McMillan Worth The impact ofsocio-cultural context on young people's condom use

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The impact of socio-cultural context on young people's condom use:
evidence from two Pacific Island countries
Karen McMillana
; Heather Wortha
a
School of Public Health and Community Medicine, University of New South Wales, Australia
First published on: 14 November 2010
To cite this Article McMillan, Karen and Worth, Heather(2010) 'The impact of socio-cultural context on young people's
condom use: evidence from two Pacific Island countries', Culture, Health & Sexuality,, First published on: 14 November
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The impact of socio-cultural context on young people’s condom use:
evidence from two Pacific Island countries
Karen McMillan* and Heather Worth
School of Public Health and Community Medicine, University of New South Wales, Australia
(Received 6 July 2010; final version received 4 October 2010)
Young people are a key group for HIV prevention in the Pacific region where levels of
STIs are high and condom use is low. During 2008, 62 in-depth interviews were
conducted with people aged between 18 and 25 years in Tonga and Vanuatu. The
research was aimed at understanding factors impacting on young peoples’ condom use
in two Pacific Island nations. The data show a marked disjuncture between attitudes and
practice with regard to condoms. This paper discusses factors underpinning that
inconsistency and directs attention to the effect of social and cultural influences on
young people’s condom use. The authors conclude that individual-level approaches to
improving rates of condom use will be inadequate unless they are informed by an
understanding of the role of identity, culture and tradition in young peoples’ decisions
around condom use. The findings also underline the need for country-specific
approaches to condom promotion efforts in the Pacific.
Keywords: condoms; culture; young people; Pacific; Tonga; Vanuatu
Introduction
Improving condom use is fundamental to efforts to reduce transmission of the Human
Immunodeficiency Virus (HIV) and young people are a central target group for HIV
prevention in the Pacific region. Young people’s sexual behaviour is influenced by wider
social factors as well as individual and interpersonal factors (Marston 2004a). With respect
to condom use, individual factors such as knowledge and attitudes are arguably easier to
measure and have received more investigative attention than social and cultural contexts.
However, it is evident that increasing knowledge and awareness of risks does not simply
translate into changes in practice (see, e.g., Jones and Haynes 2006). This paper makes
recourse to experiences of, and opinions about, condom access and use, as expressed by
young people in Tonga and Vanuatu, to describe the influence of social and cultural factors
on young people’s condom use in these two Pacific countries. The interview data presented
reveal, and shed light on, a disjuncture between attitudes and practices in relation to young
people’s condom use.
HIV in the Pacific
HIV infection has been reported in nearly every country or territory in the Pacific Island
region but, outside of Papua New Guinea, notifications are currently low (United
Nations General Assembly Special Session [UNGASS] 2008, 6). However, testing,
ISSN 1369-1058 print/ISSN 1464-5351 online
q 2010 Taylor & Francis
DOI: 10.1080/13691058.2010.529945
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*Corresponding author. Email: k.mcmillan@unsw.edu.au
Culture, Health & Sexuality
2010, 1–14, iFirst
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surveillance and reporting systems across the region are limited and, consequently, it has
been contended that the actual numbers of people infected are likely to be higher than
those captured in the records (UNGASS 2008, 4; Joint United Nations Programme on
HIV/AIDS [UNAIDS] 2009, 16). While the picture generated by available data is
limited, it does show infections continuing to rise throughout the region (UNGASS
2010). Fiji is currently low prevalence but confirmed cases of HIV increase steadily
each year (UNGASS 2010) and incidence is increasing in New Caledonia, Guam and
French Polynesia. Papua New Guinea is considered to have a more generalised
epidemic.
Outside of Guam where injecting drug use is key driver, HIV transmission is
considered to be predominantly from unprotected sex in the Pacific region (UNAIDS
2009, 2, 15). A variety of social and behavioural indicators including high rates of sexually
transmitted infections, multiple and concurrent sexual partners, sex work and the
migration and high mobility of many vulnerable groups (Secretariat of the Pacific
Community [SPC] 2005, 20; Buchanan-Aruwafu 2007; UNGASS 2008, 4) indicate a
potential for increasing prevalence should HIV become established (SPC 2005, 10;
UNAIDS 2009). Thus, outside of Papua New Guinea where testing and treatment is also a
major focus, prevention is a key priority in response to HIV in all Pacific Island countries
and territories (SPC 2005; UNAIDS 2009).
Sexual risk behaviours and young people in the Pacific
Young people have been identified as a key audience for HIV prevention in the Pacific
(SPC 2005, 26). Typically in resource poor settings where heterosexual sex tends to be the
main source of HIV transmission, the majority of HIV infections occur amongst those of re
productive age, with women being infected at a younger age than men (UNAIDS 2009, 2).
