Tackling sexually transmitted infection burden in Ugandan communities living in the United Kingdom: a qualitative analysis of the socio-cultural interpretation of disease and condom use

Abstract

Background

Despite being in a different country and social environment, Ugandans living in the UK still reportedly have the lowest rates of condom usage and one of the highest incidences of STIs in UK. In Uganda, STIs and HIV prevalence has been reported to be on the increase. Understanding peoples' beliefs and the attitudes that influence their behavior is a key factor to effectively designing control programs.

Methods

A qualitative study that interviewed 37 purposively selected Ugandans living in the UK was conducted. Lay theories and interpretations were derived using thematic analysis.

Results

Condoms generally carried a lot of stigma and were perceived for use primarily in extramarital affairs and pregnancy control. HIV/AIDS was most feared due to its perceived socio-psychological or physical effects unlike other STIs described as “non-threatening” due to wide availability of “quality” treatment in UK. Notions of trust, the purpose of relationships, symptom recognition and partner selection greatly influenced decisions to undertake consistent condom use.

Conclusions

The socio-cultural understanding of STIs, sex, trust and relationships are symbolic in influencing consistent condom use among Ugandans. This indicates a need to acknowledge community beliefs and values about sexual health and design messages about STIs and condoms that would help eliminate these serious condom-related misconceptions.

Background

The majority of the United Kingdom's black immigrants live in the 10% of Britain's most deprived neighborhoods. ¹ In the UK, condoms are one of the commonest birth control methods used with up to 76% uptake reported in 2006². However, Ugandans were more likely than others to report a Sexually Transmitted Infection (STI) in 2007, yet had one of the poorest uptakes for involvement with prevention programs such as condoms³. Evidence suggests that a handful of blacks who had resided in the UK were less likely to know where to go for sexual health services or buy condoms than other residents^4,5. This inadequate access often leads to anxiety, depression and drug taking, which increase the chances of risky behavior and infections⁶.

Ethnic socio-cultural identity and historical perceptions have often been strongly related to the way specific groups behave in their current environments⁷. Despite the fact that many people perceive condom use as having an important preventive function for HIV, socio-cultural resistance remains a considerable challenge to consistent use in control programs among black ethnic groups and needs to be further understood. This interaction of the socio-cultural factors and experiences in every ethnic group has been found to shape behavior and influence not only people's perceived efficacy or decision to use condoms but also shapes the misconceptions and myths that people of the same ethnic origins may hold⁸. According to some authors,^9–11 one cannot ignore the considerable influence that family structure, gender roles, inequalities and stereotypes in a community have on condom use, emphasizing the notion of risk as an important result of these meaningful interactions. Gupta¹⁰ for example, found that women were more likely to have unprotected sex because of their limited negotiation abilities over sexual encounters, less control being partly a result of their low socio-economic status. Their limited opportunities to access formal jobs and credit because of poor education, fewer skills or gender stereotypes also make them vulnerable to STIs and greatly affects not only their decision making but also their efficacious and consistent use of condoms¹¹. Moreover, most women found it difficult to discuss condom use with their partners who, in most cases were less concerned about disease prevention and more concerned about pregnancy prevention¹². With some women in some cultures socially expected to produce children/be fertile to be able to have a sense of family belonging or confirm their identity, it is vital that condom promotion programs explore the different socio-cultural power dynamics with much emphasis to ethnicity and gender differences.

The notion of condom use and its acceptance by the Catholic church has also been a major setback for condom use in Africa. The continued opposition to condom use by the church has greatly impeded condom uptake among the ‘faithful’ through arguing that condoms encourage promiscuity and have far more negative social effects than the claimed protection they offer¹³. Despite the established trend towards concurrent partners in Africa, some African cultures still believe that condoms are used only by prostitutes and are not for married couples¹⁴. Some campaigners have further claimed that condoms are deliberately impregnated or laced with HIV to ‘wipe them out'¹⁵. In some African cultures, sperm are taken to be of key importance in ‘nourishing’ the women and in child development during pregnancy, when repeated sex is undertaken¹⁶. The Masai in East Africa reject condom use as a ‘waste’ of sperm and this belief strongly influences their sexual behavior. Such beliefs have been instrumental in sending out mixed messages about condoms and condom use, and have taken a tangible toll on the fight against STIs.

