“ Something must kill a man ” : Beliefs about condom use in prevention of Human Papilloma Virus among men at Kpong community

Background: Human papillomavirus (HPV) infection is highly prevalent among sexually active individuals. A report by the Ghana Aids Commission highlights low condom usage among Ghana ’ s sexually active youth. Despite this, there has been no exploration of views regarding condom use for preventing HPV infection. The purpose of the study was to examine the beliefs about condom use in preventing the human papillomavirus among men at Kpong community. Methods: The study utilized a qualitative approach with an exploratory design, employing purposive sampling to select 40 participants. Data collection involved face-to-face interviews using a semi-structured interview guide. The interviews were recorded, transcribed verbatim, and analyzed through content analysis. Results: The study produced three main themes and 8 subthemes. Despite most participants having used condoms before, primarily once (57.5 %) with a preference for “ kiss condoms" (42.5 %). The primary reason for condom use was pregnancy prevention (45 %), instead of HPV infections (22.5 %). Most participants rarely used condoms, aiming to enhance sexual pleasure or assuming their partners were HPV-free. Some cited religious reasons, viewing condom use as sinful. Conclusion: Participants commonly do not use condoms to prevent HPV infections. Additionally, men have various religious and personal reasons for not using condoms to protect against HPV and other infections. This underscores the need for increased awareness of HPV transmission among men.


Background of the study
Human papillomavirus (HPV), a prevalent sexually transmitted infection, is linked to various cancers and genital lesions. 1,2It primarily spreads through sexual contact and affects both genders. 3Annually, HPV causes approximately 570,000 cancers in women and 60,000 in men globally. 4A 2014 study found 9.0 % of tested healthy men worldwide to be HPV carriers. 4HPV also correlates with other sexually transmitted diseases like HIV and HSV-2. 57][8] Men are less likely to develop natural immunity to HPV, serving as potential reservoirs or vectors, especially in high-risk populations such as men who have sex with men. 9 In the United States, 42.2 % of males aged 14 to 59 have genital HPV infections.HPV infection rates among men are higher in Africa, and lower in Asia (3.2 % annually). 10,11Consistent condom use can prevent HPV infection and cervical cell abnormalities. 12However, condom use is uncommon in Africa, especially among school-going adolescents, associated with youth, early sexual debut, multiple partners, and lack of parental support. 13Condom use among men who pay for sex in Africa ranges from 48.7 % in Benin to 98 % in Burkina Faso. 14 study revealed that HPV infection is linked to cervical cancer, the leading cancer among Ghanaian women, with 3151 annual diagnoses and 2119 deaths. 15Educating Ghanaian men can reduce cervical cancer burden by protecting their partners from HPV.Low condom use for STI prevention in Ghana is influenced by factors such as unawareness of benefits. 16,17Research has primarily focused on condom use for HIV prevention, overlooking its role in HPV prevention among African men.This study aims to assess condom use for HPV prevention among men in the Kpong community.

Design and setting
This qualitative exploratory study, aimed at understanding men's perspectives on condom use for HPV prevention, was conducted in Kpong, a town in Ghana's Eastern Region known for the Kpong Dam. 18,19It focused on men aged 18 and above residing in Kpong who voluntarily consented to participate, excluding women and men from neighboring communities.The study emphasized interpreting participants' thoughts and feelings to gain a deeper grasp of the social realities surrounding HPV prevention.

Data collection instrument and procedure
Participants were purposefully selected through this sampling strategy from a population that met the study's eligibility criteria.This technique was chosen because the participants exhibited essential characteristics required for inclusion in the study.Participants were recruited from various community settings, including homes, taxi stations, wedding venues, and churches, primarily on Sundays.Men aged 18 and above were informed about the study and recruited after obtaining permissions from community leaders, station chairmen, and church leaders.Twelve participants were recruited directly from their homes.After explaining the study's purpose, those interested provided their contact details to schedule interviews.All participants were required to sign a consent form to participate, with the understanding that they could withdraw consent at any time.No incentives were offered due to the absence of funding for the study.The sample size was established based on saturation criteria, ceasing data collection when no further information was gleaned.Saturation occurred after the 35th interview; however, five subsequent interviews yielded no new insights.Overall, 55 men were approached, with 10 declining participation and 5 failing to attend scheduled interviews.
A semi-structured interview guide served as the primary data collection tool, facilitating in-depth, face-to-face interviews.This format enabled participants to freely express their views while allowing the researcher to explore detailed aspects through probing questions.A pilot study involving five men from Loloryo in the Lower Manya Korbo community led to necessary revisions in the interview guide.Each interview spanned 40-60 min, with the overall data collection process extending over two months.
To ensure reflexivity, the authors openly discussed their personal perspectives, particularly regarding their religious beliefs, to ensure that their biases did not influence the data collection process.The authors maintained handwritten field notes to capture participants' reactions during interviews.Many participants expressed happiness, with some laughing at certain questions.However, some appeared shy, with one participant withdrawing midway, citing religious beliefs that prohibited them from answering certain questions.