The populations of Pacific Island countries are youthful and despite societal and religious
disapproval of teenage and pre-marital sex, many young people are sexually active
(Gibson 2001; Buchanan-Aruwafu, Maebiru, and Arawafu 2003; Buchanan-Aruwafu
2007). Young people’s sexual activity tends to be covert and secretive, potentially
exacerbating their vulnerability and risk (McMurray 2004; Buchanan-Aruwafu 2007, 32).
Condoms are free or cheap in the Pacific and remain the most effective method of reducing
the risk of HIV transmission for both male and female partners. While Pacific young
people’s condom use is known to be low (Buchanan-Aruwafu 2007, 33), very little is
understood about the reasons for low levels of condom use among this group.
Published research on the condom use or other sexual health behaviours of Pacific
Island young people is limited and largely confined to surveys focusing on individual
knowledge, attitudes and behaviour (see, e.g., Niras 2000; Seniloli 2003; Seniloli,
United Nations Population Fund and The University of the South Pacific Population
Studies Programme 2003; Corner et al. 2005). Investigations into other health risks for
young people in the Pacific examine alcohol, drug and substance use (McMurray 2003;
Phongsavan et al. 2005) and mental health (Rubenstein 2002; Lowe 2003; McDade and
Worthman 2004; Pinhey and Millman 2004). The results of these studies direct attention
to social factors beyond the control of the individual: peer pressure (Smith et al. 2007),
issues of identity (Lowe 2003; McDade and Worthman 2004), social change
(Rubenstein 2002; Lowe 2003; McDade and Worthman 2004) and ‘socialisation
ambiguity’ or the incompatibility of personal desires and traditional expectations
(McDade and Worthman 2004). According to these studies, the social position and
status of youth as well as religious and cultural expectations and norms around the
2 K. McMillan and H. Worth

family and community are all deeply implicated in health-risk behaviour. Jenkins and
Buchanan-Aruwafu (2007) emphasise the importance of ideologies and cultural attitudes
and practices to an understanding of HIV risk and vulnerability among all Pacific
peoples.
The findings of international research into factors influencing young people’s sexual
behaviour consistently identify the importance of social and contextual factors (Marston
2004a). Early investigations into the determinants of sexual-risk behaviour and condom
use among young people focused more on the characteristics of the individual and were
oriented to the knowledge-attitude-behaviour nexus. However, other studies (e.g. Jones
and Haynes 2006) have shown that information and the knowledge of young people alone
will not substantially change practices that generate sexual-health risks and a mounting
body of literature highlights the importance of contextual factors on youth vulnerability
and HIV risk. Contextual factors include gender inequality, relationship and partner
characteristics (Bajosa and Marquet 2000; Marston, Juarez, and Izazola 2004; Marston
2004b), income, community, family practices (Lightfoot and Milburn 2009) and socio-
cultural influences (Kaufman et al. 2007) and macro socio-economic influences (Worth
2009) on the sexual health of young people.
The international literature offers significant insights, but an appropriate identification
of influences on the health-risk behaviours of young people in the Pacific cannot simply
be extrapolated from data from other regions (Phongsavan et al. 2005). Moreover,
interventions designed for Pacific Island countries and territories will need to be culturally
relevant and country specific to be effective (Vainerere 2001; Phongsavan et al. 2005;
Stewart-Withers and O’Brien 2006).
The study: condom use among young people in Tonga and Vanuatu
Improving condom use is a cornerstone of HIV prevention. In order to gain some purchase
on the reasons why young people are not using condoms, young adults were interviewed in
the two Pacific Island nations of Tonga and Vanuatu. While Tonga and Vanuatu currently
have low rates of reported HIV infections, both populations are considered highly
vulnerable to HIV infection and prevention through behaviour change is the cornerstone of
their national responses (UNGASS 2010).
The Kingdom of Tonga is an archipelago just west of the date line in the south Pacific
Ocean. Tongans are Polynesian and over 70% of the population of 101,000 live on the
main island of Tongatapu. Tonga is a constitutional monarchy and has never completely
lost indigenous governance. Close ties are maintained to migrant populations in New
Zealand, the USA and Australia through family networks and English is a widely spoken
second language to Tongan. Tonga is a strongly Christian and deeply conservative society.
However, the impact of globalisation and social change is evident, perhaps most notably in
recent contestation over the form of political governance and the growing popular demand
for democratic reform. Hau’ofa (2008) contends that the church has now replaced the
nobility as the major authority in the community.
