RECOMMENDATIONS TO IMPROVE CONDOM USE IN MEN IN DIKGATLONG SUB DISTRICT (NORTHERN CAPE) by SOLLIE MAKGARI RECOMMENDATIONS TO IMPROVE CONDOM USE IN MEN IN DIKGATLONG SUB DISTRICT (NORTHERN CAPE) by SOLLIE MAKGARI Student number: 2006080440 DISSERTATION Submitted in accordance with the requirements for the degree MAGISTER SOCIETATIS SCIENTIAEIN NURSING The Faculty of Health Sciences School of Nursing University of the Free State Bloemfontein Study Leader: Dr. M. Reid July 2012 Certificate To whom it may concern This is to certify that the dissertation by Sollie Makgari has been edited by Ms Ronny Snyman Address: P. O. Box 17592 BAINSVLEI 9338 Telephone: (051) 451-1091 Cellphone: 0834440884 E-mail: cutman@yebo.co.za Qualification: HPOD, Cape Town and Bloemfontein Date: July 2012 i Declaration I declare that the dissertation hereby submitted by me for the Masters Social Sciences degree at the University of the Free State is my own independent work and has not previously been submitted by me at another university or faculty. All the sources I have used or quoted have been indicated and acknowledged by means of complete references. I further cede copyright of this thesis in favour of the University of the Free State. ____________________ __________________ S. MAKGARI Date ii Dedication Dedicated, in loving memory, of my sister Deborah Kerapelecwe Tshabile. iii Acknowledgements I wish to express my sincere gratitude and appreciation to:  My Heavenly Father for keeping me healthy through my research study.  My study supervisor, Dr. Marianne Reid for your assistance, dedications, encouragement, wisdom and friendship.  My precious wife Margaret and her sister Anastasia for supporting me through the hard times of my studies.  My children, Tumelo Marlin and Clyde for assisting me with computer programs and also being part of my studies.  Mrs Annemarie Du Preez, Mr Jacob Nkolonyane and Mr Keaobaka Mokae for assisting with literature research in such a loving manner.  Mrs June Klopper for doing an excellent job on the technical arrangement of the study.  Ms Ronny Snyman for willingly sharing your expertise, assisting in language editing.  Mr Thabo Mokhobo for willingly facilitating the nominal group discussions in a passionate manner.  Lorraine Naome Nkoane for encouraging me and being there as a practical friend listened to my frustrations I experienced through the research study.  Sister Durrelle Abrahams and Mr R Jafta for helping me with the technicality of the computer systems.  The Department of Health (Northern Cape) for granting me the permission to conduct the research study.  The University of the Free State for giving me the opportunity of conducting the research study. iv Summary The purpose of the study was to come up with recommendations that would improve condom use in men in the Dikgatlong Sub-district in the Northern Cape Province of South Africa. Although condom use in this province followed the national tendency in South Africa of an increase in condom use amongst men of all age groups, men from the Northern Cape had the lowest prevalence of condom use amongst men in South Africa. The research methodology used was qualitative, descriptive and consensus seeking in design. The nominal group technique was used to collect data from men who were recruited from the primary health care facilities and from schools in the Dikgatlong Sub-district. An exploratory study was conducted to test the relevance and the clarity of the question. The study consisted of two nominal groups of older men (49 years and above) and two nominal groups of younger men (18-24 years). Atrained facilitator from the University of the Free State conducted the nominal group discussions. This structured interview technique allowed prioritizing recommendations proposed by participants as to how to improve condom use amongst men in the Dikgatlong Sub-district. Data obtained during the interviews was analysed according to the steps proposed by van Breda and categories and themes identified according to the steps proposed by Tesch. The categories identified were client education, quality assurance, attitude, communication and availability of condoms. The category, client education was further divided into the following themes: content, strategy, responsibility and target group. The category, quality assurance had two themes namely, manufacturing and cost. Whereas the category attitude had one v theme namely, change. The category communication had one theme namely, interpersonal. The last availibility category had also one theme namely, sites. Trustworthiness of the data was supported by upholding the criteria of credibility, transferability, confirmability and dependability. Recommendations from the study were ordered according to the identified categories and themes. Briefly the results indicated that parents, community leaders, educators and the Department of Health in collaboration with other governmental departments have role to play in encouranging the sexual behavioural change in men. Policies and guidelines regarding the use and distribution of condoms were found to be available and should reach the community. The results of the study will be forwarded to the Department of Health in the Northern Cape and the implementation of these recommendations will be in their hands. vi Opsomming Die doelstelling van die studie was om voorstelle te genereer wat kondoom gebruik onder mans in die Dikgatlong Sub-distrik in die Noord Kaap sal bevorder. Hoewel die Noord Kaap ook die nasionale tendens in Suid Afrika van ‘n verhoogde kondoom gebruik gevolg het, is kondoom gebruik onder mans in die provinsie die laagste in Suid Afrika. Die navorsingsmetodologie wat toegepas is, was kwalitatief, beskrywend en daarop gemik om konsensus in die ontwerp te vind.Data is deur middel van Nominale Groep Tegniek onderhoude ingesamel. Deelnemers het bestaan uit ouer mans wat primêre gesondheidsorgklinieke in Dikgatlong bygewoon het, asook skoliere in die area. ‘n Verkennende onderhoud het dit moontlik gemaak om die relevansie en duidelikheid van die vraag te toets. Twee nominale groep tegniek onderhoude is met ouer mans (49 jaar en ouer) en twee met jonger mans (18-24 jaar) gevoer.’n Ervare fasiliteerder van die Universiteit van die Vrystaat het die nominale groep onderhoude gelei. Hierdie gestruktureerde onderhoudstegniek het dit moontlik gemaak om deelnemers se voorstelle om kondoomgebruik onder mans in die Dikgatlong Sub-distrik te prioritiseer. Data wat tydens die onderhoude gegenereer is, is geanaliseer volgens die stappe wat Van Breda voorstel. Kategoriëe en temas is geidentifiseer volgens die stappe wat Tesch voorstel. Die kategoriëe wat geidentifiseer is, was kliëntonderrig, kwaliteitsversekering, houding, kommunikasie en beskikbaarheid van kondome. Die kategorie kliëntonderrig is verder verdeel in die volgende temas: inhoud, strategie, verantwoordelikeheid en teikengroep. Die kategorie kwaliteitsversekering het twee temas gehad: vervaardiging en koste. Die kategorie houding het slegs een tema gehad, naamlik verandering. Daar is verder gevind dat die kategorie kommunikasie ‘n tema interpersoonlik gehad het, met die kategorie beskikbaarheid, die tema plek. vii Die geloofwaardigheid van die studie is ondersteun omdat die kriteria van waarheidsgetrouheid, oordraagbaarheid, vertroubaarheid en bevestigbaarheid nougeset deur die navorser nagestreef is. Voorstelle van die studie is volgens die geidentifiseerde kategoriëe en temas georden. Kortliks het die voorstelle daarop gedui dat dat ouers, gemeenskapsleiers, opvoedkundiges en die Departement van Gesondheid in samewerking met ander staatsdepartemente ‘n rol het om te speel ten einde die seksuele gedrag van mans te verander. Beleide en riglyne rakende die gebruik en verspreiding van kondome is beskikbaar, maar moet die gemeenskap self bereik. Die resultate van die studies al aan die Noord Kaap Departement van Gesondheid beskikbaar gestel word. Die implementering van die aanbevelings is egter in die department se hande. viii TABLE OF CONTENT SUMMARY ................................................................................................................ v OPSOMMING ......................................................................................................... vii CHAPTER ONE OVERVIEW OF THE STUDY 1.1 INTRODUCTION .............................................................................................. 1 1.2 PROBLEM STATEMENT ................................................................................. 3 1.3 THE PURPOSE OF THE STUDY .................................................................... 3 1.4 CONCEPT CLARIFICATION ............................................................................ 4 1.5 RESEARCH DESIGN ....................................................................................... 4 1.6 RESEARCH TECHNIQUE ............................................................................... 4 1.7 POPULATION .................................................................................................. 5 1.8 CONVENIENCE SAMPLING ............................................................................ 5 1.9 EXPLORATORY INTERVIEW .......................................................................... 6 1.10 DATA COLLECTION ........................................................................................ 7 1.11 DATA ANALYSIS ............................................................................................. 8 1.12 TRUSTWORTHINESS ..................................................................................... 9 1.12.1 CREDIBILITY .................................................................................... 9 1.12.2 TRANSFERABILITY ......................................................................... 9 1.12.3 CONFIRMABILITY .......................................................................... 10 1.12.4 DEPENDABILITY ............................................................................ 10 1.13 ETHICAL CONSIDERATIONS ....................................................................... 10 1.13.1 CONFIDENTIALITY AND PRIVACY ............................................... 11 1.13.2 INFORMED CONSENT AND PARTICIPATION ............................. 11 1.13.3 PROTECTION FROM PSYCHOLOGICAL HARM OR DISCOMFORT ............................................................................................... 11 1.14 EXPLANATION OF CHAPTERS .................................................................... 12 ix CHAPTER TWO RESEARCH METHODOLOGY 2.1 INTRODUCTION ......................................................................................... 13 2.2 RESEARCH DESIGN .................................................................................. 13 2.2.1 QUALITATIVE RESEARCH ............................................................ 14 2.2.2 CONSENSUS SEEKING STRATEGY ............................................ 14 2.2.3 THE STRENGTHS OF QUALITATIVE RESEARCH ....................... 15 2.2.4 LIMITATIONS OF QUALITATIVE RESEARCH .............................. 16 2.3 ANALYSIS UNIT ............................................................................................ 16 2.3.1 POPULATION ................................................................................. 17 2.3.2 INCLUSION CRITERIA ................................................................... 17 2.3.3 CONVENIENT SAMPLING ............................................................. 19 2.4 RESEARCH TECHNIQUE ............................................................................. 20 2.4.1 NOMINAL GROUP TECHNIQUE ................................................... 20 2.4.2 STRENGTHS OF NOMINAL GROUP TECHNIQUE ...................... 21 2.4.3 LIMITATIONS (SHORTCOMINGS) OF NOMINAL GROUP TECHNIQUE ................................................................................... 22 2.4.4 ROLE OF THE FACILITATOR ........................................................ 23 2.4.5 ROLE OF THE RESEARCHER ...................................................... 24 2.4.6 EXPLORATORY INTERVIEW ........................................................ 24 2.4.7 DATA COLLECTION PROCESS .................................................... 25 2.4.7.1 Preparation for Nominal group sessions .......................... 26 2.4.7.2 Conducting nominal group technique ............................... 28 2.4.8 DATA ANALYSIS ............................................................................ 32 2.4.9 MEASURES TO PROMOTE TRUSTWORTHINESS OF THE RESULTS ....................................................................................... 38 2.4.9.1 Credibility ......................................................................... 38 2.4.9.2 Transferability ................................................................... 39 2.4.9.3 Confirmability ................................................................... 39 2.4.9.4 Dependability ................................................................... 40 2.5 ETHICAL CONSIDERATIONS ...................................................................... 40 2.5.1 BENEFICENCE .............................................................................. 41 2.5.2 RESPECT FOR HUMAN DIGNITY ................................................. 42 2.5.3 JUSTICE ......................................................................................... 44 x 2.5.4 CONDUCT OF THE RESEARCHER .............................................. 44 2.6 CONCLUSIONS ............................................................................................ 45 CHAPTER THREE DISCUSSION OF RESEARCH FINDINGS 3.1 INTRODUCTION ........................................................................................... 46 3.2 DEMOGRAPHIC DATA OF NOMINAL GROUP PARTICIPANTS ................. 46 3.3 GENERAL OVERVIEW OF RESEARCH DATA ............................................ 48 3.4 RESEARCH RESULTS ................................................................................. 55 3.4.1 CATEGORY: CLIENT EDUCATION ............................................... 56 3.4.1.1 Theme one: Content ........................................................ 58 3.4.1.2 Theme two: Strategy ........................................................ 61 3.4.1.3 Theme three: Target group .............................................. 65 3.4.1.4 Theme four: Responsibility ............................................... 66 3.4.2 CATEGORY: QUALITY ASSURANCE ........................................... 69 3.4.2.1 Theme one: Manufacturing .............................................. 70 3.4.2.2 Theme two: Cost .............................................................. 72 3.4.3 CATEGORY: ATTITUDES .............................................................. 72 3.4.3.1 Theme one: Change ........................................................ 73 3.4.4 CATEGORY: COMMUNICATION ................................................... 75 3.4.4.1 Theme one: Interpersonal ................................................ 76 3.4.5 CATEGORY: AVAILABILITY .......................................................... 78 3.4.5.1 Theme one: Sites ............................................................. 79 3.5 CONCLUSION ............................................................................................... 80 CHAPTER FOUR SUMMARY OF RESEARCH FINDINGS, RECOMMENDATIONS, LIMITATIONS AND CONCLUSION 4.1 INTRODUCTION ........................................................................................... 81 4.2 SUMMARY OF RESEARCH FINDINGS OF THE STUDY ............................ 81 4.2.1 CLIENT EDUCATION ..................................................................... 82 4.2.1.1 Content............................................................................. 82 4.2.1.2 Strategy ............................................................................ 83 xi 4.2.1.3 Responsibility ................................................................... 84 4.2.1.4 Target group ..................................................................... 85 4.2.2 QUALITY ASSURANCE ................................................................. 85 4.2.2.1 Manufacturing .................................................................. 86 4.2.2.2 Cost .................................................................................. 86 4.2.3 ATTITUDE ...................................................................................... 86 4.2.3.1 Change............................................................................. 86 4.2.4 COMMUNICATION ......................................................................... 87 4.2.4.1 Interpersonal .................................................................... 87 4.2.5 AVAILABILITY ................................................................................ 87 4.2.5.1 Sites ................................................................................. 87 4.3 RECOMMENDATIONS ................................................................................. 87 4.3.1 CLIENT EDUCATION ..................................................................... 87 4.3.1.1 Content............................................................................. 88 4.3.1.2 Strategy ............................................................................ 89 4.3.1.3 Responsibility ................................................................... 92 4.3.1.4 Target group ..................................................................... 94 4.3.2 QUALITY ASSURANCE ................................................................. 95 4.3.2.1 Manufacturing .................................................................. 95 4.3.2.2 Cost .................................................................................. 96 4.3.3 ATTITUDE ...................................................................................... 96 4.3.3.1 Change............................................................................. 96 4.3.4 COMMUNICATION ......................................................................... 97 4.3.4.1 Interpersonal .................................................................... 97 4.3.5 AVAILABILITY ................................................................................ 98 4.3.5.1 Sites ................................................................................. 98 4.4 LIMITATIONS ................................................................................................ 99 4.5 VALUE OF THE STUDY .............................................................................. 100 4.6 CONCLUSION ............................................................................................. 100 REFERENCES ....................................................................................................... 102 xii TABLES TABLE 2.1 An example of paper-sheet during the nominal group discussion .................................................................................... 29 TABLE 2.2 An example of voting card ........................................................... 31 TABLE 2.3 An illustration of tally sheet used during nominal group technique ..................................................................................... 32 TABLE 2.4 An illustration of nominal group technique spreadsheet .............. 33 TABLE 2.5 Calculated rank order for combined nominal group data ............. 37 TABLE 3.1 Demographic data of nominal group participants ......................... 47 TABLE 3.2 Combined research findings reflected per category, theme, statement and priority ranking received ....................................... 49 TABLE 4.1 Combined data of the four nominal groups divided into categogies and themes.................................................................................. 82 FIGURES FIGURE 2.1 Map of Dikgatlong Sub-district ..................................................... 18 FIGURE 2.2 Shows the arrangement of the room and chairs during the nominal group discussion .......................................................................... 27 FIGURE 2.3 Schematic diagram of a nominal group technique ...................... 28 ADDENDUM Addendum A: Request letter to conduct research to the Head of Department (Health) Northern Cape.............................................................. 114 Addendum B: Consent form for the participants of the nominal groups............ 117 Addendum C: Permission letterfrom the Head of Department (Health) Northern Cape ......................................................................................... 120 Addendum D: Steps of Van Breda .................................................................... 122 Addendum E 1: Nominal group one of older men ................................................ 125 Addendum E 2: Nominal group one of young men .............................................. 130 Addendum E 3: Nominal group two of older men ................................................ 133 Addendum E 4 Nominal group two of young men .............................................. 137 Addendum F: Analysed data of the four nominal groups divided into categories, themes, statements, average, and Top five ............................... 142 xiii Addendum G: Calculated rank order for combined categories ......................... 155 Addendum H: Permission letter to conduct research from the Ethics Committee of the University of the Free State ................................................. 157 xiv CHAPTER ONE OVERVIEW OF THE STUDY 1.1 INTRODUCTION Condoms have been used thousand years before the birth of Christ, since the ancient Egyptians were using linen sheaths for protection against diseases (UNAIDS, 2000:3). Around the 1930`s latex rubber condoms were developed and mainly used for birth control, but the use declined in the 1960`s. The popularity of the use of condoms inclined around the 1980`s with the discovery of the human immunodeficiency virus (HIV) infection and was used to prevent transmission. HIV and acquired immunodeficiency syndrome (AIDS) incidence has affected the whole world drawing attention to how to combat its effects. Condoms act as barriers during sexual intercourse whereby the semen cannot pass through from the penis to the vagina. The condoms are manufactured according to World Health Organization`s specifications and standards to ensure the highest level of efficacy and safety (UNAIDS, 2005:239). It has been proven that if condoms are used correctly and consistently the level of sexually transmitted infections will decline. An effective way to control sexually transmitted infections including HIV and AIDS is the correct and consistent use of condoms so that millions of the people can benefit (Yotebieng, Halpern, Mitchell & Adimora, 2009:10).It is estimated that 39, 5 million people globally live with HIV and AIDS. Less than 10% of the world`s population reside in sub-Saharan Africa,which also is the home of two thirds of people living with HIV (Van Dyk, 2012:7-8; Yotebieng et al., 2009:10; Badenhorst, Van Staden & Coetsee, 2008:28). Condom usage sometimes implies sexual behaviour changes. Sexual behavioural changes need to be instilled in the mind set of the younger and older men, by seeking to delay the onset of sexual intercourse, reducing the number of sexual partners, and reducing the incidence of unprotected sex by increasing condom use. Encouraging i persons to know their HIV status, whether positive or negative will be instrumental in effecting behavioural change and the adoption of 1 safer sex practices (Van Dyk, 2012:137). Depending on the results of voluntary counselling and testing, people usually take steps to avoid becoming infected or infecting others. Availability of accessible voluntary counselling and testing services will be instrumental in changing perceptions and sexual behaviour of the individuals. Researchers have shown that people are prepared to change their sexual behaviour in various ways if they believe that this behaviour is beneficial and has social support (Van Dyk, 2012:136).One of such behaviours being the use of condoms. The major challenge is to have the men use condoms consistently and correctly. However, it is important to realise that the availability of the condoms does not necessarily lead to their effective use. The programme of HIV counselling and testing (HCT) was introduced by President Jacob Zuma in 2010 in order for South Africans to know their HIV status and act responsibly to ensure HIV free generations through consistent and correct use of condoms (South Africa. Department of Health, 2010:7). An area where condom use will be looked at is the Northern Cape in South Africa. The Northern Cape is one of nine provinces of the Republic of South Africa with the lowest population of 840 000 according to Statistics South Africa (2003). The Northern Cape consists of five districts namely John Taole Gaitsiwe, Siyanda, Namaqualand, Pixley ka Seme and Frances Baard. Dikgatlong Sub district is found in the Frances Baard District and consists of Barkly West, Delportshope, Windsorton, Longlands and the surrounding farms. Barkly West is the most central and biggest town where shopping is done over the weekend by people from farms and other small towns. Dikgatlong Sub district has a population of 40751 as was projected in 2004 (South Africa, 2003: online). The community speaks predominantly Tswana and Afrikaans. It is a rural community economically dependent on diamond diggings and agriculture. About 26,2% of the population are employed and 27,5% are unemployed and 32,1% do not have basic schooling (Dikgatlong Municipality, 2006:3). The literacy level is very low and there is a high percentage of unemployment in the Dikgatlong Sub-district. There are also health issues like high teenage pregnancies (534), high HIV (1728) and sexually transmitted infections (STI)(467) that are attempted to be addressed by the Department of Health through services rendered by primary health care facilities (Department of Health Northern Cape, 2008:6). 2 There are six fixed primary health care facilities, two mobile clinics and a newly built level one hospital, serving as referral hospital in Dikgatlong Sub-district. Fixed primary health care facilities are as follows: - Barkly West has 2 clinics, Delportshope has 1 clinic, Windsorton has 1 clinic and Longlands has 2 clinics, but operates only on Tuesdays and Thursdays. There isan ever increasing number of men who are attending the health facilities to be treated for STIs including HIV and AIDS. There is a major concern that men may be engaging in unprotected and risky sexual behaviour. According to the statistics received from the Anti retroviral (ARV) site and the ante natal clinics in Dikgatlong, 5400 people are already infected with HIV (Department of Health Northern Cape, 2008:4). 1.2 PROBLEM STATEMENT The high prevalence of HIV in Dikgatlong necessitates consistent condom use. The South African HIV Prevalence, Incidence, Behaviour and Communication Survey which was done in 2002, 2005 and 2008 respectively, showa national increase in condom use in men aged 15 to 24. The same survey also showed a national increase in men in the age group 49 and above. The same tendency across all age groupswas also found in the Northern Cape Province, but condom use was at a much lower rate than nationally found. Only 52,7% of males in the Northern Cape reported using condom at last sex in 2008, whereas the national average of condom use at last sex was 62,4% (Shisana, Rehle, Simbayi, Zama, Jooste, Pillay-van Wyk, Parker, Zungu & Pezi, 2009:44). Thus, the Northern Cape where Dikgatlong Sub- district is located has the lowest prevalence of condom use among men in South Africa. Asurvey has not been done to identify possible recommendations to improve condom use in Dikgatlong Sub-district. 1.3 THE PURPOSE OF THE STUDY The purpose of the study is to make recommendations to improve condom use by men in the Dikgatlong Sub-district in the Northern Cape Province. 3 1.4 CONCEPT CLARIFICATION 1.4.1 Stratergies refers to the art or science of the planning and conduct of a war (Hanks, Long & Urdang, 1979: 1437). In the study it refers to planning and implementing policy that will improve condom usage . 1.4.2 Young men refers to males who have reached the age of 15 to 24 years in the study. 1.4.3 Older men refers to males who have reached the age of 49 years and above in the study. 1.5 RESEARCH DESIGN This study will make use of a qualitative, consensus seeking design. A qualitative research design is systematic, descriptive and explorative in nature and promotes understanding of human experiences (Brink, 2008:113).Qualitative research design is characterized by the principles of believing in multiple realities, participants` viewpoints, not disrupting the natural context of the phenomenon and reporting data in literary style rich with participants` commentaries (Brink, 2008:10). The consensus seeking design allows the participants to reach consensus on a specific topic (Botma, Greeff, Mulaudzi & Wright, 2010:251).This will suit the researcher`s study asit will explore and makerecommendations that will encourage men to improvethe use of condoms. 1.6 RESEARCH TECHNIQUE This study will make use of the nominal group technique to collect data. The nominal group technique is a structured variation of a small group discussion to reach consensus.This group technique consists of 5 to 12 participants (van Breda, 2005:2 & Botma et al., 2010:251-253). Thenominal groups will be established with young men of the age 18 to 24 years andmen aged 49 years and above.The age group of the young men has been 4 adapted from the age groups used in the South African HIV Prevalence, Incidence, Behaviour and Communication Survey. This has been doneto facilitate the legal directive in South Africa, allowing young adults from 18 years and older to participate in research studies independently from their parents (South Africa, 2005). The researcher thinks that excluding ages 15-17 will not have an impact on research findings. The purpose of the nominal group technique will be to generate recommendations that might improve condom use among younger and older men. 1.7 POPULATION De Vos, Strydom, Fouche and Delport (2011:223) define population as the total set from which the individuals of the study are chosen. The researcher`s population will be chosen from male adults from Dikgatlong Sub-district aged between 18 to 24 yearswhich totals 4057.Males from the same sub-district who are 49 years and older, will also be included in the nominal group discussions. Currently 2768 males fall into this group (South Africa, 2003: online). 