Ethical consideration
Ethical clearance was obtained from the Dodowa Health Research Centre Institutional Review Board (DHRCIRB) with protocol number DHRCIRB/254/12/22.Before data collection, participants provided written and verbal consent, assured of confidentiality, autonomy, and beneficence.They were informed of their right to withdraw anytime without penalty, ensuring adherence to all ethical standards for human research.

Data analysis
In the current study content analysis was utilized for analysis of data gathered from study participants.Content analysis is a technique for methodically identifying classifying, and providing insight into patterns of meaning (themes) present across a dataset; it enables the researcher to recognize and understand collective or shared meanings and experiences by focusing on meaning across a dataset. 19As postulated by 20 there are four phases of thematic content analysis which include familiarization, generating codes, categorizing codes into themes and theme organization.

Methodological rigor
The trustworthiness of this study was ensured throughout the study by fostering credibility, transferability, dependability and confirmability.These were ensured in the current study by purposefully choosing participants for the study, and member checking was done on two of the participants who were later called to clarify some information transcribed.The researchers also provided detailed information and a clear description of the culture and context within which the research took place.Also, step-by-step process and methods used for data collecting, analysis, and interpretation provided.

Sociodemographic data of the participants
The study was conducted with forty male participants from the Kpong community in Ghana, West Africa, encompassing both married and single men aged 18 and above.Demographically, 25 % (10 participants) were aged 18-30 years, 37.5 % (15 participants) were between 30 and 40 years, and 15 % (6 participants) were between 40 and 50 years.None of the participants were above 60 years.Educational levels ranged from basic to higher education.The majority, 75 %, were married, while the remainder were single or divorced.Regarding religious affiliation, 75.5 % identified as Christians, with the rest being Muslims, and there were no traditionalists.Further demographic details are provided in Table 1.

Themes and subthemes
Three main 3 and 8 sub themes were generated.See Table 2 for details.

Justification to or not to use condoms for HPV prevention 3.3.1. Pleasure over condom protection from HPV
It is undeniable fact that the use of condom is the best means to prevent STIs including the transmission of HPV, However the use of condom was uncommon among the participants of the current study as they indicated that it does not give pleasure to enjoy sexual activities.It was commented that; "To be frank with you, if I use condom during sexual intercourse, I don't feel anything, It is like I am not having sex, but if I don't use condom which we call 'raw' … I do feel that I am having sexual intercourse and it is so sweet, so I prefer not to use condom as my girlfriend does not have this HPV″P15 "I don't use condoms for sexual encounters because they dull the sensation of sex for me.Instead, I stick to one partner to avoid diseases like HPV.Although I rarely use condoms, I did try a "Kiss Condom" once during my first sexual experience "P3 "When you are in the mood you will not remember this virus, it is after you are done that you come to your senses, The first time I used condom was about 10years ago and since then I have never used it again.Why because it does not make me feel the sexual pleasure, but rather I prefer skin to skin where the penis touches the walls of the vagina directs"P20 However, the use of condom was to prevent infection was key to some participants as they always use it during sexual activities to prevent infection.They stated that; "Why should I risk my life when I know that there are many sexually transmitted diseases?I cannot do that unless my wife, any other woman I will have sex with put on condom.I don't want to carry disease and bring home.I always have kiss or Durex condom in my bag, should in case"P10 "I once had sex with a lady with a rough rider condom who nearly removed the condom but I stopped her because I was afraid I will contract infections like the HPV, since she is not my wife I might not be the only person having sex with her"P14

