Construction Management and Economics

ISSN: 0144-6193 (Print) 1466-433X (Online) Journal homepage: http://www.tandfonline.com/loi/rcme20

Condom use by South African construction

workers

Paul Bowen, Rajen Govender & Peter Edwards

To cite this article: Paul Bowen, Rajen Govender & Peter Edwards (2017): Condom use
by South African construction workers, Construction Management and Economics, DOI:
10.1080/01446193.2017.1311019

To link to this article: http://dx.doi.org/10.1080/01446193.2017.1311019

Published online: 03 Apr 2017.

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Construction Management and Economics, 2017
http://dx.doi.org/10.1080/01446193.2017.1311019

Condom use by South African construction workers

Paul Bowena, Rajen Govenderb and Peter Edwardsc
a
Department of Construction Economics and Management, University of Cape Town, Cape Town, South Africa; bViolence, Injury and Peace
Research Unit, South African Medical Research Council, and Department of Sociology, University of Cape Town, Cape Town, South Africa; cSchool
of Property, Construction & Project Management, RMIT University, Melbourne, Australia

ABSTRACT ARTICLE HISTORY

Consistent and proper condom use is pivotal in preventing HIV infection. HIV prevalence in South Received 27 August 2016
Africa is among the highest in the world, with the construction industry especially affected, yet Accepted 20 March 2017
little is known about condom use by construction workers and the determinants thereof. Data
KEYWORDS
were gathered from 512 site-based workers in the Western Cape. A theoretical model explaining HIV/AIDS; construction
condom use as a function of demographic factors, HIV knowledge, substance usage and risky workers; condom use
sexual behaviour (excluding condom use) was proposed and tested using regression and structural
equations modelling. The findings indicated that age, gender and level of education were indirect
determinants of condom use, with higher levels of education predicting better AIDS-related
knowledge. Higher levels of risky sexual behaviour were associated with more frequent use of
condoms, suggesting greater awareness of risk. Condom use was adversely affected by greater
alcohol and drug use, probably as a result of diminished capacity to assess risk. Finally, lower and
not higher levels of AIDS-related knowledge were associated with better condom use, suggesting
that improved knowledge of HIV transmission may work contrary to safe sex practice if it lulls the
person into a false sense of confidence. Recommendations for targeted workplace interventions are
proposed.

Introduction The South African Government’s response to HIV/AIDS

during the tenure of former President Thabo Mbeki (1999–
Sub-Saharan Africa has borne the brunt of the global HIV/
2008) was largely characterized by “AIDS-denialism”, lack
AIDS pandemic. In 2013, an estimated 24.7 million persons
of political will and poor implementation of policies and
in the region were HIV+, accounting for 71% of infections
programmes (Karim et al. 2009). Following his departure,
worldwide. Moreover, it was estimated that, in the same
and as a result of considerable civil society pressure and
year, there were 1.5 million new HIV infections and 1.1 mil-
legal action, the government embarked on an ambitious
lion AIDS-related deaths (UNAIDS 2014). UNAIDS (2016)
public health programme to fight the spread of the dis-
also reported that South Africa has the largest and most
ease, including improvements in access to condoms, and
high profile national HIV epidemic in the world, with an
scale-up of free antiretroviral therapy (ART) (Karim et al.
estimated 7 million people living with HIV in 2015. The
2009). The condom programme saw considerable expan-
benchmark survey into HIV prevalence and incidence in
sion in a few years. Between 2007 and 2010, the distribu-
South Africa is the South African National HIV Prevalence,
tion of male condoms increased by 60%, from 308.5 million
Incidence and Behaviour Survey (Shisana and Simbayi
to 495 million a year. In the same period, the number of
2002, Shisana et al. 2005, 2009, 2014). The latest survey
female condoms distributed increased from 3.6 million
indicated that national HIV prevalence among South
to 5 million (South African National AIDS Council and
Africans in 2012 was 12.2% (6.4 million persons), a signif-
National Department of Health 2012). The female condom
icant (p < 0.001) increase on the 2008 national estimate
programme is regarded as one of the biggest and most
of 10.6% (5.2 million) (Shisana et al. 2014). In 2015, there
established in the world (Beksinska et al. 2012).
were an estimated 380,000 new infections while 180,000
The link between (low or inconsistent) condom use
South Africans died from AIDS-related illnesses (UNAIDS
and heightened risk of HIV infection is well researched
2016). The HIV/AIDS pandemic is considered one of the
and documented. UNAIDS (2013) reports that the correct
main health challenges facing South Africa (Mayosi and
and consistent use of condoms reduces the risk of sexu-
Benatar 2014).
ally transmitted infection (STI)/HIV transmission by over