1.8 CONVENIENCE SAMPLING Convenience sampling is also known as accidental sampling. This type of sampling is less time consuming, is inexpensive and accessible. Convenience sampling is concerned with the identification of most readily available individuals as study partakers (Brink, 2008:132-133; Leedy & Ormrod, 2010:212; Botma et al., 2010:201; Burns & Grove, 2011:305 & De Vos et al., 2011:232). This type of sampling will be implemented by starting with the recruitment of men aged 18-24 and men 49 and above from the two fixed primary health care clinics in Barkly West, then if needed, moving towards the remaining three fixed primary health care clinics in the sub- district of Dikgatlong. The remainder of the clinics are, one in each of the following towns, namely Delportshoop, Longlands and Windsorton.The researcher will remain in the fixed primary health care facilities to personally recruit the participants to enhance confidentiality and privacy and to ensure inclusion criteria is met.The first 5- 12 participants who meet the criteria will be recruited in Barkly West and from there recruitment will commence in the remaining primary health care clinics that have been mentioned. Respondents will be drafted until the point of saturation has been 5 reached. The researcher cannot foresee how many groups will be needed for saturation to be reached. Participants will be included in this study should they fall into the following categories:  Men in the age group 18-24  Men in the age group 49 and above  Given consent to participate in the study  Men who can understand and write in Afrikaans. The reason for excluding Tswana speaking men is purely practical, since the only black male facilitator available to conduct the nominal group is not conversant in Tswana. Since Afrikaans is the medium of communication in Dikgatlong, this should not influence the outcome of thestudy. 1.9 EXPLORATORY INTERVIEW An explorative study is a small version of the proposed study conducted to develop and refine the methodology or data collection process in preparation for a major study as stated by Burns and Grove (2009:359-360). The first 5-12 men who would be willing to participate in the study will be requested to do so. One group of men of any age will be interviewed to test the relevance, effectiveness of question and the response of the participants.The participants will be requested to state how they interpret the following question: “Propose recommendations that can be applied to improve the use of condoms by men”. “Stel planne voor om kondoom gebruik onder mans te bevorder” The question will only be tested and not all the steps of the nominal group will be applied. The researcher will adapt the question if needed for the study. 6 1.10 DATA COLLECTION Data collection will involve the precise and systematic gathering of the information relevant to the research purpose and questions (Burns & Grove, 2011:535). Nominal group technique as a research method will be used to collect data until saturation of data has been reached. Before commencing with data collection the researcher should have the approval letter from the ethics committee of the University of the Free State. Permission to conduct the research study should also be granted by the Head of Department of the Northern Cape Health Department. Recruitment of the participants will be done by the researcher when making appointments with them to attend the nominal group discussion. Arrangements with the municipality of Barkly West will be made to avail a suitable facility for the nominal group discussion sessions. The venue will be free of distractions. Dates and time schedules will be planned with the relevant role players. A trained black male facilitator will be used to facilitate the nominal group. The male facilitator will be used due to the sensitivity of the topic. The group facilitator will welcome the nominal group and explain the purpose and procedure of the meeting (Delbecq, Van de Ven & Gustafson, 1975; Potter, Gordon & Hamer, 2004:126-129). The nominal groups will be conducted in a 4 step process. The 4 step process will be generating ideas, recording ideas, discussing ideas and voting on ideas. The input of the participants will be limited to a single meeting.During step one each participant will be provided with a sheet of paper and pencil to write down in silence(without further discussion) his ideas regarding the recommendationsthat will improve the use of condoms by men. Ten to 15 minutes will be allowed for this phase. The second phase will be concerned with sharing and recording of ideas. Each participant will be given the opportunity to express his ideas, and the facilitator will write down each idea on the flip chart as presented by the participants. The third phase will provide opportunity for the participants to express their understanding of the issue under discussion. Participants will be encouraged to write down new ideas coming out during the discussion. No debate will be allowed during this session. Time allowed for this phase will be 30 to 45 minutes. The fourth phase will be concerned with voting on 7 ideas and ranking of the ideas. The participants will be requested to vote for ideas according to their priorities privately. The ranking procedure will be explained to the participants by the facilitator. After the voting and ranking procedure, immediate results responding to the recommendations that can be applied to improve the use of condoms by men will be available to participants. This will conclude the meeting having achieved a specific outcome (Botma et al., 2010:251-253). The facilitator will express his gratitude to the participants for having participated in the study. 1.11 DATA ANALYSIS De Vos et al (2011:397) state that data analysis is the process of bringing order, structure and meaning to the mass of collected data for its interpretive and meaningful quality. According to Joubert and Ehrlich (2007:323) there are no rigid rules for data analysis in qualitative study. Speziale and Carpenter (2007:46) state that data analysis begins when data collection begins in qualitative study. Data will be analysed by the researcher according to Van Breda (2005:4):- Step 1: Capture data on computer: The researcher will capture the data that has been collected onto a spreadsheet, making it possible for analysis of data later. Step 2: Identifying the top five: The researcher will order each group`s set of statements according to how important the group felt that statement was and then identify the five most important statements in each group. Step 3: Content analysis of the data: The researcher will categorise the individual statements that have been collected through the nominal group technique into themes or categories. Step 4: Confirm the content analysis: The researcher will subject content analysis to peer review by asking colleagues who were not involved in the research process, to check whether the same themes are identified. 8 Step 5: Calculating combined ranks: Following a number of sub steps, the researcher will determine the relative importance of each theme to all the groups combined. Step 6: Reporting the nominal group technique data: The researcher will compile the data that has been collected in a research report. 1.12 TRUSTWORTHINESS Polit and Beck (2008:768) define trustworthiness as the degree of confidence the qualitative researchers have in their data using the criteria of credibility, transferability, confirmability and dependability. The facilitator and the nominal group members will accurately record the results of the discussions.This will enhance the credibility, dependability, reliability and applicability of the data collected (Maree, 2010:81-87 & Botma et al., 2010:291 to 292). 1.12.1 CREDIBILITY Polit and Beck (2008:554) state that credibility is the level of faith in the truth value of the findings. Systematic data collection and data analysis will be enhanced by the nominal group process. Since new groups will be added until data saturation has been reached, findings will be a true reflection of participants’ views.The well versed facilitator will be conducting the nominal group discussions thus ensuring the credibility of the study. The possibilities of misinterpretation of data will not occur because the nominal groups will present data themselves together with the facilitator. 1.12.2 TRANSFERABILITY Transferability is the extent to which the findings of the study or data can be transferred to other settings in similar situations (Polit & Beck, 2008:554; Streubert& Carpenter, 2011:49). It is the responsibility of the individual to apply the context of study to his situation but not of the original researcher.The sample of men chosen to 9 partake in the study and the thorough description of the methodology and data will assist an individual to make the decision whether data would be transferable or not. 1.12.3 CONFIRMABILITY Confirmability refers to the neutrality of data according to Miles & Huberman (1994:278) and Polit & Beck (2008:554). The fact that data collection and analysis will be conducted with the active participation of the nominal group participants whilst discussion is in process will assist in achieving the confirmability of data. The notes of the nominal groups will be kept in a lockable cupboard to limit accessibility to unauthorised persons. Inquiry audits can be useful in establishing dependability and confirmability (Botma et al., 2010:292). 1.12.4 DEPENDABILITY Dependability is a process to determine the quality of data and it refers to the evidence that, if the study were to be repeated with the same or similar participants in the same context, its findings would be similar (Botma et al., 2010:292; Streubert & Carpenter, 2011:49). 1.13 ETHICAL CONSIDERATIONS Ethics is a system of moral values that is concerned with the degree to which the research procedures comply with professional, legal and social obligations to the study participants as stated by Polit and Beck (2008:753). Before commencing the study, ethical approval will be sought from the Ethics Committee of the University of the Free State. Permission to conduct the study within primary health care clinics in Dikgatlong Sub-district will be sought from the Department of Health in the Northern Cape (See Addendum A attached). The ethical considerations are more concerned with protection of the human subjects in the study and the conduct of the researcher. 10 1.13.1 CONFIDENTIALITY AND PRIVACY Confidentiality is concerned with the protection of study participants so that the information shared is not publicly revealed (Neuman, 2003:126-127; Polit & Beck 2008: 750; Streubert & Carpenter, 2011:63-64). All the responses of the participants during the discussions will be handled privately. The results of the study will be presented in anonymous manner. Privacy is concerned with the individuals` right to share or withhold personal information regarding attitudes, beliefs, opinions and records (Neuman, 2003:126 & Burns & Grove 2011:114). Unauthorized access to the data will be guarded against by locking the cupboard always. The participants will be informed about the results of the study. 1.13.2 INFORMED CONSENT AND PARTICIPATION Prospective participants will be informed about the purpose of the study. Participation will be voluntary and no coercion will be applied. The nominal groups` discussion session will be approximately two hours. Information will be shared so that the participants can withdraw from the study at any time without any penalty being imposed or loss of benefits (Burns & Grove, 2011:122-123; Streubert & Carpenter, 2011:61-63). A letter of consent will be signed by the participant, witness and the researcher (Polit & Beck, 2008:177 and see Addendum B attached). 1.13.3 PROTECTION FROM PSYCHOLOGICAL HARM OR DISCOMFORT The participants will not be intentionally subjected to psychological harm. Sensitive issues during the nominal group discussion will be treated with care and respect. When counselling is needed the participant will be referred to the professional counsellor and will not be chargeda nominal fee.The participants` opinions, views and beliefs regarding condom use will be respected. The participants should be informed that there are no wrong answers therefore are free to express themselves fully regarding the relevance of the topic (De Vos et al., 2011:115). 11 Men in the community would benefit from improved communication and counseling on condom use and through health education. Recommendations will help to improve and boost the morale of men by encouraging them to freely speak about the use of condoms. Parents and educators will be empowered to interact with the youth in a meaningful manner by imparting accurate information regarding sexuality. Governmental departments should work better together to improve condom use by echoing the same message in different levels to get the men to resort to protected sexual behavior. The condom distribution will be increased in the private owned business like taverns, fuel stations and shebeens and the responsible officials from the Department of Health will monitor the availability of condoms. In closing the researcher believes that if the recommendations that emulated from this study could be applied by various stakeholders including the community on the Dikgatlong Sub-district will make the difference to the well being of men. 1.14 EXPLANATION OF CHAPTERS In order to formally present the study, the report will be divided into four chapters. The first chapter introduces the study, by describing the purpose of the study, research methodology, and ethical considerations that will be considered. Measures that will be taken to promote trustworthiness of data are also highlighted. Chapter two will describe the research design and methodology. The researcher will present a discussion on the choice of method as well as how it will be implemented. The ethical considerations will be expanded on in this chapter. In the third chapter the data analysis and interpretation of findings will be reported. These findings will be supported by literature. Finally the fourth chapter will present an overall discussion of the results and so conclude remarks on the outcome of the study. Research recommendations will further be given. 12 CHAPTER TWO RESEARCH METHODOLOGY 2.1 INTRODUCTION In the first chapter the purpose of the study has been set out as recommendations to improve condom use by men in the Dikgatlong Sub-district.In this chapter the researcher has described the research methodology of this study. Methodology is a scientific approach used in an orderly fashion to address or acquire information in order to bring a solution to the problem (Polit & Hungler, 1997:15). The research methodology encompasses the research design. Additionally, analysis unit, research technique, data collection, data analysis, trustworthiness of the study and ethical considerations would be part of discussions (Joubert &Ehrlich, 2007:49; Polit & Beck, 2008:328-329; Brink, 2008:191-193 & Streubert & Carpenter, 2011:366- 367). The discussion following the qualitative consensus seeking research design is followed by the researcher. 2.2 RESEARCH DESIGN A research design refers to the blueprint or the strategy that was used by the researcher to conduct the research study (De Vos et al., 2011:142-143; Stommel & Wills, 2004:32; Burns & Grove, 2009:218 & Brink, 2008:207). Further the design of a study is interpreted as the end result of a series of conclusions which is drawn by the researcher regarding the implemented study. Additionally the research design should be efficient and effective so that it can offer knowledge needed in an uncomplicated and cost effective manner (De Vos et al., 2011:451-452). Since this study followed a qualitative research design, this type of design will now be discussed. 13 2.2.1 QUALITATIVE RESEARCH A qualitative research design is systematic, descriptive and explorative in nature and promotes understanding of human experiences (Brink, 2008:113). During this study the participants were allowed to systematically explore their recommendations on the use of condoms through the nominal group technique. Qualitative research is non number based and does not rely on statistics to prove a result. It allows unstructured data to be collected via the participants` perspectives, attitudes, insights and behaviours (O`Grady, 2011: online). In this study the participants discussed recommendations that could lead to improvement of condom usage by men based on men`s perspectives and understanding. Qualitative research is characterized by six principles, described by Brink (2008:10-11) and Streubert and Carpenter (2011:20). Those principles are as follows:-  Belief in multiple realities,  Commitment in identifying an approach to understand the support of the phenomena to be studied,  Acknowledgement of participants in the research process,  Commitment to the participants` viewpoints,  Conducting of inquiry in a way that limits disruption of the natural context of the phenomena of interest and  The reporting of data in a literary style rich with participants commentaries. The qualitative design was used as part of a consensus seeking strategy. 2.2.2 CONSENSUS SEEKING STRATEGY Consensus seeking methods refer to methods whose results are based on general agreement of the group. Examples of consensus methods are nominal group techniques and the Delphi technique (Potter, Gordon & Hamer, 2004:126; Muller, 2006:111; Botma.et al., 2010:251). In this study the nominal group technique was used to make recommendations to improve the use of condoms in the context of the Dikgatlong sub-district community. Each participant was given an opportunity to 14 make recommendations to improve the use of condoms. Consensus seeking strategies promoted ownership by the participants regarding the outcomes of the study. Participants were motivated and enthusiastic in making the decisions that would affect them (Conradt & Roper, 2005:450 and Muller, 2006:111). Other strengths of qualitative research are discussed below. 2.2.3 THE STRENGTHS OF QUALITATIVE RESEARCH Qualitative research provides deeper understanding of or insights into phenomena (Streubert & Carpenter, 2011:22). The nominal group technique discussion was particularly instrumental in this regard. In this study the nominal group technique was used to better understand the recommendations to improve condom usage amongst young and older men. Qualitative approaches are responsive to local situations, conditions and stakeholders` needs. The current study was responsive to the low rate of condom usage by young and older men. Only 52,7% of males in the Northern Cape were reported using condoms at last sex in 2008, whereas the national average of condom use at last sex was 62,4% (Shisanaet al., 2009:44). Data are usually collected in a naturalistic setting (Streubert & Carpenter, 2011:26). This was also the case in this study, with participants from Dikgatlong sub-district being selected to partake in the study. Streubert and Carpenter (2011:23) say, “Doing qualitative research is similar to reading a good novel. When conducted in the spirit of the philosophy that supports it, qualitative research is rich and rewarding, leaving researchers and consumers with a desire to understand more about the phenomena of interest”. The researcher shared the sentiments of the above mentioned quotation hence so keen to find out more about possible recommendations from men to improve condom use. It was of paramount importance for the researcher to also be aware of the limitations of qualitative research. 15 2.2.4 LIMITATIONS OF QUALITATIVE RESEARCH Compared to quantitative research techniques, qualitative research techniques generally take more time to collect data (Creswell, 2009:178; Streubert & Carpenter, 2011:20-21). The nominal group technique was used as a consensus seeking strategy in this study to speed up the process of data collection. Further, knowledge produced might not be generalized to other settings or other people. However the researcher was more concerned with the development of rich or dense description of phenomena rather than supporting generalizability of the findings (Streubert & Carpenter, 2011:29). What was important was to have recommendations that would improve condom use in the Northern Cape. Additionally qualitative research may not produce definitive conclusions (O`Grady, 2011: online). However, the nominal group technique used provided definite recommendations to be used within Dikgatlong community. Possible researcher bias throughout a study could be problematic to the qualitative researcher, in his search to uncover a specific issue (Streubert & Carpenter, 2011:25-26). Again, since the nominal group technique used was a consensus seeking strategy amongst participants, it did not allow the researcher any say in the recommendations generated by the participants. Being sensitive towards possible limitations of qualitative research, the researcher had to be clear on the unit of analysis used in the study. 2.3 ANALYSIS UNIT Analysis unit is the basic unit or focus of a researcher`s analysis, referring to what is being studied (Babbie& Mouton, 2007:84 & Polit & Beck, 2008:768). Analysis unit generally refers to a group or organization that is under study. In this study the researcher identified a specific population that acted as the unit of analysis under study. 16 2.3.1 POPULATION Population is referred to as the entire group of people that meet a designated set of criteria (Stommel & Wills, 2004:297; Burns & Grove, 2009:343-344; Polit & Beck, 2008:67; Brink, 2008:123; Botma et al., 2010:6. & Leedy & Ormrod, 2010:276). In the study the population consisted of two groups of men within the Dikgatlong sub- district of the Northern Cape. The first group consisted of 4057 men, between the age of 18 to 24 years and, the next group was 2768 men from 49 years and older. The group of younger men had been adapted from the age group used in the South African HIV Prevalence, Incidence, Behaviour and Communication Survey. This had been done, in order to facilitate the legal directives in South Africa, and allowed young adults from 18 years and older to participate in research studies independentof their parents (South Africa, 2005). The researcher was of the opinion that excluding ages 15 to 17 years would not have an impact on the research findings, because 18 to 24 years old still attended school as did the 15 to 17 year olds. The South African HIV Prevalence, Incidence, Behaviour and Communication Survey served as a guide for the inclusion criteria (Shisana et al., 2009:44-45). 2.3.2 INCLUSION CRITERIA Inclusion criteria are defined as who should be included in the population that is to be studied (Polit & Beck, 2008:338 & Botma et al., 2010:124). The practical method of selecting the population that would be included in the study was performed carefully. Participants who were included in this study consisted of men:  in the age group 18-24  in the age group 49 and above  who gave consent to participate in the study and  who could understand and write in Afrikaans. 17 The reason for excluding Tswana speaking men was purely practical, since the only black male facilitator available to conduct the nominal group was not conversant in Tswana. Since Afrikaans was the medium of communication in Dikgatlong, that did not influence the outcome of the study. The first 5-12 participants who met the criteria were recruited in Barkly West, as the biggest and most central town of Dikgatlong sub-distrct. Recruitment started in De Beershoogte Primary Health Care clinic, one of the two Primary Health care clinics in Barkly West. The other primary health care clinic was Mataleng. See figure 2.1 depicting a map of Dikgatlong sub-district. Windsorton, with Primary Health care clinic, 31 km north east of Barkly West and Longlands and Delportshope, respectively 20 km and 28 km in the western direction served as identified areas where recruitment of participants would be conducted after Barkly West. Respondents were drafted until the point of saturation had been reached. Recruitment of participants was performed according to convenient sampling. Figure 2.1 below is the map showing Dikgatlong. Figure 2.1 Map of Dikgatlong sub-district. 18 (Barkly West 2 Primary health facilities (P H C), Longlands 1 P H C, Delportshoop 1 P H C and Windsorton 1 P H C). 2.3.3 CONVENIENT SAMPLING Convenient sampling is also called accidental sampling because it is characterized by conveniently using readily available people as participants (Uys & Basson, 2004:93; Stommel & Wills, 2004:301-302; Berg 2007:43; Polit & Beck, 2008:341; Botma et al., 2010:201 & De Vos et al., 2011:232). The first nominal group of older men (49 years and older) was selected from De Beershoogte primary health care facility. The researcher requested the sister in charge to show him the appointment book to identify the suitable participants who would come in the morning for their chronic medication. The identified participants were recruited by the researcher, and appointment date, time and venue were arranged and contact details of the prospective participants were recorded. The morning session was preferred as older men were unemployed and some were off duty. The second nominal group of younger men (18 to 24 years) was from De Beershoogte primary health care facility. The discussion session was held in the afternoon as some participants were still scholars and others were workers. It was convenient to have nominal group discussion with younger men in the afternoon and after school, so there was no interference with the school program. The first and second group discussions were held on the same day. The third nominal group of older men was from Mataleng primary health care facility and was recruited in the same manner as that of De Beershoogte primary health clinic. The fourth nominal group of younger men was selected also from Mataleng and was scheduled in the afternoon as some of them were still scholars and others were workers. The third and fourth group discussions were held on the same day. The fifth and sixth nominal group of the older and younger men were selected respectively from Windsorton facility as stand by if saturation of data was not reached at Barkly West primary health care facilities. The fifth and the sixth groups were not used as data saturation was reached with the four nominal groups. The unused nominal group members were notified telephonically by the researcher that they would not be used. These participants were clients that attended the primary health care facility. Recruitment was done according to the inclusion criteria. 19 The discussion will now turn to the specific research technique followed and its strengths and limitations. 2.4 RESEARCH TECHNIQUE The purpose of a research technique is to assist the researcher to obtain information during the research study. The data collection strategy in qualitative research studies will include observations, interviews, focus groups and nominal groups (Uys & Basson, 2004:55 & Botma et al., 2010:290). In the study the nominal group technique was followed. 2.4.1 NOMINAL GROUP TECHNIQUE A research technique is a procedure that is followed to collect data during a research study or survey (Van Breda, 2005:2 & Botma et al., 2010:290). The technique the researcher used was the nominal group technique. This technique was developed by Delbecq and Van den Ven in 1968. A nominal group technique is a brainstorming technique that consists of a small group of participants engaged in discussion to reach consensus. Every group participant`s opinion is taken into account (Potter et al., 2004:126; Botma et al., 2010:251& De Vos et al., 2011:503). The ideal number of the group participants is 5 to 9 and the meeting usually lasts for about 2 hours. The technique involves generation of ideas, the recording of ideas, and discussions of ideas which are followed up by voting on ideas (Potter et al., 2004:126). In order to achieve the correct outcome, the technique followed four phases: 1 Introduction and topic presentation to the participants; 2 Silent generations of ideas by participants; 3 Sharing of ideas in round robin manner and 4 Voting on and ranking of ideas by participants (Botma et al., 2010:251). 20 The nominal group technique enabled participants to generate recommendations that would improve condom use among younger and older men. However in order to understand the effectiveness of the nominal group technique one had to know its strengths. 2.4.2 STRENGTHS OF NOMINAL GROUP TECHNIQUE Sharing of ideas led more people to make judgements regarding certain aspects of the topic. During the second phase many ideas were generated within a short space of time by the participants. All participants were involved and motivated to share their recommendations (Delbecq et al., 1975:81; Sample, 1984: online; University of Vermont, 1996: online; Reid, 2009:89 & Botma et al., 2010:251). Participants felt free to express their ideas without fear of criticisms. The process followed in the phases enhanced critical thinking by the participants. The introverts were given equal opportunity to generate their ideas without intimidation. The facilitator did not allow any participants to dominate the discussion, and no verbal interaction among participants was permitted, unless there was clarification needed that would help the discussions, focus was only on the single topic. The round robin approach offered an equal opportunity for all participants to express themselves (Botma et al., 2010:251). Round robin recording means going around the table and asking for one idea from one member at a time (Dunham, 2006: online). U- shaped arrangement of chairs was made in the room where nominal group discussions were held to encourage openness by the participants. All participants were in a position to maintain eye contact during discussion. The facilitator and group dynamics encouraged the participants to confront issues through constructive problem solving; hence participants were stimulated to come up with recommendations that would encourage men to use condoms (Department of Health & Human Services, 2006: online; & Dunham, 2006: online). There were no threats posed during the nominal group discussions, hence participants were encouraged to reach consensus regarding issues faster. 