Vanuatu is a chain of islands lying between the Pacific Ocean and the Coral Sea, nearly
2000 kilometres west of Tonga. Ni-Vanuatu people are Melanesian and Vanuatu
(population approximately 240,000) is ethnically and culturally diverse with over 100
local languages being spoken. Bislama is the official language and English and French are
taught in school. While many Ni-Vanuatu are multilingual, literacy levels are low.
Christian religions predominate, but many customary religions survive. The islands of
Vanuatu have been subject to numerous waves of colonisers since the eighteenth century.
Culture, Health & Sexuality 3

Independence from Britain and France marked a recent period of significant political and
social transition and an increasing urbanisation that has affected young people in particular
(Mitchell 2003).
Methods
During March and April 2008, in-depth interviews were conducted with 62 young adults
aged between 18 and 25 years of age. Of these interviews, 32 took place in Tonga, in and
around the Tongan capital, Nuku’alofa, on the island of Tongatapu. Another 30 were
conducted in Vanuatu, in and around the capital, Port Vila, on the island of E´fate´ and in
and around Luganville on the island Espiritu Santo.
Interviews were conducted by experienced HIV social research cadets from the Papua
New Guinea Institute of Medical Research under the supervision of a research associate
from the University of New South Wales. Three interviewers worked in each country. In
Vanuatu, interviews were conducted in both English and Bislama. Bislama is the first
language of many urban Ni-Vanuatu and is very similar to the Tok Pisin spoken in Papua
New Guinea. This enabled the young Papua New Guinean interviewers to offer an
alternative to English for the interview and also to clarify participants’ use of local sexual
slang. Groes-Green (2009) has argued that the use of local language elicits more accurate
and open information from young people about their sexual behaviour. The Bislama
interviews were translated into English by each interviewer immediately after the
interview. All the Bislama speakers also spoke some English and many interviews
employed both languages in order to clarify points.
In Tonga, interviews were conducted in English only. However, the employment of
non-local young people from the wider Pacific region as interviewers proved very
advantageous for the gathering of information about sensitive and personal topics. In
Tonga in particular, despite the disadvantage of not being able to guarantee an interview in
the interviewees’ first languages, participants were guaranteed an anonymity that would
not have been possible with a local interviewer. Numerous Tongan respondents
commented that they would not talk so openly to a Tongan interviewer.
A variety of recruitment strategies were used, including peer and key informant
introductions, chain referrals and invitations to young people on the street, in bars, at training
institutes and places of work. A quota approach was adopted to ensure a similar number
of male and female participants and also to include a number of fakaleiti/transgender in
the Tongan sample and men who have sex with men in the sample from Vanuatu. As the
samples were non-probability, they may not be representative of the overall populations of
Tonga and Vanuatu aged between 18 and 25. However, the sample did capture both married
and single, sexually active and inactive youth as well as a broad range of occupational status:
employed, unemployed, trainees and students. The sampling approach aimed at inclusivity
rather than generalisablity and no authoritative conclusions can be drawn about the specific
sub-groups.
The interviews were semi-structured, conducted in an informal conversational manner
and recorded on audio tape. Interviews lasted between 30 and 60 minutes. Young people’s
experiences of, and their opinions about, condom use and condom access were the central
focus of the interviews. Each interview transcript was coded independently by at least two
members of the research team. Thematic code lists were generated based on repeated and
close readings of the transcripts and the coded data were then further scrutinised,
generalised and summarised. The analysis aimed to identify range, patterns and
consistencies and points of difference in the data.

Ethical approval for this research was obtained from the Human Research Ethics
Committee of the University of New South Wales and also from the Ministries of Health in
Tonga and Vanuatu.
Results
Interviewees were asked to talk about their personal experiences of, and attitudes towards,
condoms, condom access and condom use. The participants’ narratives turned on topics
consistent with international literature (see Marston 2004a): the criteria used for assessing
which sexual partners condoms should be used with; stigma attached to condoms; gossip
as a deterrent to accessing condoms; who young people did and did not discuss sex with;
gender roles; and other social and familial expectations. However, the data were strongly
marked by a disjuncture between attitudes towards, and beliefs about, the efficacy and
usefulness of condoms and the actual non-use of condoms – an inconsistency that
demands closer attention. This paper draws on data that shed some light on that mismatch
between attitudes and practice.
Young people interviewed in both Tonga and Vanuatu expressed very positive
opinions about condoms. Interviewees typically insisted that condoms were ‘a really good
thing’ because they keep young people safe and afford protection against HIV and STIs as
well as unplanned pregnancy. It was frequently pointed out that because of this, condoms
enable young people to ‘live their own life’ (Mosesi1
, male, aged 25). But, despite an
overwhelming endorsement of condoms, very few of the interviewees actually used them
on a regular or even sporadic basis.
