Using condoms consistently in casual sexual relationships protects sexual partners from the risk of HIV transmission. Prior work on HIV indicates lower condoms use amongst mobile population groups such as truck drivers, mine workers, construction workers, traders, commercial sex workers, military personnel, and fishers (Seeley and Allison, 2005). These human population groups are described as a high risk of HIV transmission owing to their high mobility, engagement in multiple interactions with foreign and local populations, and sexual exchanges with itinerant traders and sex workers as they move from one destination to another doing their work (Kissling, 2005; Seeley and Allison, 2005).
Earlier fisheries studies around the world report low and inconsistent usage of condoms among fisherfolks resulting in their having high rates of HIV infection (Lungu and Husken, 2010; Bouanchaud, 2011). Prior studies in West Africa also describe fishers as a human population group that do not utilize condoms consistently (Bouanchaud, 2011; Korankye and Dwomoh, 2012). In Ghana, similar findings of low condom use among artisanal fishers have also been reported in fishing destinations (Korankye and Dwomoh, 2012; Kyei-Gyamfi, 2019). Prior works that have reported poor condom use among fisherfolks adduce barriers to condoms use to several reasons. In Kwena et al. (2013), they mention that female fishers constitute a group that do not use condoms in sexual exchanges due to refusal to condoms by their partners. Some fishers also refuse to use condoms since they usually do not have any when they engage in sexual activity in the fishing locations where they engage in the act (Kyei-Gyamfi, 2019). Eleftheriou et al. (2016) also reports in an earlier work of fishers not using condoms because they trusted their partners to be disease free. These reports from earlier studies highlight unsafe sexual practices and consequences for HIV exposure in fishing locations due to low condom usage among fishers.
Although studies in developing countries in Africa, South and South-East Asia, and Central American fishing communities have indicated that fishers have poor attitudes toward condom use (Bouanchaud, 2011; Lungu and Husken, 2010; Kissling et al., 2005; Korankye and Dwomoh, 2012; Seeley et al., 2009), little is known about the circumstances in Ghanaian fishing communities. Therefore, the underlying assumption of this paper is that attitudes, behaviors, and barriers related to condom usage among Ghanaian fisheries workers are poorly documented and overlooked in literature and discourses concerning fisheries production and management. Underestimating the susceptibility, severity, and threat of HIV exposure because of fishers' adverse attitudes and behaviors regarding condom use has negative implications on fishers' health as well as the fishing industry. Therefore, it is critical to understand the dynamics of HIV threats, transmission, and prevention among fishers in relation to condom usage. The objective of this paper is to examine condom usage and perceived barriers to its use during sex among fishers in the Elmina fishing community. This work will fill a significant gap in the design, execution, and management of programs that are essential for decision-making processes directed toward HIV prevention among fisheries workers. The Health Belief Model (HBM) has been used to analyse and explain fishers’ perception of condoms, and whether they view it as a method of assuring protected sex and lowering the risk of HIV in the study area.