CONTACT  Paul Bowen  Paul.Bowen@uct.ac.za

© 2017 Informa UK Limited, trading as Taylor & Francis Group
2   P. BOWEN ET AL.

90%. In South Africa, Hargreaves et al. (2007) identified Background to the study
poor and inconsistent male condom use as a key driver
A cornerstone in the response to the South African pan-
of HIV infection. Further, Shisana et al. (2014) noted that
demic is the National Strategic Plan (NSP) for HIV, TB and
overall condom use at last sexual intercourse occasion
STIs (South African National AIDS Council 2017a), currently
increased significantly from 2002 to 2008, but then sig-
in its fourth iteration. The NSP leverages lessons from past
nificantly decreased in 2012 across all age groups and for
public health gains and provides a strategic framework
both genders except among females aged 50 years and
for a multi-sector partnerships. Goal 5 of NSP 2017–2022
older. With regard to consistent condom use during sexual
proposes “…. deeper involvement of the private sector and
intercourse, Shisana et al. (2014) reported that, in 2012,
capacitation of civil society sectors and community networks”
27.4% of all sexually active respondents 15 years and older
(South African National AIDS Council 2017a, p. 5). This has
indicated that they had always used a condom at last sex
been elaborated into calls for the private sector to engage
in the preceding 12 months with their most recent sexual
in workplace programmes, including use of peer educa-
partner. However, over half of respondents (52.9%) who
tors, support and capacity building, condom distribution,
had regular sex in the last 12 months had not used a con-
and anti-retroviral therapy (ART). In addition, the private
dom. The report did not, however, indicate whether the
sector is encouraged to integrate HIV prevention and care
52.9% included regular sex partners or not.
into sexual behaviour and wellness programmes (South
Compared with other economic sectors and industries,
African National AIDS Council 2017b).
the construction industry is disproportionately adversely
The imperative for greater engagement by the private
affected by the HIV/AIDS pandemic (Bureau for Economic
and civil sectors is premised on the considerable chal-
Research/South African Business Coalition on HIV/AIDS
lenges faced by the public health care system. After two
2004, Bowen et al. 2008). The heightened susceptibil-
decades of democracy, profound health care inequalities
ity of the construction industry may be attributed to its
still exist (Eyles et al. 2015), as well as a number of other
fragmented nature; the predominance of small firms;
problems. The South African Human Rights Commission’s
comparatively low levels of worker education and liter-
(2010) inquiry into the accessibility of health care services
acy (especially for older workers); the widespread use of
identified poor staff attitudes and inadequate staff levels
“informal” labour; the migratory nature of its workforce;
as significant challenges at all levels of the health system,
and the diversity of construction work in terms of nature
impacting negatively on the quality and availability of care.
and location (Meintjes et al. 2007). The migratory employ-
Similarly, Gilbert (2006) and Wouters et al. (2009) empha-
ment pattern (rural to urban) typically found in the South
size overburdened health care staff, and an overstretched
African construction industry may exacerbate this as work-
public health system. Moreover, despite improvements
ers seek to satisfy their sexual needs in between infrequent
in leadership, greater coordination in addressing HIV and
visits to their rural homes (Smallwood and Venter 2001).
tuberculosis (TB), and recognition of the need for better
Despite this increased susceptibility, the sector has been
integration of all health care services, challenges remain
one of the slowest to respond to the pandemic (Meintjes
with a growing non-communicable disease burden, diffi-
et al. 2007), placing greater strain on other institutions and
culties in coordinating and strengthening the health sys-
actors to compensate for this inaction. Given the overbur-
tem, and a weak information and surveillance capacity
dened public sector’s inability to combat the pandemic
(Mayosi et al. 2012).
by itself (Gilbert 2006, Cleary et al. 2008, Wouters et al.
The inattention of private sector companies in respect of
2009, Knijn and Slabbert 2012), civil society (Kelly and van
HIV prevention and treatment has been criticized and char-
Donk 2009) and the private sector (Overseas Development
acterized as negligent and contrary to the public good as it
Institute 2007) arguably have an increasingly greater and
places the burden solely on the public sector with its limited
more important role to play.
resources (see Sanders and Chopra 2001, 2006). Historically
Despite extensive research in South Africa into con-
the focus of the construction industry has been on safety
dom use and its antecedents, little relates directly to the
rather than on health per se, though more recently the focus
extent to which these factors are associated with con-
has widened amongst a few companies to include the need
dom use by construction workers. The aim of the study,
to reduce work-related illnesses, and, to a lesser extent, pro-
within the broader context of related public health
vide primary health care and management (Smallwood et al.
research, is to better understand how demographic and
n.d.). However, in general the sector continues to lag behind
risky sexual behaviour factors of construction workers
other sectors, most notably mining, in its overall response to
are associated with their attitudes towards and use of
the pandemic. The mining sector provides useful pointers
condoms.