Interviewees were asked what they did not like about condoms. While particular
qualities of condoms such as touch and smell, and also reduced male pleasure, were
sometimes cited as specific aspects of condoms that were disliked, these were rarely given
as reasons for not using condoms. Interpersonal factors such as condoms being a barrier to
intimacy and an interruption of the ‘mood’ were occasionally identified as disincentives to
condom use. However, the most consistently cited, and insistently expressed, deterrents
to condom use stemmed from young people’s understandings of peer and community
attitudes to condom use and condom users. Reasons given for non-use were underpinned
by an interrelated complex of social expectations, gender norms and cultural values. For
most of those interviewed, these socio-cultural factors were a potent deterrent to condom
use, exerting an influence on their sexual practices that outweighed their own personal
attitudes towards condoms.
Free condoms were available from clinics and resource centres across the study sites,
but access and use of condoms was complicated by a range of social practices and cultural
values. For the Tongan interviewees, these were typically very deeply imbricated in
traditional mores related to family roles, responsibility and authority. Among the male
Ni-Vanuatu interviewees, peer approval exerted a powerful influence on condom access
and use and the desires of young Ni-Vanuatu women to use condoms were generally not
matched in their male counterparts. While a discrepancy between attitudes and practices
was evident in both countries and the importance of social factors was similarly apparent,
differences in the data from the two countries flagged important distinctions.
‘The Tongan way’: culture, family and feminine modesty
Tongan interviewees described individual benefits but also social risks associated with
condom use. Condoms themselves were overwhelmingly described in positive terms;

‘really good’ typically because they ‘protect’ and keep teenagers ‘safe’ from STIs, HIV
and unwanted pregnancy. However, this endorsement was frequently tempered by
ambivalence – as reflected in the following statement:
condoms are good protection for a teenager but it might, it might kill their life when they use it
wrong. (Sisilia, female, aged 21)
When probed about this, it became clear that Sisilia was referring to a moral rather than a
technical ‘wrong’, pointing out that HIV, STIs and pregnancy are not the only risks
associated with having sex outside of marriage that young people take into account when
thinking about condom use. Other interviewees similarly alluded to a potential for ‘wrong
decisions’ afforded by condom availability. In the views of these participants, condom use
renders young people vulnerable both to ‘wrong’ behaviour – extramarital, premarital or
paid sex that defies the rules set down by parents and the church – and also to the social
disapprobation and castigation consequent on that behaviour becoming known to others,
both of which are considered to be the path to social ruin.
Being seen obtaining or in possession of condoms was described as giving rise to very
negative social consequences for young people in Tonga. At the same time as individuals
may be positive about condoms in principle, in practice the possession of condoms invited
gossip, censure and discredit – not only for the individual themselves but also, and more
importantly, for their family too:
[I]f [young people] go buy a condom, other people will say ‘Who’s that? Who are his parents?
Who are her parents? Why do they let them do that?’(Tony, male, aged 18)
Here in Tongan culture, people think that sex for the young people is bad, that’s why young
people are shy to go to the shop to buy condoms. (Aleki, male, aged 21)
In addition, while condoms are described as being a good thing, throughout the
interviewees’ narratives condom use is both explicitly and implicitly associated with
teenage sex, promiscuity, sex for money and extramarital sex. All of which, despite being
cited as commonplace, are socially proscribed and cast as irresponsible, delinquent and
illicit. Furthermore, interviewees described living in a Tongan community as being always
subject to the view of others. If one were to be seen purchasing or in possession of
condoms, then this will inevitably and rapidly become public knowledge:
It is, you know, Tongan culture. People talk, you know, and they say ‘look at that person’.
(Jonah, male, aged 18)
If that person knows that person [who is buying condoms], like me if I know that person I will –
it’s the Tongan way – I will immediately go to the person’s family or parents and tell them that
I saw your daughter or son went and bought condoms. That’s the Tongan way and culture.
(Nelly, female, aged 19)
Young people face strong community censure and believe that they would be severely
punished by their family for having condoms or for being known to have condoms, as this
is a signal of having sex or the intent to have sex. In this way the possession of condoms is
a signal of open disobedience and disrespect for the authority of the family and of church.
The expected punishments included being beaten by their parents, getting kicked out of
school or home or even being disowned.
Condom use then has some serious individual, social and familial ramifications.
