Where Do Adolescents Obtain Condoms? The Role of Financial Access and Desired Quality in Jamaica

Ruth R. Berg, Abt Associates Inc.

Introduction Growing concerns about contraceptive security in developing countries over recent years have led donors and governments to encourage greater commercial sector participation in the provision of family planning methods and services. Some observers question whether the commercial sector can adequately meet the family planning needs of more vulnerable groups, including adolescents (Interim Working Group 2001), who have relatively limited financial resources. A recent review of the data for all DHS III countries, however, reveals that the private sector already provides the majority of modern contraceptives to adolescents in nearly half of the 29 countries reviewed (Murray et al. 2002). While that study shows the potential for the private sector to play an important role in family planning service provision to youth, the key determinants of private sector use among adolescents remain largely unknown. The present study examines the extent to which desired family planning service quality and financial access to the commercial sector determine whether adolescent boys in Jamaica obtain condoms from friends, the commercial sector, or the public sector. Policy implications regarding the strengths and limitations of the commercial sector’s ability to serve adolescent reproductive health needs are discussed. Data and Methods This study is based on data from the 2001 Adolescent Condom Knowledge, Attitudes, and Practice Survey conducted by the Commercial Market Strategies Project with funding from the Agency for International Development (USAID). A three-stage sampling design with a targeted size of 1500 respondents was used. Enumeration districts were randomly selected in the first stage. A list of households with at least one eligible person was prepared and households were randomly selected in the second stage. One eligible person per household was randomly selected in the last stage. The survey questionnaire asks a broad range of questions related to reproductive health knowledge, sexual relations, and contraceptive practices. In addition, the survey asks respondents to name the characteristics of condom outlets that are important to them. Response categories include elements of service quality such as privacy/confidentiality, the availability of a wide range of products, and short waiting time. We use responses to this question to create indicators of desired service quality. The questionnaire also asks respondents to name the characteristics of condoms that are important to them when choosing a condom. Response categories include indicators of condom quality such as texture, strength, lubrication, and reliability. We use responses to this question to develop indicators of desired product quality. We rely on information about whether the respondent works for money as a proxy for financial access to commercial sector outlets. We restrict the analysis to boys who have been sexually active in the three months prior to the survey and who used a condom the last time that they had sexual intercourse (total number is 270). The dependent variable in the analysis is a polytomous variable with three categories for condom source: (1) respondents who obtained their condoms from a commercial sector outlet; (2) respondents who obtained their condoms from a public sector outlet; and (3) respondents who obtained their condoms from friends or relatives. To estimate the net effects of financial access and desired product and service quality on condom source, we use multinomial logistic regression analysis. The analysis controls for a number of factors, including age, area of residence, socio-economic status, and exposure to mass media communication about condoms and HIV/AIDS prevention. Results The findings that pertain to financial access reveal that boys who do not earn their own income are more likely to obtain condoms from friends and relatives than from either the private sector (p<.05) or the public sector (p<.10). With respect to the estimated effects of desired product quality, boys who report that the material of condoms (i.e., texture or thickness) is one of the most important considerations when choosing a condom are more likely to obtain condoms from the commercial sector than from friends or relatives (p<.05). Similarly, boys who report that the reliability of condoms is one of the most important considerations when choosing condoms are more likely to obtain condoms from the commercial sector than from friends or relatives (p<.05). This latter finding is consistent with the results of qualitative research in urban Botswana (Meekers et al. 2001). With respect to the effects of desired service quality, boys who prefer privacy/confidentiality are more likely to obtain condoms from friends or relatives than from either the private sector (p<.05) or the public sector (p<.10). The only indicator of desired service quality that appears to distinguish boys who obtain condoms from the private sector from those who obtain condoms from the public sector is the desire for health information. Specifically, boys who report that access to health information in a condom outlet is important to them are more likely to obtain condoms from the public sector than from the private sector (p<.05). Conclusions As donors and governments seek ways to increase the role of the commercial sector in the provision of family planning products and services in developing countries, it becomes increasingly important to understand the strengths and limitations of the commercial sector’s ability to serve more vulnerable groups such as adolescents. The present analysis shows that, net of other effects, youth without their own money are less likely to obtain condoms from either the commercial sector or the public sector, and instead are more likely to rely on friends and relatives for condoms. Potential problems associated with reliance on friends and relatives as condom sources include lack of condom quality control (i.e., condoms are more likely to have passed their expiration date) and inconsistent availability. The analysis also finds that boys concerned about the quality of condoms are more likely to obtain condoms from the commercial sector than from friends or relatives. This finding suggests that commercial sector outlets are likely to remain an important source of condoms for Jamaican adolescents.