Condom Usage Negotiation Among Customarily Married Women in Katlehong, Johannesburg

South Africa has the highest number of HIV-infected people in the Southern African Region, and of great concern is the fact that cases of new infections among young people, especially young women and girls, are on the increase. The prevalence of HIV and deaths caused by AIDS are still on the increase, whereas condom use, particularly in rural areas, remains low. Consistent condom use is central to the prevention of unwanted pregnancies, HIV, and other sexually transmitted infections (STIs); yet, young men and women alike are hesitant to use condoms because of threats to their relationships, cultural roles, and, at times, economic survival. This study explored the views of customarily married housewives regarding condom use negotiation with their husbands. The findings point toward the need to empower women while they are still young so that they can be assertive, financially independent, and able to make their own decisions with regard to their sexuality.


Introduction
Like many other Sub-Saharan countries, South Africa has a high rate of sexually transmitted infections (STIs), which includes the HIV (Key, Denoon, & Boyles, 1997). One of the strategies that could be used to prevent STIs, HIV in particular, is the correct and consistent use of condoms. However, condoms are not always used effectively and consistently, which has led many researchers to investigate this issue (Santelli et al., 1997). In addition, despite having much knowledge on HIV and AIDS and how it is transmitted, people still have unprotected sex with their partners. Even though condom use is one of the elements in the ABC strategy-Abstinence, Be Faithful, and Condom Use-when this strategy was implemented in South Africa, it became clear that it had little or no regard from local culture, especially when you take into consideration the cultural beliefs that women are expected to bear children once they are married. This, therefore, makes it nearly impossible for women to negotiate condom use with their partners.
The main purpose of this article, therefore, is to explore the views of customarily married housewives to identify how easy or difficult it is for them to negotiate condom use with their husbands. Osuafor and Mturi (2014) stated that customary marriage takes place when two families are joined together by the groom and bride through the payment of lobola or the bride price. This practice is common among Black South Africans. According to the Department of Social Development (2003), marriage symbolizes many social ideas, and it embodies morality. Moreover, Corvino (2005) further stated that marriage also result in an accomplishment, stability, acceptance, and general good standing in communities as well as in personal commitment, sexual fidelity, and emotional fulfillment. Marriage is often regarded as a protective institution when it comes to issues around exposure to HIV and AIDS. This study seeks to explore the experiences of customarily married housewives in their intimate relationships with regard to condom use negotiation in Katlehong, the East Rand of Gauteng Province in South Africa.
Condom use has helped in reducing the risk of HIV transmission (Potts et al., 2008). However, evidence has shown that the use of condoms has remained low, given the rise in HIV infection among women, particularly those in steady relationships (Osuafor, 2014). Maharaj and Cleland (2005) argued that the promotion of condom use among married couples have been neglected despite the fact that HIV is mostly infectious through sexual intercourse within marital 687345S GOXXX10.1177/2158244016687345SAGE OpenDube et al.

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1 University of the Witwatersrand, Johannesburg, South Africa and cohabiting unions because of either prior infection by one partner or due to infidelity. In South Africa, the HIV prevalence has declined among women between the ages of 15 to 24 years, while there has been an increase in older groups of between 30 to 39 years (Ross & Deverell, 2004). Studies by Maharaj and Cleland (2005), Potts et al. (2008), and Osuafor and Mturi (2014) found that there is a lot of resistance concerning condom use, particularly in stable and long-term relationships because of it being associated with lack of trust, and the fact that there is no consistency in the use of condoms. It is therefore significant to investigate factors related to condom use negotiation among customarily married women.