Interviewees situated these firmly in the context of ‘the Tongan way’; explicitly invoking
Tongan culture and turning on expectations of others and self and one’s place within the
wider social system. In turn the issues of culture, community and authority always come
back to family in these narratives:

It is because of culture, Tongan culture. There is the way of living, the way we see families
and stuff. It’s about respect from the children and it’s kind of hard to get condoms in
Tonga because of family stuff. As you see, it’s the culture that’s making it hard. (Sam,
male, aged 22)
Moreover as an issue of identity and reputation, shame is not an individual matter but
is social and borne by the whole family and parents in particular are held responsible
for the behaviour of their children. Because of this, family are fully implicated in
all their children’s actions, including that of possessing a condom, which indicates an
intention to have irresponsible and illicit sex. Participants explained that an instance of
shameful behaviour by a young person would be considered an ultimately forgivable
lapse by the wider community, but that it would signal a far less forgivable lack of
proper guidance on the part of the parents and other authority figures. Thus, parents
would be held more to blame for the behaviour of their offspring than the young person
themselves:
When a girl gets pregnant it’s the girl’s foolishness and all that. So it’s not the girl that gets
shamed, it’s the parents that mostly get pointed to, for how they bring up their children.
(Hanna, female, aged 21)
From the parents’ point of view it’s just shame you know. Feeling shame of having your
daughter or your son being known as a condom user. . . . The neighbours would think, ‘Ahhh,
maybe their mother was a prostitute, maybe she was using [condoms] before. Now she’s, like,
teaching it to her children’. (Poppy, female, aged 25)
Standards of proper feminine behaviour emerged as another constraint on condom use and
the young Tongan women interviewed expressed resistance to condom use in stronger
terms than the young men. Two young women described being aghast and firmly refused
the request by their husband and boyfriend to try a condom ‘for fun’. As participants
explained, modesty is arguably the most highly valued feminine trait in Tonga. Given
the associations of condoms with improper sexual activity, condom use signifies a
licentiousness that is anathema to respectable Tongan girls.
Three female participants who were enthusiastic condom users, suggested that once
other Tongan women tried condoms they would like them too. Certainly, unfamiliarity was
a strongly expressed deterrent to condom use by those who had never used one. These
young women described condoms as ‘strange’, ‘yucky’ and ‘unknown’ and the strangeness
of condoms was the central reason they gave for not wanting to use one themselves. Ana
described her refusal to use a condom the first time she saw one:
I felt very afraid of it. My boyfriend told me to go with it and I told him, ‘I’m very afraid of it –
to hold it. It’s too funny’. (Ana, female, aged 21)
Two other participants described having refrained from touching or even looking at
condoms presented during school sex education. This reluctance to approach condoms,
even within the context of the classroom, is consistent with demonstrations of modesty and
chaste behaviour required of Tongan girls. Being among a group of peers did not mitigate
their reluctance to look at or handle a condom and numerous young women also expressed
an anxiety that their friends would judge them badly for being ‘sexy’ if they showed any
familiarity with condoms.
Consequently, young people’s fear of judgement created a secretiveness that often
extended to concealing sexual relationships and experiences from friends and peers, as
well as from their family and wider community:
Because if my friends know about it they will say, ‘You! you are a sexy girl’. They would look
down on me or something like that. It’s not good. (Sisilia, female, aged 21)

Nearly all the young Tongan women described condoms as a necessary safeguard for
young people who are having sex, but most dissociated themselves from the category of
people for whom condom use was ‘good’, despite being in a sexual relationship. Condoms
signalled a non-exclusive relationship and were for this reason considered to be
inappropriate within marriage or other committed relationships. The contraceptive
function of condoms further rendered them unsuitable for use within marriage because for
most of the young women having babies was the prime function of marriage. Even outside
marriage it seems that the contraceptive qualities of condoms could sometimes be a
disincentive to use. One young man, who was a consistent condom user, suggested that
the resistance to condom use that he sometimes encountered from his female partners
stemmed from their desire to consolidate the relationship through conception and having a
baby. Others suggested that young men themselves were eager to father numerous children
from multiple mothers, because of the status that fatherhood bestowed.
A number of young men commented on the restrictions placed on girls in Tongan society
and made fun of traditional procedures for courting. But even while identifying these
strictures as unrealistic and outdated, many not only understood but also endorsed parents
taking a stance against condoms and premarital sex. These endorsements speciﬁcally
acknowledged parental responsibility for maintaining tradition and upholding culture.