Generally, it is understood that a person is more likely to change their health behavior if they believe they are at great risk of getting the disease. Some authors¹⁷ argue that people act in keeping with social perceptions and thus their behavior is shaped by cultural norms and networks. Others have referred to risk as a socio-cultural construct that has in many instances been politicized^18,19. These politics have often been a source of opposition between expatriate and lay or indigenous knowledge²⁰. Moreover, STIs in some cultures are not freely discussed and this avoidance fuels stigma, partly by blaming the victim for their sexual involvement and through ignoring other, wider routes of transmission²¹. In other cases, the politicians or policy makers have been cited to avoid taking responsibility and being accountable in instances where people have contracted the disease through negligence on their part. These mixed messages coupled with insufficient information about STIs, their transmission and their prevalence are always key influences to risk perception, representation and disincentives to condom use²². This therefore means that promoting condoms alone, without addressing the socio-cultural constructs surrounding risk is only a part of the story and definitely an insufficient intervention for addressing the STI spread. Whereas scholars argue that risk perception is always rooted in culture, is always expressed through the eyes of the beholder and intercommunicated between ‘social networks’²³, positive strides have to be taken to ‘conclusively’ establish lay perspectives, cause-effect relationships to diseases and their prevention to enable control programs take root.

Methods

This study used qualitative research methods and aimed to explore and obtain useful information about unique beliefs and attitudes on condoms and condom use. These individual lay accounts provide unique and valuable insights into peoples' views and further make integration of findings easy for effective and meaningful preventive programs^24,25. Qualitative analysis also helps to visualize and unpick the mechanisms that link particular variables by looking at the accounts provided by the respondents²⁶. The design was key into illuminating people's ‘embedded’ processes and understanding of concepts and the types of ‘trade-offs’ involved in weighing health promotion messages and making decisions on whether to take up the promoted behavior.

A snowball method of sampling was used to contact Ugandans ranging from 18–49 years living in different cities around UK at regular meetings held in Leeds. Participants who had lived in UK for at least one year were selected for the interviews. Thirty seven Ugandans living in the UK out of the forty contacted for the interviews agreed to participate and returned consent forms; of these 20 were female and 17 male. Interviews were conducted, transcribed and coded by the principal researcher. Thirty four transcripts were considered for data analysis due to difficulty with clarity in the transcription process.

In line with the research objectives, a semi-structured interview guide with open ended questions was used to explore and generate views, opinions and insights about condoms and condom use. Participants were not asked about their own HIV/AIDS status, personal use of condoms or their actual experiences but simply their views on these issues. Semi-structured interview questions were audio taped with the respondents permission and used to guide the researcher in conducting a ‘conversational style’ of interview with broad questions incorporated first to create rapport and set the scene for subsequently more probing questions. Care was taken to ensure consistency in questioning. Alterations to the interviewing guide were contingent on responses given by participants but the researcher re-directed participants to discussions relevant to answering the research objectives when required. This consistency contributed to the reliability of the data collected. The interview probes and clarifications also facilitated generation of in-depth, rich and respondent-led data.

Questions were structured around the existing Health Belief Model constructs in order to generate data that would help the researcher explore and develop an understanding of Ugandans' perceptions about condoms and their use. The interview guide was piloted with 3 respondents to make sure the questions were well understood and interpreted similarly. Questions were revised accordingly to make sure the intended meaning was understood. All interviews were confidential and only gender, age and family name initials were used for confidentiality in the data analysis. For socio-cultural reasons, the researcher recognized that some Ugandans would not be comfortable with discussing condoms and condom use face to face thus respondents were given the choice of telephone interviews and four respondents chose this option.