The Overview of the South African HIV Epidemic
Introduction Brouard, Maritz, and Lazarus (2013) declared that the National Department of Health estimated that in 2011, South Africa was home to approximately 5.6 million people living with HIV (PLHIV)-the highest number of PLHIV of any country in the world. In addition, using the Actuarial Society of South Africa's model for projecting the impact of HIV and AIDS on the South African population in general, and findings from household surveys undertaken by the Human Sciences Research Council (HSRC), are slightly lower but broadly in line with the Joint United Programme on HIV and AIDS (UNAIDS) estimates of 5.3 million in addition. In 2012, the South African National HIV Prevalence, Incidence, and Behaviour Survey found out that 6.4 million people in South Africa live with HIV. This figure represents a quarter of the burden of HIV infections in Sub-Saharan Africa and 18% of the global burden (Shisana et al., 2014).

Women's Vulnerability to HIV and AIDS
South Africa has been rated among other African countries to have one of the highest incidence and prevalence rates of HIV and AIDS in the world (Brouard et al., 2013). According to Ramjee and Wand (2012), women are particularly heavily affected by the epidemic; they are at the greater risk of infection due to biological, social, and economic factors. Women are also more vulnerable to HIV's and AIDS' impact for several reasons, for example, the epidemic's potential of breaking down the relationship between partners, parents, and children. Furthermore, Ross and Deverell (2004) argued that due to HIV and AIDS, "families fall apart and burden of sustaining the family life is socially placed on women who are also disadvantaged by cultural and gender inequalities" (p. 259).
In terms of the risk of exposure to HIV infection, marriage is often presented as a protective institution, because it is assumed that in marriage, there is a monogamous fidelity (Weed, Ericksen, & Birch, 2005). This assumption underlies the traditional belief that when one enters into marriage, sexual relationships should be done with the sole marriage partner. However, it should be noted that where societies apply different norms to sexual regulation, marriage becomes an institution of vulnerability to HIV infection for women (Department of Social Development, 2003). Anecdotal evidence points to the idea that women continue to have unprotected sex with their wife even when they know the man has other wives. For example, Scamber (2009) stated that some married men have multiple and concurrent wives who put their partners at risk of getting infected. In 1998, a South African Demographic and Health survey was conducted and the results indicated that condom use in marriage was very low; for example, only 5% of the men on the mines said they used condoms with regular partners (Van Dyk, 2008). According to Hardee and Leahy (2008), condom use is infrequent among married couples for multiple reasons, including the desire for children and the widespread association of condoms with infidelity and lack of trust. In Kenya, 97% of people in marriage or cohabitating relationships reported that they did not use condom the last time they had sex. Similarly, a study in Zaire found that women were not able to insist on condom use-even when they suspected their husbands of having multiple partners-because of their fear of an angry reaction (Maharaj & Cleland, 2005). Moreover, many couples throughout Sub-Saharan Africa want to have large families; thus, use of condoms-particularly if it is prolonged-may be considered unacceptable (Central Bureau of Statistics [Kenya], Ministry of Health, and ORC Marco, 2004). Based on this study, it is clear that condoms are one of the least frequently used contraceptive methods by married couples in African countries.
Another contributing factor to women's vulnerability to HIV is gender-based violence. According to Maharaj and Cleland (2005), gender-based violence plays an overlooked but significant role in women's vulnerability to HIV. Forced unprotected sex obliterates women's ability to negotiate condom use, and the threat of physical violence is a strong deterrent to requesting condom use, particularly with a husband who may view the request as an admission or accusation of infidelity. Social and legal factors that impede women's empowerment also have important impacts on married women's vulnerability to HIV. Hunter (2010) stated that in Sub-Saharan Africa and many other parts of the world, women have lower educational attainment and, subsequently, fewer economic opportunities than men. Much of women's work is unpaid or exists in the informal sector. Furthermore, economic dependence on a husband makes it difficult to leave an unsafe marriage or refuse unprotected sex (Hardee & Leahy, 2008).