Nearly all the Tongan participants were regular churchgoers and a similar respect for
the authority of the church – that is to say, a respect in principle but not in action – was
evident. There was a strong consensus that few young people behave in accordance with
the wishes of their family and church. Indeed an incongruity between social and familial
expectations of behaviour based on Tongan tradition and the realities of how young people
behave appeared to be so commonplace and pervasive that interviewees described a
consequent necessity for secretiveness and covert behaviour in all things as being part of
‘the Tongan way’:
It’s the nature of the Tongan people: I feel shy, I have to hide everything I have from the other,
keep it secret. So, I don’t need – if you were from Tonga for example – I don’t need you to
know I have a girlfriend. (Filipe, male, aged 23)
Vanuatu: male peers and the ambivalent position of young women
Young people in Vanuatu were also very positive about condoms and for the same reasons
as young people in Tonga, but with even greater emphasis on protection from HIV. One
clear distinction was that, with a single exception, the young Ni-Vanuatu women were
not only positive about condoms, but also believed that they would be appropriate for
their own use. Also, young people interviewed in Vanuatu expressed few inhibitions or
reservations about carrying condoms. Indeed many did routinely pack a condom into their
bag. However, most did not actually ever use them.
A number of young men said that they carried condoms in case their friends needed
them. Peers and friends were absolutely central to access to and use of condoms for young
men in Vanuatu: friends provided supplies of condoms and accompanied others for
support when accessing them from health and resource centres. Peer educators were
important mechanisms of condom distribution. But peers also constituted a deterrent when
they were not supportive of condom use, because young men were predominantly
concerned about ridicule from others. One man who has sex with men claimed that, among
his group of friends, no one would admit to using condoms even if they did:
They say skin to skin is best . . . maybe they are using [condoms] but they don’t want
everybody to know that they are using it. (Marco, male, aged 21)

In contrast to the Tongan stories, talk about family and tradition was markedly absent from
the narratives of Ni-Vanuatu. When family were referred to, it was typically a mother who
was invoked – most often to say that she supported or had advised condom use for her
daughter. Consistent with this, there was very seldom any mention of expectations or
restrictions imposed by church and family. And while young women were wary of gossip,
it did not deter them from carrying or accessing condoms. A number of young women who
were not yet sexually active, routinely carried a condom as they wanted to be prepared for
the day that they did have a first sexual encounter:
Because I know that sometimes I have thoughts [about sex] . . . I usually take them around.
Any places where I go I usually take them – but to use it? I don’t know yet. (Florence, female,
aged 18)
Young women with boyfriends felt it was their responsibility to carry a condom too:
I carry [condoms] in my basket. When I walk around I carry condoms with me . . . and
especially if I go to a dance, I have to take condoms with me in case I meet my boyfriend.
If he doesn’t have a condom, I will. (Marisann, female, aged 19)
Although young Ni-Van women appeared to move about relatively unfettered, and
felt free to discuss sex with friends, they described dual burdens of vulnerability and
responsibility with regard to sex. The women interviewed expressed a strong belief in
their need to take responsibility for condom use and a correlative expectation of male
irresponsibility in general. These young women’s need to ‘be prepared’ was underpinned,
specifically, by a sense of vulnerability to men. This vulnerability was expressed by some
young married women who wished to introduce condoms into marriage because husbands
strayed, literally, sometimes leaving home for months. Even single women did not assume
that condoms would become unnecessary within marriage and long-term relationships.
This reflected a perception that men were likely to have extra marital relationships and that
husbands could not automatically be trusted to be monogamous:
I don’t know what he’s doing in Vila. I don’t know. Maybe he’s seeing other girls. I don’t
know. But I heard rumours all around. . . . It’d be good for me if we used a condom (Honorine,
female, aged 19)
I really want us to use condoms because I’m afraid in case my husband goes out and stays with
another girl and gets a disease and comes back and gives it to me. Because of this I’d like us to
use condoms. (Wanda, female, aged 22)
Female vulnerability and a need to be prepared were also broached through repeated
references to the risk of rape when out walking:
Well, sometimes when you walk to unknown places there are boys who rape. So if they are
there, at least you have a condom to protect you. (Marta, female, aged 21)
There are some rape cases, not all the time, but to be on the safe side I think it’s best for us to
have condoms in our bags when we’re walking around. (Vanessa, female, aged 25)
Young men also understood rape as a situation with a risk of HIV transmission risk, but
they saw men as being the ones at risk:
Sometimes boys gang rape women. One woman for ten boys. It’s not good. She might have
some disease and the boys can catch it from her. If there is no condom, no one is going to go
and get one – it takes too long. By the time he gets back with a condom the woman will have
run off and you won’t have sex. (Samson, male, aged 20)
Samson’s framing of the risk associated with gang rape reflects a commonly expressed
view that women are the vectors of an infection that is in essence, foreign and associated
with travel:

More women get HIV. For the men, I heard, not many really. I didn’t hear about men but I
heard about ladies . . . sometimes one of our women goes to school at [an overseas
University] up there, to get a degree and goes out. She goes out, gets some disease from
outside – from another country – and she brings it inside. Then she starts passing it around
and passes it to the men. Then sometimes you hear about the air hostesses . . . Ahhh! So many
stories I’ve heard about them. They get it from that country and they bring it in. (Alic, male,
aged 20)
It is not only international travel but also the notion of unfamiliar places that is perceived
to be associated with HIV risk and thus with a need for condom use. Throughout the
Ni-Vanuatu narratives, travel is both literally and metaphorically associated with the need
for condoms:
Yes, when I travel far, I take condoms with me. (Frances, female, aged 24)
If I was to ‘bus ride’ [have multiple concurrent sexual partners] I’d probably use a condom.