Data analysis: Transcripts were analyzed according to the research objectives by using thematic analysis to derive and inspect meaningful sequences of responses. The transcripts were given unique codes to facilitate simple cross-checks during the analysis process and facilitate easy identification, analysis, generation and reporting patterns within the data²⁷. Thematic analysis further focused on the actual details of the responses (verbatim accounts) to derive a sequence that could explain social meanings²⁸. Thematic analysis also facilitated systematic analysis of transcripts, allowed a complete and full review of the data collected. The codes carrying similarity or recurring issues were identified and compared to derive patterns of associations within the data and the potential themes for analysis. This enabled assessment of excerpts and facilitated the researchers in deriving meaningful connections between the ideas expressed. It also helped to improve the validity and rigor of the findings²⁶.

Ethical issues: Informed consent was obtained from each participant. Confidentiality was ensured at all times and ethical clearance was obtained from the Research and Ethical Committee of Leeds Metropolitan University prior to data collection.

Results and findings

Themes arising

Relationship dynamics

The average age of respondents was 29.3 years with a balance of men and women included in the sample. A key theme identified was that condom use was generally associated with the type of relationship one was in and the length of that relationship. Trust was seen as having great value in a stable relationship and thus many described condom use as unnecessary. All participants argued that condoms were not an easy option and one needed to trust that their sexual partners were not having extra-marital affairs. This was especially the case for those who were married or in long term relationships. They pointed out that suggesting condom use would be likely to endanger their partner's suspicion of infidelity. Although most of those interviewed described condom use as unnecessary, especially if their partners were on the pill, some said it was necessary especially if one was to get involved in an extra-marital affair. According to B/34,

You use condoms with strangers, someone you've never met in that situation. If you have a long term relationship, then you trust them to have sex without problems, this or that. It's hard to show her you really love her when like [and] use or suggest condoms. Me I am trusting her but I don't know of course if she's messing around. I put my life, you know, everything on her.

C/26 said,

If I'm in a relationship with a lady, I should be able to trust her to sleep with her. In that case I don't need a damn condom. Because the woman I love and marry, I belong to her and she belongs to me, as long as I trust you as my wife. Only like people who want to cheat use condoms, not for marriage.

P/30 also stated:

you just have to trust that your partner is not sleeping around. I mean, if a man is not sleeping around, you wouldn't need it … You are kind of not in control with these things. In reality, we should be able to trust our partners but at the same time, a nagging woman can push you to limits. You basically commit to someone, whatever happens. It's as simple as that.

You can never use a condom on a lady twice before they complain you don't trust them anyway. Culturally, when people date for like a long time and one or both are foreseeing a possible future together, they usually think well, they should be able to trust each other. You are emotionally close, you know. She may leave, you know. It's like committing your life to someone, whatever happens, you convince yourself it will be alright.(R/28)

J/27 added, We can't just sit there and moan about STIs. Obviously no one can use condoms forever so let's just be honest, why would anyone want to use a condom in marriage. I mean she's on a pill. You just trust that your partner is safe. My friend, you just trust.

Condom use and stigma

From the data set analyzed, it was evident that condoms and their use were linked conceptually to extra-relationship affairs, which made it hard for people to openly talk about, buy, keep or suggest their use. The ongoing stigma surrounding sex as an adult and privacy issues were also key factors in fueling cultural resistance against condom use. It was rare for people to talk about condoms generally, either with their children or sexual partners for fear of embarrassment. These feelings of embarrassment generally affected consistent use and peoples' access to correct information about STIs and condoms use. According to RR/28: Many people here feel embarrassed to ask for condoms because of the culture we come from. The issue of sex is a private matter, for adults or married people. You can't just talk about condoms, it's strange for some people. It's like a new thing. Most people will use condoms when they want to cheat for a change or otherwise most couples will prefer family planning pills or injection and that's how we understand it.