for a variety of reasons. Firstly, it highlights the important
role of worker unions, often in conjunction with mine man-
agement, in raising the profile of HIV/AIDS and educating
workers regarding HIV transmission. Another instance
would be the development of relevant resources such as
the “HIV: Guide for the Mining Sector” (International Finance
Corporation 2004), which sets out detailed proactive inter-
ventions for mining companies. A further example is an
innovative development that departs from traditional IEC
(information, education, and communication) approaches
to a focus on the root causes of transmission e.g. poverty
alleviation, cultural norms around sex (for example, condom
use), and social and economic instability. The construction
industry, although faced with very similar problems, has no
such initiatives (Bowen et al. 2010, 2014).
Condom use and associated risk factors
Condom use and risky sexual behaviour
Condom use and risky sexual behaviour are closely interre-
lated behaviours, though with some important distinction
between them. Whereas condom use refers specifically to
the use of prophylactics, risky sexual behaviours encom-
pass a range of behaviours associated with greater risk for
infection from STIs and HIV, including but not limited to,
transactional sex, number of concurrent partners, general
promiscuity (new partners), etc. For the purposes of this
research, these are regarded as two distinct constructs.
Additionally, as will be argued later, risky sexual behaviour
is also distinguished from use and abuse of alcohol and
illegal substances, though these two are also associated
behaviours in terms of risk of STI/HIV infection.
High rates (28% - 54%) of unprotected sex have been
found in surveys in the general population in South Africa
(e.g. Crepaz and Marks 2003, Olley et al. 2005). In a study
of condom use among young people in a South African
township, MacPhail and Campbell (2001) identified six fac-
tors that adversely influence condom use: low perceptions
of risk; peer group norms and expectations; relative lack
of condom availability (or failure to ensure appropriate
availability); adult attitudes and preferences about con-
doms and sex; male-skewed gendered power relations;
and adolescent condom affordability.
Sexual promiscuity has been found to be a contributing
factor to the spread of HIV/AIDS (Smallwood and Venter
2001), as has sexual concurrency (more than one sexual
partner overlapping in time) (see Morris and Kretzschmar
1997, Eaton et al. 2011, Mah and Shelton 2011, Fox 2014).
Transactional sex (intercourse with a non-primary partner
in exchange for money, housing, or material goods) (driven
by a survival imperative) also places women at increased
risk of HIV infection (Dunkle et al. 2004).
CONSTRUCTION MANAGEMENT AND ECONOMICS   3
Substance use
Poor and inconsistent condom use is one element of risk-
based sexual behaviour and its association with the risk of
HIV infection. Another is substance use (Parry et al. 2004,
Morojele et al. 2013). Drug use and heavy use of alcohol
before sexual intercourse have been found to be associ-
ated with risky sexual behaviours and with lack of con-
dom use (Eich-Hochli et al. 1998, Shisana et al. 2004, Cook
and Clark 2005, Parry et al. 2005, Kalichman et al. 2007,
Peltzer et al. 2011, Seth et al. 2011). Morojele et al. (2006)
and Kalichman et al. (2008) highlighted the association
between alcohol consumption, sexual promiscuity and
lack of condom use at informal drinking establishments
(“shebeens”) in townships. Shisana et al. (2004) and Seth
et al. (2011) showed a strong link between sexual risk-tak-
ing behaviour and alcohol use. Shisana et al. (2004) also
established a positive link between higher levels of alcohol
consumption and having multiple sex partners, and that
condom use during the last coital act was significantly
and negatively associated with frequency of alcohol use.
Kalichman et al. (2006) identified alcohol as a major factor
in risky sex behaviour because intoxication often leads to
casual sex and inconsistent condom use, and found that
men were more likely than women to have used drugs and
to have had multiple sex partners.
AIDS-related knowledge
Although empirical support for a direct link between HIV
transmission knowledge and risky sexual behaviour is
reportedly mixed and inconsistent (see Fisher et al. 2009),
Scott-Sheldon et al. (2013), in a study of "Black" African
men drawn from four townships outside Cape Town, found