Conceptualization of Marriage
According to Giddens (2008), marriage is defined as "a socially acknowledgeable and approved sexual union between two adult individuals" (p. 207). However, in the South African society, it is socially acceptable for a man to have extramarital affairs which may place their partners at risk of contracting HIV. This is one of the factors that lead to the increasing number of HIV and AIDS cases in South Africa.
There are different concepts and expectations that go along with marriage. Scholars such as Mohlahlane (2004) and Hunter (2007) have presented marriage using an optimistic perspective, where the focus tended to be on the positive aspects, whereas this study explored other contributing factors in marriages which put couples at risk of contracting HIV and AIDS. Giddens (2008) argued that marriage normally forms the bases of family through procreation; that is, it is expected that married couples will bear and raise children. It is from this perspective of reproduction that disease exchange transmission can happen among married couples. Particularly as this is where non-use of contraception, especially condoms, occurs.

Condom Use and Power
Power is defined as an ability of the individual, or marriage partners, to achieve aims or further their interests (Giddens, 2008). Max Weber, one of the sociology's founding figures generally defines power as the "chance of man or a number of men to realize their own will in a command action even against the resistance of others who are participating in the action" (Giddens, 2008, p. 71). Hence, power is viewed as a pervasive aspect of all human relationships. In many different societies, conflicts occur due to struggles for power, because of how much power an individual or group has to achieve or to realize as their own wishes at the expense of others (Harvey, Bird, Galavotti, Duncan, & Greenberg, 2002). It is also argued that power in a society is all about getting your own way, even when others do not want you to (Parker & Aggleton, 2003).
In South Africa, power differentials are derived from economic, political, and social relations, which include gender, race, age, and locality (Squire, 2007). In this research, the concept of power was considered because some activities or experiences that influence people's daily living revolve around who has power and how that power is utilized. In male-dominated society, women do not hold a significant power especially in decision making. This notion makes it highly impossible for women to exercise their abilities to a full potential. For example, in a marriage, the man may always have power when it comes to sexual decision making, like condom use. Women tend to listen to their husbands because they are the ones who have the financial power in the relationship, especially the housewives.
There have been so many debates on issues concerning women empowerment, and this study reveals how women perceive this notion of empowerment. This was done through the research question as it tests the women's structure and agency initiatives when it comes to condom use negotiation with their partners. In South Africa, the structure of the economy and gender relations place women in a dependent relationship to men, often outweighing educational, political, and other social gains (Rehle et al., 2010). The fact that women are not empowered to exercise the power with their partners can put their health status at risk, due to constant inability to control decision making regarding sexual consent and protection in marriage. Condom negotiation is made difficult due to a popular belief that the main objective of marriage is to reproduce and expand the family; this perception makes the use of protection to be difficult within marriages (Walker, Reid, & Cornell, 2004).

Culture and Socialization
According to Williamson, Liku, McLoughlin, Nyamongo, and Nakayima (2006), condom use among married and stable couples is low and underresearched in developing countries, even in countries with high HIV prevalence like South Africa. Hence, introducing condoms into a longstanding relationship, in spite of HIV risk, is likely to be awkward (Williamson et al., 2006). Maharaj and Cleland (2005) are of the view that most HIV prevention efforts focus on premarital and extramarital sexual behavior, but in areas with high HIV prevalence, the protective needs of married and cohabiting couples are just as great and often go unmet. Condom use by these couples is generally low, with resistance from men and cultural norms commonly cited as barriers to increased use.
In most African societies, culture plays a major role in marriage. It is argued that women are more physiologically, biologically, social-culturally, and economically vulnerable than men when it comes to HIV infection because they are commonly subjected to patriarchal social cultures that do not allow them to exercise control over their health and wellbeing (Department of Social Development, 2003). However, it is a contested concept and it can be understood differently depending on the context and background. For example, most women in the African context do not have the power and the initiative to challenge their husbands as it will be viewed as culturally unaccepted behavior.
Socialization is another element which determines women's ability/inability to negotiate for condom use. According to Korpi (2000), socialization refers to "a lifelong process of social interaction through which we become a consistent and recognizable person and acquire the physical, mental and social skills needed for survival in the society" (p. 81). On the contrary, Giddens (2008) views socialization as involving a situation whereby "a helpless infant gradually becomes selfaware, knowledgeable and a skilled person in terms of the culture into which he or she was born" (p. 72). He further argues that development occurs through learning, genetic heritage, as well as through the norms, values, and roles we learn through interacting with others. According to Giddens, socialization can take place through different agencies, for example, family, schools, peer relationships, and mass media. It is through socialization that sexual taboos are created and reinforced within different societies. If behavior is said to be learned from childhood, it continues throughout life to influence people to modify their behavior in relation to the people around them. Socialization is, therefore, important in understanding women and their ability and/or inability to negotiate for condom use when they are within the circles of marriage as a social institution. Generally in the African tradition, men are socialized to be in charge of decision making in all aspects of life, and therefore, women have to succumb to those decisions even if it is at the detriment of their health, including the aspect of negotiating for condom use.