21 All the nominal group members prioritized ideas they generated democratically. They voted and ranked the ideas. The results were easily interpreted as participants had already weighed the importance of statements in the process of engaging in the nominal group technique (Jones, 2004:23). That minimized the researcher bias and misinterpretation of the results. The nominal group technique was very effective as there were limited resources and saved time as the meeting was limited to about two to two and a half hours. Task completion and immediate dissemination of results to the group promoted satisfaction with participation, and researcher bias was minimized due to highly structured nature of the process (Potter et al., 2004:127). It was important to recognize the limitations of the nominal group technique. 2.4.3 LIMITATIONS (SHORTCOMINGS) OF NOMINAL GROUP TECHNIQUE The limitations of the nominal group technique will be discussed and how the researcher aimed to limit the impact thereof on the study. The nominal group technique required more timethan other techniques for preparation (Sample, 1984: online). The researcher had personally recruited the participants from the primary health care facilities. Preparation consisted of:  Permission from Head of Department of Health (Northern Cape),  Arrangement of venue,  Invitation of participants and  Preparation of index cards, flip-chart, and other stationery. All the participants were required to express their ideas in writing and communicated them orally with the group. Some participants might have found it difficult or uncomfortable to express themselves in the group (Sample, 1984: online; Jones, 2004:20). The facilitator had given each participant an opportunity to express his idea regarding the topic. The participants were allowed to use their local language, 22 which was Afrikaans which promoted comfortability and relaxation. All participants were able to express themselves when writing down recommendations. Participants might have found it difficult to think in depth about the topic because of the short time allocated for generation of ideas (Sample, 1984: online). The structured manner of the nominal group allowed participants enough time to structure their thoughts. Selection criterion was based on specific characteristics of the participants that would fulfil the aim of the study and not generalize the research findings to the wider population. The participants of the study were selected from Dikgatlong sub-district; the results were in context of the community mentioned (Potter et al., 2004:127; Jones, 2004:20). Some participants might have felt uncomfortable to talk about condom use because of cultural issues. Since the participants were men and a trained male facilitator was used to conduct the nominal group discussions, possible feelings of discomfort were minimized (Moore, Dahl, Gorn & Weinberg, 2006:77). The data analysis of qualitative research was a time consuming process due to the volume of information collected and the nature of analytical procedures required (Potter et al., 2004:127). The structured guidelines provided by Van Breda (2005) was followed and assisted to speed up the process. The role of the facilitator was of paramount importance, because of the sensitivity of the topic. 2.4.4 ROLE OF THE FACILITATOR A trained black male facilitator was used because of the sensitivity of the topic addressed during the nominal group discussions. For a nominal group to be successful a skilled and credible facilitator was required. The facilitator would need to be an expert on the topic to be discussed by the 23 participants or at least a credible non expert (University of Vermont, 1996: online, and Potter et al., 2004:127). Leadership qualities and communication skills were needed to direct the discussion (Delbecq et al., 1975). The facilitator of the study was comfortable with nominal group discussions and had a special manner of approaching participants, as the sensitivity of the topic was known to him. Ice breakers were used to start the discussions so that participants would feel free and relaxed during the meeting. Before the nominal group discussions were started the facilitator explained the role of the researcher to the participants. 2.4.5 ROLE OF THE RESEARCHER The researcher was ethically obligated to ensure that he was competent and adequately skilled to conduct the proposed research, although he did not act as facilitator during the nominal group discussion. The researcher was given the task during the nominal group discussions to jot down ideas of the participants on the flip chart. Since the researcher was not known to participants and would not influence the generation of ideas during the nominal group discussion, the researcher would assist the facilitator in acting as the scribe. The exploratory interview was conducted to test whether the participants understood the meaning of the question that would be used during the nominal group discussions before the data collection process commenced. 2.4.6 EXPLORATORY INTERVIEW An explorative study is a small version of the proposed study conducted to develop and refine the methodology or data collection process in preparation for a major study (Burns & Grove 2009: 359-360; Botma et al., 2010:50 & De Vos et al., 2011:240-241). De Beershoogte primary health care facility was used to recruit the first 5-12 men who were willing to participate in the study by the researcher. That group was men of the age of 49 years and older. They were interviewed to test whether they understood the meaning of the question. The exploratory interview was 24 conducted at Barkly West in the local hospital`s board room. This hospital was 300 metres from De Beershoogte primary health care facilities. The participants were requested to state how they interpreted the following question: “Propose recommendations that can be applied to improve the use of condoms by men”. “Stel planne voor om kondoom gebruik onder mans te bevorder”. The question was only tested and not all the steps of the nominal group technique were followed. The researcher did not adapt the question because the participants understood the question clearly. After testing the question the facilitator decided to continue with all the nominal group discussion. Those participants were included in the study, thus forming the first group from whom data was collected for the study. It was very important to consider how the data collection process had occurred. 2.4.7 DATA COLLECTION PROCESS Data collection involves the precise and systematic gathering of the information relevant to the research purpose and questions (Burns & Grove, 2009:44). Before commencing with data collection the researcher had received approval to conduct the research study from the Ethical Committee of the Faculty of Health Sciences of the University of the Free State. Permission to conduct the research study was also granted by the Head of Department of the Northern Cape Health Department (Refer addendum C and H for a copy of a letter to the clinic supervisors and the hospital manager). The board room of the nearby hospital was secured for the purpose of the nominal group discussions. The venue was free of distractions. Dates and time schedules were planned with the relevant role players. A preliminary meeting was held between the researcher and the clinic supervisor in June 2011. The researcher explained the research purpose and inclusion criteria of participants required to partake in the research. The researcher attended the De Beershoogte and Mataleng primary health facilities on separate days and identified possible participants. 25 However, the researcher followed up by making appointment dates with the participants to partake in the nominal group discussions. The first nominal group was held with a group of older men (49 years and older) from De Beershoogte primary health care facility. This was the same group the question posed during the nominal group discussion was tested on, when conducting the exploratory interview. Of the 12 men recruited by the researcher to attend this group discussion 5 turned up to partake in the nominal group. The second nominal group was held with a group of the younger men (18 to 24 years of age) from De Beershoogte primary health care facility. This group discussion was held in the afternoon on the 19th July 2011. Of the 10 men recruited by the researcher to attend this group discussion 8 younger men turned up to participate in the nominal group. The third nominal group was held with a group of older men (49 years and older) from Mataleng primary health care facility. This group discussion was held in the morning of the 20th July 2011. Of the 12 men recruited by the researcher to attend this group discussion 6 older men turned up to participate in the nominal group discussion. The fourth nominal group was held with a group of younger men (18 to 24 years of age) from Mataleng primary health care facility. This nominal group discussion was held in the afternoon on the 20th July 2011. Of the 12 younger men recruited to attend this group discussion 10 men turned up to participate in the nominal group discussion. Before conducting any of the nominal group discussion necessary preparations were undertaken by the researcher. 2.4.7.1 Preparation for Nominal group sessions The board room was free of distractions and prepared to accommodate 5 to 12 men. It was booked 2 weeks before the scheduled nominal group discussions. Each 26 participant was provided with water and a packet of sweets. Each file had a piece of paper on which responses would be written and 5 index cards for voting, a pen and written informed consent form. Chairs were arranged in a U-shape and a flip chart was placed at the open end of the U-formation. Figure 2.2 below shows how the board room was arranged during the nominal group technique discussions (Reid, 2009:96). Flip chart Table Participant Researcher Facilitator Figure 2.2 Shows the arrangement of the room and chairs during the NGT discussion. Source: Adapted from Reid, 2009: 96. 27 2.4.7.2 Conducting nominal group technique The nominal group process was repeated in all four groups.The facilitator welcomed the participants and thanked them for their willingness to participate in the research study. The written informed consent form was completed by participants before the group discussion would commence (Refer addendum B). The nominal group technique process was explained to the participants by the facilitator and the estimated time that would be spent on the discussion (Potter et al., 2004:128 and Botma et al., 2010:251). A discussion will follow as to how the phases of the nominal group discussion were conducted. See Figure 2.3 depicting the flow of the nominal group discussion. Topic Identification of subjects Introduction & topic Phase 1 presentation to subjects 10 minutes Silent generation of ideas Phase 2 5 – 10 minutes Sharing of ideas in round robin Phase 3 manner 20 to 40 minutes Phase 4 Voting & Ranking of ideas Summary & Results of the 20 – 40 minutes NGT conclusion Figure 2.3 Schematic diagram of a nominal group technique 28 The participants in the nominal group technique were not allowed to interact directly with one another. The facilitator conducted the nominal group discussions, welcomed the group members, introduced the topic and explained the process of the discussions. The importance of participants` contribution to the discussion was emphasised by the facilitator. This lasted for 10 minutes (Sample, 1984: online & Potter et al., 2004:128). Phase 1 Generating ideas (5-10 minutes) Silent generation of ideas –The facilitator provided the participants with pens and paper on which to write. The facilitator posed the following question to participants on the flip-chart, ”Stel planne voor om kondoom gebruik onder mans te bevorder” (Propose recommendations that can be applied to improve the use of condoms by men). Participants worked in the presence of one another, by jotting down ideas independently and quietly in bulleted, abbreviated format. Participants were not allowed to talk to one another. Participants were requested to indicate by putting their pens down if they had finished writing. This step lasted for 5 to 10 minutes (Potter et al., 2004:128; Dunham, 2006: online & Botma et al., 2010:251). In the first nominal group of older men one member had difficulty to write down the ideas and was assisted by the facilitator to write the ideas he generated. Table 2.1 is an example of paper sheet that was used in the phase 1. Table 2.1 An example of paper sheet during the nominal group discussion. Nominal group: Y. M 1 Statements 1 Dept van Gesondheid moet werkswinkels hou vir die jeug oor die belangrikheid van kondoom gebruik. 2 Kondome moet beskikbaar wees by die tarvans, klinieke, hospitale en petrol vulstasies. 29 3 Kondome moet gemaak word volgens verskillende grootte, klein, medium en groot. 4 Vrou mense moet aangemoedig word om die gebruik van kondome deur mans te aanvaar. 5 Mans moenie skaam wees om te praat oor kondoom gebruik nie. Phase 2 Verbalizing ideas, using round robin technique (20-40 minutes) Sharing of ideas-The facilitator had invited the participants to share the ideas they had generated regarding strategies to improve condom use in men. The phase had continued for 20 to 40 minutes. The ideas were presented on a flip-chart. All participants were given equal opportunity to contribute and provide written ideas regarding strategies to improve condom use in men. No debate was allowed during this phase (Potter et al., 2004:128; Dunham, 2006: online and Botma et al., 2010:251). Group members engaged in a round robin feedback session to concisely record each idea. Round robin recording meant going around the table, and asking for one idea from one participant at a time. The researcher wrote the idea of a group participant on the flip-chart and the facilitator proceeded to ask for one idea from the next participant (Dunham, 2006: online). Phase 3 Discussion of ideas (20-40 minutes) Group discussion- Participants were invited to seek spoken explanation about any of the ideas that any other participant had generated that might not be clear to them. During this phase the facilitator`s task was to ensure that every participant should contribute to the discussion. The participants found it easy and comfortable to talk about condoms in the group. No criticism or judgmental statement was allowed. The group could suggest new items for discussion and combined items, but no idea was eliminated. This phase had lasted for 20 to 40 minutes (Potter et al., 2004:128; Dunham, 2006: online & Botma et al., 2010:251). 30 Phase 4 Prioritizing of ideas (20-40 minutes Voting and ranking of ideas-This involved prioritizing the recorded ideas in relation to the original question (Potter et al., 2004:128 & Dunham, 2006: online). After the issues were clarified by the participants each was given five cards and asked to silently consider and write down, in order of priority five of the responses captured on the flip-chart (Five being the highest priority and one being the lowest ranked priority). Table 2.2 reflects an example of the voting card. Top right indicated the nominal group number; top left side number indicatedthe priority number of the statement and in the middle of the card was the allocated number and its statement. Prior to the nominal group discussions already prepared cards with coding of group as well as the 5 priorities were prepared by the researcher in order to assist participants and to speed up the prioritizing process. Table 2.2 An example of voting card. Y M 1 2 _________________________________________________________________ 16 NGO`s moet plakate beskikbaar maak aan die gemeenskap oor kondoom gebruik. After each participant had ranked his response in order of priority, the facilitator drew a tally sheet on the flip-chart. This chart depicted in Table 2.3 clearly shows from left to right the number allocated to a statement (column 1). The idea generated (column 2) score allocated to the statement (column 3) and lastly on the far right the total scores of a statement (column 4). The numbers in column 1 corresponded with the statements generated during the round robin feedback. The facilitator collected all 31 the cards from the participants and shuffled them to promote confidentiality. The facilitator read the idea number and number of points allocated to each one in the presence of the participants. The researcher recorded and then added the scores on the tally sheet. The ideas that were the most highly rated by the participants were the most favoured participant ideas in response to the question posed by the facilitator. Following the voting and ranking process, immediate results in response to the question were available to the participants. The meeting was concluded having reached a specific outcome (Dunham, 2006: online & Botma et al., 2010:251). Table 2.3 An illustration of tally sheet used during nominal group technique Allocated number Idea generated Scores allocated Total scores 1 2 3 4 1 Use condom 3, 4, 1 8 consistently 12 Discuss condom 5, 5 10 use with sexual partner After capturing data generated by the nominal group, data analysis commenced (Delbecq et al., 1975:68). 2.4.8 DATA ANALYSIS De Vos et al (2011:397) state that data analysis is the process of bringing order, structure and meaning to the mass of collected data for its interpretive and meaningful quality. Speziale and Carpenter (2007:46) state that data analysis begins when data collection begins in qualitative study. Data has been analysed by the researcher according to steps proposed by Van Breda (2005:4) namely to:-  Capture data on computer;  Identify top five statements;  Analyse content ;  Confirm content analysis;  Calculate combined ranks; and  Report of data. 32 Step 1: Capture data on computer: The researcher captured the data that had been collected onto a spreadsheet, from all four nominal groups making it possible for analysis of data later.See Table 2.4 reflecting an illustration of the nominal group spreadsheet. The researcher drew a table consisting of six columns in word format with the following headings, one heading in each column from left to right:  Column A Group  Column B Theme  Column C Statement  Column D Scores  Column E Sum of total of averages  Column F Top 5 Each of the four groups had their own spreadsheet of the mentioned table. Table 2.4: Illustration of nominal group technique spreadsheet Group Category & Idea/ statement (C) Scores Sum total of Top 5 (A) N=5 Theme (B) (D) averages of all (F) responses per category÷number of resposes (E) Older 5. Mans moet meer 3,4,2,4 13 men (1) praat oor kondoom (2.6) gebruik en nie skaam wees oor die kondoom nie.- (Men must talk more about condom use). Older 7. Mans moet meer 5,1,5,2 13 men (1) ingelig word oor die (2.6) gebruik van die kondoom. (Men must be more informed about the use of condom). 33 The group column, column A, indicated the number of participants (for example N=5), and identified the specific group, for example older men (1). On this account the nominal group data would be differentiated easily from one another at face value. Column B, depicting theme and categories were omitted for now. Statements or responses of the participants were written in the idea column C as they were captured during the round-robin discussions. Clarifications of the ideas or statements by participants were written in italics and brackets were used for translated responses in English. The scores of the responses of participants were in the score column Column D (Van Breda, 2005:4). The sum total of averages of all responses per category divided by the number of responseswas reflected in column E. Column F was also not completed as part of step 1. Step 2: Identifying the top five: The nominal group prioritized the first five statements, and it was only recorded as such by the researcher. Each nominal group`s responses were arranged from highest to the lowest total scores. Out of this data the five most important statements were identified. This was made possible by sorting the data occurring in the Top five (F) column in descending order, identifying the top five statements identified by the participants. It was possible for more than one statement to receive the same ranking. Each of the four nominal groups had its` own statement sheet. See Addendum F. The analyses of the content followed the prioritizing of the statements. Step 3: Content analysis of data: Content analysis is the process of combining individual statements into categories, themes and sub themes (Van Breda, 2005:5). Since saturation of data was reached across the age groups of the participants, data of these groups were combined during the analysis of the data. However, it was still possible for the researcher to identify individual statements made by either participant from the young or older age groups. See Addendum E 1 to E4. The researcher acted as scribe during the 34 nominal group discussion, this already gave the researcher a feeling of what participants wanted to convey. The researcher typed the data on a spreadsheet as described in Step 1 of van Breda`s steps in data analysis. Any clarifications made by participants were also added by the researcher on the newly typed spreadsheet. Therefore the researcher became familiar with the content early on. Then the researcher started working through each statement, continuously asking, “What is the main idea or meaning behind the response?” That main idea was written down next to each statement. These main ideas were then placed into categories and possible themes were simultaneously identified. Each response could only have been placed under one category and theme (Van Breda, 2005:5-6). The steps of Tesch (1990:138-145) were used as the guideline to identify the categories as well as the themes. Content analysis combines individual statements grouping them into categories and themes. The steps that were followed by the researcher in data analysis were as follows; 1. Organize and prepare the data for analysis. This encompassed the first data document that was available. 2. Read through all the data. This had been performed when the researcher was typing data on computer. 3. Begin detailed analysis with a coding process. The researcher had performed that step when he followed Van Breda`s step three and four. 4. Descriptions. The completed coding process was used to generate a description of the categories and themes for analysis. These represented the perspectives from participants and were supported with evidence from the study. 5. Representation of the qualitative narrative. A discussion of the themes and categories will be used to convey the findings of the analysis in chapter 3. 6. Interpretation of the data. This step will be followed in chapter 3. According to the researcher the systematic process of data analysis started at the typing of the raw data. The researcher had constantly, after every group interview, written the raw data that were jotted on the flip-chart, to the computer. This process had given the researcher the opportunity to be acquainted with the data and was clarified with the facilitator. According to Brink (2006:55) the research data must be 35 controlled at the end of the data collection process for completeness and correctness before data analysis could commence. The researcher and the facilitator together went through the typed data concerned to control for completeness and correctness. Unclear and incomprehensible statements were cleared out with the facilitator at that stage. The statements of nominal group participants had been written in bold letters, where clarifications had been stated written in italics and the English version was written in brackets. The response of the participants had been categorized as according to Van Breda (2005:5).See an example of calculated rank orders for combined categories of the nominal groups (Refer Table 2.5). The researcher and the study leader had done the categorization process together. As they had worked through the individual responses, they had asked themselves on what every response focussed precisely and had to decide individually what the main thought of each response is. The first thought was written down in the margin of the hard copies against the specific response. A concept of meaning was given to each response. At this stage of the data analysis process there were searches for similarities and unique statements. Every response was categorized to one clear distinguishable category as recommended by Van Breda (2005:6). An appropriately identified category and theme on which the researcher and the study leader had reached consensus were then put in lead pencil against each response. A lead pencil was used to make possible changes to proposed grouping. After consensus was reached the final themes and categories were written down on the category and theme column.The researcher was then ready to follow the next step, step four to confirm content analysis. Step 4: Confirm the content analysis: The researcher subjected content analysis to peer review by asking two nominal group technique experts, who were not involved in the research process, to check whether the same themes were identified. Two independent experts in qualitative research with a lot of experience including the study leader were requested to verify the categories and the themes of the responses of the participants (Van Breda, 2005:7). The two experts were given a brief background of the study and the nominal group technique question posed to participants. Each of the experts was provided 36 with a printed hard copy of the list of statements gathered during the nominal group discussions. Some changes were effected in categories and themes through consensus. The discussion with the experts regarding statement classification into categories and themes was very successful and served as a confirmation of data analysis. The researcher together with the study leader had to recheck the categories and the themes to promote credibility of the data. This step completed the qualitative analysis of data. The researcher was then offered the opportunity to proceed to the next step of calculating the combined ranks. Step 5: Calculating combined ranks: Following a number of sub steps, the researcher determined the relative importance of each theme to all the groups combined (Van Breda, 2005:7). The researcher was led by few sub-steps to determine the relative importance of each combined categories that were identified in the nominal group technique data. The researcher had done the calculations in this step himself and the study leader and nominal group expert re-checked these calculations (Refer to Addendum D for detailed version of calculation of ranks according to Van Breda). Each group`s first priority was allocated a score of five then second priority a score of four, third priority a score of three, fourth priority a score of 2 and the fifth a score of one. Table 2.5: Example of calculated rank orders for combined nominal group data. Categories Theme Top5 a Top5 b No. 1 No. 2 Average.1 Average.2 Final rank Total Ranking Total Ranking Sum total of Ranking order Values priority order of response of total averages of order of in column response total per response all averages category Top5b+No2+ per priority category per of all the average Average category response category responses b=Final rank per per category order category ÷by number of responses Client Content 17 5 38 5 9.2÷38=0.25 3 13 Education Strategy Responsibility Target group *OM 1 *O M 2 *Y M 1 *Y M 2 37 Step 6: Reporting the nominal group technique data: The researcher compiled the data that had been collected into a research report. The discussion of categories and themes from the list of statements will be presented in chapter three. 2.4.9 MEASURES TO PROMOTE TRUSTWORTHINESS OF THE RESULTS Polit & Beck (2008:768) define trustworthiness as the degree of confidence the qualitative researchers have in their data using the criteria of credibility, transferability, confirmability and dependability. The facilitator and the nominal group participants have accurately recorded the results of the discussions. Combined data of nominal groups held with older and young men further enhanced trustworthiness of data (Maree, 2010:81-87 & Botma et al., 2010:291-292). The two older men nominal group discussions were held separately from the two of the young men so that each age group could talk freely without embarrassment or fear. 2.4.9.1 Credibility Polit and Beck (2008:554) state that credibility (truth value) is the level of faith in the truth value of the findings. The researcher described all of the procedures used in conducting the study, including explaining the research setting as well as the data analysis methods used, for the reader to make appropriate judgements, and to use the same procedures in order to replicate the study under different circumstances if deemed necessary. The researcher kept up constant interaction with his supervisor during all levels of conducting the study, from inception of the research idea, to the proposal writing stage, through data collection and during data analysis. The research supervisor was an experienced qualitative researcher (Burns & Grove, 2009:507). Systematic data collection and data analysis were enhanced by the nominal group process. Since new groups were added until data saturation had been reached, findings were a true reflection of the participants’ views. During the nominal group discussion each participant was given an equal opportunity to verbalize his idea through the round robin technique. Participants prioritized the 38 generated ideas themselves which were in agreement with the results of the study (Van Breda, 2005:6). The well versed facilitator conducted the nominal group discussions thus ensuring the credibility of the study. The possibilities of misinterpretation of data did not occur because the nominal groups presented data themselves together with the credible facilitator. The researcher had made use of a review session with academics skilled in nominal group technique to confirm analysis of content (Streubert & Carpenter, 2011:406).In this study two experts in qualitative research were involved in the data analysis when they assisted the researcher with finalizing categories and themes of data obtained from participants (Van Breda, 2005:6). This further enhanced the credibility of the study. The other criterion data that was assessed was that of transferability. 