L/19 said: First of all, talking about sex and all that stuffis like embarrassing. Some colleagues will probably tell you they have never used condom[s]. It's simple, you can't ask someone to like show you how to do it. May be they don't know how to. The women are kind of shy. Point is, why would you want to learn to use it if you are probably, like, not going to have sex. Everyone will be, like, she is having sex, like tonight. Big deal isn't it. But if no one teaches you how to drive [a] car, how will someone drive it? I mean nobody is gonna tell you, hey, I've started doing sex.

“For me as a Christian, it's not good idea to use condoms, it's like you are preaching to people to engage in sexual activities outside marriage, which is not good. You would be encouraging people to sleep around. I don't like the idea of condoms. It's immoral. True love waits, not condom, condom. (C/26)

STI symptom recognition.

Some participants believed they could judge their potential sexual partners' health by just looking at them. Generally, participants were not likely to clearly or specifically describe the signs that they would look out for in an infected person. This belief that one was able to recognize people who had an STI was identified by respondents as one of the key contributors to condom use or non use. R/28 argued:

like when you look at people out there, you can tell there's a problem if one is sick. Everything points to the fact that something is massively wrong. Someone with HIV for example can't hide completely. You can tell somehow, you know the things we read about and see everyday back home … the youngsters fall victims unknowingly. They make wrong judgments and discover later that they've been netted and are sick.

According to F/38: “It's about where you were brought up at the end of the day … bottom line is, we have been there, we have lived there and I think I've got a clue when I meet someone closely. AIDS is AIDS, but people can't easily think about it. It just skips their minds.

To a good extent, yea. I can tell this person is sick [with HIV]. I mean, you have an answer staring in your face, like you run for your life. Sometimes people realize when they've started going out and it can be luck sometimes but if you can't observe carefully, just getting excited you know, then you are a dead man. (B/34)

Don't give me that. Of course you use your judgment in whatever you are gonna do. You can't go around asking people about issues or like HIV and stuff. You would be stupid. You just know when to use condoms and when it is unnecessary. (P/30)

Fatalism

From the data collected, fourteen of the people interviewed believed it was beyond peoples' means to prevent themselves from STIs. They believed it was peoples' fate to live with HIV if they were unlucky to get it. This belief in fatalism was partly seen to affect consistent condom use among those who shared these beliefs. According to B/34,

“Once it happens and you have an STI, you probably can't undo what's already done. You just pray for whatever comes out. You pray you don't have the bad blood. Everyone maybe like, waits for their turn, we can't do anything to stop whatever wants to happen”.

Obviously, it doesn't take twice to get pregnant or infected with STI unless you are meant to get it anyway. I think people surrender their lives after the first mistake and they realize they are sick. They wouldn't be in position to change things anyway. Period. Why keep moaning about it? You definitely can't stop living. May be you were unlucky after all. M/19

Our condoms at home are poor. We can't definitely afford better ones. We heavily depend on donations, which sucks. I would genuinely think people have no way to contain it and its unfortunate we have to live with that. D/24

However, some people disagreed. H/20 argued that

“when you see how people live here, what can you believe? I've got no faith in what we are told about those STIs. People think there's no or little HIV here but I think that's not true. It can be misleading. People go out, take one or two beers and probably think, well, this is it. They later think they were unlucky after all”.

STI risk perception

Results indicated that some people believed they were at a lower risk of getting an STI while in the UK than in Uganda. This was understood by participants as one the major factors that influenced condom use. The belief that STIs were common among young people, as opposed to the older respondents who were believed to be ‘mature’ and settled down seemed to influence decisions to use condoms. P/ 25 stated:

You have to be careful not to sleep around but I think the diseases are not as bad as back home. Well, personally I don't think HIV is a big issue here than back home. I think STIs are most in the young ones, say who haven't settled down.

