Horizons Report | December 2005 | ABCs: Not as Simple as They Sound

ABCs: Not as Simple as They Sound
Kenya study highlights how adults and youth interpret key messages

A group of about 10 African school children in school uniforms pose for a picture.

Youth from the Sher Agencies Flower Farm School, one of the study sites.

Photo credit: Louis Apicella

It is widely accepted that the “ABC” behaviors—being abstinent or delaying sex until marriage, being faithful to one sexual partner, and consistently using condoms during sex—are key to reducing the sexual transmission of HIV and that there is a need to tailor messages about the ABCs to fit different audiences and cultural contexts. Yet considerable debate surrounds how best to deliver the messages and apply them to prevention efforts. Furthermore, questions remain about how well the terms are actually understood by the various groups they are meant to target. Are they clear or confusing? Seen as useful or irrelevant? Viewed as complementary or contradictory?

Horizons and the IMPACT Project of Family Health International (FHI) collaborated on a study in 2004 to explore how different groups in two communities in Kenya, Naivasha and Molo, perceive ABC terms and behaviors. Self-administered questionnaires were given to groups of youth and adults—working adults at flower farms and in-school youth ages 13–19. Interviewers were available to help respondents, if needed, fill out the questionnaires. Focus group discussions were also held with flower farm workers and in-school youth, as well as with female sex workers and male truck drivers. The study findings highlight attitudes and norms around the ABC behaviors, as well as barriers to and facilitators of the behaviors, and the role of important actors in transmitting messages about them.

Understanding the ABC Terms

Both adults and in-school youth have an almost universal awareness of HIV, and the great majority have heard the ABC terms used in the context of HIV prevention. However, when asked to define the ABC behaviors in open-ended survey questions, many did not have a clear understanding of the terms, and they offered incorrect or partially correct definitions of the terms, or opinions instead of definitions (see Table 1).

Both groups understood the term “abstinence” the best, and generally described it as not having sex. Compared to adults, youth were more likely to supply a correct answer (46 vs. 39 percent). However, among those who answered incorrectly or only partially correct, it was common for both adults and youth to confuse abstinence with “being faithful to one partner” or to indicate the opposite of the definition with responses like “having sex with many people.”

When asked specifically about the term “being faithful,” it was often misunderstood and confused with other concepts and qualities, such as loyalty to another person or being honest and trustworthy. In this case, youth were more likely than adults to confuse the term, with only 23 percent answering the question correctly compared to 35 percent of adults.

When asked about “being faithful,” the term was often misunderstood and confused with other concepts and qualities.

Only a small proportion of both adult flower farm workers (17 percent) and in-school youth (13 percent) supplied a correct definition of “consistent condom use.” Many youth, particularly younger students, answered the question with an opinion on condom use, with some advising their fellow youth not to use them. A large proportion of adult respondents left the answer space blank.

“Respondents had different levels of clarity about the meaning of abstinence, mutual monogamy, and correct condom use, as well as widely disparate views about the behaviors,” summarized Dr. Julie Pulerwitz, Research Director for Horizons and the lead author of the study report.

When survey respondents supplied an opinion about the ABCs instead of a definition, they usually cited the advantages and disadvantages of the behaviors. Respondents from both groups perceived abstinence and being faithful as positive and widely supported behaviors, whether or not they correctly defined the behavior. When asked specifically for their opinions, 99 percent of adults and 98 percent of youth reported that being faithful is a “good” idea. These positive views were further emphasized in focus group discussions.

On the other hand, opinions about condoms were often negative, particularly among youth. Many youth perceived condom use as ineffective or inappropriate. When specifically asked whether condoms were good or bad, about a third of in-school youth felt that condom use was a “bad” idea. Further, while many adults reported that condoms prevent HIV and other STIs, more than two thirds of survey respondents indicated that they “may be ineffective” for reasons such as their having holes in them, regularly bursting, or being intentionally damaged.

Despite the fact that respondents reported that abstinence and faithfulness were morally appropriate behaviors supported by the greater society, they cited many reasons as to why they were difficult or impossible to implement in actuality. People from all backgrounds—men, women, girls, and boys—mentioned the driving need for sex and an inability to control sexuality. During focus group discussions, participants shared the idea that abstaining and being faithful has negative physical repercussions, particularly for men. These potential ailments included back and joint pain, a susceptibility to malaria, and an inability to urinate.

There was also a prevailing sense of fatalism that HIV is so common that there is no way to avoid infection nor any need to engage in risk reduction behaviors such as mutual monogamy. This was combined with ideas on other, often incorrect, ways of acquiring the virus. For example, when asked in a focus group discussion if an individual abstaining would prevent the spread of HIV/AIDS a female flower farm worker responded, “Even if people abstained, sex is not the only way one can get HIV/AIDS. For instance, I can abstain. I have not even married, and I have not had sex with anybody but then I get infected through...injections in hospitals. I will be having the virus and I will die like anyone else.”