2.4.9.2 Transferability Transferability is the extent to which the findings of the study or data can be transferred to other settings in a similar situation (Uys & Basson, 2004: 88; Babbie & Mouton, 2007:277; Polit & Beck, 2010:554 & Streubert & Carpenter, 2011:406). The aim of the nominal group discussion of the study was not to create transferable findings, but to come up with recommendations that would improve condom use in men in the Dikgatlong sub-district. It would be the responsibility of the individual to apply the context of the study to his situation on his own accord but not of the original researcher. The sample of men chosen to partake in the study and the thorough description of the methodology and data will assist an individual to make the decision whether data would be transferable or not. Confirmability would also influence the trustworthiness of the results of the study. 2.4.9.3 Confirmability Confirmability refers to the neutrality and replicability of data according to Polit and Beck (2008:554) and Streubert and Carpenter (2011:406). The fact that data collection and analysis were conducted with the active participation of the nominal group participants whilst discussion was in process has assisted in achieving confirmability of the data. Data verification was conducted with active participation of 39 nominal group participants whilst the nominal group discussion was in process. The notes of the nominal groups were kept in a lockable cupboard to limit accessibility to unauthorised persons and will only be made available for future reference, scrutiny and confirmation. Inquiry audits were useful in establishing dependability and confirmability (Botma et al., 2010:292). A research supervisor trained in qualitative research followed the path of the researcher to see how the themes and interpretations were arrived at to maintain objectivity and neutrality of the study. 2.4.9.4 Dependability Dependability is a process to determine the quality of data and it refers to the evidence that, if the study were to be repeated with the same or similar participants in the same context, its findings would be similar (Babbie& Mouton, 2007:278 & Botma et al., 2010:292). Dependability was enhanced by conducting an exploratory interview to determine whether the research question was clear before the researcher proceeded to the main study. The researcher used the same research question in all of the four nominal groups. The procedure of the nominal group process was clear and concise, safeguarding against any biases (De Vos et al., 2011:503). The nominal group participants clarified their information whilst the nominal group discussion was in process. Participants clarified the statements to ensure uniform understanding and minimized misinterpretations. The data gathering methods, analysis and the findings of the study were described to enhance dependability of the study. Ethical considerations are discussed below in order to address the democratic rights of the participants. 2.5 ETHICAL CONSIDERATIONS Ethics is a system of moral values that is concerned with the degree to which the research procedures comply with professional, legal and social obligations to the study participants as stated by Polit and Beck (2008:753). All those who engage in the research studies are to adhere to the codes of ethics responding to protection of 40 human rights. The Nuremberg code was the first to address human injustices that occurred during the Second World War. These injustices amongst others included soldiers being subjected to research without their consent, and their being subjected to physical harm and psychological discomfort (Neuman, 2003:129; Uys &Basson, 2004:97; Brink, 2008:30 & Streubert & Carpenter, 2011:60). In South Africa the Democratic Nursing Organization of South Africa and South African Medical Research Council have guidelines governing research studies. These guidelines were set from the Nuremberg Code (Brink, 2008:30-31). Before commencing the study, ethical approval was sought from the Ethical Committee of the Faculty of Health Sciences of the University of the Free State. Permission to conduct the study within primary health care clinics in Dikgatlong Sub- district was sought from the Department of Health in the Northern Cape (See Addendum A attached). The study was guided by the three primary ethical principles on which standards of ethical conduct in research should be based, as was expressed in the Belmont report. The Belmont report entrenches the principles of beneficence, respect for human dignity and justice (Burns & Grove, 2009:187-188; Joubert & Ehrlich, 2007:30-36 & Streubert & Carpenter, 2011:60). The principle of beneficence will be addressed. 2.5.1 BENEFICENCE The beneficence principle is concerned with the well being of the participants in the research study. Beneficence addresses the issue of protecting the participants from undue harm and discomfort. The participants were protected from physical, psychological, emotional, spiritual, economical and social harm (Muller, 2006:67; Brink, 2008:32-33 & De Vos et al., 2011:116). See Addendum B reflecting the informed consent form participants signed before partaking in the research. The credible facilitator was used to conduct the nominal group technique and handled the participants with respect. The facilitator was aware of the sensitivity of the topic, so no undue questions were asked to make the participants uncomfortable.The facilitator did not report any harm suffered by participants during the nominal group discussion because he was sensitive towards participants` reactions. 41 The participants` right to protection from exploitation was acknowledged by the researcher. Participants were assured verbally and through the consent form that the information they provided during the research study would not be used against them (Neuman, 2003:123 & Polit & Beck, 2006:88). The facilitator was very cautious not to put participants onto an undue stress by avoiding asking too personal information other than the one demanded by the study. The facilitator was sensitive towards possible threat that the older men being the leaders of the community would feel, being requested to come up with recommendations to improve condom use. Confidentiality is concerned with the protection of study participants so that the information shared is not publicly revealed (Uys & Basson, 2004:98 & Polit & Beck, 2008:750). All the responses of the participants during the discussions were handled privately. The results of the study will be presented, without breaking the confidentiality pledged to the participants. Privacy is concerned with the individuals` right to share or withhold personal information regarding attitudes, beliefs, opinions and records (Botma et al., 2010:17- 19 & Burns & Grove 2009:194-195). Unauthorized access to the data was prevented by locking the cupboard at all times. The participants were informed about the results of the study.The second principle to be discussed is that of respect for human dignity. 2.5.2 RESPECT FOR HUMAN DIGNITY The principle of respect for human dignity was considered by addressing participants` right to privacy, right to full disclosure, self determination and informed consent before inclusion to the study. After comprehensive explanation of the research study to the prospective participants, the individuals had the opportunity to decide independently whether to partake or not (South Africa, Department of Health, 2002:5-6 & Brink, 2008:32). Anonymity implies namelessness. The researcher kept the identity of the participants` private. During the nominal group discussions no name of any participant was mentioned. The information or data collected was not attached to any 42 participants. Only codes were used thus concealing the identity of the participants (Neuman, 2003:126 & Brink, 2008:34). Right to full disclosure means that the researcher had explicitly explained the purposeand nature of the study to the participants. If at some stage the participants disagree with the researcher`s goal or intent of the study, they had the right to decline participation (Burns & Grove, 2009:201). The researcher was obligated to provide the participants with relevant and comprehensive information when obtaining informed consent (Streubert & Carpenter, 2011:61). The researcher had to be careful not to deceive participants by misrepresenting research purposes and deliberately withholding information in order to ensure participation that would have been refused (De Vos, 2002:66; Stommel & Wills, 2004:380-381 & Streubert & Carpenter, 2011:61). The nature of this study was not complicated, so deception was not a problem. Right to self determination implies autonomy (Muller, 2006:67; Brink, 2008:32& Burns & Grove, 2009:189-190). This means that the participants were allowed to excise their democratic right, to decide whether or not to participate in the research study. Participants had the right to withdraw from the study at any time. The researcher and the facilitator did not apply any force on the participants to partake in the study. Informed consent is an ongoing process in which a participant is informed about the facts of research study, so that the participant can decide whether or not to partake in the study. Informed consent is a necessary requirement for ethical and scientific research. The participants were provided with all the information regarding the study. The information was given in a simple and clear style. This information was provided in the participants` home language, Afrikaans for better understanding. Participants were given opportunity to ask questions for clarity (Refer to Addendum B). Participants were free to decide whether or not to participate without coercion, undue influence or incentives (South Africa, Department of Health, 2002:5-6 & De Vos, 2011:117). 43 Debriefing was very important to be conducted with the prospective participants, to enlighten them how important their contribution would be in the study (Treece, 1986:132-133; Leedy & Ormrod, 2010:10 & Streubert & Carpenter, 2011:61). The facilitator did enlighten participants on the importance of their contribution and thanked them for their contribution. The principle of justice will be discussed below. 2.5.3 JUSTICE The principle of justice implies fairness. The researcher treated and selected the participants who met the set criteria on a fair basis (Stommel & Wills, 2004:382-383 & Muller, 2006:67). The younger men and older men who were selected were directly relevant to the research topic. The participants were privately recruited by the researcher. Informed consent was obtained from the participants prior to the nominal group discussions. The participants were not discriminated against on the basis of colour or social background. No incentives were promised to the participants in order to convince them to participate in the study. The facilitator and the researcher were punctual to times agreed on with the participants (Brink, 2008:33). No information was withheld from the participants. The participants had the right to ask questions regarding the study and were entitled to full disclosure of information regarding the study. No minor or mentally incapacitated participants were selected. The legal age to sign informed consent form in South Africa is 18 years of age, which was adhered to in this study. 2.5.4 CONDUCT OF THE RESEARCHER Brink (2008:30) states that the researcher must conduct the research project in an ethical manner. The researcher had undergone research training by studying the modules dealing with applied research project in the University of the Free State. That was to enhance the competence, honesty, diligence and integrity of the researcher. To add to the accurate recording and analysis of the nominal group technique the researcher worked under the guidance of an experienced supervisor (Burns & Grove, 2009:507). This experienced supervisor is a professional researcher who 44 continually supervises postgraduate students. Further assistance and suggestions were granted by a team of nominal group technique experts during the process of data analysis at the School of Nursing, University of the Free State. 2.6 CONCLUSIONS The researcher had discussed the research qualitative design which was used. The analysis unit consisted of two groups of men within Dikgatlong sub-district. The researcher further made use of the nominal group technique as research technique in the study. Ethical considerations and limitations of the study were acknowledged. In chapter 3 data findings will be discussed. 45 CHAPTER THREE DISCUSSION OF RESEARCH FINDINGS 3.1 INTRODUCTION The research methodology had been discussed in Chapter two. This chapter will be discussing the research findings of four nominal group discussions regarding recommendations made by the participants to improve condom use by men in the Dikgatlong Sub-district. The combined research findings of the nominal group data and analysis will be described later in this chapter, supported by relevant literature. This combined research findings will be discussed following the ranking order of the various categories of data. The highest ranked category will be discussed followed by the lower ranking categories.The discussion will first focus on the demographic data of nominal group participants. A brief overview of research data by the participants will follow and then a discussion of the identified categories and their themes and research results. 3.2 DEMOGRAPHIC DATA OF NOMINAL GROUP PARTICIPANTS Data of this study was collected through nominal group discussions with participants who were conveniently selected from Dikgatlong Sub district. The demographic data of the participants are depicted in Table 3.1. A breakdown of participants` highest educational level, occupational status and race is given. The specific groups held with the older and younger men are depicted as Older men 1 and Older men 2.The same was reflected with the younger men, depicted as Younger men 1 and Younger men 2. 46 Table 3.1: Demographic data of nominal group participants. Characteristics Nominal Group Participants Older Men 1 Young Men 1 Older Men 2 Young Men 2 (N=5) (N=8) (N=6) (N=10) Highest educational level Primary school 4 1 3 0 Secondary school 1 7 2 10 Tertiary level 0 0 1 0 Occupational status Employed 5 3 2 3 Unemployed 0 1 3 5 Pensioners 0 0 1 0 Scholars 0 4 0 2 Race Coloured 4 6 5 3 Blacks 1 2 1 7 Asians 0 0 0 0 Whites 0 0 0 0 Young men: age 18-24 years Older men: 49 years and above All participants were literate, with seven of the 11 participants in the 49 years and above age group having at least a primary school education. One member in this group was a minister of religion with tertiary education. The majority of younger men between the ages of 18-24 were scholars with a secondary school education. Among the older men seven of the 11 older men were employed and one was a pensioner. Of the younger men six were employed, six were still scholars and the other six were unemployed. 47 In the Northern Cape Province there are four races, namely black and coloured with whites and Asians in the minority. The blacks and coloureds were well represented in the study. No white or Asians participated in this study. As has been stated, Afrikaans is the language most commonly spoken by all races. The general overview of research data will be discussed below. 3.3 GENERAL OVERVIEW OF RESEARCH DATA Data of this study was collected through the nominal group discussions. In chapter two the collection and analysis of data according to the steps of Van Breda were discussed (Refer Addendum D).Four nominal group discussions were conducted, two with the older men and two with the young men. Participants were generally well informed about condoms and their benefits. The responses of the participants of the four nominal groups were captured on the computer as Step one of Van Breda and are attached as Addendum E 1-E 4. What was interesting was the fact that all the nominal groups emphasized the importance of manufacturing condoms in different sizes namely small, medium and large. All participants believed the condoms must be thicker to ensure that no virus will pass through the wall of the condoms. Group statements generally agreed that the Department of Health had a pivotal role to play in promoting condom use and empowering the consumers by organizing workshops. The participants did not take responsibility for practising safer sexual behaviour themselves. However, there were also marked differences amongst the various groups. Young men spoke freely about the use of condoms. Young men felt strongly that the parents should be involved in educating the youth about sex, including the use of condoms. The older men were shy, hence the facilitator had to be sensitive towards older men in order to assist them with their possible feeling of embarrassment. Step two of Van Breda which is concerned with identification of the Top five statements is also reflected in Addendum E1-E4. The statements are written in bold in Afrikaans, with an English translation in brackets. Whereas the analysis of data from each of the four nominal groups are reflected in Addendum F as Step three of 48 Van Breda. Statements are directly quoted and presented as they were uttered by participants and reflected in Table 3.2 below. Combined research findings are reflected as per identified category, theme, statement and priority ranking in Table 3.2. Bold numbers reflected under group and priority ranking are the ranking scores of the concerned group. Sentences written in italic reflect clarification received from participants during the nominal group discussions. Table 3.2: Combined research findings reflected per category, theme, statement and priority ranking received. CATEGORY THEME STATEMENT GROUP & PRIORITY RANKING Client Content Mans moet meer ingelig word oor die gebruik Older men (1)*1 Education van die kondoom. (Men must be more informed about the use of condoms). Meer verduidelik oor hoe lank die kondoom Older men (1) kan hou, meer oor die vervaldatum.(Expiry date and safe keeping of condoms should be emphasized). Die jeug moet weet hoe om die kondoom te Young men (1)*4 gebruik want dis hulle verantwoor-delikheid om dit te gebruik.(The youth must know how to use condoms as it is their responsibility). Jeug moet meer ingelig word dat die gebruik Young men (1) van kondome nie net is om HIV/AIDS te verhoed, maar ook onbeplande swangerskappe en infeksies te voorkom. (The youth must be taught that condoms not only prevent HIV/AIDS but can also prevent unplanned pregnancies and other infections). Mans moet geleer word om kondome te Older men (2) gebruik, alhoewel hulle gesirkumseer is. (Circumcised men must be encouraged to use condoms). Departement van Gesondheid moet die mans Young men (2) wat sirkumsisie ondergaan het en die gemeenskap leer om kondome te gebruik. Want mans wat sirkumsisie ondergaan het, het nie minder risiko om die virus te kry nie.(The Department of Health must teach circumcised men and the community to use condoms). Client Content Misgissings moet aangespreek word met die Older men (2) Education algemene publiek aangaande kondoom gebruik.(Myths regarding condom use ought to be addressed in general public). 49 CATEGORY THEME STATEMENT GROUP & PRIORITY RANKING Strategy Plaaslike statistieke van HIV/AIDS in Older men (2)*4 Dikgatlong moet bekend gestel word aan die gemeenskap. Sodat hulle die verspreiding kan bekamp en dan begin om kondomete gebruik. (Local statistics of HIV/AIDS in the Dikgatlong sub district should be published to the community). Inligtingspapiere/kennisgewings moet Older men (1)*4 uitgedeel word by die klinieke en dokters om te sê hoekom moet die kondoom gebruik word.(Information leaflets/ notices must be distributed from the clinics and doctors`consulting rooms about condom use). Die Departement van Gesondheid moet altyd Older men (1) die werkswinkels hou oor die gebruik van die kondoom.(The Department of Health should organize workshops regarding condom use). Meer gemeenskapsprojekte moet ingestel Older men (1) word om kondoomgebruik aan te moedig.(More community projects should be instituted on how to use condoms). Departement van Gesondheid moet die Young men (1)*2 werkswinkel hou om die kondoom te gebruik. (The Department of Health should organize workshops of how to use condoms). NGO`s (non governmental organizations) moet Young men (1) die plakkaat maak waar die kondome beskikbaar is.(NGO`s must have posters showing where condoms could be accessed). Client Strategy Departement van Gesondheid moet huis tot Older men (2)*2 Education huis besoeke doen, mans, vroue en families moet bewus gemaak word van die belangrikheid van kondoom. (The Department of Health should launch door to door visits to make men and women aware of the importance of condoms). Jeugkomitee moet gestig word om die jeug Older men (2)*3 te leer om kondome te gebruik. Elke maand moet `n “talk show” gehou word. (Youth committees should be established to teach the youth how to use condoms). Werkswinkels moet gehou word om Older men (2)*3 kondoom gebruik te bevorder.(Workshops should be organized to promote condom use). Gereelde saamtrek te hou om die gebruik Older men (2) van kondoom te verduidelik, hoe gebruik jy dit.en die belangrikheid daarvan. (Regular meetings must be convened to explain how to use condoms). 50 CATEGORY THEME STATEMENT GROUP & PRIORITY RANKING Department van Gesondheid moet jeug Young men (2)*2 gebruik om by die skole te leer oor die gebruik van kondome, met dramas, spele, T- hemde. (The Department of Health must teach the youth about the use of condoms by using dramas, sketches and T-shirts). Departement van Gesondheid moet meer Young men (2)*4 werkswinkels hou oor die gebruik van kondome en HIV/AIDS.(More workshops must be organized by the Department of Health regarding condom use and HIV/AIDS). Client Strategy Die regering moet musiekante/sangers Young men (2) Education aanmoedig om liedjies oor die kondoomgebruik saam te stel. (The government should encourage musician to compose songs about condom use). Departement van Gesondheid moet begin Young men (2) met ‘n deur-tot-deur veldtog oor die gebruik van kondome.(The Department of Health must launch door to door campaigns regarding condom use). Departement van Gesondheid tesame met Young men (2) ander NGO’s soos Red Cross, Love Life, ens. moet meer effektiewe programme opstel wat mans gaan in kennis stel oor die gebruik van kondome. (The Department of Health in collaboration with NGO`s like Red Cross, Love Life should come up with effective programs that will encourage men to use condoms). Departement van Gesondheid moet meer Young men (2) bewusmakingsveldtogte oor die gebruik van kondome hou.(Condom use awareness campaigns must be organized by the Department of Health). Departement van Gesondheid moet meer Young men (2) bewusmakingsveldtogte oor die gebruik van kondome hou. (The Department of Heath ought to encourage youth to use condoms regularly). Responsi- Departement van Gesondheid moet die Young men (1)*2 bility gevaar van die nie-gebruik van kondome beklemtoon.(The Department of Health should emphasize the risk of not using condoms). Client Responsi- Klein areas in die Noord Kaap moet meer Older men (1)*4 Education bility geleer word oor die gebruik van die kondoom, deur die Departement van Gesondheid. (Rural areas in the Northern Cape must be given information about the importance of condom use). 51 CATEGORY THEME STATEMENT GROUP & PRIORITY RANKING Mans moet geleer word hoe om die kondoom Older men (1) te gebruik deur gesondheidspersoneel.(Staff members of the Department of Health should give men information on how to use condoms). Die ouers moet altyd die jong mans vertel Young men (1)*5 oor die belangrikheid van kondoom gebruik.(Parents ought to tell young men about the importance of condom use all the time). Opvoeding moet begin by die skole dat dit Older men (2)*1 belangrik is om die kondome te gebruik met samewerking van gemeenskapsgebaseerde organisasies, kerke, besighede, ens.(Teaching ought to begin at schools about the importance of condom use amongst the youth, home based care organizations, churches, businesses etc should play a part). Departement van Kuns en Sport moet ook Older men (2)*5 help om sport, ontspanningsgeriewe op te rig vir die jeug om hulle besig te hou en om kondome te gebruik.(The Department of Arts and Sport should help to organize sport and recreation for youth to keep them busy). Client Responsi- Departement van Gesondheid moet die skole Young men (2)*1 education bility van gesondheid begin, waar jeug van jonger jare kan leer oor kondome gebruik. En HIV/AIDS, gesondheidsopvoeding, STI`s (sexually transmitted infections). (The Department of Health should start with school health, whereby younger scholars are taught about the use of condoms). Die leiers moet betrokke raak by die Young men (2) kondome gebruik en die opvoeding daarvan.Rolmodelle ook, polisie, nurses, educators, dokters.(Community leaders ought to be involved to encourage condom usage). Target Departement van Gesondheid moet ook die Young men (2)*3 group ouers leer oor die gebruik van die kondoom. Die ouers moet vry wees om te praat met die kinders oor die gebruik van die kondoom.(The Department of Health should teach the parents about the use of condoms, and must not be ashamed to talk to children). Jong mense moet altyd die kondoom in hulle Young men (1) sakke hê. (Young men ought to have condoms in their pockets all the time). Department van Gesondheid moet die jeug Young men (2) meer aanmoedig om die kondoom te gebruik. Gereeld,dag en nag. (The Department of Health ought to encourage youth to use condoms regularly). 52 CATEGORY THEME STATEMENT GROUP & PRIORITY RANKING As mans dronk is dan slaap hulle sonder Older men (2) kondome, hulle moet geleer word om kondome te gebruikin enige situasie.(When men are drunk they are inclined not to use condoms, must be advised to use condoms). Client Target Mans wat meer kondome gebruik moet ander Older men (1)*4 education group mans wat nie kondoom gebruik nie advies gee. (Men who use condoms must give advice to those who are not using condoms). Leiers van gemeenskap moet ook geleer Older men (2) word oor die belangrikheid van kondome.Want die gemeenskap glo en luister na hulle.(Community leaders must be taught about the importance of condoms). Quality Manufac- Kondome moet small, medium, large en extra Older men (1)*2 assurance turing large gemaak word om almal te akkommodeer. (Condoms must be made in small, medium and large sizes in order to accommodate all). Die kondome moet small, medium, large en Young men (1)*4 extra large gemaak word. (Condoms should be available in different sizes, small, medium and large). Instruksies moet geplaas word in elke Older men (1)*5 kondoom pakkie. Om die manne meer inligting te gee hoe om die kondoom te gebruik. (Instructions should be enclosed in the condom packets explaining how to use condoms). Die kondoom van die Departement van Older men (1) Gesondheid moet dikker gemaak word om die risiko van skeure te voorkom.(The Department of Health should make the condoms thicker to minimize the risk of tears). Die Departement van Gesondheid moet die Young men (1)*3 Choice kondoom wat nou beskikbaar is uitwis, aangesien ditte olierige ruik en nie sterk genoeg is nie. (The Department of Health must get rid of Choice condoms because they have an oily smell and is not strong enough). Quality Manufac- Kondome moet meer sterker gemaak Young men (1) assurance turing word.Sodat hulle nie moet skeur nie.(Condoms should be made stronger so as not to tear easily). Die kondome moet gemaak word met Young men (2)*3 verskillende soorte kleure en reuke. (Condoms must be made with different colours and fragrance). 53 CATEGORY THEME STATEMENT GROUP & PRIORITY RANKING Kondome moet gemaak word met groottes: Young men (2) small, medium en large. Want mans van jonger jare het al begin met seks eksperimenteer. (Condoms must be made in different sizes, small medium and large to accommodate young men as they have already started sexual activities). Kondome moet sterker gemaak Young men (2) word.(Condoms must be made stronger). Cost Departement van Gesondheid moet Young men (1)*2 voorspraak maak vir die goedkoopste pryse vir die kondome by die winkels. (The Department of Health should advocate for lower price of condoms in the shops). Attitude Change Mans wat ouer is, moet gemotiveer word om Older men (1)*3 die kondoom te gebruik, want ouer mans glo nie aan die gebruik van die kondoom nie. (Older men must be motivated to use condoms because they do not believe in condom use). Mans in die Noord Kaap moet meer ernstig Older men (1)*3 raak oor die gebruik van die kondoom. (Men in the Northern Cape must be serious about condom use). Attitude Change Maak die gebruik van die kondoom `n Young men (1)*1 tradisie onder swart mense.Want tradisie is baie belangrik by hulle. (Black people should practice condom use as tradition). Jeug moet begin met gedagte verandering Young men (2) oor die gereelde gebruik van kondome. (The Youth must start to change their mind and use condoms consistently). Mans mense moet bewus gemaak word as Older men (2) vrou se nee, nie sonder maar met `n kondoom. (Men must be made to respect the women’s wishes, and use condoms if requested by women to use them). Communi- Interper- Mans moet meer praat oor kondoom gebruik Older men (1)*1 cation sonal en nie skaam wees oor die kondoom nie. (Men must talk more about condom use). Families moet vry wees om oor kondoom Older men (2) gebruik te praat. (Families are not supposed to be ashamed of talking about the use of condoms). Availability Sites Departement van Gesondheid moet elke Young men (2)*5 maand pakke van kondome aflewer by elke familie. Kontrolleer hoeveel jong mense is daar in die familie (The Department of Health should deliver packets of condoms to each family. They have to be aware of how many young people are in a family). 54 CATEGORY THEME STATEMENT GROUP & PRIORITY RANKING Kondome moet beskikbaar wees by die Older men (1)*5 tarvens, sjebeens, kerke en taxi’s. (Condoms should be available in the tarvens, shebeens, churches and taxi ranks). Availability Sites Mans moet meer aangemoedig word oor die Older men (1) gebruik van die kondoom en beskikbaar wees in die werk situasie/omgewing. (Men should be encouraged to use condoms and must be available in work environment). Stel meer die kondoom beskikbaar in Young men (1)*4 plaaslike gebiede. (More condoms must be available in the rural/local areas). Kondoom en plakkate wat mense bewus Older men (2) maak moet gegee word in die drankplekke. (Posters raising awareness of condom use must be displayed in the shebeens). Step three of Van Breda was applied through content analysis and categorization of the individual statements which were collected during the nominal group discussions. These statements were put together according to the identified categories and themes. Step four of Van Breda was applied through confirmation of analyzed data into categories and themes which were verified by two experts in qualitative research from the University of the Free State. See Addendum F reflecting the analysed data of the four nominal groups divided into categories, themes, statements, scores, average and Top five ranking. Addendum Freflects step three and four of van Breda as followed by the researcher. The analysis of combined multiple nominal group data was further followed through in Step five of Van Breda. This step led to the calculation of combined ranks for the four nominal groups as depicted in Addendum G. 3.4 RESEARCH RESULTS In Step five a number of sub-steps to determine the relative importance of each theme to all groups were followed. That resulted in a consolidated and prioritized list of categories and themes (Van Breda, 2005:7). 