that, for men who had tested HIV-negative, HIV (transmis-
sion) knowledge was inversely related to sexual risk behav-
iours. They concluded that HIV knowledge might be an
important predictor of risky sexual behaviour in the South
African context (Scott-Sheldon et al. 2013), but cautioned
that ongoing post-test HIV education and support may
be required for South African men to maintain their HIV-
negative status. In a study of high school students in the
USA, Anderson et al. (1990) found that students who knew
more about HIV transmission were less likely to have had
multiple sex partners. Similarly, in their study of at-risk
African-American women, Carey et al. (1997) reported
that increased AIDS-related knowledge strengthened
their intentions to adopt safer sexual practices and that
they engaged in fewer acts of unprotected vaginal inter-
course. These effects were observed immediately and,
importantly, most were maintained at follow-up.
Govender et al. (2016) found AIDS-related knowledge
to be a significant differentiator of persons endorsing
4   P. BOWEN ET AL.
Substance use and
Demographic Factors
AIDS-related knowledge
SUBSTANCE USE:
Alcohol and drug use
Age
Gender
Education
AIDS KNOWLEDGE:
AIDS-related knowledge
Figure 1. Graphical overview of the conceptual model.
customary (traditional) beliefs (e.g. supernatural forces
and spirits) about the cause of AIDS, as compared to per-
sons not endorsing such beliefs. Incorrect AIDS-related
knowledge may be thus be amplified by adherence to
customary beliefs about the cause of AIDS that discount
scientific explanations, potentially impacting on increased
risky sexual behaviour and reduced condom use.
Cumulative effects
Apart from their independent effects, risky sexual behav-
iour, substance abuse and HIV transmission knowledge
have a combined effect on condom use. Zetola et al.
(2014) argue that individuals choose to engage in high-
risk sex behaviours (measured as number of primary and
casual partners in the last year, frequency of condom use,
a diagnosis of a sexually transmitted disease within the
prior year, and tranactional sex), as a direct consequence
of alcohol consumption and despite having high levels of
HIV transmission knowledge. Schwitters et al. (2015), in
a study of young Namibian HIV-negative men identified
as harmful or hazardous drinkers, found that participants
understood their risk of HIV infection as being high due
to their alcohol use and notwithstanding their high levels
of HIV transmission and prevention knowledge. In a study
of Nigerian tertiary education students, Ugwa et al. (2015)
found that, despite high knowledge about HIV transmis-
sion and prevention, students continued to engage in
high-risk sexual behaviour such as having multiple sexual
partners. These studies highlight that these behaviours
have both singular and collective effects on condom use,
and may in some instances work despite some of them
e.g. high levels of transmission knowledge.
Risky sexual behaviour
and Condom use
Risky sexual Attitudes towards and
behaviour use of condoms
Given these associations between, on the one hand, the
use and abuse of alcohol and drugs, risky sexual behaviour,
and AIDS-related knowledge and, on the other hand, con-
dom use, further investigation of these multivariate rela-
tionships is important not only in terms of understanding
the motivation for such behaviour, but also for ascertain-
ing the management interventions available to employer
organizations as their contribution to the public health
response to the HIV/AIDS pandemic.
A conceptual model of condom use
Based on the literature review, a conceptual model of fac-
tors predicting condom use was proposed (see Figure 1).
The conceptual model proposes that age, gender and
level of education can be regarded as exogenous variables
for the model as they are deemed as given conditions for
the survey respondents and hence do not require expla-
nation. These exogenous variables are hypothesized to
explain AIDS-related knowledge, alcohol and drug use,
and risky sexual behaviour. AIDS-related knowledge and
alcohol and drug use are hypothesized to explain risky sex-
ual behaviour, and, collectively with risky sexual behaviour,
explain attitudes towards and use of condoms.
Research method
Participants and setting
A supervised field setting (construction sites) was used to
conduct the survey with self-administered questionnaires
used as the data collection instrument. Convenience sam-
pling was used for the selection of construction firms and