Trust in sexual partners
Trust impacts condom use; some participants skipped them, having trust in their partners, as their narratives revealed.
"Ohh I am fully aware that the use of condom is good to prevent HPV from women; but I know that my partner will not cheat and have sex with other men.Currently, I know that she is not having HPV and so I am free to have sex without wearing condom" P6 "As it is now, I have only one wife she has been my sexual partner for about 5 years now.I trust in her and she also trust me that I will not have sex with another woman.So we trust each other and there is no need for to wear condom for the fear of HPV …..no ….we trust each other"P14 Some participants in their narration however reported that they use condom for sexual intercourse due to trust issues they have with the lady partners.Here are some of their comments; "I don't have trust in the woman I am dating now looking at the way she behaves towards me; and I think that she could have been having sexual affairs with another man elsewhere.As a result, whenever she comes to my end, I use condom because I am afraid of contracting viral infections" P19

Effectiveness of condom use
Condom effectiveness varies; breakage can reduce their reliability in preventing HPV, as participants reported differing experiences.
"I mostly use condoms during sexual affairs; it is reliable and safe to use.I spend approximately 80 Ghana cedis a month for condom alone.I believe that this is the main reason why I have not contracted HPV or other STIs as I sometimes take sexual workers to have affairs with them, sometimes I have sex with about 3 of them before day break if I have money so you know why I spend a lot on condom"P5 "In actual fact, condom has never failed me before; I heard people complaining that they used condom but their lady got pregnant.Perhaps, it may be as a result of the type of condom they use, but personally I have not experience condom failure neither getting a lady pregnant or contracted infections like HPV before"P3 However, some of the participants stated that they had ever experienced condom failure and therefore condom cannot be relied upon to prevent HPV.They commented that "I used condom every week.One thing about the condom is that it can break or remove during rough sex.I am saying this because I was using a condom for sexual intercourse it broke one time and removed severally.So, if the lady is having HPV or any infections, I would have contracted them" P18

Personal beliefs and values about condom use
Participants' beliefs, particularly faith-based, influenced their condom use, as reflected in their diverse statements.
"Hmm I am not aware condom can be used to prevent HPV.I hold to the faith that it is a means of abortion because the sperm is poured in the condom and throw away.I understand it to be an abortion which the bible says we should not do" P28 "The fact is that some of us are religious people and so engaging in sexual affairs with the use of condom I belief it is a sin and should not be done, after all I am married person with strong Christian faith so I cannot contract HPV" P22 However, some of the participants expressed that they did not have any belief and values regarding condom use.One of the participants stated that; "I use condom for the reason it supposed to be used, I don't have any sort of beliefs or values regarding condom use.All that I want is protection from HPV and other infections.You cannot trust ladies of today" P13

Preference for coitus interruptus over condom use to prevent HPV
In this study, participants preferred withdrawal over condoms for HPV prevention, citing various reasons.
"Well, I say that anytime I am having sex using condom, I don't really feel the enjoyment.I feel that it just a waste of energy because I don't enjoy it.So, I prefer to have sex as raw so that if I am about to ejaculate, I withdraw.If you are ready for sex you should forget about infection" P31 "Haven't you heard the term something musk kill a man?If I decide to enjoy I want to do it to the max.I have only used condom once.I only have to remove the penis earlier to ejaculation out of the vagina as I am not yet married to the girls yet" P10 In the contrary, some of the participants stated that they were not influenced by the preference to coitus interruptus.These were their views; "The reason why condom was manufactured must be considered and if I do coitus interruptus I know that I will definitely be infected with HPV and other infections.To me my philosophy is protection as the lady will leave you if you are sick or dead" P32

Availability and accessibility of condom for HPV prevention
The study examined participants' varying views on the availability and accessibility of condoms, as illustrated in comments below.
"Look condom is available in every chemical shop to buy.With as low as 10-20 cedis you can get some to buy and it has 3 each inside.I will not believe if someone says there is no condom available in the system to buy, so if someone do not use it for infection prevention like HPV, then he or she does not want to use it … …."P1 "Some health care providers even share condom to us in school so accessing it is not problem.They told us we should use it should in case we engage in sex so we can be protected from all infections including HPV" P33