55 The discussion of data will therefore follow the ranking order of the various categories as in Addendum G. The order of discussion thus being the category of:  Client education,  Quality assurance,  Attitudes,  Communication and  Availability Van Breda (2005:10) has emphasized that the more statements are made within a specific theme, the more important that theme is likely to be. That is the case in the theme “Content” that resorts under the category “Client education”. This category received the most (38) responses of all the categories, even though not all responses received priority ranking. 3.4.1 CATEGORY: CLIENT EDUCATION Client education is the process of providing verbal or written material to the client to improve understanding and prevent complications (South Africa, Department of Health, 2011a:107). Client education offers instructions about behaviours and activities to assist the client. Provision of client education can improve long term outcomes leading to better coping and decision making skills (Jernigan, 2009: online). Health education concentrates on wellness, prevention and health promotion, aiming at changing and improving societal health behaviours. Successful client education is the result of comprehensive, proven solutions that are thoughtfully instituted by the health care providers and integrated into the client health care delivery system. The primary role of the health care provider is to better help clients` progress and facilitates the effect of the needed life modification for example the consistent use of condoms in each sexual encounter (Jernigan, 2009: online). The advantages of client education according to Dreeben (2010:5) are that it:  Enables clients to assume better responsibility for their own health care;  Provides clients opportunities to choose healthier lifestyles; 56  Promotes client-centred care and results in clients` active involvement in their plan of care;  Ensures continuity of care that is always to have supplies of condoms at all times and  Attracts clients to the health care providers and increases clients` satisfaction. During client education client`s cultural traditions, personal preferences, values and family situations and lifestyles are considered. Through education clients learn to accept joint responsibility in respect of their health, including protected sexual behavior (Booyens, 1999:213). Education will assist clients to work through their feelings. Education regarding condom use should be given without feeling shy or embarrassed (Van Dyk, 2012:178). In the research study of Weinstein, Walsh and Ward (2008: 214) there was indication of the adolescents who displayed less traditional attitudes towards gender issues and discussed more sexual issues with their partners, and so they contributed more too effective sexual communication. That alone was ushering in assertiveness regarding safe sexual practice. Consequently sexual health knowledge may encourage communication skills, which would lead to confidence and negotiation of safe sexual practice. The clients should play a major role in determining their recommendations to improving condom use. Clients’ involvement will lead to a better quality of life, by being free of sexual infections when employing safe sexual practice behaviour. The strategies to deal with barriers to condom usage were dealt with by the Department of Health. The South African Health Department has recently introduced basic training for community health workers who will deal with client education in order to address health issues adequately (South Africa, Department of Health, 2011a:38-46). This encompasses the destigmatization of condom use and support healthy behaviours. Whitaker, Miller, May and Levin (1999:117) reported norms that prohibiting openness can hinder discussions about sexual behaviours and could be the obstacle to sexuality education and the dissemination of information about sex. The importance of community leaders cannot be overlooked. 57 Barriers to condom use must be highlighted to make people overcome them (Eisenberg, Bernat, Bearinger & Resnick, 2009:417). Myths regarding condom use should be addressed through the involvement of the traditional healers and community leaders. According to Van Dyk (2012:229) traditional healers are effective agents of changing community behaviour owing to the authority they manifest. Participants in the study did not view traditional healers as important, rather the emphasis was on the responsibility of the Department of Health to conduct workshops. Education would assist groups at risk to understand the necessity of using condoms consistently and correctly. The following themes formed part of client education:  Content;  Strategy;  Target group and  Responsibility. For client education to be successful the content need to be determined. The clients did identify content they felt need to form part of a client education strategy. 3.4.1.1 Theme one: Content Content refers to the facts, concepts, theories, principles, laws, skills and the attitudes clients have to learn (Uys & Gwele, 2005:53).Content was concerned with the aspects and details of issues to be discussed regarding recommendations to improve condom use. Content would address the requirements of the clients. According to Booyens (1999:213) content would match the level of understanding of the clients, be logical, systematic and relevant to the current situation. In order for content to be successful its criteria would be carefully selected. The following criteria would be borne in mind:  Validity and meaningfulness would reflect current scientific thinking and evidence based practice,  Relevance to social context would be built on actual realities regarding social, political, economic, occupational, judicial and geographic aspects, and 58  Balance between depth and breadth, concerned with decision would be made regarding the volume of aspects to be covered and how deep the content would be (Uys & Gwele, 2005:53). Once content selection had been effected, based on the realities of circumstances then the clients would start to reap the advantages thereof. Those advantages would be to assist the client to make responsible decisions regarding his condition for example decision to use condom consistently, encourage the client to accept joint responsibility because of knowledge he already acquired and, assist improving the quality of life and reducing complications (Booyens, 1999:213 & South Africa, Department of Health, 2003:44). The content would cover sex education with the following aspects, anatomy of the human body, reproductive health issues, different sexual orientations or abstinence focused. Information regarding carrying, storage, expiry dates, correct use and disposal of used condoms were necessary to be addressed to ensure safety to the children (Versteeg & Murray, 2008:87; UNAIDS, 2010:103 & Van Dyk, 2012:169- 170). At school the subject of condom use, HIV/AIDS could be presented as Life Orientation not as an isolated subject (Castle & Kiggundu, 2007:56; Han & Bennish, 2009: 27; Francis, 2010:316 & Peu, Napoles, Wenhold, Mostert- Wentzel & Seane, 2010:39). Young men agreed, stating: “Die jeug moet weet hoe om die kondome te gebruik want dis hulle verantwoordelikheid om te gebruik” (The youth must know how to use condoms as it is their responsibility) However, only knowing about condoms is not good enough. The quality of condoms must also not be compromised. Condoms must be kept at room temperature and not be exposed to sunlight to avoid premature condom breakage during sexual intercourse, which might lead to sexual transmission of infections and unwanted pregnancies (UNAIDS, 2010:103 & Van Dyk, 2012:169-170). The initiative of undergoing any training on how condoms should be used correctly as well as the avoidance of spillage of semen during sexual intercoursebe taken by clients (Flannigan, 2007:55). Apart from quality assurance health care professionals and 59 community workers should put concerted effort to demonstrate the proper method of using condoms, in order to avoid tearing of condoms during sexual intercourse. Proper disposal of the used condoms to avoid children`s access to contaminated condoms that would infect them should be emphasized (South Africa, Department of Health, 2003:49 & Han & Bennish, 2009:27). Older men highlighted the importance of teaching youth regarding the use of condoms: “Meer verduidelik oor hoe lank die kondoom kan hou, meer oor die vervaldatum” (Expiry date and safe keeping of condoms should be emphasized). Evans (2008:192) states that teaching concerning HIV/AIDS should address the following aspects namely to:  increase awareness regarding HIV/AIDS and how to prevent it;  encourage and promote testing after counselling;  address the role that stigma and discrimination play in spreading the disease;  encourage dialogue between partners and health care providers concerning sexual health issues and  promote safer sexual behaviour. Young men and older men felt that: “Departement van Gesondheid moet mans wat sirkumsisie ondergaan het en die gemeenskap leer om kondome te gebruik.”Want mans wat sirkumsisie gedoen het, het nie minder risiko om nie virus te kry nie” (Department of Health must teach circumcised men and the community to use condoms). USAID (2009:2) states the importance of all men, whether circumcised or not to reduce their risk of acquiring HIV by limiting number of sexual partners, using condoms consistently and correctly. There is a tendency of men and their partners after circumcision of relaxing their attitudes toward safer sex. Both circumcised and uncircumcised men are at risk of acquiring HIV if not practising protected sex or even infecting their sexual partners. 60 Young men and older men should be in a position to negotiate for condom use in order to protect themselves from contracting STI`s, HIV and AIDS. Lack of accurate information regarding the practice of condomization should be addressed as need arises. The motive will be to increase the interest of young and older men to use condoms without any doubts. Weinstein et al (2008:220) found in their study that having more knowledge regarding sex education did not enhance condom use elucidating that sexual behaviour and knowledge could be hard to pin down. Baker, Leon and Collins (2010:1321) in their study argued that the individuals with education are almost more likely to use condoms than the ones who were not enlightened. About 35 research studies were conducted by World Health Organization on HIV/AIDS and found no evidence that exposure to sex education led to earlier or increased sex activity in young people (Wellings, Wadsworth, Johnson, Field, Whitaker & Field, 1995:420). The sexually educated will be able to make informed decision to engage in protected sexual behavior knowing the advantages of using condoms consistently and correctly. Accurate information will also address any myths among the community as older men emphasized. Therefore a strategy should be put in place to address successfully protected sexual behaviours. 3.4.1.2 Theme two: Strategy Strategy is a declaration of intent, providing the framework for guiding decisions and actions towards a predetermined goal. This term originates from the Greek word strategia meaning generalship. It is clear that the concept was borrowed from the military. However, it was adapted for business meaning to plan. According to George Steiner (1997:12 online) strategy includes the following:  What top management wants to achieve in the organization (objectives);  Addressing the basic directional decisions committed to the visions and mission statement of the organization;  Stipulating steps necessary leading to important actions to realize these directions (action plan) and  Offers answers to questions like what will the ends sought and how will it be achieved. 61 Pratt and Bowman (2008: online) proposed a strategy that will reduce the environmental conditions that support negative behaviours, and increase the conditions that support positive or desired behaviours. Environmental conditions can illicit positive behaviors for example distributing pamphlets, displaying bill boards that highlight the advantages of using male condoms consistently and correctly, branding of taxis by displaying messages regarding condoms and where they can be accessed. Favourable attitudes should be displayed by health care professionals by educating the community regarding the burning health issues. Negative attitudes by health care providers can be a barrier to condom use (Versteeg & Murray, 2008:86). Participants did not mention any negative attitudes displayed by health professionals. Participants of the nominal groups also felt the necessity to use the influence a specific environment can create: “Inligtings papiere / kennisgewings moet uitgedeel word by die klinieke en dokters om te se hoekom moet die kondoom gebruik word” (Information leaflets/ notices must be distributed at the clinics and doctors explaining why condoms should be used). Contemporary health issues are addressed through televisions, radios, newspapers, life skills and education packages. Media is currently used to play dramas in programs like Soul City by South African Broadcasting Cooperation. This strategy is used to reach communities in rural areas as well (South Africa, Department of Health, 2001:26-27; UNICEF, 2005:9; Akinsola & Mulaudzi, 2009:213 & Van Dyk, 2012:150). Participants proposed that such dramas be conducted much closer to home: ‘Departement van Gesondheid moet jeug gebruik om by die skole te leer oor die gebruik van kondome, met dramas, spele en T-hemde’(Department of Health must teach the youth about the use of condoms by using dramas, sketches and T- shirts). Apart from dramas, door to door health campaign was suggested by the participants whereby life demonstration of condom use could be executed by the community health workers. The Department of Health has recently trained community health 62 workers and have absorbed them permanently into the health system. These community health workers will be instrumental in orchestrating condom use program in the Dikgatlong community. Shisana et al (2008:xviii) showed that more than a third of adults 50 years and above are not reached by any national program, and adults aged 25-49 more than one in nine have exposure to HIV/AIDS communication programs. Young men suggested that: “Departement van Gesondheid tesame met ander NGO`s soos Red Cross, Love Life, ens. Moet meer effektiewe programme opstel wat mans gaan in kennis stel oor gebruik van kondome” (Department of Health in collaboration with NGO`s like Red Cross, Love Life should come up with effective programs that will encourage men to use condoms). Love Life is a youth focused HIV prevention initiative, by employing a holistic approach to youth development and behavioural change that motivates adolescents to take charge of their lives for brighter future in South Africa. Love Life is an active youth organization in the Dikgatlong Sub-district. According to the research study done by Evans (2008:193) in the United States of America Love Life campaigns were instrumental and effective in reducing HIV by half, STI`s and the incidence of teenage pregnancies. Love Life promoted a lifestyle of choice ranging from abstinence, delayed initiation of sexual activity, fewer partners among already sexual active teenagers and condom use. These NGO`s should also distribute condoms in the strategic points like in taverns, shebeens, night clubs and fuel stations. However, health awareness campaigns should be regularly organized in consultation with the community to determine their health needs. Young men and older men emphasized the importance of conducting workshops: “Departement van Gesondheid moet altyd die werkswinkels hou oor die gebruik van die kondoom” (Department of Health should organize workshops regarding condom use). 63 Support groups of men should be established where current issues affecting men could be discussed. Evening sessions of workshops could be organized to accommodate men who were employed so that they would not be left out. That would also encourage those who were employed to play an active role in the activities of the community (Van Dyk, 2012:152-153). Issues like condom use, alcoholism as a problem could be discussed in these support groups meeting. These support groups would act as platforms, whereby individuals would communicate their suggestions and could even start community development projects (Van Dyk, 2012:153). Singers would be encouraged to compose songs that would bring the message across of how to use condoms (Van Dyk, 2012:227). This would encourage the community to use condoms when they got the message from their idols. Recently the Northern Cape Department have branded taxis with messages identifying the symptoms of pulmonary Tuberculosis Bacilli and encouraging more people to go to the primary health clinics to be tested for TB (Baitsiwe, 2011: Personal communication). Similar messages concerning condom use could be disseminated to arouse the interest of the people. Older men additionally proposed: “Plaaslike statistieke van HIV/AIDS in Dikgatlong moet bekend gestel word aan die gemeenskap.Sodat hulle die verspreiding kan bekamp en dan begin om kondome te gebruik” (Local statistics of HIV/AIDS in Dikgatlong sub-district should be published to the community). Local HIV/AIDS statistics should be made available to the community on a regular basis. This would emphasize the role condom usage has on limiting the spread of HIV/AIDS. Men as the target group are the ones to be convinced and encouraged to use condoms. 64 3.4.1.3 Theme three: Target group Target audiences are the groups or individuals at the local, national, or international level with whom you are seeking to develop a synergy and to share information. Each target group has specific characteristics and faced with different problems or situations which would need a specific communication strategy. Shisana et al (2008:44-45) identified older men and young men as the target groups who had problems of not using male condoms. The importance of defining a target group cannot be overemphasized. Knowledge, beliefs and customs often differ from one group to another. For this reason the older men and the young men as target groups were not mixed, but divided into separate nominal group discussions. That was to encourage each group of participants to express their views without any restrictions being placed on groups. In order for parents to be able to equip their children about prevention of HIV/AIDS, parents must have basic knowledge of HIV/AIDS and condoms (Han & Bennish, 2009:27). Parental support is of utmost importance concerning condom distribution at school. However, the Department of Education has a role to play in empowering parents regarding general health affecting their children at schools including sexual health education. The young men emphasized that parents should be taught about the use of condoms so that they in turn should be able to transfer accurate information to the young people, clearly seen in the following statement: “Departement van Gesondheid moet ook die ouers leer oor die gebruik van die kondoom” (Department of Health should teach the parents about the use of condoms). Community leaders should also be engaged; so that their involvement could influence and convince men to use condoms (Han & Bennish, 2009:27). Involvement of the community leaders would be a sign of not undermining their traditional values and morals as condom usage is a sensitive and private matter (Van Dyk, 2012:227- 228). The approach should show recognition that leaders` roles in the community is of paramount importance. Involvement of the community concerning planning, 65 implementation and evaluation of AIDS and condom education programs would also determine the success of such programs. Basic knowledge of HIV/AIDS should be imparted in simple understandable language. Local spoken language of the target population would be an effective tool if used (Mathibe-Neke, 2008:9 & South Africa, Department of Health, 2010:58). It would be the responsibility of the Department of Health to organize the workshops to address condom availability and demonstrations. Older men felt strongly by stating: “Leiers van gemeenskap moet ook geleer word oor die belangrikheid van kondome. Want die gemeenskap glo en luister na hulle” (Community leaders must be taught about the importance of condoms because the community listen to them). Participants emphasized the fact that the Department of Health has a major responsibility to execute regarding condom use. 3.4.1.4 Theme four: Responsibility Responsibility refers to the obligation to carry forward an assigned task to a successful conclusion. Responsibility encompasses authority to guide and take remedial action to enhance success (Hanks, Long & Urdong, 1979:1243). The South African government took responsibility to address adolescents` access to reproductive health through the Children`s Act adopted in 2007. Children over the age of 12 years have an access to information regarding contraceptives including condoms (South Africa, 2005:94). Strategies should be employed by the schools themselves to address the issue surrounding condom access and distribution to students. Meetings should be convened by principals to discuss these strategies with the educators, parents, school governing body and students` representatives. The subject could be approached from a Life Orientation angle, whereby the students would be informed of the impact of HIV/AIDS, STI`s and teenage pregnancies (Han & Bennish, 2009:27). In the United States of America many schools provided information concerning condoms as part of classroom-based sexuality education (Eisenberg et al., 66 2009:417). American parents were overwhelmingly in favour of condom education. Young men felt that school health nursing could be of use in condom demonstration and distribution in Dikgatlong sub-district: “Departement van Gesondheid moet die skole van gesondheid begin, waar jeug van jonger jare kan leer oor kondoom gebruik. En HIV/AIDS, Gesongheidopvoeding, STI`s” (The Department of Health should start with school health, whereby younger scholars are taught about the use of condoms). School health nursing would offer support to the educators to overcome embarrassment and uneasiness in dealing with the subject of sexuality. Parents, educators and community leaders should take responsibility of teaching regarding condom and its use. This would be done on the basis of moral and cultural practices, to exclude the notion of promoting sexual activities and undermining on traditional values. Communicational skills and accurate knowledge regarding HIV/AIDS be imparted to the parents to address lack of information. The research studies have shown that no gatekeeper to condom access should be maintained as this will block or serve as barrier to condom use (Han & Bennish, 2009:27). Accessibility and supply of condoms to schools could be done by the Non Governmental organizations in collaboration with the stake holders from Department of Health. This will address the limited access to condoms mentioned by Han and Bennish (2009:25). With sufficient consultation with parents, community, administrators and school governing body by the health stake holders, distribution points of condoms may be recommended by the educators. Eisenberg et al. (2009:417) pointed out that international data suggested that large scale condom promotion policies and distribution had been effective in reducing HIV, STI`s and teenage pregnancy. Young and older men should also take responsibility of practising safer sex in order to protect themselves and their sexual partners. It must be instilled in their minds that they have a role to play in order to curb sexually transmitted infections that will do harm to them. Shared or joined responsibility is necessary with the government. Van Dyk (2012:141) states that men should be aware that the use of alcohol and 67 recreational drugs has an influence in diminishing power to make responsible decisions. Collaboration with other departments is of utmost importance. Department of Sport, Arts and Culture should be responsible for developing recreation activities, workshops regarding contemporary issues, playwriting and equip youth and older men with life orientation programs which will develop them (Song, Calsyn, Doyle, Dierst-Davies, Chen & Sorensen, 2009:461& Van Dyk, 2012:160-161). A youth structure in the form of clubs may be established to run youth matters. Issues of condom use may be best addressed at that level. Police forums may be invited to come and address the youth regarding the social issues. Hence this statement was made by older men: ”Departement van Sport en Kuns moet ook help om sport, ontspanningsgeriewe op te rig vir die jeug om hulle besig te hou en om kondome te gebruik” (Department of sport, arts and culture should help to organize sport and recreation for youth to keep them busy and to use condoms). By involving influential individuals like doctors and nurses the message will hopefully encourage men to use condoms consistently and correctly in town and rural areas. If health professionals show selfless care, support and responsibility to all people regardless of their status it will instill a sense of responsibility to the community (Van Dyk, 2012:154). Doctors and nurses are the ones who have direct contact with the community so by organizing health campaigns and road shows it will have significant impact. Older men emphasized that: “Klein areas in die Noord Kaap moet geleer word oor die gebruik van kondoom deur Departement van Gesondheid” (Rural areas in the Northern Cape must be given information about the importance of condom use). The Department of Health is responsible to serve the rural communities, they should not be ignored or marginalized but rather be responsible to render the services needed. Mobile clinics should be well equipped to render the services like giving health talks regarding HIV/AIDS and how to curb it through the use of condoms. Demonstration of condom use should be performed tirelessly in these remote areas 68 (Flannigan, 2007:55). Knowledge regarding HIV/AIDS should be based on updated information and quality should be ensured at all times, hence the discussion of quality assurance. 3.4.2 CATEGORY: QUALITY ASSURANCE Quality assurance emerged as a noteworthy category. Participants were concerned about the quality of condoms available in the public health sector. Quality assurance implied a guarantee of quality, in accordance with the characteristics linked with excellence. Quality assurance implied that a formal program to monitor, assess and evaluate the quality of services rendered and opportunities for improvement were identified, and a mechanism was provided to take remedial steps to maintain improvements (Booyens, 2005:597-601; Hattingh & Acutt, 2009:238-239 & South Africa, Department of Health, 2010:55). This assured the cost effectiveness and the efficiency of the products offered to the clients. Essential elements of quality assurance system would be concerned withmonitoring and evaluation of the product (condoms); accreditation of product manufacturers; quality audits; and management of quality assurance and remedial action (Vasuthevan & Viljoen, 2003:66). The Department of Health entrenches quality assurance by regularly evaluating accessibility to health care services, yearly review of unit standards, increased client participation on health issues, management of complaints to improve services and availability of medicines and supplies including condoms (South Africa, Department of Health, 2011b:2-3). The following themes formed part of quality assurance as a category:  Manufacturing and  Cost. 69 Quality condoms carry the mark of South Africa Bureau of Standards, meaning certain specifications were followed to ensure quality during the manufacturing of condoms (Boleme, 2012: Personal communication). 3.4.2.1 Theme one: Manufacturing Manufacturing is the process of converting raw materials, components, or parts into finished goods that meet a customer`s expectations. Manufacturing commonly employs a man machine setup with division of labor in a large scale production. Good quality condoms must comply with the following specifications;  Very low allergenic properties,  Individually packed in sealed sterile packaging,  Compatible with water soluble lubricants,  High density low porosity at a low gauge thickness,  Packaging reflects expiry date of the condom,  Aesthetically acceptable,  Multi directional elasticity,  Long shelf life if stored at room temperature and out of sunlight, and  Capable of taking dyes without compromising quality (UNAIDS, 2005:239- 240). These specifications are performed by the South African Bureau of Standards on the batch sample of the condom. If the SABS is satisfied about the quality test done on that batch sample of condom then a certificate of compliance is offered. The Department of Health would then use those condoms carrying the mark of SABS (Boleme, 2012: Personal communication). The Department of Health will only be able to evaluate frequency of reports regarding allergies to latex condoms, check packaging of condom whether sealed, expiry dates, and storage at room temperature and keep them out of sunlight. This would be to ensure that the quality of condoms was not compromised. 