Table 1. Scale items for composite variables (n = 512).
Items
1. Demographic variables
Age
Gender
Ethnicity
Education
Nature of employment
Marital status
Children
Knowing HIV+ persons
HIV testing
HIV status
2. AIDS-related knowledge (AK)
AK1. Can men give AIDS to women? (Yes)
AK2. Can women give AIDS to men? (Yes)
AK3. Must a person have many different sex partners to get AIDS? (No)
AK4. Does washing after sex help protect someone from getting AIDS? (No)
AK5. Can a pregnant woman give AIDS to her baby? (Yes)
AK6. Can the use of vitamins and healthy foods cure AIDS? (No)
AK7. Can traditional African medicines cure AIDS? (No)
3. Alcohol and drug use (AD) – in the past 3 months, how often have you used:
AD1. Alcohol
AD2. “Dagga” (cannabis)
AD3. “Tik” (crystal methadone)
AD4. Cocaine
AD5. Mandrax (Methaqualone)
4. Life risk (LR)
LR1. Have you had two or more sex partners in the last 3 months?
LR2. Have you ever received money, housing, gifts or food for sex?
LR3. Have you ever given money, housing, gifts or food for sex?
5. Condom use (CU):
CU1. Did you use a condom the last time you had sex?
CU2. Do you like to use a condom during sex?
Note: For AIDS-related knowledge, correct responses are indicated in parentheses.
sites, as well as the workers interviewed. The sampling was
convenient in the sense that these firms had previously
participated in an investigation into HIV/AIDS policies
and treatment programmes implemented by Western
Cape construction firms (see Bowen et al. 2010, 2014).
The sample frame consisted of all employees present
when researchers visited the sites by prior arrangement.
For logistical reasons, the geographical scope of the study
was restricted to the Western Cape region of South Africa.
Participants (n  =  512) were site-based skilled and
unskilled workers and site-based office staff drawn from
6 firms on 18 construction sites in the province. The ques-
tionnaires were made available in English, Afrikaans and
isiXhosa (an indigenous African language), the most com-
monly spoken languages in the Western Cape. Workers
were briefed on the nature of the study. They were assured
that their participation was entirely voluntary and anon-
ymous, and informed that they could withdraw such par-
ticipation at their will. Following the briefings, participants
who provided informed consent then proceeded to com-
plete the questionnaires. At each of the 18 sites, this took
place in large container offices equipped with tables and
CONSTRUCTION MANAGEMENT AND ECONOMICS   5
Response options
Age in years
Male = 1; Female = 2
“Black African” = 1 “Colored” = 2; Indian = 3; “White” = 4
Primary of less = 1; Secondary = 2; Tertiary or higher  = 3
Permanent = 1; Temporary/Contract = 2; Casual = 3
Married/Long-term relationship = 1; Single = 2
Yes = 1; No = 0
At least 1 = 1; None = 0
Tested = 1; Not tested = 0
Positive = 1; Negative = 0
Response options: Agree; Disagree; Do not know
Correct response = 1; Incorrect response  = 0; Do not know = 0
None = 0; Once only = 1; More than once = 2
Yes = 1; No = 0
Yes = 1; No = 0
chairs. On each occasion, proficiency in all three languages
was available through the attending field researchers,
whose assistance was limited to clarifying the meaning
of particular questions for participants who had experi-
enced difficulty in understanding them in the language
version they had chosen. One researcher was female, and
the other two were male. The time taken to complete the
questionnaires ranged from 30 min to 1-h, depending on
participant literacy levels.
Measures
The full set of questions, together with their scoring
regimes, is depicted in Table 1. The questionnaire was
based on instruments previously employed in the general
population in South Africa (Kalichman and Simbayi 2003,
2004). These comprise validated instruments especially
developed for application in South Africa.
Demographic characteristics
Participants provided personal information including age,
gender and level of education.
6   P. BOWEN ET AL.