Hiv Vulnerability And Condom Use Among Fishers
The first recorded usage of the condom was during the Roman era, when animal bladders were employed to stop the spread of STDs (Bauni & Jarabi, 2003). The first mention was made public by Italian anatomist Gabriel Fallopio, who suggested using a linen sheath soaked with lotion to prevent syphilis in 1564 (Potts, 1999). Condoms are only particularly mentioned as a method of family planning to avoid conception in the 18th century. But when HIV spread, policymakers and program managers for reproductive health turned their emphasis on to strategies to prevent the disease, particularly condom use, which was promoted as a preventative measure and a contraceptive (Bauni & Jarabi, 2003). Pinkerton & Abramson (1997) explain that individuals who use condoms consistently are ten to twenty times less likely to be infected with HIV than non-condom users. Inconsistent use of condoms in any non-regular sexual activity is regarded as unprotected sex which could expose an individual to sexually transmitted infections. Earlier studies on fishers in fishing communities in some developing countries in Africa, South and South-East Asia, and Central America have produced evidence that suggests high HIV infection rates among fishers and other people living in fishing communities (Kissling et al., 2005; Seeley et al., 2009; Korankye and Dwomoh, 2012). Earlier works estimate rates of HIV prevalence in fishing communities to be five to ten times higher than those in the general population (Kissling et al., 2005; Seeley et al., 2009; Korankye and Dwomoh, 2012; Zafar et al., 2014). Some reason given for the high HIV rates in fishing communities is the high mobility of fishers, which contributes to changing sexual behaviors among them (Duwal et al., 2015; Holvoet, 2011; Olowosegun et al., 2013; Tumwesigye et al., 2012; Zafar et al., 2014). The low use of condoms by fishers in sexual exchanges at fishing destinations also accounts for their high HIV rates (Lungu and Husken, 2010). Prior studies in Kenya, Zambia, and Uganda adduce fishers’ non-use of condoms to ignorance and poor knowledge about HIV prevention methods (Lungu & Husken, 2010; Camlin et al., 2013; Kwena et al., 2013). Kyei-Gyamfi (2019) describes the high mobility of fishers poses a challenge for many to participate in HIV education at fishing destinations, leading to their poor knowledge, and behavior regarding HIV transmission and protection.
Holvoet (2011) notes the state of living conditions in fishing communities favors promiscuous lifestyles, whilst Lungu and Husken (2010) also argue that inadequate accommodation for mobile fishers in fishing destinations leads to sexual relations and risky sexual engagements there. Lungu and Husken (2010) further elaborate that the inadequate accommodation facilities in the fishing communities facilitate fish traders cohabiting with single male fishers, which often leads to risky sexual engagements. According to Kyei-Gyamfi (2022), some female fish traders travel to the fish markets with very little trading capital and often do not want to use their income for accommodation if they must spend a night at a fishing destination outside their homes. The fish traders, often out of desperation to get a comfortable place to sleep as well as to keep their trading capital intact, offer sex in exchange for accommodation and to secure their trading capital (Lungu and Husken, 2010). Many of these women who have been given free lodging are frequently put in situations where they are unable to negotiate the usage of condoms because they are afraid of losing the offer when the men suggest having sex without them (Lungu and Husken, 2010).
Another reason for low condom usage among fishers is their HIV risk denial attitudes (Allison and Seeley, 2004; Lubega et al., 2015). Fishing is generally regarded as a high-risk occupation in terms of livelihood insecurity, and physical danger (Kher, 2008). According to Allison and Seeley (2004), fishing's inherent risks and uncertainties encourage fishermen to engage in hazardous sexual activity, abuse drugs and consume excessive alcohol. Lubega et al. (2015) found in a study in Kasensero of Uganda that lack of HIV-related fear among fishers was a determining factor in the high HIV transmission in the study area. Besides, they observe that in Kasensero many fishers have had experiences of seeing their colleagues dying at sea whilst fishing, and as a result, these fishers see this activity as a life-threatening and more dangerous undertaking than the fear of HIV infection. Owing to this, the decision to use condoms hardly occurs to fishers with an HIV-risk denial attitude and this works against HIV protection efforts in fishing communities (Allison and Seeley, 2004; Lubega et al., 2015; Holvoet, 2011). According to Kwena et al. (2013), some female fish traders engage in unprotected sex when their male partners refuse to use condoms out of fear of losing access to the fish. Most of these women find it difficult to bargain for protection during sex because they are afraid of losing fish supplies to other female fish traders. According to Kyei-Gyamfi (2022), women in most fishing villages depend on their male counterparts either for fish or other economic gains, which exposes them to these sexual exploitations.