(Alic, male, aged 22)
At the same time as the young women appear to accept, or at least admit to, their own
sexual activity relatively readily, the distinction between social, sexual and promiscuous
activity is ill-defined and the slippage between them is evident in the use of the term
‘walkabout’. While walking was a practical daily necessity, the road was also described
as a social place and ‘walkabout’ as a pastime of socialisation and entertainment.
‘Walkabout’ also stood for sexual availability with ‘walkabout-man’ and ‘walkabout-
woman’ being pejorative labels referring to promiscuity. This ambiguity underwrites the
instatement of young women as being both vulnerable and culpable with regard to HIV
and sexual risk, particularly when they occupy the social space of the road.
Discussion
The interview data collected from the two island nations was markedly distinct and the
programmatic implications very different, cautioning against any recourse to a generalised
Pacific when developing strategies for improving condom use. A comparison of HIV
education messages and condom promotion strategies in the two countries was outside
parameters of the study, but there are clear traces of HIV awareness and condom
promotion discourse in the interviewees’ statements and stories. The young Tongans
endorsed condoms largely on the basis of taking individual responsibility for oneself – a
notion of responsibility somewhat at odds with the notion of a social responsibility to
others that colours their explanations and reasons for non-condom use. In Vanuatu where
the popular television edu-tainment series ‘Love Patrol’ is a vehicle for information on
HIV and STIs, the narratives of young women in particular evidences a more nuanced and
self-reflective framing of the issues around the need for condom use. It may also be that
because the first Ni-Vanuatu HIV-positive activist was a woman, women have appeared to
be the vectors of infection.
In addition, the data problematise simple knowledge-attitude-practice assumptions,
illustrating the intervention of socio-cultural factors as they circumscribe and often inhibit
the condom use of young people. More specifically, this second matter underscores the
need to scrutinise the phenomena underwriting risk behaviours (as contended by Dowsett
[1999]). Research has paid too little attention to the role of adults in creating and
sustaining the vulnerabilities of young people, for instance (Ingham 2006). The Tongan
data presented here highlights the influence that adults and social authorities exert on
young people’s condom use. This influence emerges as an important mechanism through
which culture impacts on condom uptake in Tonga.

A fully developed argument about the concept of culture is beyond the scope of this
article. However, it should be noted that culture, as it appears here within the narratives of
the young Tongans, should neither be operationalised as a risk factor in itself, nor as a set
of discrete social factors that might be added up in some risk calculation. Rather, culture is
invoked as the bedrock of daily life underpinning young peoples’ everyday actions and
decisions, including those of whether or not to use condoms. In addition, the narratives of
the young Ni-Vanuatu would indicate that the culture or social world at play is mutable
and not always traditional. As outlined above, there is also evidence of exposure to
the discursive culture of HIV prevention and condom promotion in the narratives of both
Tongan and Ni-Vanuatu participants, particularly in the grounds on which condoms are
endorsed. These grounds are not always commensurate with the young peoples’ everyday
experiences – the demands of and risks inherent in their daily social world. Shifting social
and economic realities and a co-existence of traditional and contemporary cultural values
produce mismatches and incongruities in social expectations that are reflected not only in
sexual practice but also in the conceptualisation of risk, harm and safety as well as those of
gender, self and responsibility. Ambivalence is an inevitable result, and expression, of the
accommodation of incommensurable or irreconcilable messages and values.
The older generation did not appear to exert a strong influence on young people in the
(peri-urban) areas of Vanuatu in which we conducted interviews. It may be that a shifting
ground and role of traditional authority underpins the insecurity evident in the terms
of gendered identity, for instance, the narrative positioning of young women as both
vulnerable and culpable and young men’s need for actions to be validated by their peers.