J/27 added; “I think the major problem here is not HIV. Maybe cancer, or diabetes. It's hard to tell but I would like to think that's the case, otherwise with a lot of sleeping around, Britain would be on fire.

According to P/30, “the situation in UK is over estimated, there's no way it can be that high. Yea there's a lot, the disease can be more, maybe if they didn't control the situation, but they do. All the time”.

F/38 also argued, “talk about the numbers, obviously I think this country has the highest number of teenage pregnancy, so that tells you a lot. So you want to tell me they are always using condoms? Hell no. But there's maybe less of an HIV problem here anyway and obviously, here, you could do it [and] live, it's no big deal. You wouldn't risk it in Uganda. It's different”.

Perceived threat of STIs

Most of the Ugandans interviewed reportedly feared HIV/AIDS because of its physically “devastating effects” such as “exposing your little secrets” as opposed to other STIs. Participants also believed other STIs were not life threatening since they were able to be treated successfully in the UK unlike in Uganda. This perception of wide availability of STI treatment in the UK was identified as a key contributing factor to not using condoms. According to R/28:

Of course all diseases are bad. No one wants to get ill but AIDS is deadly. It will expose you just like that. You get it, you have no treatment, you are finished. It's not like say syphilis. Everyone like knows your little secrets, damn it. I think people also look at the disease in many years to come, say like 7 years. And the drugs may be for about another 25 years. Come on, that's a bloody 32 years and for them, it makes sense. It's get the money, get rich and everything is great.

J/27 added, “People always get it, you never know but they get treated anyway. No big deal. Maybe if it's HIV, that one scares me to death. I mean it. It's a bloody killer. It's a common story especially back home. No joke. If you were in Uganda, you die. But here, you've got a choice.

D/24 also said, “There may be few sufferers of STIs here. If they got sick, they would be treated anyway. It's not as life threatening as the types we have in Kampala. Here, it's not on people's mind. It's where to get the next trendy outfit or a nice sandwich”.

My grandfather used to have several women, okay. He used to enjoy life. He passed on at 60 years and I feel that's how this life is. We are here and at one time we have to go. Back home, it's easy to die because we lack the right treatment. Whoever gets HIV, yea, the life expectancy would be in months but here, they've got the drugs, come on. (F/38)

Discussion

Various beliefs and attitudes influencing condom use among expatriate Ugandans have been identified. It was clear that condom use to prevent STIs is not fully appreciated in this community due to stigma or other social-cultural misrepresentations. For one partner to suggest condom use to another, also raised a lot of suspicion about their fidelity. Beliefs in one's ability to recognize STI symptoms played a key role in influencing consistent condom use. Clearly individuals are at risk of STIs since recent reports indicate an increase in new HIV/AIDS cases among people in stable relationships in Uganda.²⁹ The fact that less attention is given to prevention programs, awareness about condoms or behavioral change and is instead concentrating on ARV treatment has thus been widely criticized for this trend.³⁰ In this report, for every individual beginning ARV treatment, an estimated five people become infected with the virus and this is also being seen as one of the key reasons for the increase in HIV/AIDS cases in Uganda.

Relationship dynamics

The type of relationship one was involved in, in terms of length, commitment and purpose was a key factor in influencing peoples' decision to use condoms during sexual encounters. Most participants pointed out that it was of vital importance to trust their sexual partners for a healthy relationship especially if the partners were using an alternative method of contraception. It was therefore clear that most people expected their sexual partners to have built trust in their partners' fidelity for each other as time passed. In line with Manning and colleagues³¹, the length or duration in terms of feelings of importance was negatively associated with consistent use of condoms. The authors pointed out that both negative (control, mistrust, conflict, partner inferiority or jealousy) and positive relationship dynamics (love, self-disclosure or salience) were very complex but were both strongly determinative of consistent use of condoms and more important than simple socio-demographic characteristics.