70 Good quality condoms should not fail when used correctly during sexual intercourse. The characteristics of condoms would be low porosity, elasticity with high tensile breaking point and good quality latex. In the Castle and Kiggundu (2007:55) study the participants expressed their concerns regarding the reliability of the government condoms. Participants claimed in the same study that condoms were too thin and small or had holes in them. Akinsola and Mulaudzi (2009:211) state that in 2007 the South African government withdrew some batches of condoms from circulation due to doubts regarding their quality. Since then some people still doubt the quality of condoms purchased by the government. Young and older men emphasized that: “Kondome van Departement van Gesondheid moet dikker gemaak word om die risiko van skeure te voorkom” (Department of Health should make the condoms thicker to minimize the risk of tears). Participants showed no confidence on the condoms distributed by Department of Health. More health education and proof of the quality of latex condoms need to be demonstrated to win back the confidence of the community as a whole. Maree (2010:1) states that latex condoms are impermeable to most viruses including HIV and the use of condoms would decrease the risk of cervical cancer and HIV and AIDS.The nominal group participants in this study were concerned with the efficacy of the government condom supply. Hence participants queried the thickness of the condoms. Liddell, Giles and Rae (2008:497) reported that doubts regarding condom efficacy were associated with reduced condom usage in the studies done in Ghana and Benin. Young and older men felt strongly that: “Kondome moet small, medium, large en extra large gemaak word om almal te akkommodeer” (Condoms must be made in small, medium, large and extra large sizes in order to accommodate all). The use of condoms is a private and sensitive issue that needs to be managed respectfully, efficiently and effectively. The manufacturing and availability of condoms in small, medium, large and extra large sizes was mentioned, because one sized condom is not user friendly to the younger men, and should also be appealing 71 and attractive to them. Flannigan (2007:53) states that for the encouragement of condom use by men to happen, condoms need to be acceptable in terms of comfort and sensation. In the same study Flannigan (2007:52) emphasized that in the United Kingdom condoms were manufactured different sizes, shapes, colors, flavors and textures. Condom users should be sensitized that particular commercially manufactured condom brands which may be suitable for them are available in retail shops (South Africa, Department of Health, 2003:44). The cost of condoms may also act as barrier to condom usage. 3.4.2.2 Theme two: Cost UNAIDS (2004:24) stated that the affordability and availability of condoms has encouraged people to use condoms consistently. In South Africa condoms are available free of charge in the public health sector (Hendriksen, Pettifor, Lee, Coates & Rees, 2007:1241). Older men were not keen to know the prices of the condoms in the retail shops. Young men were not overly enthusiastic to use free condoms provided by the Department of Health instead they proposed: “Departement van Gesondheid moet voorspraak maak vir die goedkoopste pryse vir die kondome by die winkels” (Department of Health should advocate for lower price of condoms in the shops). Participants were of the opinion that condoms sold at retail shops or market were not affordable. One packet of condom contains three condoms. A packet of durex condoms cost R 55.00, Lovers condoms R10.00, Rocky condoms cost R10.00 and Trust condoms cost R19 00 in South Africa (Spanenberg, 2012: Personal communication). Affordable prices of condoms may have an impact on the attitudes of the condom users. 3.4.3 CATEGORY: ATTITUDES An attitude is an assigned hypothetical construct that represents an individual`s degree of like or dislike for something. Attitude is generally a positive or negative 72 view of a person, place, thing or event. Mellish, Brink and Paton (2004:29) and Noar, Crosby, Benac, Snow and Troutman (2009:1046) state that attitude is seen as acquired internal states of understanding and feeling which direct the choice of personal action. Attitudes have three components; a cognitive or the belief held, an affective- related to feeling of the individual and behavioral aspect which is the person`s predisposition to act in a certain way. Only one theme was identified under attitudes category namely change. 3.4.3.1 Theme one: Change Through new knowledge new behaviours can be founded. Attitudes can be changed through persuasion and as a response to communication. Baiden and Rajulton (2011:53) and Van Dyk (2012:139) state that researchers have detected that people were prepared to change their sexual behavior in various ways especially if that behavioural change was beneficial in the sense of decreasing HIV infection. People cannot just change their attitudes until they know exactly what needed to change, what the benefits will be for their attitudinal change. Behavioural change include the following aspects namely precontemplation (not intending to change), contemplation (changing in future), preparation (making an attempt to changing in near future), action (recently changed behavior) and maintenance (practicing changed behavior) (Noar et al., 2009:1046 & Van Dyk, 2012:143-144). The educator should identify the obstacles towards and deal with them tactically e.g. by addressing the myths associated with condom use. Behavioural change is a process that needs time and dedication to enforce positive meaning to people regarding the use of condoms. In this study participants displayed (preparation) positive attitudes regarding the use of condoms by responding that: “Mans in die Noord Kaap Provinsie moet ernstig raak oor die gebruik van kondome” (Men in the Northern Cape Province must be serious about condom use). Men in the Northern Cape are in the preparatory stage thereby making attempts to change their behaviour in the near future by using condoms consistently. The advantages of protected sexual behaviour should be highlighted and reinforced on a 73 daily basis in order to bring about change. Change could take place with the assistance of influential people as we have seen in Thailand and Uganda. Versteeg and Murray (2008:91) indicated how Thailand achieved international recognition for successfully promoting condom use in brothels. UNAIDS (2004:10) mentioned how Uganda succeeded on condom promotion by involving all the influential stakeholders like the president and high ranking government officials. Uganda was successful in reducing the number of sexual partners in the general public through motivation (Kenyon, Boulle, Badri & Asselman, 2010:46). People living with HIV can be used as influential peoplein the community who will be the best advocate and activist for behavioural change (Van Dyk, 2012:152). Persons living with HIV will present a powerful message that will mobilize people to change and start to practise protected sexual behaviour. Life message from a person living with HIV will also break silence and de-stigmatize condom use. Open communication and de-stigmatization were used as strategies to break silence regarding condom promotion and to change the sexual behavior of men. In South Africa the President encouraged people to know their HIV and TB status, so that the infected could be treated and those who were negative could be encouraged to change their attitudes by using condoms. The South African President took the public initiative by undergoing HIV counseling, testing and propagated condom use himself. Luckily, that step encouraged the de-stigmatization of HIV and condom use as a preventative measure to curb sexually transmitted infections (South Africa, Department of Health, 2010:iv & Van Dyk, 2012:152). The support and commitment of high profile country`s leader is of utmost importance for prevention programs to be successful. That served as an encouragement that the recommendations to use condom could also succeed in the Dikgatlong Sub-district. Participants felt that change was not only needed amongst the politicians, but men in general had to change their attitudes as well:- “Mans mense moet bewus gemaak word as vrou se nee, nie sonder kondoom maar met `n kondoom” (Men must be made to attend to women`s wishes, and use condoms if requested by women to use condoms). 74 Women in many instances did not have power to negotiate condom use with their sexual partners (Van Dyk, 2012:141). The South African Government has introduced Promotion of Equality and Prevention of Unfair Discrimination Act whereby the rights of the woman should be respected. Every year from the 16thNovember to 10th December activism against women and children has been instituted, as an attempt to protect the vulnerable and to change the attitudes of men, to respect the rights of the vulnerable (South Africa, 2000:4). Men should be taught and encouraged to take their own reproductive responsibilities so that change must take place to respect women`s reproductive health, so as to lessen sexually transmitted infections. Women should be empowered by having equal access to education, employment and skill development (Hendriksen et al., 2007:1246 & Van Dyk, 2012:147-148). Condom negotiation skills should be provided to women in order to change them to practise safe sexual behaviour (Castle & Kiggundu, 2007:57 & Baiden & Rajulton, 2011:53). Those skills should involve the society as a whole and cannot occur without effective communication which was the cornerstone. 3.4.4 CATEGORY: COMMUNICATION Communication refers to interactive behaviour between people and involving the transmission of a message from a person to another person. Effective communication implies that the message that is received is the same as the message that was intended. It is the ability to convey ideas and meaning to another person in a comprehensible manner (Mellishet al., 2004:309). Communication process involves sender of message, receiver of message, interpretation of message and response (Mellish et al., 2004:310). Communication as a strategy has been used for a century to influence people`s behaviours, thinking and feelings (UNICEF, 2005:31). Once these thoughts radiate outward like the ripples in or within a group or culture then communication will be deemed interpersonal. Whitaker et al (1999:117) state that communicating with a sex partner is important self-protective health behaviour. It can help one to learn about a partner`s prior sexual behaviour and level of risk, information that will presumably 75 lead to safer sexual behaviours like abstaining from sex with high number partners and using condoms. Communication about sex as a means to promote safer sex is especially important for adolescents. Several researchers have reported a positive association between communication about sex and safer sexual behaviours among adolescents (Boyle & O`Sullivan, 2010:54; Casey, Timmermann, Allen, Krahn & Turkiewicz, 2009:60 & Hendriksen et al., 2007:1246). For example, in one study of adolescent women, communicating to a partner a desire to use condoms was associated with increased condom use, and ability to communicate with prospective partners about their sexual history was associated with having fewer partners. In order for communication to be effective people should be involved by talking to each other hence interpersonal. Interpersonal as a theme was identified under communication as a category. 3.4.4.1 Theme one: Interpersonal Interpersonal communication has two functions, namely to transfer the content of the message but also to establish a specific relationship or to strengthen an existing relationship between sender and receiver. A conversation between two people is referred to as interpersonal communication (Van der Berg & Nicolaisen, 2011:134). In the family for effective communication to occur, interaction should take place, and family members must be willing to listen to each other and respond appropriately to what has been communicated. Opportunity should be offered to listen to each other without interfering when one stating his case (Myburgh, Poggenpoel & Du Plessis. 2011:593). Through building trusting relationship one can feel free to talk or express ones emotions and opinions. The following response by participants pointed out the need for talking more about the use of condoms: “Mans moet meer praat oor kondoom gebruik en nie skaam wees oor die kondoom nie.” (Men must talk more about condom use and not be ashamed about it). 76 Talking openly about the use of condoms and their advantages should be the fundamental issue without feeling embarrassed. Noar et al (2009:1046) state that interpersonal factors such as condom use communication and negotiations are of utmost importance, to overcome barriers to condom use. Boyle and O`Sullivan (2010:54) mentioned that direct communication concerning the use of condom has been connected closely with tangible condom use in relationships. Talks regarding the use of condom should be encouraged by health personnel and community health workers amongst the community members (South Africa, Department of Health, 2011a:38). Silence about condom use should be broken, and men must come forward to express themselves without any fears. Participants emphasized the need to talk about condom use in the families. “Families moet vry wees om oor kondoom gebruik te praat” (Families must feel free to talk about the use of condom). Burkholder, Harlow and Washkwich (1999:35) mentioned that more family communication is associated with higher self-efficacy, showing that at-home communication about condom use and sexual issues may be having a positive behavioural impact. Whitaker et al (1999:118) mentioned that a discussion that consisted solely of a parent`s demanding that a child refrain from having sex may send a message that everything about sex is to be avoided. This may suppress the teenager`s desire to discuss sex with a partner or even feel embarrassed to negotiate for condom use. The study shows that parent-teenager communication about sexuality and about sexual risks may promote teenagers` discussions with their partners about sex, but only when parents communicate with their teenagers in a skilled and open manner (Beneto, 2010:24). Parent-teenagers communication may persuade teenagers to use condoms. Evans (2008:182) has found out in his study that social marketing strategy is able to promote health behaviour change through the media and can improve communication between parents and the children. Through social marketing awareness of HIV/AIDS and intention to use condoms among adolescents and adults increased. The availability of condoms to be used is of paramount imperative. 77 3.4.5 CATEGORY: AVAILABILITY In Versteeg and Murray`s study (2008:86) it was clear that the Department of Health in South Africa has successfully made male condoms to be available to the communities free of charge from a variety of outlets such as taverns, clinics and petrol stations. In essence condoms are readily available to the majority of the people in South Africa. Condoms should be supplied in adequate quantities to clients to avoid frequent client visits for re-supply (South Africa, Department of Health, 2003:44). That will serve as an encouragement to clients to use condoms consistently. UNAIDS (2004:24) mentioned that non-availability of condoms has been associated with non condom use. Therefore reliable distribution of condoms is essential and important even during the evenings and weekends as the need to use condoms occurs at awkward times. Knowledge concerning range of condoms available will also increase the extent to which men will use condoms consistently (Reece, Briggs, Dodge, Herbenick & Glover, 2010:439). Flannigan (2007:51) mentioned that the availability of condoms in United Kingdom is in range of shapes, sizes, flavors, textures and colors. Sarkar (2008:119) states in his study that although condoms being available free of charge to the public still about 20% of men in South Africa do not use condoms when engaged in sex. Condom program activities are therefore essential components of public health approaches to STI prevention and control:-  Ensuring condom availability (supply activities), and  Providing support for condom use and condom programs (Omi, 2001:5). Young people should be informed about the brand of condoms that are commercially available as the standard sized condoms may not fit them adequately. The category availability consists of one theme, namely sites. 78 3.4.5.1 Theme one: Sites Sites where condoms are served should be identifiable and yet privacy be maintained to lessen the level of embarrassment. Moore, Dahl, Gorn and Weinberg (2006:70) defined embarrassment as a reaction to or the anticipation of a negative evaluation of oneself by a real or imagined audience, leading to an aversive and awkward emotional state. The study shows that embarrassed individuals use condoms less often and purchase fewer condoms when they do buy. Self service point of condom dispensing should be private and easily identifiable by the clients, to lessen the level of embarrassment (Eisenberg et al., 2009:417). This could be a source of encouragement to the clients to use condoms consistently. According to the research study of Piot, Mukherjee, Navin, Krishnan, Bhardwaj, Sharma and Marjara (2010:56) the visibility of condoms was believed to be a factor that stimulated the clients to use condoms. Young and older men emphasized that: “Kondome moet beskikbaar wees by die taverns, sjebeens, kerke en taxi`s” (Condoms should be available in the taverns, shebeens, churches and taxi ranks). The research study of Versteeg and Murray (2008:86) stated that Department of Health has achieved success in getting condoms to the people. Male condoms were free of charge and distributed from various outlets like clinics, taverns, petrol stations, home based organizations, bottle stores, support groups, pharmacies and churches. Participants in the study did also not complain about the non availability of condoms. That clearly confirmed the study of Versteeg and Murray.In the South African Public health sector six most critical areas for patient-centered care were identified. One of the critical areas was to ensure that medicine supplies and equipment were available. Medical supplies include the availability of condoms. The supply chains should make sure that the clients get their prescribed medicines and condoms on the same day. This implied that condoms supply should not run dry for consistent condom use to be successful (South Africa, Department of Health, 2011:5). Young men went a step further in identifying sites for condom distribution: 79 “Departement van Gesondheid moet elke maand pakke van kondome aflewer by elke familie. Kontrolleer hoeveel jong mense is daar in die familie” (The Department of Health should deliver packets of condoms to each family. They have to be aware of how many young people are in a family). Delivering condoms to the families might sound farfetched. Fortunately the Department of Health has recently absorbed community health workers within the health system. This category of workers will be visiting families within the community. Distribution of condoms will form part of home visitations (South Africa, Department of Health, 2011a:38-46). Thus ensuring the availability of condoms on yet another level, assisting in the use of condoms (Van Dyk, 2012:141). 3.5 CONCLUSION This chapter has given a broad view of the recommendations proposed by men to improve the use of condoms in the Dikgatlong Sub-district. It started off by giving a brief overview of the demographic data of group participants, followed by a general overview of research data. The combined research findings reflected per category, theme and statement was discussed. Chapter four depicts a summary of the research findings, recommendation flowing from the study, possible limitations of the study as well as the value of the study. 80 CHAPTER FOUR SUMMARY OF RESEARCH FINDINGS, RECOMMENDATIONS, LIMITATIONS AND CONCLUSION 4.1 INTRODUCTION The previous chapter discussed the categories and themes that emerged during the data analysis as described by the content analysis, supported by existing literature. This data was obtained from the question posed during the nominal group discussions namely, “Stel planne voor om kondoom gebruik onder mans te bevorder”. (Propose recommendations that can be applied to improve the use of condoms by men). This chapter presents a discussion of a summary of the findings of the research and recommendations flowing from it. Limitations, as well as the value and conclusion of the study will be discussed towards the end of the chapter. 4.2 SUMMARY OF RESEARCH FINDINGS OF THE STUDY This portion will discuss the categories and themes that emerged from the four nominal groups with young and older men who proposed recommendations to improve the use of condoms by men as was discussed in chapter three. From analysis of data, prevalent categories regarding proposed recommendations to improve the use of condoms were client education, quality assurance, attitude, communication and availability of condoms.The category client education was divided into the following themes: content, strategy, responsibility and target group. The category quality assurance had two themes namely, manufacturing and cost. The category attitude had one theme namely, change. The category 81 communication had one theme namely, interpersonal. The last category had also one theme namely, sites. Table 4.1 below gives a summary of categories and themes of combined data of the four nominal groups. Table 4.1: Combined Data of the four nominal groups divided into categories and themes. CATEGORY THEMES Client Education Content Strategy Responsibility Target Group Quality Assurance Manufacturing Cost Attitude Change Communication Interpersonal Availability Sites The main research findings within the mentioned categories and themes will be highlighted. The category client education will be discussed first, followed by the second category quality assurance, then thirdly the category attitude, then fourthly the category communication and then the final category namely, availability. 4.2.1 CLIENT EDUCATION Within this category participants identified their educational needs. The main research findings in the client education category will be discussed according to the already mentioned themes, namely, content, strategy, responsibility and target group. 4.2.1.1 Content The three main findings in the content theme consisted of the youth being taught how to use condoms and in this way practise responsible sex. 82 A further need for education in the storage and expiry of condoms was found in order to avert the incidence of bursting condoms. Fortunately instructions and direction for use are written in each packet of the condoms. Lastly circumcised men had to be informed that they had a responsibility to protect themselves against contracting HIV/AIDS and STI`s by using condoms. However, it does not mean that if circumcised then the men have immunity against contracting sexually transmitted diseases or infections. 4.2.1.2 Strategy Creation of positive environment regarding the use of condom was articulated by young and older men. This strategy should be used in order to de-stigmatize the use of condoms amongst the potential users. Participants suggested that primary health care facilities and doctors` consulting rooms should be used as distribution point for information concerning condom use. Pamphlets and information leaflets had to be utilized to disseminate information regarding the advantages of using condoms, in order to break down silence and condom barriers. In the study of Castle and Kiggundu (2007:52) posters from the clinics were used as source of information regarding HIV/AIDS and condom use awareness programs. As part of awareness programs the participants proposed the use of dramas, sketches and T-shirts. The message that is brought across in the form of a play has more impact than what one hears. Mass media including radio, flyers, newspapers, videos, internet and live theatre performance can be of great value to deliver the message across (South Africa, Department of Health, 2001:27 & Evans, 2008:183). Young men suggested the use of NGO`s and Love Life structures to encourage the use of condoms amongst men. Currently the Love Life organization is active in the townships of the Dikgatlong Sub-district. Love Life presents plays and sketches regarding contemporary health issues affecting the community including topics such as use of condoms. 83 Older men proposed that local HIV/AIDS statistics should be made available to the community on a regular basis, as an indication whether condom usage has limited the spread of HIV/AIDS. These statistics can also be used during workshop presentations. Not only does the government have a responsibility to promote condom use, the community has a role to play as well. Participants proposed that the Department of Health had to organize workshops that would enlighten them concerning the use of condoms. 4.2.1.3 Responsibility During the discussion it was established by participants that role players should be parents, educators, community leaders and even young and older men from the community. Participants mentioned that the Department of Health should start with school health nursing which can be used to empower the young about the use of condoms. Young men felt strongly about the involvement of parents in addressing the issue of protected sexual behaviour of the young people. Parents should be given basic knowledge concerning the use of condoms so that the message could be passed to the young. The influence of the parents upon the young carries more weight. Community health workers should also be able to impart that knowledge to the parents during home visits, by demonstrating how to use condoms. Parents should also be encouraged not to feel embarrassed when talking to the youth, rather take the responsibility of inspiring them to practice protected sex if they are sexually active. Young men proposed that role models like nurses, police and doctors should be involved. They should deliver speeches or messages to encourage men to use condoms consistently in the community. It is hoped that the community will listen to them because of their influence upon them. 84 Older men were burdened by the fact that rural areas must be given information concerning the importance of condom use. Mobile clinics that are servicing the farms should be well equipped; they offer a range of services, including family planning and condom dispensing. All these endeavors should be channelled in such a way that the target group can be reached. 4.2.1.4 Target group Participants identified the target group to include the community leaders and parents, young and older men. Participants pointed out that the community leaders should not be excluded. They rather should be taught how to use condoms and their advantages. Young men felt strongly that parents should be taught how to use condoms, so that in turn the accurate message is carried over to the young people. Young and older men felt that it was their responsibility to use condoms every time they had sexual contact with their casual partners. Participants agreed to carry condoms in their pockets, so that when need arose they should be readily available. Men who were using alcohol should also be taught to be responsible, by controlling their own emotions and use condoms. 4.2.2 QUALITY ASSURANCE Quality assurance is practiced in order to monitor and evaluate the standard and quality of the product, which is the condom in this instance. It allayed anxiety and doubts regarding the quality of condoms. Manufacturing of condoms is anticipated to meet specified standards. 85 4.2.2.1 Manufacturing Young and older men felt strongly that condoms should be manufactured according to different sizes namely, small, medium and large. This is not currently the case within the public health sector. Condoms supplied by the Department of Health are one size fit all. The costs of condoms were checked to determine the issue of affordability. 4.2.2.2 Cost Young men were concerned with the price of the condoms from the retail market, which the Department of Health should negotiate with the private sector to provide better retail prices. This concern was identified during the nominal group discussions in all four groups, which could change attitude to be one of negativity. 4.2.3 ATTITUDE Attitude deals with specific behaviour that needs to be altered. When people believe that condom utilization would have positive results for them, then they will most likely use condoms more frequently (Van Dyk, 2012:139). Many negotiations and persuasions would be needed to change negative attitudes regarding the use of condoms. 4.2.3.1 Change Participants echoed that men should be serious in using condoms. That alone would be a positive sign that through seriousness and earnesty men can change their attitude and use condoms without difficulties. Participants further felt strongly regarding protection and respect for women. They therefore suggested that if women negotiated for condoms to be used, men should listen and practise safe sex. Negotiation for condom use cannot take place without the use of communication skills. 86 4.2.4 COMMUNICATION The role of interpersonal communication would be vital in negotiating for condom usage in relationships. 4.2.4.1 Interpersonal Participants of the nominal groups felt that the more men who spoke about the use of condom the more would they not feel ashamed. Peer communication should be encouraged among men, so that spontaneity regarding condom use should just be natural. This would also influence families to converse about condoms freely and without embarrassment. 4.2.5 AVAILABILITY The availability of condoms would be essential and therefore sites where condoms should be dispensed were identified. 4.2.5.1 Sites Participants identified sites where condoms could be dispensed especially after hours, were shebeens, taverns, churches, taxi ranks, fuel filling stations and schools. 4.3 RECOMMENDATIONS Based on the findings culminating from the study recommendations would be discussed. The same sequence would be followed namely the various categories and the themes resorting under each category. See Table 4.1. 4.3.1 CLIENT EDUCATION Client education consisted of the following themes, namely, content, strategy, target group and responsibility. Content would be discussed first. 87 4.3.1.1 Content How to use condoms  Youth knowledge regarding sexuality and the use of condoms could be strengthened at schools. Teachers offering Life Orientation should be provided with updated information concerning adolescent sexuality, HIV infections and method of practising protected sexual behaviour. The school health professional nurse can play an important role in assisting teachers with such a program.  