In addition to their own negative perceptions of condom use, many focus group participants felt that asking a partner to use a condom implied a lack of trust. While both men and women shared this concern, women commonly cited fear of anger or violence should their partner suspect infidelity. Both male and female respondents also stated a reduction in sexual pleasure as an additional barrier to their use.

Another key barrier to condom use that emerged during focus group discussions was the pressure to have unprotected sex, mentioned by female adults and some female youth. Many of these respondents cited the need for transactional sex as a way for women to earn an income or to supplement an existing income and did not feel condom use could be insisted upon in this context. Sex workers reported that transactional sex was their only source of income, and to further complicate matters, male truckers revealed that men pay additional money to encourage sex workers not to use condoms, or even refuse to pay a sex worker unless she agrees not to use them. Rape and forced sex were also commonly mentioned issues affecting women that pose insurmountable barriers to implementing condom use, as well as to being abstinent and faithful.

Messages about the ABCs

Although respondents had largely heard of the ABC behaviors and understood that they were intended for HIV prevention, focus group discussions revealed that messages were often confusing or conflicting. Many youth explicitly indicated that they received different information from different sources about how they should behave sexually, predominantly on abstinence and condom use. They also stated that those providing messages on the need to abstain or be faithful were rarely doing so themselves.

Both adults and youth cited receiving conflicting and confusing messages about condom use. Many respondents indicated that they were told that condoms are protective against HIV transmission, but that they are also ineffective. Focus group participants also expressed concerns that condoms actually spread HIV, and reported receiving this information from the radio or other respected sources. As one female youth said, “The radio says they [condoms] have the virus…we are told they have small holes that can allow the virus to go through.”

A billboard in Kenya shows a couple at a crossroads. The poster says: "Choose da best direction...Maisha Iwe Poa!!"

A billboard encourages viewers to choose the best option for them—abstinence, faithfulness, or protection.

Photo credit: FHI/IMPACT

When asked about the best way to transmit key ABC messages, both adults and youth reported a preference for interpersonal and interactive methods, such as workshops and group discussions. This preference was in spite of the fact that radio and television were reported as the main sources of information. Radio announcements were found to be too general, and respondents reported liking the opportunity to discuss issues in detail and to have their questions answered.

Strengthening ABC Programs

HIV prevention programs that incorporate ABC messages should consider a number of important lessons learned from this study. The findings highlight the need to clarify what is meant by the ABC behaviors, particularly being faithful to a sexual partner in the context of HIV prevention and consistent condom use. Programs focusing on the behaviors should utilize terminology that is locally appropriate and clear. Local perceptions about sexuality and HIV, such as the widespread belief that it is impossible for men to control their sexual behavior and the perception that HIV is impossible to avoid, must also be addressed.

There is potential for programs to build upon the strong support for the AB behaviors indicated by respondents. However, numerous barriers to the AB behaviors, as well as to consistent condom use, highlight the need to combine ABC-related messages with other types of interventions that would allow individuals to practice these behaviors, if they choose to do so.

“These findings indicate that to successfully implement a balanced ABC approach you need to also implement strategies that move beyond building knowledge to take into account important contextual barriers. These include forced sex, women’s dependence on transactional sex, and women’s frequent inability to negotiate their own sexual behavior,” explained Dr. Pulerwitz.

Relevant interventions would focus on reducing gender-based violence, changing perceptions of masculinity and sexuality, and providing microcredit and vocational training to enable women to find alternative sources of income to sex work.

In a balanced ABC program, all components of the paradigm are offered as options, yet targeted to specific audiences. To achieve this balance in Kenya, negative views about and discomfort with condoms must be addressed.

“Many community members did not understand the meaning of consistent condom use, as well as abstinence, and being faithful. Yet, they felt that abstinence and being faithful were socially supported and acceptable behaviors but that condom use was not. FHI is striving to clarify the ABC terms and support community members to practice the ABC behaviors through a balanced and more accurately targeted message mix,” explained study investigator Tiffany Lillie of FHI.

She went on to say that HIV prevention programs need to apply the 4Cs to the ABCs. “ABC messages need to be clear, consistent, compelling, and coordinated.”

FHI/IMPACT is currently implementing a behavior change intervention in Naivasha. As a first step the project brought together various non-governmental, civil, and faith-based organizations to discuss the barriers individuals face in adopting the ABC behaviors and to develop a clear and balanced HIV prevention strategy. The ongoing intervention builds on these discussions and delivers ABC messages to different audiences through a variety of methods such as community meetings, discussion groups, street theatre, and billboards.