The Health Belief Model (HBM)
The HBM is an important psychological model that emphasizes individual attitudes and beliefs to explain and predict health behaviors. It was created in the 1950s by social psychologists working for the US Public Health Service and updated in the 1980s. It was developed to explain the lack of public participation in health screening and prevention initiatives. It is a tool that scientists use to try to predict health behaviors (Boskey, 2022; Hochbaum, 1958). The HBM has since been adapted to examine a range of health behaviors, including sexual risk behaviors and the spread of HIV. The fundamental idea of the HBM, according to Hochbaum (1958), is that individual beliefs or perceptions about a disease and the methods available to reduce its incidence influence health behavior. Therefore, the model which has six constructs sees "belief" as the key component in preventing a health condition. It has been used in this paper to explain attitudes and behaviours regarding the use of condoms among fishers.
Perceived susceptibility is the first HBM construct, and it reflects how susceptible a person feels to a certain health risk, such as their propensity to contract a virus like HIV. Therefore, a person must first believe they are at risk of contracting HIV before taking any action to prevent it. People are typically more driven to take action to avoid contracting an illness when they perceive they are at risk of becoming infected. In other words, people tend to engage in less healthy behaviors when they perceive they are not at risk or are at low risk. Previous studies on fishers have found that most of them believe they are invincible to HIV because they see themselves as physically fit people who regularly face and overcome various hazards while carrying out their regular fishing responsibilities (Allison and Seeley, 2004; Lubega et al., 2015). Given that many fishers perceive the fishing occupation to be more dangerous than HIV, their belief about their susceptibility to HIV is very low, accounting for their unpreparedness to take precautions like wearing condoms during sex. In a previous study, Korankye and Dwomoh (2012) revealed that although fishers in Elmina, were aware of HIV, most of them did not see the disease as a concern. Many of them believed that HIV only affects others and not themselves, and therefore not view it as a dangerous condition that should be taken seriously. The chance of participating in behaviors to reduce risk increases with perceived risk.
The second construct on perceived severity refers to one's perception of the gravity of a disease or other health condition. Medical outcomes, such as death or disability, or individual beliefs about how the illness would affect their life can both be used to determine severity. When people are unaware of how serious an illness is, as the HBM proposes, they are less likely to take preventive actions. This explains why people who do not consider HIV to be a severe virus never use condoms (Holvoet, 2011). Individuals are more inclined to act when they view their vulnerability and severity to be greater. The severity of HIV will be viewed differently by fishers if they are made aware of its threat.
The third construct is known as perceived benefits, and it refers to an individual's assessment of the worth or usefulness of a new behavior in lowering the risk of contracting a disease. When people think their new action may lower their risk of contracting an illness, they are more likely to adopt healthy habits. Individuals frequently wonder what gains or losses they would experience if they altered their behavior. Likewise, they will not perceive the need to modify their bad behaviors if they do not understand the advantages of changing their behavior. For example, female fishers in fish-for-sex (FFS) relationships have reported in previous studies that their male sexual partners have refused to use condoms during their encounters (Kher, 2008; Mojola, 2011). Incidentally, the women are either afraid to insist on their partners using condom or are unconcerned about the risk of a STI, since using condoms would mean losing access to fish or other financial gain from their male fisher partners. Not using condoms during sex puts the women and their partners at risk of contracting STI, but they stand to benefit by getting easy and regular access to fish supply. These female fishers have always had unprotected sex with their FFS partners, so it is a challenge convincing them to change a behavior knowing that they stand to lose access to fish supplies or a kind of financial benefit. The HBM espouses that many people will not give up something they enjoy if they will not get something in return. People need to have faith in the change's ability to produce beneficial outcomes to make it.
A person's perception of the barriers to behavior change is known as perceived barriers. Barriers might be tangible or intangible. For instance, in fishing communities, tangible barriers may include a lack of funding, poor condom access, and a dearth of HIV education initiatives owing to the remote nature of fishing communities. Intangible obstacles are usually psychological or emotional in nature such as people being afraid to insist on the use of condoms, or ashamed to buy condoms, or are intimidated to seek help for a health condition. According to the HBM, for a person to adopt a new behavior, they must perceive that the advantages of the new behavior outweigh the consequences of retaining the old behavior. Sometimes people need assistance in figuring out how to get beyond obstacles. A hurdle to identifying a behavior change in condom usage among the female fishers involved in FFS in Elmina is the anxiety of asking male fishers to use condoms during sex. A fisher who wants to use condom and cannot get one to buy due to lack of access in a remote fishing village may serve as a barrier to having safe and protective sex. Perceived barriers are the HBM construct that has the greatest impact on behavior change, according to Janz & Becker (1984). Change is not something that comes easily, but it is likely to occur once the individual is able to overcome the barriers.
