BACKGROUND: Any knowledge that can help us influence more people to use condoms saves lives and plays a key role in arresting the HIV pandemic. My motivation for writing this thesis was to determine whether a change in attitude towards the use of condoms among youths in Zambia had occurred between 1995 and 2003. Evidence from surveys suggests that there has been a positive change in sexual behavior. During the eight year period, data from the same population show a marked increase in the use of condoms, particularly among urban women and in individuals in the population with an above average educational attainment. Unfortunately the changes have not been as great as expected. Therefore knowledge of the change in attitude regarding the use of condoms might give us vital information and have an impact on policy interventions. It was necessary as part of this assessment to explore how well selected aspects of attitude explain the use of condoms, and whether these relationships have changed during the eight year period.
METHOD: By analyzing selected attitude-items from three population-based surveys conducted in 1995 (n=1720), 1999 (n=1946) and 2003 (n=2637), I predicted changes in attitude among Zambian youth classified by residence, gender and educational attainment. Analyses of a single item attitude and a joint item attitude were conducted by creating an attitude-index. Further logistic regression was used to examine variables associated with the use of condoms when assessing the association between attitude and behavior.
RESULTS: The most important finding in the single attitude-item analysis revealed was that young people have become more skeptical regarding the safety of the condom during this time period. The attitude-index analysis showed that despite a significant increase in the reported use of condoms in the population, the observations indicated no substantial changes in attitudes. The attitudes did not change over time with respect to educational attainment. However, there was a small but significant change among rural women. In addition, regression models indicated that the attitude index towards condom usage was strongly associated with the actual use of condoms. The findings also reveal that the association between attitude and behavior was substantially stronger among young women and in the age group 25-49 in the data from the initial survey in 1995 than in the observations eight years later. CONCLUSION: It is alarming that young people have become more skeptical towards the safety of the condom. My recommendation is that the National AIDS council in Zambia organizes all stakeholders to communicate a joint message that is in line with what is the scientific basis, i.e. condoms are safe. The attitude-behavior relationship is far more complicated than most prevention campaigns assume. Both evidence accumulated in this thesis and prevailing theories on attitude-behavior association illustrates this. The existing theories and models, however, are not sufficient to explain the findings in this thesis. We need to develop an interdisciplinary model/theory that can better explain how attitudes influence sexual behavior (and vice versa) on different levels of society.The evidence accumulated in this thesis indicates the importance of monitoring attitude change towards the use of condoms as well as actual behavior change. When monitoring attitudes towards the use of condoms, it is also crucial to include other determinants for the use of condoms on the micro, meso and macro levels. A further recommendation is to generate an “attitude-towards-condom-use scale” that is customized for Zambian youth. That will help us to obtain a broad knowledge of attitude changes among Zambian youth, from which functional guidelines for policy intervention might be constructed. These measures would play a key role in helping to reduce the HIV epidemic.