Adherence to precautionary measures to prevent HPV
Participants discussed the practical aspects and techniques of wearing condoms before engaging in sexual activities.Here are some of their comments: "Some of the condoms come with a precaution for example, we should not tear the condom with our teeth.I know,because \ it is something that will benefit us and so personally I don't use my teeth to open or tear the condom pack before removing it because if it tears, I will contract infections" P27 "I was told that I should not use sharps to open the condom to avoid cut am not sure of all infections and even the HPV but I know if it tears it has lost its protection and I will not have enough time to go get new one, I am always in a hurry at that point" P18

Effects of condom use on relationship
Participants noted that condom use, despite preventing sexually transmitted diseases, can negatively impact relationships.Here are some of their comments: "My girlfriend prefers it raw because she knows what to do after, but I like condom because I have a wife and children, I do not want to transmit any infections like HPV to my wife.However, she always quarrels with me if I want to use a condom and sometimes, she has to leave without the sex if I says no" P4 "I have 10 children, so I prefer using condom when I have sex since.I do not want to get pregnant, but my wife do not like the condom because she has the idea that condom is not for married couples, so it become a fight in the house and she has denied me of sex 2 whole months because of this" P8

Discussion
Participants noted diminished sexual pleasure with condom use, heightening their vulnerability to HPV.Condoms prevent STI transmission, including HPV, by blocking fluid exchange.Monogamy with an HPV-free partner lowers risk, while multiple partners increase it.Education is essential to promote condom use, especially among those with multiple partners.This is supported by research among young black men in New Orleans, which found that condomless sex is preferred for emotional closeness and increased pleasure. 21ome participants reported a reduced likelihood of using condoms due to trust in their partners' fidelity, increasing their vulnerability to HPV.Engaging in unprotected sex with others based on trust, especially outside of marriage, raises the risk of HPV and other STDs.Therefore, abstaining or maintaining monogamy is advisable.A study among 800 Nigerian students reported trust as a common reason for not using condoms. 22Conversely, a lack of trust led some participants to consistently use condoms during sexual encounters.Some participants link condom use with controversial beliefs like abortion or satanic practices, and worry about breakage leading to HPV transmission.Within religious communities, opinions vary: some Christians view it as conflicting with procreation norms, while others accept it.It's important to separate public health from spiritual beliefs.Those with such views might choose abstinence with a faithful partner to prevent HPV.Studies in Ghana showed no effect of religiosity on condom use, whereas in Tanzania, opinions were mixed among religious leaders and parents regarding condom promotion 23 , 24 .
The study indicated a preference for withdrawal among participants, who often forego condoms for increased sexual pleasure despite its ineffectiveness against HPV and STIs.Educating on condom effectiveness for HPV prevention is vital.Although some adolescents recognize various contraceptive methods, they may not fully understand their protective differences against STIs. 25In Kpong Katamanso, Ghana, condoms are noted to be both available and accessible, enhancing HPV prevention. 26Ensuring consistent condom supply is critical to meet immediate protection needs and effectively prevent HPV, as confirmed by 85 % of participants acknowledging easy access to condoms.
Participants emphasized the importance of adhering to condom package instructions, such as avoiding sharp objects when opening and following application guidelines, to prevent HPV transmission.Proper techniques help prevent tears, reducing infection risks. 26Nationwide education on these practices is crucial for HPV control.Moreover, exploring innovative factors like AI can enhance HPV management by improving personalized treatments and early detection in oncology. 27ducation should extend to men in both urban and rural areas to mitigate HPV spread effectively, emphasizing AI's potential in reaching a broader male population and advancing research in the field.

Conclusion
In conclusion, this study reveals a troubling trend of frequent condom neglect among participants, heightening the risk of HPV infections.Religious beliefs and personal attitudes were identified as significant barriers to condom use.This underscores the critical need for targeted educational campaigns that specifically address these factors and promote awareness about HPV transmission.Involving local religious leaders in these prevention efforts could help dispel myths and encourage safer practices.Future research should prioritize the development of customized educational initiatives that effectively communicate the risks associated with HPV and the critical role of consistent condom use.Additionally, exploring the potential of artificial intelligence to enhance education on HPV, improve screening processes, and reduce HPV-related mortalities could provide valuable insights into more effective strategies for combating this public health issue.

Limitation of study
The study was confined to a single region in Ghana, and the sample size may impact the generalizability of the findings.However, it provided valuable insights into men's perspectives on condom use to prevent HPV, which could inform future interventions and research endeavors.

Table 1
Socio-demographic data of participants.

Table 2
Organization of the themes and subthemes.