Why don’t urban youth in Zambia use condoms? The influence of gender and marriage on non-use of male condoms among young adults

Despite widespread availability and knowledge of male condoms, self-reported use in the past 12 months is low among young adults, with only 45% reporting use. This study aims to describe factors associated with non-use of male condoms among urban young adults in Zambia. A household cross-sectional survey was conducted in four urban districts from November 2015 to January 2016 among sexually active young adults aged 18-24 years. The survey included 2,388 individuals, with 69% being female and 35% being married. Non-use of male condoms was reported by 59% of participants at their most recent sexual intercourse. In a multivariate model, women were more likely to report non-use of a male condom compared to men, with an adjusted relative risk (aRR) of 1.24 (95% CI: 1.11, 1.38). Married individuals were also more likely to report non-use compared to unmarried individuals, with an aRR of 1.59 (1.46, 1.73). Residing in the highest poverty wards was associated with a higher likelihood of non-use of male condoms, with an aRR of 1.31 (1.16, 1.48). Negative perceptions of male condom use were also associated with a higher likelihood of non-use, with an aRR of 1.06 (1.03, 1.09). However, discussing contraception with a partner decreased non-use by 13%, and agreement regarding male condom use with a partner decreased non-use by 16%. The study highlights the importance of addressing social and structural barriers to condom use in Zambia, including stigma around promiscuity and condom use, religion, and lack of knowledge regarding condom use. Effective marketing strategies for dual protection methods, such as male condoms and modern contraception, are critical to ensure protection against both unintended pregnancy and HIV/STI infection. The study's findings emphasize the need for targeted interventions to increase condom use among young adults in Zambia, particularly among women and married individuals. Urban Zambia is an important context for the development of effective condom promotion strategies, given its high rate of unmet need for family planning and high HIV prevalence. The Zambian government has demonstrated a strong commitment to expanding family planning services, but consistent condom use remains low. The study's findings suggest that addressing the social and structural barriers to condom use, as well as promoting dual protection methods, is critical to reducing the high rates of HIV and unintended pregnancy among young adults in Zambia. The study's methodology involved a cross-sectional survey of young individuals aged 18-24 years living in 40 urban wards in Zambia. The survey was conducted between November 2015 and January 2016, and included 2,388 individuals. The survey teams used a random walk strategy to select households, and surveyors were trained to conduct the questionnaire in a private setting. The study's findings have important implications for the development of effective condom promotion strategies in Zambia and other sub-Saharan African settings.