People in this study were trusted or not according to the stability of the relationship, largely perceiving condoms as a functional prevention measure for unplanned pregnancy and, surprisingly, to a lesser extent preventing STIs including HIV. This relationship stability was also viewed as key to determining partner safety for STI/HIV. In line with Masaro and colleagues³², those in long steady relationships were more concerned about pregnancy and considered themselves to be at reduced risk of STI/HIV infection than those engaged in casual relationships. It was clear that individuals who presumably believed they were in a monogamous relationship were also more likely to underestimate their risk to STIs and less likely to believe their partners were involved in other concurrent or overlapping sexual relationships, a similar trend registered by Lenoir and colleagues³³. Other factors responsible for increased motivation in a relationship over time have also been documented and associated with ‘maturity’ of the relationship in terms of intimacy and trust between partners^34,35. It was reported in these studies that with the passing of time in a relationship, it became important to trust partners and this reduced the perceived risk or threat of STIs and thus reduced incidences of condom use due to the new found ‘confidence’ from the fact that no signs or symptoms of STIs were observed, the perception developed that infections were not a ‘real’ possibility. It is therefore clear that condom use has an important symbolic representationor meaning in relationships and this is associated with the way many people assess their potential sexual partners as to different health risks. Although this notion of trust based on perceptions of ‘increased' knowledge about peoples sexual behaviors by their partners has often been found to be inaccurate³⁶, it plays a significant role in decisions on condom use and needs vigilant attention through awareness and support.

Some participants interviewed believed that the STI problem was especially found among the young who had not ‘settled down’ yet. However, recent revelations about the new ‘face’ of the STI/HIV epidemic has caused concerns about what had previously been described as a low risk group, namely, those in stable or married relationships. HIV/AIDS risk has previously been associated with the young and unmarried but is now reported as increasingly high among the married and those in stable relationships, with many married or cohabiting people unknowingly living with HIV positive sexual partners^29,37. In support of other studies documenting that men are more likely to display higher levels of ‘not regular relations' and engaging in casual sex with younger women in comparison to women who had more relationships involving marriage or cohabitation,³⁸ our findings about relationship dynamics suggest that as much as trust is a key virtue in relationships, people need to understand and learn that they are nevertheless at a high risk of contracting STIs. This involves understanding the risks of being in concurrent relationships. It is equally important for people to develop key communication skills to help in condom negotiations with their sexual partners. This should be part of the STI prevention and control program strategy since power in relationships has been widely documented as key in determining decisions to use condoms during sexual encounters³⁹. As these authors have noted, public health campaigners in community-based health education programs may need to consider promoting the idea of ‘safe love’, probably by ‘romanticizing’ condom use as a sign of love and trust, and placing great emphasis on the benefits of condoms for protecting one's partner.

Condom use and stigma

From the study findings, it was found that condom use was highly stigmatized and therefore was hardly discussed at all partly because sex or condom use were understood to be a private issue for ‘adults’. Condoms were further believed to be used primarily when one wanted to cheat on their partners (extra-marital affairs) and thus were believed to encourage promiscuity. Cultural stigma regarding condoms and their use has often been associated with little actual knowledge about condoms and lack of confidence in their use generally⁴⁰. This socio-cultural stigma has also been related to an increase in feelings of embarrassment and decreased perceived risk to STIs, pregnancy or condom use among ethnic groups⁴¹. The increase in feelings of embarrassment, according to Dahl and colleagues, often acted as an inhibition to consistent purchase (in terms of frequency and number of condoms) and use of condoms. This socio-cultural stigma was further associated with negative social evaluation on condoms generally in terms of their effectiveness and role in preventing STIs. From our study, sex was often seen as a dirty word or ‘dirty practice’ and thus condoms would be referred to as ‘dirty’ because they indicated that one intended to have sex after all. Portraying condoms and sex in this manner suggests that people would feel they should not publicize themselves as engaging in ‘unclean and dirty’ behavior and this generally can affect condom purchase or use.