Aim
The aim of this study was to explore the views of customarily married women in Katlehong, Johannesburg, regarding condom use negotiation with their husbands.

Research Question 1:
What are the views of customarily married women regarding condom use negotiation with their husbands?

Research Approach and Design
The study utilized a qualitative research approach. Within the qualitative research dimension, an exploratory-descriptive research design was used to understand the phenomenon studied. The study sample comprised of eight customarily married housewives who were selected using snowball sampling, which is a non-probability sampling technique. Snowball sampling is useful in the investigation of sensitive topics that explore issues that are too personal such as condom use negotiation (Monette, Sullivan, DeJong, & Hilton, 2014). The criteria that were used for selection was that each participant was supposed to be a resident of Katlehong's Khumalo section and be a customarily married housewife aged between 25 and 30 years. The age range of 25 to 30 years was used because it has been found that women within this age range are the most affected and infected with HIV and AIDS (Shisana et al., 2014).
In-depth one-on-one interviews were used to collect data. All participants were interviewed individually due to the sensitivity and personal nature of the study. A minimum of 45 min and a maximum of 60 min were allocated per interview. The interviews were guided by the use of a semistructured interview schedule that is comprised of openended questions. The use of open-ended questions allowed for flexibility and further probing of the responses that participants gave. All the interviews were conducted on Saturdays in the homes of the participants. Saturday was chosen because it was the most convenient day for the participants as their husbands were at work and they also did not have the responsibility of fetching children to and from school. Given the fact that an appointment was arranged prior to the interview, there was less destruction during the interviews. This ensured that privacy and confidentiality were maintained. Thematic content analysis was used to analyze data. Data analysis was based on notes that the researchers took during the data collection process, through which different themes were identified. Therefore, identified themes were then used as headings and sub-headings guiding the reporting of the study findings.
Avoidance of harm, informed consent, voluntary participation, confidentiality, and anonymity were some of the ethical considerations that were employed in the study. Participants were informed beforehand about the potential impact of the study so that they can make informed decision about whether they wanted to participate or not. Also, information about the purpose of the study, what participation is required of them, and duration of participation was made available to the participants. Moreover, participation was voluntary and refusal to participate did not have negative consequences on any of the potential participants. Participants' information was treated with utmost confidentiality regardless of their social, health, and socioeconomic status. The study was ethically cleared by the University of the Witwatersrand's nonmedical ethics committee. Limitations that were inherent in the study might have included the provision of socially desirable answers by participants; however, to minimize this, all participants were told that there was no right or wrong answer.

Findings and Discussion
The findings from the study indicate that customarily married housewives in Katlehong found it challenging to negotiate for condom use with their husbands due to a variety of reasons. Below is a discussion of the key findings that emanated from the study.