Jean Mitchell’s (2003) study of urban youth in Port Vila in the late-1990s, describes young
people positioned somewhat at odds with traditional values by the social and economic
transformations and rapid urbanisation taking place and having to renegotiate their sense
of identity and occupation of proper place – expressed in and as kastom. While a direct
reference to kastom and invocation of tradition is (perhaps surprisingly) absent from these
Ni-Vanuatu narratives, the concept of place does emerge as central to condom access
and also to young peoples’ conceptualisations of HIV risk. Tradition as expressed in ‘the
Tongan Way’ manifests as the assurance of social place and a touchstone for identity
within the Tongan narratives. In these Tongan stories, the ambivalence is attached to
the condoms themselves. Privacy and confidentiality was the prime concern for young
Tongans wanting access to condoms.
Conclusion
While attitudes and knowledge are deeply implicated in condom use, the data from this
research show that individual uptake is also impacted by wider socio-cultural factors. The
young people’s decisions and considerations around condom use turn on issues of identity,
culture and community – in particular expectations of others and self and one’s place
within the wider social system.
These study data indicate that, in some cases, interventions aimed at increasing rates
of condom use among young people would need to effect a change in the attitudes of
the wider community – or at least sectors of that community – who are not necessarily
vulnerable themselves. Further, it is important to ensure that condom promotion messages
and initiatives are underpinned by, and respond to, cultural understandings of health
and identity as well as the everyday social realities and demands of young peoples’ lives.
The data signal to the similar sets of contextual issues as identified in studies on other
health-risk behaviours of Pacific Island young people, underscoring the importance of

socio-cultural factors. Furthermore, the marked differences in the specific societal and
cultural barriers of condom use between the two countries flag the need for country
specific, rather than regional, approaches to efforts to improve rates of condom use.
Acknowledgements
The authors wish to thank the study teams from the Papua New Guinea Institute of Medical
Research/University of New South Wales HIV Research Cadetship Program who conducted the
interviews and contributed to the coding and also Wan SmolBag Vanuatu, Tonga Family Health
Association and the Secretariat of the Pacific Community for their support. The study was funded by
the Global Fund for HIV, TB and Malaria. Most of all, thanks are due to all the young people who
shared their stories.
Note
1. All participants’ names have been changed.
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Re´sume´
Les jeunes sont un groupe prioritaire pour la pre´vention du VIH dans la re´gion Pacifique, ou` les taux
d’IST sont e´leve´s et ou` ceux de l’usage du pre´servatif sont faibles. Au cours de l’anneé 2008, 62
entretiens en profondeur ont e´te´ conduits avec des jeunes aˆge´s de 18 a` 25 ans au royaume de Tonga et
au Vanuatu. Cette recherche avait pour objectif d’approfondir les connaissances sur les facteurs qui
influencent l’usage du pre´servatif chez les jeunes, dans ces deux nations insulaires du Pacifique.
Les donneés montrent une importante dećonnexion entre les attitudes et les pratiques vis-a`-vis du
pre´servatif. Cet article examine les facteurs de cette incohe´rence, et met en avant l’impact des
influences sociales et culturelles sur l’usage du pre´servatif chez les jeunes. Les auteurs concluent

que les approches employeés au plan individuel en vue de stimuler l’usage du pre´servatif seront
inapproprieés, a` moins qu’elles aient e´te´ informeés par une compre´hension des roˆles de l’identite´, de
la culture et de la tradition dans les prises de dećision des jeunes concernant l’usage du pre´servatif.
Les re´sultats mettent aussi l’accent sur la nećessite´ d’e´laborer des me´thodes de promotion du
pre´servatif spećifiques a` chacun des pays de la re´gion Pacifique.
Resumen
Para la prevencioń del VIH en la regioń del Pacı´fico, donde hay un alto nivel de infecciones de
transmisioń sexual y un bajo uso de preservativos, habrıá que prestar especial atencioń a los jo´venes.
En 2008 se llevaron a cabo 62 entrevistas exhaustivas con personas con edades comprendidas entre
los 18 y los 25 anõs en Tonga y Vanuatu. El objetivo de este estudio fue conocer que´ factores
influyen en los jo´venes de dos paı´ses de las Islas del Pacı´fico para que decidan hacer uso de los
preservativos. Los datos muestran una marcada brecha entre las actitudes y las praćticas con respecto
a los preservativos. En este artıćulo analizamos los factores que sostienen esta contradiccioń y
prestamos atencioń al efecto de las influencias sociales y culturales en lo que respecta al uso de
preservativos por parte de los jo´venes. Concluimos que los enfoques en un plano individual para
mejorar las tasas del uso de preservativos serań inadecuados a menos que se entienda el papel que
desempenãn la identidad, cultura y tradicioń en la decisioń de los jo´venes a usar preservativos. Los
resultados tambień destacan que es necesario presentar planteamientos especı´ficos para cada paı´s a
fin de fomentar el uso de preservativos en el Pacı´fico.

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