Given that most Ugandans associated condom use with promiscuity/ infidelity, disease, multiple sexual partners or mistrust from partners, there is a need to develop and incorporate effective health communication skills in the campaigns designed to tackle stigma and promote better attitude towards condom use. There is also a need to incorporate these programs in the informal monthly meetings involving this community which are usually well attended gatherings as people look forward to seeing, chatting and sharing up to date information with one another. In these meetings, a lot of financial, immigration or social issues affecting the Ugandan community are interactively discussed and solutions suggested by members. Incorporating discussions about sexual health, including STIs and condoms would help alleviate the feelings of embarrassment and general stigma attached to clinic-based intervention programs. People would also come to appreciate sexual health as an important issue that actually affects their community and their children. The media could also aim to normalize people's tendency to associate condoms with irresponsible sexual behaviors by promoting them as a smart and responsible way to avoid unwanted pregnancies and STIs.

STI representation and partner selection

There were many participants who had faith in their ability to recognize someone with an STI based on their physical appearance. This perceived ability seemed to have a considerable impact on determining peoples' decision whether to use condoms during sexual encounters. Nonetheless, individuals had no accurate information about STIs, their signs and symptoms and thus were clearly depending on their ‘lay’ knowledge from their public or private networks to ‘assess’ someone as infected with an STI. Other studies have related sex based on physical partner selection to physical benefits in terms of compensation for their financial, emotional or social status among their peer groups⁴². These beliefs in partner selection have also previously been strongly associated with increased sexual partner network patterns and these patterns reflect the increase in incidences of STI/HIV³². That key factors favoring partner selection behavior were based on partners' physical appearance, past or present social and sexual history, clearly associated with a decrease in the perception of STI risk. This belief in the veracity of symptom recognition also appears to decrease the likelihood of consistent condom use. There is therefore a need to en-gage and sensitize this community about STIs generally, since STI symptoms do not necessarily manifest in ways that allow for easy assessment by a potential partner⁴³.

Conclusions and recommendations

The perception of STIs as less common and less life threatening due to the wide availability of ‘quality’ treatment available in the UK seemed to be a strong factor in contributing to inconsistent condom use. Most participants seemed to fear HIV/AIDS the most because of its perceived social, psychological or physical effects unlike other STIs which were described as non-threatening because treatment was widely available in the UK. Less knowledge about STIs, the notion of trust in relationships and the lay beliefs in partner selection or symptom recognition also appeared to mould peoples' decisions to use condom or not. Misconceptions about sex and condoms further increased the socio-cultural stigma to condom use within the Ugandan community. These socio-cultural under pinnings of STIs, sex, trust and relationships therefore seem to be symbolic in influencing consistent condom use.

The socio-cultural dynamics surrounding sex, trust and relationships influence the notion of risk perception to STIs, allowing condom use to be symbolically meaningful in this community. Unprotected sex being represented as ‘proof ‘ that one was faithful, loved, trusted their sexual partners especially those involved in long term/ married relationships meant that relationship dynamics played an important role in influencing participants' perceptions of condom use. These and others that seem to associate unprotected sex with a sense of trust and ‘sexual control’ that gives them what is perceived as ‘natural’ feeling of enjoyment during sexual encounters with their partners could benefit from awareness of voluntary HIV testing through education and support. The misrepresentation of disease, risk, sex or condoms seems to increase cultural and social resistance to condom use and consequently generates a real challenge to STI prevention programs. There is therefore a great need to explicate and openly acknowledge the community's socio-cultural beliefs and values regarding their sexual health, STIs, STI risk and to design messages about STIs and condoms that reflect these beliefs. This would help to eliminate the serious misconceptions related to condom use that are present in this community and improve health outcomes generally. This participatory initiative could also help not only to empower people to responsibly take control of their health against STIs through increased condom uptake but also to break the cultural stigma attached to sex and condom use generally.

Competing interests

The authors declare that they have no competing interests arising from this research.