Older men could only be successfully taught on how to use condoms if community health care workers were themselves comfortable and knowledgeable on condom usage. Therefore the topic should be addressed during in-service training of health care workers.  A policy guideline for Youth and Adolescent Health in South Africa is available from the Department of Health (South Africa, Department of Health, 2001). This guideline document has accurate information that addresses the health needs of youth and should be distributed to all health workers involved with adolescents and youth. Expiry dates and storage of condoms  The Department of Health is responsible to distribute condoms that have not expired. When condoms were given to the clients, responsible community health care workers should explain the importance of expiry dates and storage guidelines to prospective condom users.  Expiry dates should be checked by the user before using condoms on the package. Condoms should be kept at a room temperature and should not be exposed to sunlight. Sunlight affects latex negatively, compromising its quality. This information should be emphasized by professional nurses during workshops targeting condom users. 88 Counseling of circumcised men  It is recommended that medical male circumcision services should consist of a core package that would include counseling about HIV, counseling on the need to adopt and maintain safer sex practices following circumcision and provision of condoms (Ramikissoon, Smit, Searle, Drace, Burns & Milford, 2010:41). Male circumcision reduces the risk of acquiring HIV infection by 50- 60%; but does not guarantee complete protection. Therefore the manner to offer protection would be to minimize the number of sexual partners, to propagate correct and consistent condom usage. This is another topic to be explained during health education outreaches by health care workers in the community.  Counsellors and other relevant health care workers should be offered in- service training regarding circumcision so that accurate information could be given to the men who would like to undergo medical circumcision. 4.3.1.2 Strategy Primary health care facilities and doctors consulting rooms as source of information  Display useful and attractive information for example, posters and charts on the walls. Hand leaflets and brochures out to clients regarding condom use and use TV monitors in waiting rooms to strengthen health messages in this regard. Dedicated nursing personnel in a health facility can strengthen such a drive.  The Department of Health should allocate a realistic budget for printing of pamphlets and posters. Professional nurses should be co-responsible for the programs of condom should be identified, so that the current pamphlets can be evaluated to establish their efficacy. Currently printing of pamphlets is done as a joint venture with NGO`s like Khomonani and Soul City because printing of pamphlets is too costly. These pamphlets and brochures are very useful in transferring the intended information to the community. It is important that these brochures be printed in the local spoken languages, namely 89 Tswana, Xhosa and Afrikaans to arouse an interest in reading and understanding of the message. The role of dramas, sketches and T-shirts  The message that is echoed in the form of a play and sketches has more impact than what one hears. Printed T-shirts` message can arouse the interest of the community to know more about what is advertised. Therefore partnership between non-governmental organizations and business should be established to assist financing such ventures. Professional nurses know the needs of a specific community, they can assist Love Life with the planning of programs.  Mass media including flyers, radio, newspapers, videos, internet and live theatre performance can be of great value in spreading the news to many people (South Africa, Department of Health, Youth & Adolescent Health, 2001:27; Evans, 2008:183). A slot can be arranged with the local radio station (Radio Teemaneng) whereby awareness programs can be run.  The DCeopllaarbtmoreantitv oef rHeleaatilothn sinh icpo ollaf bDoerpaatirotmn ewnitth o Nf HGeOa`lsth l ikweit hR eNdG cOro`ss s and  Love Life should develop effective programs that will encourage men to use condoms. Presently Love Life organization is active in the Dikgatlong Sub- district. Love Life presents plays and sketches concerning the contemporary health issues affecting the community including the condom use.  Home based care givers play an important role in the community. They have first hand information regarding health challenges facing the community. Meetings should be convened by a person identified oremployed by the Department of Health to run condom programs within period a of six months after the findings of the research has been communicated to the Department of Health with the stakeholders, to discuss jointly the strategy to encourage condom usage amongst the young and older men in the Dikgatlong Sub- district. Condom programs should entail the following aspects:- o Educating people about the need for condom use; 90 o Ensuring condom availability; o Providing support for condom use and o Monitoring and evaluation of condom use and activities by keeping track of problems and constraints. Workshops program  The Department of Health also has a responsibility to conduct workshops regarding the use of condoms. A dedicated professional nurse should be identified by the Department of Health within a period of six months. This person should be responsible to institute workshops to train the community health care workers and health care professionals. Training should provide practical guidelines and self learning materials. Times and venues of these workshops should be decided upon in conjunction with the community, to encourage attendance and interest.  Community leaders like ward councillors should be involved in planning of workshops. They can also be responsible to make announcement in the community during funeral attendance or community meetings concerning workshops or the need to use condoms.  The Department of Health should allocate budget to run these workshops and provide materials needed like dildos and training manuals.  Because of the sensitivity of the subject more male community health care workers should be trained so that men in the Dikgatlong Sub-district should be reached. Men will be keen and freer to ask questions that will be relevant to their personal experience and practice if they could talk to men. Availability of HIV/AIDS statistics  Presentation of these statistics should be in the local languages for better understanding and meaning by the community. These statistics can also be used during workshop presentations by professional nurses as point of departure and emphasizing the importance of condom use. 91  Professional nurses should keep accurate statistics of HIV/AIDS and condoms used. This will serve as measurement of well distribution and condom usage by the community. 4.3.1.3 Responsibility The South African Government cannot alone be held responsible for spreading health education. It is the business of every South African including the cooperate sectors to participate in instilling positive health behaviours, as well as promoting condom use. The role of the school health nursing  The National School Health policy has been instituted since June 2002 to address youth health issues at schools (South Africa, National Department of Health, 2002:14). In this document health education has been incorporated into the school curriculum. Health education is dealing with issues like sex education, the use of condoms, contraceptives and HIV/AIDS. Educators are offered the opportunity of giving sex education through Life Orientation. School health nurses can also be useful in conducting health education to the youth and accurate information regarding condom use can be addressed at that level. Through knowledge and accurate information one is able to make informed and responsible decisions in this case of practising protected sex.  An in-service training and support program should include the development of communication skills to improve parent-learner-teacher relationships (Mestry & Grobler, 2007:183). The school health nurses should be the ones to establish in-service training.  Health issues concerning the learners can be addressed in the parents meeting in conjunction with the school governing body. Knowledge concerning condom use and sex education should be shared with the parents in order to empower them in dealing with their children at home. School health nurses should create youth friendly atmosphere that will encourage youth to freely express their concerns regarding their sexuality including condom use 92 (Formby, Hirst, Owen, Hayter & Stapleton, 2010:432). Interaction by the school health nurses with the educators will be very important to address issues of condom provision in the school premises. Compilation of a monthly report with identified challenges and successes will be imperative and presented at school meetings.  School health nurses should further have a quarterlyscheduled meeting with educators whereby current health issues will be discussed, for example identification of areas where condoms will be distributed. This will encourage the youth to take responsible decisions by practicing protected sex. Collaboration with other governmental departments  Professional nurses of the Department of Health should liaise with the Department of Sport, Arts, Culture and Recreation in an effort to share responsibility of empowering the community to practice safe sex. The educative value of sport and art cannot be underestimated.  The ministerial health campaigns, targeting rural areas, of the Ministry of Health in the Northern Cape should be supported by other political and community leaders. Involvement of rural areas  Mobile clinics which provide services in rural areas should receive specific support enabling them to provide comprehensive care including condom distribution. Professional nurses from rural areas should take the responsibility to inform their management of their needs.  Responsible health care workers should become active in the monitoring and evaluation process of condom distribution. 93 4.3.1.4 Target group Teaching parents about the use of condoms and the advantages thereof  Professional nurses of the Department of Health must take the trouble or challenge of teaching parents on how condoms are used, so that when speaking to their youthful children they must know exactly what to say to them. Involvement and influence of parents in education of the youth will encourage youth to make responsible decisions (Mestry & Grobler, 2007:177). Youth whose parents are involved in their education tend to do well, so parental support means a lot to them. Parental influence upon their children`s behaviours is very important, so reinforcing the use of condoms by parents will have an impact (Zecevic, Tremblay, Lovsin & Michel, 2010: online).  Authoritarian parenting style has been associated with high risk of unprotected sex, while parents who provide love, warm and nurturing environment increases chances of practising protected sex (Panday, Makiwane, Ranchod & Letsoalo, 2009:35). Teaching must be provided within a warm environment for success.  Community health care workers can carry the responsibility of teaching parents about the use and advantages of condoms during home visits. Educators` role concerning sex education  Educators should be trained by the Department of Education in collaboration with the professional nurses from the Department of Health regarding HIV/AIDS and the use of condoms. Currently the Department of Education`s policies of condom distribution has been left to the discretion of the individual schools (Han & Bennish, 2009:26). This knowledge should be imparted to the youth. The significance of school and parents support of constructive behaviour was found to be important in reinforcing positive lifestyles of teenagers (Lebese, Davhana-Maselesele & Obi, 2010:40). 94  School health nurses may be used to identify the training needs of the schools they are serving and bring to the attention of the person accountable for arranging workshops. The influence of community leaders  Leaders should be used to encourage men in the community to use condoms. The involvement of community leaders is of paramount importance (Van Dyk, 2012:227-228). Recently in the Northern Cape Province there were health campaigns launched by the Member of Executive Council (MEC) of Health. During his visits to various towns he encouraged the communities to stick to healthy habits. In his speeches he mentioned prevention of tuberculosis, smoking, HIV/AIDS and included the use of condoms to limit the spread of sexually transmitted infections (Sokhatsha, 2012: Personal communication). This initiative by the MEC needs to be expanded upon. The ward councillors should be encouraged to spread message delivered by the MEC to further educate their constituency. Again professional nurses can use local clinics committees to establish a platform for community leaders. The responsibility should be shared by every citizen of the Republic of South Africa. 4.3.2 QUALITY ASSURANCE Quality assurance as a category has two themes namely, manufacturing and cost. 4.3.2.1 Manufacturing Concerns regarding condom sizes  All possible platforms, such as workshops or health education talks, should be utilized to explain to men why a one-size fits all condom is suitable to be used by all men. It is clear that the physiological change during erection is not clearly understood by some men. Since sexual intercourse does not consist of 95 a physiological reaction alone, the emotional reasoning of the male partner needs also to be considered when addressing the various condom sizes. Cost of different brands of condoms must be highlighted to the prospective users. 4.3.2.2 Cost Because of high unemployment rate in the Dikgatlong Sub-district most of men cannot afford the prices of condoms, sold by local pharmacy. Free condom supply  Therefore men should be encouraged by professional nurses to use the freely available condoms this can be done through counselling, health education and demonstrations on the effectiveness and reliability of condoms to enhance correct condom use. This information should be readily available to the users in order to bring back the confidence men have lost on government distributed condoms. This can only be dealt with through changing the attitudes towards condoms distributed by government. 4.3.3 ATTITUDE Attitude as a category has only one theme that was identified namely, change. 4.3.3.1 Change Seriousness by men to use condoms  Community leaders should support the example set by the MEC of Health in encouraging condom use. These messages can be stated publicly at gatherings such as funerals and community meetings. 96 Protection and respect for women  The Department of Social Development should be asked by professional nurses to present workshops in the Dikgatlong Sub-district addressing gender inequality issues.  In a further collaboration police forum members can be invited to present information on dealing with domestic violence at available settings. Communication is the cornerstone of the condom program. 4.3.4 COMMUNICATION Communication as a category has only one theme that was identified namely, interpersonal. 4.3.4.1 Interpersonal Communication about the use of condoms  In Dikgatlong Sub-district there is an older men organization called Manne Bond which deals with church activities as well as current affairs that affect men. It is at this level where men can be encouraged to talk openly about the use of condoms. This platform can be used by professional nurses as a point of departure to influence men positively about the advantages of using condoms consistently and correctly. The dedicated person responsible for condom programs can arrange a meeting with the leadership of Manne Bond to plan a workshop within six months. The date and venue to conduct a workshop should be planned with the members and be aligned with the program of Manne Bond. Among the young men there is also an organization called Rising Stars, it can be used as a platform to reach out to the young men. Through these organizations open discussions amongst men could be encouraged. Accurate knowledge regarding condom use and its effectiveness can influence them to practise protected sex. 97 Communication of families  Through open communication and accurate information the families will be able to combat the barriers to condom use. Panday et al (2009:35) state that positive, open and frequent family communication regarding sex is linked to postponement of sexual activity, increased contraceptive use like condoms and fewer sexual partners. Community health care workers are one of the useful resources that would encourage families to talk about condoms, sex matters in order to break communication barriers. They should give monthly statistics to the Department of Health of the service rendered; this information can serve as a measuring tool to indicate progress or to effect remedial actions. The availability of condoms is of utmost importance for improvement of condom use. 4.3.5 AVAILABILITY Availability as a category has only one theme that was identified namely, sites. 4.3.5.1 Sites Dispensing sites of condoms  Professional nurses should make condoms available in the taverns, shebeens, churches, fuel stations and taxi ranks. Contact must be made with the site owners regarding the dispensing of the condoms. The identified sites should be regularly supplied with condoms on a weekly basis. There should be individuals who would be responsible to maintain condom supply. A private spot should be identified where the condoms will be dispensed with minimal observation to lessen the impact of embarrassment. Sites dispensing condoms should be known to the community to enhance accessibility. 98  Monthly statistics should be kept by the individuals employed by Department of Health. This statistics will show whether condoms are used or not. Provision of family with condoms  The community health care workers will be used to deliver condoms to families during home visits. Through an on-going health education and counselling by the community health care workers families will be encouraged to employ protected sexual behaviour. The researcher was aware of aspects posing limitations on the study. 4.4 LIMITATIONS The researcher is aware that exclusion of certain groups, ages and groups might pose a limitation on the study. Recommendations to improve condom use were only obtained from men, excluding women and other groups. Not including these groups could have limited the depth of recommendations received. The researcher focused on young and older men, due to findings from a national survey conducted in South Africa indicating the difference in condom use amongst men in these age groups. It was therefore not the intention of the study to include men of all age groups, but rather to follow up on the national survey’s findings. Since the study was contextualized, the exclusion of minority groups such as White and Asian participants must be seen in the backdrop of the population distribution of the Northern Cape Province – having a majority of black and coloured residents. The recruitment of participants attending primary health care facilities and high schools in the area does pose the possibility of bias. A more varied recruitment strategy in the future may decrease this possible bias. However, the sample represents an important and understudied population and information obtained provides useful insights on recommendations to improve condom use in men in the Dikgatlong Sub- district. 99 4.5 VALUE OF THE STUDY The recommendations made by study participants and the subsequent recommendations flowing from the researcher will be of value to the Northern Cape Department of Health and the community of Dikgatlong. Dissertation document or copy will be discussed and given to the Department of Health. The expectations and recommendations, albeit realistic or not, received from participants regarding the proposed role the Department of Health could serve as a point of departure for the department in future planning to better condom usage in the Northern Cape province. The practical recommendations culminating from the study would further assist this Department of Health in increasing the prevalence of condom use in the province, so addressing the issue of being the province with the lowest condom use in South Africa. Although participants’ recommendations cannot be seen as representative of men in Dikgatlong or the Northern Cape, men and their sexual partners, will benefit from the implementation of any of the suggested recommendations. The necessity of using condoms for the protection against sexually transmitted infections, including HIV, cannot be emphasized enough, especially in the context of South Africa being the country carrying the highest burden of HIV infected persons worldwide. 4.6 CONCLUSION In this final chapter, the researcher attempted to present the findings of the study and make recommendations that could be implemented to improve condom use by men. 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Correlates of condom use among sexually experienced secondary school male students in Nairobi, Kenya. Journal of aspectsof HIV/AIDS. 6(1):10. March. Zecevic, C. A., Tremblay, L., Lovsin, T. & Michel, L. 2010. Parental influence on young children`s physical activity. International journal of pediatrics, 2010: 1-9, June. http://www.hindwi.com/journals/ijped/2010/468526 [23 March 2012]. 113 Addendum A Permission letter to the HOD of the Department of Health in the Northern Cape 114 Addendum A P O Box 211 Barkly West 8375 29 March 2011 Dr. D. J. Theys Head of Department Department of Health Private Bag x 5049 Kimberley Dear Dr Theys Permission to conduct research I am the principal investigator of the study to determine recommendation to improve condom use in men in Dikgatlong sub-District. I am a master degree student at the University of the Free State. Based on the South African HIV Prevalence, Incidence, Behaviour and Communication survey which was conducted in 2002, 2005 and 2008 respectively, showed an increase in condom use in men to 52, 7% in the Northern Cape Province. This percentage is the lowest in all the provinces in South Africa. The statistics received from the Dikgatlong Sub-district in Primary health care clinics show an increase in teenage pregnancies, sexually transmitted infections including HIV. I have compiled a research proposal on the recommendations to improve condom use in men in Dikgatlong Sub-district. This research proposal was approved by the Ethics Committee of the University of the Free State. I plan to conduct the research study from June 2011 to the end of April 2012. 115 Nominal group discussions will be conducted in Dikgatlong Sub-district by a trained facilitator from the University of the Free State. The nominal groups will consist of men aged18 to 24 and men aged 49 and above. The purpose of the nominal group technique will be to determine recommendations to improve condom use in men. It is hoped that the value of the study will improve the quality of life in the community, lower prevalence of HIV and improve health care services by the Department of Health in the Northern Cape Province. I will recruit the men to partake in the research myself and therefore it will not impact on the human resources within the department. I will also need a hall for facilitation of nominal group discussions. I will appreciate your permission to conduct this study in your Primary health care clinics in Dikgatlong Sub-district. Please be assured that the participants` privacy and confidentiality will be protected. The results of the study will be made known to you. If you have any concerns or queries regarding the study you are most welcome to contact Mr S Makgari at this number 0828869600. Yours truly, ____________________________ S Makgari Principal investigator 116 Addendum B Consent form for the participants of the Nominal group 117 Addendum B INFORMED CONSENT- NOMINAL GROUP Dear Colleague, This letter is to ask you to participate in a research project of the University of the Free State. The researchers are trying to establish recommendations to improve condom use by men in the Dikgatlong Sub-district in the Northern Cape. A group discussion, using the nominal group technique, will be held. The discussion will last approximately two hours. During this group discussion you will be asked to propose the mentioned recommendations. Thereafter the opinions will be clustered and prioritized according to the group`s consent. All information will be handled confidentially and will only be used for research purposes. Participation is voluntary with no retribution should you refuse to participate or want to withdraw.The results of the study may be published. No remuneration for participation in the study is available. Your participation will be much appreciated and valued. You may contact Mr Sollie Makgari, Cell no 0828869600, with further enquiries. If you are willing to participate, will you please complete the form below? I...........................................................................am willing to participate in a group discussion dealing with recommendations to improve condom use by men in the Dikgatlong Sub-district in the Northern Cape. ___________________________________________________________________ ____________________ ___________________ Signature of participant Signature of witness ___________________ ___________________ Date permission given Date permission witnessed 118 Addendum B TOESTEMMING NOMINALE GROEP DEELNAME Geagte kollega Hiermee wil ek u graag vra om deel te neem aan n navorsings projek van die Universiteit van die Vrystaat. Die navorser poog om aanbevelings te maak wat sal bydra tot verbeterde gebruik van kondome deur mans in Dikgatlong Sub-distrik in die Noord Kaap. `n Groepsbespreking sal gehou word wat van die nominale groep tegniek gebruik sal maak. Die bespreking sal ongeveer 2 ure duur. Gedurende die groepsbespreking sal u gevra word om die genoemde aanbevelings voor te stel, waarna die voorgestelde aanbevelingsgegroepeer en geprioritiseer sal word, soos deur die groep voorgestel.Alle inligting sal konfidensieel hanteer word en slegs vir navorsingsdoeleindes aangewend word U sal geen vergoeding ontvang vir u deelname aan die studie nie. U deelname is vrywillig en daar sal nie teen u gediskrimineer word indien u sou besluit om te onttrek nie.. U samewerking sal waardeer word.U mag Mnr Sollie Makgari kontak by selfoon nommer 0828869600, met verdere navrae. Indien u sou besluit om deel te neem, sal u asseblief die onderstaande vorm voltooi? Ek ________________________ isbereid om deel te neem aan `n groepsbespreking wat handel oor aanbevelings aangaande verbeterde kondoomgebruik deur mans in Dikgatlong sub-Distrik in die Noord Kaap. ________________________ ___________________________ Handtekening van deelnemerHandtekening van getuie ________________________ ____________________________ Datum toestemming gegee Datum toestemming waargeneem 119 Addendum C A permission letter from the HOD of the Department of Health in the Northern Cape 120 Addendum C 121 122 Addendum D Steps of Van Breda 123 Addendum D VAN BREDA’S GUIDELINE CALCULATE NOMINAL GROUP TECHNIQUE RANKS Step 5: Calculating Combined Ranks In step five you will follow a number of substeps to determine the relative importance of each theme to all the groups combined. This will result in a consolidated and prioritized list of themes/categories. Having completed the qualitative analysis of the data (ie the content analysis), you are now ready to do the quantitative analysis. This involves calculating the relative importance of the themes you have generated for the entire sample. Select all the data on the spreadsheet and sort it as follows:  By Column B (Theme) first, in ascending order,  and by Column F (Top5) second, in descending order. Save the file and print it. Refer to this printed list of statements during the following steps. It is helpful to draw a line between the groups/themes of statements. Now create a second spreadsheet and type the following headings into the top row: Column A Theme Column B Top5 1 Column C Top5 2 Column D Number 1 Column E Number 2 Column F Average 1 Column G Average 2 Column H Final Rank Column A (Theme). In Column A type the themes that you created in the previous two steps. Type in both the theme number and the theme name, eg ‘1: Support Systems’. Column B (Top5 1). Add up how many times you typed an ‘x’ in Column F (Top5) of the printed list of statements, per theme. All of the x’s should appear at the top of the list of statements for each theme. Type these totals into Column B for each theme. 124 Column D (Number 1). Add up the number of statements that fall into each theme on your printed list. Type these totals into Column D for each theme. Column F (Average 1). Calculate the average score for the statements in each theme, by adding up all of the average scores in Column F of the printout and dividing it by the number of statements as you calculated in the previous paragraph. Type these averages into Column F for each theme. Now select all the information in this file and sort it according to Column B (Top5 1) in ascending order. Check to ensure that the table has sorted correctly. In Column C (Top5 2) type the numbers 1, 2, 3, etc to the end of the list of themes. Now covert these numbers into ranks, following the procedures described below:  Compare the numbers in Column B (Top5 1) with the numbers you have entered in Column C (Top5 2). If some adjacent statements received the same score in Column B, you will need to adjust the scores in Column C for those statements. If two or more statements got the same Column B score, calculate the average of the Column C scores for these statements and change the Column C scores for these statements to this average score. For example, if statements 3 and 4 in Column C both got a Column B score of 18, calculate the average of 3+4, which is 3.5. So both of these statements would get a Column C score of 3.5. Now Column C would be numbered: 1, 2, 3.5, 3.5, 5, 6… Follow this same procedure if there are two or more statements with the same Column B scores.  A shortcut for Odd Numbers of Statements. If there is an odd number of statements which all have the same Column B score, take the value of the middle Column C score, and give this value to the Column C scores for all of these statements.  