low, accounting for their unpre-
paredness 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 use-
fulness of a new behavior in lowering the risk of contract-
ing 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 won-
der 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 under-
stand 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 encoun-
ters.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 some-
thing 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, tangi-
ble 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

4 Journal of Public Health Research
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 conse-
quences of retaining the old behavior. Sometimes people
need assistance in figuring out how to get beyond obsta-
cles. 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 ini-
tiative by boosting individual or collective readiness.
These may include programs that encourage people to
make specific decisions, such as those that provide infor-
mation, 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 dis-
ease. 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 diffi-
culty 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 pro-
tective 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 confi-
dence in their ability to do so. A person who believes chang-
ing 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 encoun-
ters is very low. According to Kwena,28 most sexual encoun-
ters 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 fre-
quently 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 deci-
sions about their sex lives. This is typical of fishing com-
munities where many women depend on men for fish or
for financial support. Men have a lot of power to manipu-
late 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 cul-
tural 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 cur-
rent 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 inter-
ventions 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 con-
ducted between July 2017 and August 2017 in the Elmina
fishing community in the Komenda Edina Eguafo Abrem

Kyei-Gyamfi 5
(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 arti-
sanal 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 popula-
tion 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 propor-
tions. To arrive at an estimated sample size of 385 respon-
dents 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 pur-
poseful 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 arrange-
ments, 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 qualita-
tive 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 par-
ticipants 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 partici-
pants in the survey have been analyzed by sex, age, mobil-
ity 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.
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% report-
ing to have secondary/vocational school and higher educa-
tion. 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 partici-
pants 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 dur-
ing 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.
Additionally, Table 2 shows a statistically significant
association between age and condom use (p-value = 0.000).

6 Journal of Public Health Research
With increasing age, the respondents’ usage of a condom
during the previous 12 months declines. According to
Table 2, younger respondents use condoms more fre-
quently than older respondents. Regarding mobility, com-
pared 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 edu-
cational 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 edu-
cation because they tend to know more about them. In
terms of religion, respondents who claimed to use con-
doms 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 preva-
lent 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, particu-
larly 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
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.

Kyei-Gyamfi 7
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 mainte-
nance 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’ justifica-
tions 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 qualita-
tive 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 con-
doms 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).
More than one in four (26.9%) of the respondents indi-
cated they did not use condoms because they felt safe hav-
ing intercourse with their partners and thought they were
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.

8 Journal of Public Health Research
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 exception-
ally 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 con-
dom during their most recent sex. Due to assertions of con-
fidence 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 per-
centage of female respondents (29.5%) than men (23.3%)
failed to wear a condom because one was not easily acces-
sible 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 con-
doms during their most recent sexual activity since their
partners were very attractive and unlikely to have any sex-
ually 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 per-
centage of female participants (51.4%) than male partici-
pants (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 signifi-
cant 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 con-
dom 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 part-
ners, which may necessitate the use of condoms for pre-
vention 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 fre-
quently than older respondents.33 The HBM’s fifth con-
struct 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
Table 3. Reasons for non-use of condoms in last sexual encounter by sex.
Reason Sex Total
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.

Kyei-Gyamfi 9
Mnyika et al.36, which discovered that mobile workers
carry condoms to help prevent STIs. In the male FGD, par-
ticipants indicated that mobile fishers carry condoms with
them so they may use them when they have sex while trav-
eling. 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 con-
doms 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 con-
doms 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 suscep-
tibility 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, demon-
strating that educated people are more likely to compre-
hend the seriousness of HIV and value the use of condoms
during sexual encounters than those with little to no educa-
tion. 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 reproduc-
tive capacity. The message of the clerics is that contracep-
tion is usually haram, or forbidden, or immoral. The
numerous misinterpretations of Islamic teaching on con-
traception 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 con-
dition, 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 disrespect-
ful to their spouse. This finding was previously reported in
research which explains why condoms usage is low among
married couples37,43 because they are afraid of straining or
ending their relationships, even when they suspect adul-
tery.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 dan-
ger 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 mar-
riage. 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 admin-
istrators 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

10 Journal of Public Health Research
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 dis-
counting 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-look-
ing people are STI-free is borne out of ignorance, suggest-
ing 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 commu-
nity do not view themselves as susceptible to HIV, do not
contemplate its severity, and are vulnerable to HIV infec-
tion. 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 fish-
ers 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 follow-
ers 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, ben-
efits, self-efficacy, and threats will result in the best behav-
ior 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 con-
sideration 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 coun-
terparts. 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 concern-
ing. Similar worries are raised about the threat married
couples are likely to face if they choose not to use con-
doms due to the fear of fostering marital distrust. These are
areas program managers could consider in their commu-
nity 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 increas-
ing perceptions about the severity and threats of HIV
among the fishers.
In sum, increasing perceived severity, perceived sus-
ceptibility, 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.

Kyei-Gyamfi 11
Acknowledgments
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 anony-
mous 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 https://www.researchsquare.com/article/rs-2169975/v1
Consent
During data collection, oral consent was obtained from all par-
ticipants 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 tak-
ing 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 http://
ugspace.ug.edu.gh/handle/123456789/33464. 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 https://orcid.org/0000-0003-3058-
5831
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