Women's Financial Dependency on Men
According to Bassett and Mhloyi (1991), economic dependence on men has been identified as a key structural factor at the root of women's vulnerability to poverty, sexual violence, unwanted childbirth, and STIs including HIV. This study shows that the majority of women were financially dependent on their male partners, and this was highlighted by one participant who said, "I am not working because my husband said, why should I work when he can provide for the family?" Cases such as this pose a great issue as most of the women interviewed did not have any source of capital for their general and day-to-day requirements. This therefore placed their husbands at very powerful positions and influence in terms of how their households were run. Even though some women indicated that they were the ones who kept the bank cards, they did not have the power to go and withdraw cash without informing and getting permission from their partners. For example, one participant said, " . . . I also have a bank card, so I can withdraw cash anytime I want as long as I phone my husband first and tell him about it and the reason why I want the money." This response concurs with literature where Chitsike (2000) and Endley (2001) reported that a question need to be raised of whether women's access to cash income gives them more decision-making power within the household, or does not always lead to greater decision-making power in the household or in wider society. Furthermore, the statement shows that even though the customarily married housewife appears to be handling the finances, she does not have the power to spend as she pleases and/or as need arises, but will have to clear with the partner first, of which sometimes the partner refuses to authorize the transaction. This concurs with what Rehle et al. (2010) found that within the South African context, the structure of the economy and gender relations places women in a dependent relationship to men, which outweighs educational, political, and other social gains. Selikow, Zulu, and Cedras (2002) also highlighted that in one of the studies that they conducted with males, some males indicated that they deliberately keep their wives as housewives so that they can control them, which gives males even more power to engage in sexual intercourse with their wives without using condoms.

Culture and Condom Use
The authors are of the view that cultural norms such as the need to have children, polygamy, and negative attitudes toward condom use are viewed as not being African and will promote promiscuity, thereby contributing to the inability to negotiate for condom use. When a woman is married, there are so many expectations from different people, especially from the family that she is married into. She is expected to bear children, and condom use is viewed as an obstacle that can hinder the fulfillment of her expected role of child bearing. Therefore, it becomes nearly impossible for her to introduce the issue of condom use during sexual intercourse. One customarily married housewife said, Sometimes you can say that you want to use a condom but then your partner forces you not to use it. Or maybe sometimes he may say you are not faithful to him or you do not trust him, and that you do not want to give him a child and threatens to leave you. Why do you want to use condoms and stuff, especially when you are married. This statement shows that unequal gender relations within married partners promote male dominance over their husbands. It is also an indication that some women are coerced into engaging in un-protective sexual practices with their partners due to the fear of being dumped or divorced. This poses a high risk to women because a condom is only seen as a preventive measure for unwanted pregnancy and not as a preventive measure for sexually transmitted diseases, which includes HIV/AIDS. Moreover, Walker et al. (2004) also stated that condom negotiation is made difficult due to a popular belief that the main objective of marriage is to reproduce and expand the family, and this perception makes the use of protection to be difficult within marriage. This idea was supported by one participant who said, if you fail to reproduce in your marriage you will be labeled as a barren and an evil woman and in some instances your husband's family will encourage their son to look for and marry someone else who will bear children for him. This idea of expansion and reproduction is embedded within the cultural practices and beliefs in South Africa and it makes it difficult for women to disentangle it. Furthermore, within the sphere of cultural practice and expectations, one participant stated, "the payment of lobola (pride price) makes the woman to be like her husband's asset or property that he owns, to the extent that the husband decides on what the woman can do and at what time." This cultural practice which is common, not only to South Africa but also in other African countries, makes it difficult for women to negotiate for condom use with their husbands as their male counterparts normally claim that they paid for them; therefore, they should respect and listen to what they order them to do. Also, once the lobola is paid, the aunts of the woman emphasizes to the woman that she must be strong and endure whatever circumstances she is subjected to. It is common knowledge that it is a disgrace or embarrassment to the family should a woman decide to return home when facing challenges in her marriage. In such instances, the woman may not be accepted back home. Therefore, the decision of women on whether or not to use condoms is shaped by factors such as culture.