For example. If the Column C scores 4, 5 and 6 all have the same Column B score, make the Column C scores for all three statements equal 5, which is the middle of the three scores. Note that the average of 4+5+6 is 5.  Another example. If the Column C scores 9, 10, 11, 12 and 13 all have the same Column B score, make the Column C scores for all five statements equal 11, which is the middle of the five scores. Note that the average of 9+10+11+12+13 is 11.  A shortcut for Even Numbers of Statements. If there is an even number of statements which all have the same Column B score, work out where the mid point is between the Column C scores, take the smaller of the numbers on either side of that point and add .5 to it. Give this value to the Column C scores for all of these statements.  For example. If the Column C scores 2 and 3 have the same Column B score, the midpoint is between 2 and 3. The smaller number is 2. Add .5 to 2 and you get 2.5. Make the Column C scores for both statements equal 2.5. Note that the average of 2+3 is 2.5. 125 Addendum E 1 Nominal Group one of Older men 126 Addendum E 1 Group 1 of Older men, reflecting categories, themes, statements, scores, average and Top five. Group Category & Idea/ statement (C) Scores (D) Average Top 5 (A) Theme (B) (E) (F) N=5 Older 5. Mans moet meer 3,4,2,4 13 1 men praat oor kondoom (2.6) (1) gebruik en nie skaam wees oor die kondoom nie.- (Men must talk more about condom use). Older 7. Mans moet meer 5,1,5,2 13 1 men ingelig word oor die (2.6) (1) gebruik van die kondoom. (Men must be more informed about the use of condom). Older 20. Kondoom moet 4,3,1,4 12 2 men (small, medium, large en (2.4) (1) extra large) gemaak word om almal te akkommodeer. (Condom must be in small, medium and large sizes). Older 8. Mans wat ouer is, 5,1,5 11 3 men moet gemotiveer word (2.2) (1) om die kondoom te gebruik, want ouer mans glo nie aan die gebruik van die kondoom nie. (Older men must be motivated to use condoms because they do not believe in condom use). Older 3. Mans in die Noord 5,5,1 11 3 men Kaap moet meer ernstig (2.2) (1) raak oor die gebruik van die kondoom. (Men in the Northern Cape must be serious about condom use). 127 Group Category & Idea/ statement (C) Scores (D) Average Top 5 (A) Theme (B) (E) (F) N=5 Older 9. Mans wat meer 2,2,5 9 4 men kondome gebruik moet (1.8) (1) ander manne wat nie kondoom gebruik nie advies gee. (Men who use condoms must give advice to those who are not using condoms). Older 1.Inligtings papier / 5,4 9 4 men kennisgewing wat moet (1.8) (1) uitgedeel word by die klinieke en dokters om te sê hoekom moet die kondoom gebruik moet word. (Information leaflet/ notice must be distributed from the clinics and doctors`consulting rooms about condom use). Older 17. Klein areas in die 2,1,3,3 9 4 men Noord Kaap moet meer (1.8) (1) geleer word oor die gebruik vandie kondoom, deur die Departement van Gesondheid. (Rural areas in the Northern Cape must be given information about the importance of condom use). Older 18. Instruksies moet 2,4 6 5 men geplaas word in elke (1.2) (1) kondoom pakkie. Om die manne meer inligting te gee hoe om die kondoom te gebruik. (Instructions should be enclosed in the condom packets explaining how to use condoms). 128 Group Category & Idea/ statement (C) Scores (D) Average Top 5 (A) Theme (B) (E) (F) N=5 Older 4. Kondome moet 3,3 6 5 men beskikbaar wees by die (1.2) (1) tarvens, sjebeens, kerke en taxi’s. (Condoms should be available in the tarvens, shebeens, churches and taxi ranks). Older 15. Meer verduidelik oor 1,1 2 men hoe om lank die (0.4) (1) kondoom kan hou, meer oor die vervaldatum.(Expiry date and safe keeping of condoms should be emphasized) Older 14. Die kondoom van 3,2 5 men die Departement van (1) (1) Gesondheid moet dikker gemaak word om die risiko van skeure te voorkom. (Department of Health should make the condoms thicker to minimize the risk of tears or bursting). Older 13. Die Departement van 4 4 men Gesondheid moet altyd (0.8) (1) die werkswinkel hou oor die gebruik van die kondoom. (Department of Health should organize workshops regarding condom use). Older 11. Mans moet meer 2 2 men aangemoedig word oor (0.4) (1) die gebruik van die kondoom en beskikbaar wees in die werk situasie/ omgewing.(Men should be encouraged to use condoms and must be available in work environment). 129 Group Category & Idea/ statement (C) Scores (D) Average Top 5 (A) Theme (B) (E) (F) N=5 Older 2. Mans moet geleer 3 3 men word hoe om die (0.6) (1) kondoom te gebruik deur gesondheids personeel. (Staff members of Department of Health should give men information of how to use condom). Older 19. Meer gemeenskaps 1,4 5 men projekte moet ingestel (1) (1) word om die kondoom gebruik aan te moedig.(More community project should be instituted of how to use condom). 130 Addendum E 2 Nominal Group one of Young men 131 Addendum E 2 Group 1 of young men, reflecting categories, themes, statements, scores, average and Top five Group Theme & Idea/ Statement (C) Scores Average Top (A) N=8 Categories (D) (E) 5 (F) (B) Young 5. Maak die gebruik van die 5,4 9 1 men (1) kondoom `n tradisie onder (1.23) swart mense.Want tradisie is baie belangrik by hulle.(Black people should practice condom use as tradition). Young 1. Departement van Gesond- 5,3 8 2 men (1) heid moet die gevaar van die (1) nie gebruik van kondoom beklemtoon. (Department of Heath should emphasize the risk of not using condoms). Young 7. Departement van 3,5 8 2 men (1) Gesondheid moet (1) voorspraak maak vir die goedkoopste pryse vir die kondome by die winkels. (Department of Health should advocate for lower prize of condoms in the shops). Young 4. Departement van Gesond- 5,3 8 2 men (1) heid moet die werkswinkel (1) hou om die kondoom te gebruik. (Department of Health should organize workshops of how to use condoms). Young 3. Die Departement van 2,5 7 3 men (1) Gesondheid moet die choice (0.88) kondoom wat nou beskikbaar is uitwus, aangesien ditte oilrig reuk en nie sterk genoeg genoeg is nie. (Department of Heath must get rid of choice condoms because have oily smell). Young 18. Die kondome moet small, 1,1,3,1 6 4 men (1) medium, large en extra large (0.75) gemaak word. (Condoms should be available in different sizes, small, medium and large). 132 Group Theme & Idea/ Statement (C) Scores Average Top (A) N=8 Categories (D) (E) 5 (F) (B) Young 11. Die jeug moet weet hoe 2,4 6 4 men (1) om die kondoom gebruik (0.75) want dis hulle se verantwoodelikheid om dit te gebruik.(Youths must know how to use condoms as it is their responsibility). Young 14. Stel meer die kondoom 2,4 6 4 men (1) beskikbaar in plaaslike (0.75) gebiede. (Moer condoms must be available in the rural areas). Young 15. Die ouers moet altyd die 4,1 5 5 men (1) jong mans vertel oor die (0.63) belangrikheid van kondoom gebruik.(Parents ought to all the time tell the young men about the importance of condom use). Young 13. Jong mense moet altyd 2,1 3 men (1) die kondoom in hulle sakke (0.38) het. (Young men ought to have condoms in their pockets all the time). Young 17. Kondome moet meer 4 4 men (1) sterker gemaak.Sodat hulle (0.5) moet nie skeur nie.(Condoms should be strong enough not to tear easily). Young 16. NGO`s moet die plakkate 2 2 men (1) maak waar die kondome (0.25) beskikbaar is.(NGO`s must have placard showing where condoms could be accessed). Young 14. Jeug moet meer ingelig 3 3 men (1) word dat die gebruik van (0.38) kondoom nie net is om die HIV/AIDS te verhoed, maar ook onbeplanne swanger- skappe en infeksie te voorkom. (Youths must be taught that the use of condom can prevent unplanned pregnancies and infections). 133 Addendum E 3 Nominal Group two of Older men 134 Addendum E 3 Group 2 of older men, reflecting categories, themes, statements, scores, average and Top five Group Theme & Idea/ Statement (C) Scores (D) Average Top 5 (A) N=6 Categories (E) (F) (B) Older 3. Opvoeding moet begin 5,5,4 14 1 men (2) by die skole dat dit (2.3) belangrik is om die kondome te gebruik met samewerking van gemeenskaplike geba- seerde organisasies, kerke, besighede, ens. (Teaching ought to begin at schools about the importance of condom use amongst the youths, home based care organizations, churches, business etc should play a part). Older 11. Departement van 5,3,4 12 2 men (2) Gesondheid moet huis (2) tot huis besoek te doen, man en vrou, familie bewus gemaak word van die belangrikheid van kondoom. (Department of Health should launch door to door visits to make men and women aware of the importance of condoms). Older 10. Jeug komitee moet 2,3,2,4 11 3 men (2) gestig word om die jeug (1.8) te leer om kondoom te gebruik. Elke maand moet `n “talk show” gehou word. (Youth committee should be established to teach how to use condoms). Older 6. Werkswinkel moet 5,2,4 11 3 men (2) gehou word om (1.8) kondoom gebruik te bevorder.(Workshops be supposed to be organized to promote condom use). 135 Group Theme & Idea/ Statement (C) Scores (D) Average Top 5 (A) N=6 Categories (E) (F) (B) Older 12. Plaaslike stastistieke 5,1,2,1 9 4 men (2) van HIV/AIDS in (1.5) Dikgatlong moet bekend gestel word aan die gemeenskap. So dat hulle kan die verspruiding te bekamp en dan begin kondomete gebruik.(Local statistics of HIV/AIDS in the Dikgatlong sub district should be published to the community). Older 8. Departement van Kuns 5,3 8 5 men (2) en Sport moet ook help (1.3) om sport, ontspanning geriewe op te rig vir die jeug om hulle besig te hou en om kondome te gebruik. (Department of Arts and Sport should help to organize sport and recreation for youth to keep them busy). Older 7. Kondoom en plakkate 4,2 6 men (2) wat mense bewus maak (1) moet gegee word in die drank plekke.(Placards raising awareness of condom use must be displayed in the shebeens). Older 4. As mans dronk is dan 1,2 3 men (2) slaap hulle sonder (0.5) kondome, hulle moet geleer word om kondome te gebruikin enige situasie.(When men are drunk are inclined not to use condoms, must be advised to use condoms). Older 9. Mans mense moet 1 1 men (2) bewus gemaak word as (0.17) vrou se nee, nie sonder maar met `n kondoom. (Men must be advised to respect women, and use condoms if requested by 136 Group Theme & Idea/ Statement (C) Scores (D) Average Top 5 (A) N=6 Categories (E) (F) (B) women to use them). Older 15. Leiers van gemeen- 1 1 men (2) skap moet ook geleer (0.17) word oor die belangrik- heid van kondome.Want die gemeenskap glo en luister na hulle. (Community leaders must be taught about the importance of condoms). Older 1. Gereelde saamtrek te 4 4 men (2) hou om die gebruik van (0.67) kondoom te verduidelik, hoe gebruik jy dit.en die belangrikheid daarvan.(Regular meetings must be convened to explain how to use condoms). Older 14. Families moet vry 3,1 4 men (2) wees om oor kondoom (0.67) gebruik te praat. (Families be supposed to not be ashamed of talking about the use of condoms). Older 13. Misgissings moet 3 3 men (2) aangespreek word met (0.5) algemene publiek aan- gaande kondoom gebruik. (Myths regarding condom use ought to be addressed in general). Older 5. Mans moet geleer 3 3 men (2) word om kondoom te (0.5) gebruik alhoewel hulle gesirkumseer is. (Circumcised men must be encouraged to use condoms). 137 Addendum E 4 Nominal Group two of Young men 138 Addendum E 4 Group 2 of Young men, reflecting categories, themes, statements, scores, average and Top five. Group Theme & Idea/ Statement (C) Scores (D) Average Top 5 (A) Categories (E) (F) N=10 (B) Young 7. Departement van 4,5,3,4,3,2 21 1 men (2) Gesondheid moet die skole (2.1) van gesondheid begin, waar jeug van jonger jare kan leer oor kondome gebruik. En HIV/AIDS, gesondheid opvoeding, STI`s. (Department of Health should start with school health, whereby younger scholars are taught about the use of condoms). Young 10.Departement van 5,2,5,4 16 2 men (2) Gesondheid moet jeug (1.6) gebruik om by die skole te leer oor die gebruik van kondome, met dramas, spele, T-hemde. (Department of Health must teach youth about the use of condoms by using dramas, sketches, T-shirts). Young 18. Departement van 2,3,3,5 13 3 men (2) Gesondheid moet ook die (1.3) ouers leer oor die gebruik van die kondoom. Die ouers moet vry wees om te praat met die kinders oor die gebruik van die kondoom. (Dept of health should teach the parents about the use of condoms, and must not be ashamed to talk to children). Young 8. Die kondome moet 4,3,5,1 13 3 men (2) gemaak word met (1.3) verskillende soorte kleure en reuke. (Condoms must be made with different colours and fragrance). 139 Group Theme & Idea/ Statement (C) Scores (D) Average Top 5 (A) Categories (E) (F) N=10 (B) Young 2. Departement van 1,3,4,4 12 4 men (2) Gesondheid moet meer (1.2) werkswinkel hou oor die gebruik van kondome en HIV/AIDS. (More workshops must be organized by Department of Health regarding condom use and HIV/AIDS). Young 3. Departement van 2,4,5 11 5 men (2) Gesondheid moet elke (1.1) maand pakke van kondome aflewer by elke familie. Kontrolleer dat hoeveel jong mense is daar in die familie. (The Department of Health should deliver packets of condoms to each family. They have to be aware of how many young people are in a family). Young 16. Die leiers moet 3,1,2 6 men (2) betrokke raak by die (0.6) kondome gebruik en die opvoeding daarvan.Rolmodelle ook (police, nurses, educators, dokters). (Community leaders ought to be involved to encourage condom usage). Young 11. Kondome moet gemaak 1,1,5 7 men (2) word met groottes (small, (0.7) medium ,large). Want mans van jonger jare het al begin met seks eksperimenteer. (Condoms must be made in different sizes, small medium and large to accommodate young men as they have already started sexual experimentation). Young 21. Die regering moet die 1,2,1,2 6 men (2) musiekkante of singers (0.6) aanmoedig om die gesange oor die kondome 140 Group Theme & Idea/ Statement (C) Scores (D) Average Top 5 (A) Categories (E) (F) N=10 (B) gebruik begin saamstel. (The government should encourage musician to compose songs about condom use). Young 12. Kondome moet sterker 5,4 9 men (2) gemaak word. (Condoms (0.9) must be made stronger). Young 14. Departement van 3,5 8 men (2) Gesondheid moet begin (0.8) met ‘n deur-tot-deur veldtog oor die gebruik van kondome. (Department of Health must start with door to door campaign regarding condom use). Young 9. Jeug moet begin met 1,2 3 men (2) gedagte verandering oor (0.3) die gereelde gebruik van kondome. (Youth must start to change their mind and use condoms consistently). Young 5. Departement van 3,2 5 men (2) Gesondheid tesame met (0.5) ander NGO`s soos Red Cross, Love Life, ens. moet meer effektiewe program- me opstel wat manne gaan in kennis stel oor die gebruik van kondome. (Department of Health in collaboration with NGO`s like Red Cross, Love Life should come up with effective programmes that will encourage men to use condoms). Young 1. Departement van 3,1 4 men (2) Gesondheid moet die jeug (0.4) meer aanmoedig om die kondoom te gebruik. Gereeld, dag en nag. (Department of Health ought to encourage youth to use condoms regularly). 141 Group Theme & Idea/ Statement (C) Scores (D) Average Top 5 (A) Categories (E) (F) N=10 (B) Young 20. Departement van 4 4 men (2) Gesondheid moet die (0.4) mans wat sirkumsisie gedoen het en gemeenskap, leer om die kondome te gebruik. Want mans wat sirkumsisie gedoen het, het nie minder risiko om die virus te kry, nie total nie. (Department of Health must teach circum- cised men and community to use condoms). Young 6. Departement van 2 2 men (2) Gesondheid moet meer (0.2) bewusmakings veltogte oor die gebruik van kondome hou. (Condom use awareness campaign must be organized by the Department of Health). Young 15. Departement van 1,5,4 10 men (2) Gesondheid moet begin (1) die kondome wat latex-vry en normale kondome maak. Want ander mense is allergies aan latex. (Department of Health should start manufacturing latex free condoms to accommodate those who are allergic to latex). 142 Addendum F Analysed data of the four nominal groups divided into categories, themes, statements, scores, average and Top five 143 Addendum F Analysed data of the four nominal groups divided into categories, themes, statements, scores, average and Top five GROUP CATEGORY THEME STATEMENT SCORES AVERAGE TOP 5 Older men (1) Client Education Content 7. Mans moet meer ingelig word oor 5,1,5,2 13 1 die gebruik van die kondoom. (Men must be more informed about the use of the condom). Older men (1) Content 15. Meer verduidelik oor hoe lank die 1,1 2 kondoom kan hou, meer oor die vervaldatum. (Explanations needed regarding expiry date). Young men (1) Content 11. Die jeug moet weet hoe om die 2,4 6 4 kondoom te gebruik want dis hulle verantwoordelikheid om dit te gebruik. (Youths must know how to use condoms as it is their responsibility). Young men (1) Content 14.Jeug moet meer ingelig word dat 3 3 die gebruik van kondome nie net is om HIV/AIDS te verhoed, maar ook onbeplande swangerskappe en infeksies te voorkom. (Youths must be taught that apart from HIV/AIDS prevention, the use of condoms can prevent unplanned pregnancies and infections). 144 Older men (2) Content 5. Mans moet geleer word om 3 3 kondome te gebruik, alhoewel hulle gesirkumseer is. (Circumcised men must be encouraged to use condoms). Young men (2) Content 20. Departement van Gesondheid moet 4 4 die mans wat sirkumsisie gedoen het en die gemeenskap leer om kondome te gebruik. Want manne wat sirkumsisie gedoen het, het nie minder risiko om die virus te kry nie. (Department of Health must teach circumcised men and community to use condoms). Older men (2) Content 13. Misgissings moet aangespreek 3 3 word met die algemene publiek aangaande kondoom gebruik. (Public myths regarding condom use ought to be addressed). Older men (2) Client Education Strategy 12. Plaaslike stastistieke van HIV/AIDS 5,1,2,1 9 4 in Dikgatlong moet bekend gestel word aan die gemeenskap. Sodat hulle die verspreiding kan bekamp en dan begin om kondomete gebruik. (Local statistics of HIV/AIDS in Dikgatlong should be made available to the community). Older men (1) Strategy 1. Inligtingspapiere/kennisgewings 5,4 9 4 moet uitgedeel word by die klinieke en dokters om te sê hoekom moet die kondoom gebruik word. (Information leaflets/notices must be distributed at the clinics and doctors explaining why condoms should be used). 145 Older men (1) Strategy 13. Die Departement van Gesondheid 4 4 moet altyd die werkswinkels hou oor die gebruik van die kondoom. (Department of Health should organize workshops regarding condom use). Older men (1) Strategy 19. Meer gemeenskapsprojekte moet 1,4 5 ingestel word om kondoomgebruik aan te moedig. (More community projecst should be instituted on how to use condoms). Young men (1) Strategy 4. Departement van Gesondheid moet 5,3 8 2 die werkswinkel hou om die kondoom te gebruik. (Department of Health should organize workshops on how to use condoms). Young men (1) Strategy 16. NGO`s (non governmental 2 2 organizations) moet die plakkaat maak waar die kondome beskikbaar is. (NGO`s must produce posters indicating where condoms could be accessed). Older men (2) Strategy 11. Departement van Gesondheid moet 5,3,4 12 2 huis tot huis besoeke doen, man en vrou, familie moet bewus gemaak word van die belangrikheid van kondoom. (Department of Health should launch door to door visits to make men and women aware of the importance of condoms). Older men (2) Strategy 10. Jeugkomitee moet gestig word om 2,3,2,4 11 3 die jeug te leer om kondoom te gebruik. Elke maand moet `n “talk show” gehou word. (Youth committee should be 146 established to teach how to use condoms) Older men (2) Strategy 6. Werkswinkel moet gehou word om 5,2,4 11 3 kondoom gebruik te bevorder. (Workshops be held to promote condom use). Older men (2) Strategy 1. Gereelde saamtrek te hou om die 4 4 gebruik van kondoom te verduidelik, hoe gebruik jy dit.en die belangrikheid daarvan. (Regular meetings must be convened to explain how to use condoms). Young men (2) Strategy 10. Departement van Gesondheid 5,2,5,4 16 2 moet jeug gebruik om by die skole te leer oor die gebruik van kondome, met dramas, spele, T-hemde. (Department of Health must teach youth about the use of condoms by using dramas, sketches, T-shirts). Young men (2) Strategy 2. Departement van Gesondheid moet 1,3,4,4 12 4 meer werkswinkels hou oor die gebruik van kondome en HIV/AIDS. (More workshops must be organized by Department of Health regarding condom use and HIV/AIDS). Young men (2) Strategy 21. Die regering moet musiekante/ 1,2,1,2 6 sangers aanmoedig om liedjies oor die kondoomgebruik saam te stel. (The government should encourage musicians to compose songs about condom use). 147 Young men (2) Strategy 14. Departement van Gesondheid moet 3,5 8 begin met ‘n deur-tot-deur veldtog oor die gebruik van kondome. (Department of Health must start with door to door campaign regarding condom use). Young men (2) Strategy 5. Department van Gesondheid tesame 3,2 5 met ander NGO’s soos Red Cross, Love Life, ens. moet meer effektiewe programme opstel wat mans gaan in kennis stel oor die gebruik van kondome. (Department of Health in collaboration with NGO`s like Red Cross, Love Life should come up with effective programmes that will encourage men to use condoms). Young men (2) Strategy 6. Departement van Gesondheid moet 1,5,4 10 meer bewusmakingsveltogte oor die gebruik van kondome hou.(Condom use awareness campaign must be organized by the Department of Health). Young men (2) Strategy 6. Departement van Gesondheid moet 2 2 meer bewusmakingsveldtogte oor die gebruik van kondome hou. (Condom use awareness campaign must be organized by the Department of Health). Young men (1) Client Education Responsibility 1. Departement van Gesondheid moet 5,3 8 2 die gevaar van die nie-gebruik van kondome beklemtoon. (Department of Health should emphasize the risk of not using condoms). Older men (1) Responsibility 17. Klein areas in die Noord Kaap moet 2,1,3,3 9 4 meer geleer word oor die gebruik van 148 die kondoom, deur die Departement van Gesondheid. (Rural areas in the Northern Cape must be given information about the importance of condom use by the Department of Health). Older men (1) Responsibility 2. Mans moet geleer word hoe om die 3 3 kondoom te gebruik deur gesond- heidspersoneel. (Health personnel should teach men how to use condoms). Young men (1) Responsibility 15. Die ouers moet altyd die jong mans 4,1 5 5 vertel oor die belangrikheid van kondoom gebruik. (Parents ought to tell the young men about the importance of condom use all the time). Older men (2) Responsibility 3. Opvoeding moet begin by die skole 5,5,4 14 1 dat dit belangrik is om die kondome te gebruik met samewerking van gemeenskapsgebaseerde organisa- sies, kerke, besighede, ens. (Teaching ought to begin at schools about the importance of condom use in association with home based care organizations, churches, business etc). Older men (2) Responsibility 8. Departement van Kunsen Sport 5,3 8 5 moet ook help om sport, ontspanningsgeriewe op te rig vir die jeug om hulle besig te hou en om kondome te gebruik. (Department of Arts and Sport should help to organize sport and recreation for youth to keep them busy and to use condoms). 149 Young men (2) Responsibility 7. Departement van Gesondheid moet 4,5,3,4, 21 1 die skole van gesondheid begin, waar 3,2 jeug van jonger jare kan leer oor kondome gebruik. En HIV/AIDS, gesondheidsopvoeding, STI`s (sexually transmitted infections). (Department of Health should start with school health, whereby younger scholars are taught about the use of condoms). Young men (2) Responsibility 16. Die leiers moet betrokke raak by 3,1,2 6 die kondome gebruik en die opvoeding daarvan.Rolmodelle ook, polisie, nurses, educators, dokters. (Community leaders ought to be involved with condom usage and the education thereof). Young men (2) Client education Target group 18. Departement van Gesondheid moet 2,3,3,5 13 3 ook die ouers leer oor die gebruik van die kondoom. Die ouers moet vry wees om te praat met die kinders oor die gebruik van die kondoom. (Department of Health should teach the parents about the use of condoms, and must not be ashamed to talk to children). Young men (1) Target group 13. Jong mense moet altyd die 2,1 3 kondoom in hulle sakke hê. (Young men ought to have condoms in their pockets all the time). Young men (2) Target group 1. Department van Gesondheid moet 3,1 4 die jeug meer aanmoedig om die kondoom te gebruik. Gereeld, dag en nag. (Department of Health ought to 150 encourage youth to use condoms regularly). Older men (2) Target group 4. As mans dronk is dan slaap hulle 1,2 3 sonder kondome, hulle moet geleer word om kondome te gebruik in enige situasie. (When men are drunk they are inclined not to use condoms, must be advised to use condoms). Older men (1) Target group 9. Mans wat meer kondome gebruik 2,2,5 9 4 moet ander mans wat nie kondoom gebruik nie advies gee. (Men who use condoms must give advice those who are not using condoms). Older men (2) Target group 15. Leiers van gemeenskap moet ook 1 1 geleer word oor die belangrikheid van kondome.Want die gemeenskap glo en luister na hulle. (Community leaders must be taught about the importance of condoms). Older men (1) Quality Manufacturing 20. Kondoom moet small, medium, 4,3,1,4 12 2 assurance large en extra large gemaak word om almal te akkommodeer. (Condom must be in small, medium and large sizes in order to accommodate all). Young men (1) Manufacturing 18. Die kondome moet small, medium, 1,1,3,1 6 4 large en extra large gemaak word. (Condoms should be available in different sizes, small, medium and large) Older men (1) Manufacturing 15. Instruksies moet geplaas word in 2,4 6 5 elke kondoom pakkie. Om die manne meer inligting te gee hoe om die kondoom te gebruik. (Instructions 151 should be enclosed in the condom packets explaining how to use condoms). Older men (1) Manufacturing 14. Die kondoom van die Departement 3,2 5 van Gesondheid moet dikker gemaak word om die risiko van skeure te voorkom. (Department of Health should make the condoms thicker to minimize the risk of tears). Young men (1) Manufacturing 3. Die Departement van Gesondheid 2,5 7 3 moet die Choice kondoom wat nou beskikbaar is uitwis, aangesien ditte olierige ruik en nie sterk genoeg is nie. (Department of Health must get rid of Choice condoms because they have an oily smell and is not strong enough). Young men (1) Manufacturing 17. Kondome moet meer sterker 4 4 gemaak word.Sodat hulle nie moet skeur nie. (Condoms should be strong enough not to tear easily). Young men (2) Manufacturing 8. Die kondome moet gemaak word 4,3,5,1 13 3 met verskillende soorte kleure en reuke. (Condoms must be made with different colours and fragrance). Young men (2) Manufacturing 11. Kondome moet gemaak word met 1,1,5 7 groottes: small, medium, large. Want manne van jonger jare het al begin met seks eksperimenteer. (Condoms must be made in different sizes, small medium and large to accommodate young men as they have already started sexual experimentation.). 152 Young men (2) Manufacturing 12. Kondome moet sterker gemaak 5,4 9 word. (Condoms must be made stronger). Young men (1) Quality Cost 7. Departement van Gesondheid moet 3,5 8 2 assurance voorspraak maak vir die goedkoopste pryse vir die kondome by die winkels. (Department of Health should advocate for lower price of condoms in the shops). Older men (1) Attitude Change 8. Mans wat ouer is, moet gemotiveer 5,1,5 11 3 word om die kondoom te gebruik, want ouer mans glo nie aan die gebruik van die kondoom nie. (Older men must be motivated to use condoms because they do not believe in condom use). Older men (1) Change 3. Mans in die Noord Kaap moet meer 5,5,1 11 3 ernstig raak oor die gebruik van die kondoom. (Men in the Northern Cape must be serious about condom use). Young men (1) Change 5. Maak die gebruik van die kondoom 5,4 9 1 `n tradisie onder swart mense.Want tradisie is baie belangrik by hulle. (Black people should practice condom use as tradition). Young men (2) change 9. Jeug moet begin met gedagte 1,2 3 verandering oor die gereelde gebruik van kondome. (Youth must start to change their mind and use condoms consistently). Older men (2) Change 9. Mans mense moet bewus gemaak 1 1 word as vrou se nee, nie sonder maar met `n kondoom. (Men must be made to attend to women’s wishes, and use 153 condoms if requested by women to use them). Older men (1) Communication Interpersonal 5. Mans moet meer praat oor kondoom 3,4,2,4 13 1 gebruik en nie skaam wees oor die kondoom nie. (Men must talk more about condom use and not be ashamed about it). Older men (2) Interpersonal 14. Families moet vry wees om oor 3,1 4 kondoom gebruik te praat. (Families must feel free to talk about the use of condoms). Young men (2) Availability Sites 3. Departement van Gesondheid moet 2,4,5 11 5 elke maand pakke van kondome aflewer by elke familie. Kontrolleer hoeveel jong mense is daar in die familie. (The Department of Health should deliver packets of condoms to each family. They have to be aware of how many young people are in a family). Older men (1) Sites 4. Kondome moet beskikbaar wees by 3,3 6 5 die tarvens, sjebeens, kerke en taxi’s. (Condoms should be available in the tarvens, shebeens, churches and taxi ranks). Older men (1) Sites 11. Mans moet meer aangemoedig 2 2 word oor die gebruik van die kondoom en beskikbaar wees in die werk situasie/omgewing. (Men should be encouraged to use condoms and must be available in work environment). 154 Young men (1) Sites 14. Stel meer die kondoom beskikbaar 2,4 6 4 in plaaslike gebiede. (More condoms must be available in the rural/local areas) Older men (2) Sites 7. Kondoom en plakkate wat mense 4,2 6 bewus maak moet gegee word in die drankplekke. (Posters raising awareness of condom use must be displayed in the shebeens). 155 Addendum G Calculated rank order for combined categories 156 Addendum G Calculated rank order for combined categories of nominal group technique data according to main responses. Categories Theme Top5 a Total Top5 b No. 1 Total No. 2 Ranking Average.1 Average.2 Final rank priority Ranking order response per of total Sum total of Ranking order order Values response per of total category response per all averages of of category in column category priority category all the average Top5b+No2+ response per responses per Average category category ÷by 2=Final rank number of order responses Client Content 18 5 38 5 38.93÷38=1.0 2 12 Education Strategy 2 Responsibility Target group Quality ManufacturingCo 6 4 10 4 11.03÷10=1.1 3 11 assurance st Attitude Change 3 2.5 5 2.5 6.1÷5=1.22 4 9 Communi- Interpersonal 1 1 2 1 3.27÷2=1.64 5 7 cation Availability Sites 3 2.5 5 2.5 3.95÷5=0.79 1 6 157 Addendum H Permission letter to conduct research from the Ethics Committee of the University of the Free State 158 Addendum H 159 160