The HBM contends that in addition to the four beliefs or perceptions and moderating factors, cues to action also have an impact on behavior. The fifth construct relates to internal and external cues for action which constitute the circumstances that lead to risky or protective behaviour. These are strategies used to encourage people to take initiative by boosting individual or collective readiness. These may include programs that encourage people to make specific decisions, such as those that provide information, raise awareness, and serve as reminders about HIV and AIDS. In other words, a person's risky or protective behaviors depend on how well HIV and AIDS education initiatives inform the public about the infection and disease. Incidentally, fishing communities are described in the fisheries literature as hard-to-reach areas with HIV and AIDS education programs (Duwal et al., 2015; Kyei-Gyamfi, 2019). In addition to the difficulty of reaching fishers to sensitize them, many of them lack the time or are uninterested in participating in such programs because of the mobile nature of their work (Duwal et al. 2015). These factors account for poor knowledge, attitude and behaviours regarding HIV and AIDS among fisher groups.
The perceived self-efficacy, also known as personal competence or capability, of the individual to engage in protective behaviors, is the sixth construct of the HBM. Self-efficacy is the assurance that a person has in their capacity to act or carry out a specific behavior. People usually do not attempt to acquire new behaviors unless they have confidence in their ability to do so. A person who believes changing their conduct would be beneficial but is skeptical of their ability to do so is unlikely to try changing their way of life. For example, in a very divisive fishing community where a lot of women are marginalized and largely dependent on male fishers for sustenance, the capacity and tenacity of women to bargain for the use of condoms in sexual encounters is very low. According to Kwena (2006), most sexual encounters in fishing communities take place in unprotected circumstances with very little condom use since many women are unable to bargain for the use of condoms out of fear of being denied access to fish. In such circumstances, it becomes impossible to carry out a suggested course of action, such as negotiating condom use. The HBM, however argues that with support, training, and other encouragement, self-efficacy can be strengthened.
The HBM has been criticized for failing to pay enough attention to environmental and economic factors that frequently have an impact on health behaviors (Bene and Merten, 2008; Traube et al., 2011). It ignores for instance, gender-based economic disparities between men and women, which have a significant impact on how much control men and women have when making decisions about their sex lives. This is typical of fishing communities where many women depend on men for fish or for financial support. Men have a lot of power to manipulate decisions about having sexual encounters because women rely on them for these supports. For instance, some women are afraid of losing a favor they are asking of their male partner if they try to negotiate the use of a condom during a sexual encounter where a man insists on not using one. The model is also critiqued for being individualistic and failing to sufficiently account for how peer pressure and societal norms affect people's choices in terms of their health-related behaviors. It is also possible that some cultural influences are out of a person's control. When young individuals are away from home, peer pressure and peer modeling effects have a stronger influence on the choices they make about their sexual behavior. Young mobile employees, like fishers, who are frequently away from their homes and lose familial ties, are susceptible to this. The model, according to critics, also focuses more on describing health behaviors than it does on demonstrating how to alter them (Boskey, 2022).
Despite its limitations, the HBM is effective in the current paper's explanations of the hazardous and protective behaviors of fishers. The model explains why some people would choose to wear condoms during sex and why other people might not. The model also describes advances in reducing HIV risk behaviors that can be realized when efforts are placed towards improving knowledge, attitudes, and perceptions through the construct on the cues for action. In the same way it forecasts individual sexual behaviors, it enables the development of appropriate interventions for increasing safe sex in fishing communities. The use of the HBM in this paper is very suitable in explaining attitudes and behaviours regarding the use of condoms by fishers in fishing communities.