Conformity Associated With Marriage
According to Schulman (2006), women find themselves in a difficult position of having to conform to the values and norms of society for them to be socially accepted. Traditionally, the decision-making process is regarded as an exclusive preserve of the male folks, which places women at an inferior position in marriage. The fact that there should be consultations before one takes a decision shows that marriage reinforces the structural ideas of patriarchy, where males become dominant over women. Almost half of the women interviewed expressed fear of losing their partners, especially after suggesting that they need to use condoms. This is a sensitive area that women felt that even though they might test HIV positive, they will never disclose to their partners due to the fear of the implications, for example, domestic violence and stigma. One participant said, I am fully aware of the manner in which HIV spreads, and the things that I can do to protect myself from being infected. But I am married and I feel that I have little or no voice to suggest to my partner that we use condoms, because I can lose my marriage through that and also my man.
Women find themselves in a compromising position and being unable to voice out their concerns due to the fear of the unknown. It was clear that some women did things not just because they wanted to but because they wanted to conform to certain popular beliefs and expectations from their male partners. It also appeared that in some marriages, women didn't have much say in terms of reproductive health issues, for example, when to start a family.
However, it was said to be an innate expectation that once one gets married, she should not be worried about falling pregnant, even though it might not be her choice. This is also due to the inequalities that the institution of marriage presents to married partners. Losing one's man takes precedence to one's life and right to good health. To support this argument, one participant also said, "When one gets married, condom use automatically falls away as you will no longer be afraid of getting pregnant because as a woman you are required to start having children and this means non-use of contraceptives of any type." This statement is an indication that women were at high risk of contracting STIs due to their inability to negotiate for condom use with their husbands. Hunter (2004) also pointed out that society, through oral praise poems, puts pressure on men to have as many children as they can, as he will be viewed as a powerful and strong man who might be respected within his society.

Implications and Recommendations for Social Work Practice
An intensive effort is required from social work services, regarding support, education, and enhancement of all programs related to HIV and AIDS transmission. This could be done through the involvement of all affected family members in all HIV and AIDS related programs within Katlehong. However, there is a need to create a mutually trusting environment to enable the establishment of a functional and positive flow of communication between customarily married couples. This strategy might serve to effectively breakdown the negative effects of silence and the abuse of power.
There is a need for improved awareness and prevention campaigns on HIV and AIDS. This might enhance in moving away from traditional taboo that a man is responsible for decision making, including sexually related issues that affects women. Furthermore, professional support from social workers is recommended through active engagement in empowering couples and communities to access available resources with an aim of building successful and healthier relationships. By doing this, the social work profession will be on the lead in spearheading psychosocial challenges related to social justice and power struggles within customary marriages in different communities.

Conclusion
The study showed that the majority of the participants could not negotiate for condom use because they were dependent on their husbands for financial support, which reduced their chances of having sexual control in their relationships. In addition, such tendencies are mostly perpetuated by the societal expectations and roles that men are the breadwinners and women are supposed to stay at home and look after the children. Furthermore, the study revealed that some of the participants choose not to go against their husbands' decision of not using a condom during sexual intercourse due to fear of separation and/or divorce. This is mostly attributed to some of the cultural beliefs that a man has the whole power to mandate what the woman can or cannot do after paying lobola. The study also found that the majority of women fear to challenge their male partners with the view that it was socially unacceptable in the traditional African society. This is an indication that women, especially housewives, still subscribe to the societal roles that are said to be unfit for women. Hence, the study revealed that the majority of the participants had very little involvement in the decision making concerning their sexual activities. Findings showed that condom use was negatively associated with lack of trust in the relationship, and therefore, women were willing to forgo their independence in decision making even though they might have suspected that their husbands were having an extra marital affair. Therefore, studies on gender and HIV are imperative given the fact that HIV vulnerability among women is prevalent and associated with gender inequality, gendered power relations, inhibitive social structure, low sexual agency among women, forced sex, lack of sexual autonomy and sexual pleasure-seeking, and economic dependence on men.
In conclusion, it is apparent that women are unable to negotiate for condom use in their relationships due to their financial dependency on their husbands. Therefore, there is a need for women to be empowered while they are still young, through education, so that they can be assertive, financially independent, and able to make their own decisions with regard to their sexual-related matters. Furthermore, HIV and AIDS prevention strategies have to incorporate issues around social, cultural, and psychological aspects of behavior change to win the fight against this epidemic.

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 and/or authorship of this article.