AIDS-related knowledge and greater). Model improvements and parsimony were

Seven items, drawn from Carey and Schroder (2002) and tested using the Chi-Square Difference Test (Tabachnick
Kalichman and Simbayi (2003, 2004), were used to create and Fidell 2014).
a scalar measure of AIDS-related knowledge. The scale was Multiple linear regression analysis was used to identify
scored for the number of correct responses, with higher significant predictors of AIDS-related knowledge, alcohol
scores indicating higher levels of AIDS-related knowledge. and drug use, risky sexual behaviour, and condom use.
Variables entered into the regression models were selected
Alcohol and drug (substance) use on the basis of evidence from the extant literature.
Five items, drawn from Kalichman and Simbayi (2003, Following the regression analyses, an integrated the-
2004), were used to create a scalar measure of substance oretical model to examine the direct and indirect deter-
use (the consumption of alcohol and the use of illegal minants of risky sexual behaviour and condom use was
drugs in the preceding three months). Alcohol was not specified and tested using structural equation modelling.
distinguished by type. The illegal drugs examined included
“Dagga” (cannabis), “Tik” (crystal methadone), cocaine, and
Results
mandrax (methaqualone). An additive scale was computed
with higher scores indicating higher levels of substance Missing value analysis
use).
Missing value analysis indicated that the proportion of the
sample with missing values on all of the items of inter-
Risky sexual behaviour
est was less than 5%, with most items having less than
Three items, based on Kalichman and Simbayi (2003,
2% missing values. The low frequency of missing values
2004), were used to create a scale measure for risky sexual
meant that these could be addressed by listwise deletion
behaviour. Participants were asked about sexual encoun-
(Graham 2012).
ters in the previous three months, and whether or not
they had ever exchanged sex for money, housing, gifts or
food for sex (“transactional sex”). The scale was scored so Participant characteristics
that higher scores indicated higher levels of risky sexual
Most participants were male (91%; n = 461) and between
behaviour.
18 and 69  years (mean  =  36, SD  =  10.86), with most
respondents in the 21–30 year age group (34%; n = 168).
Use of, and attitudes towards, condoms (condom use)
Almost two-thirds (62%; n = 313) were “Black” African (as
Drawing on Kalichman and Simbayi (2003, 2004), use of
distinct from the other ethnic groupings). Over a quarter
and attitudes towards condoms was explored through
(29%; n = 144) had at most primary level education, whilst
dichotomous questions that asked participants whether
52% (n = 260) had secondary level education. Sixty-two
a condom was used at last coital activity, and whether or
per cent (n = 304) of participants were permanent employ-
not they liked using a condom. The computed scale was
ees, as distinct from contract (employed on a project basis:
scored such that a higher score indicated more positive
34%; n = 167) and occasional (casually hired: 4%; n = 22)
attitudes towards, and more frequent use of, condoms.
workers. Sixty-five per cent (n = 320) were either married
or in long-term relationships, and 76% (n = 380) had chil-
Statistical analysis dren. Forty-nine per cent (n = 234) reported not knowing
any HIV + persons, and 26% (n = 131) claimed not to have
The data were analysed using IBM SPSS Ver. 24.0 for
tested for HIV. Ten per cent (n = 34) reported that they were
Macintosh (IBM Corporation 2013a). Confirmatory factor
HIV + . Fifty per cent (50%) had used a condom at last sex,
analysis was done using IBM AMOS Ver. 24.0 for Windows
and 56% claimed to like using a condom.
(IBM Corporation 2013b).
Using structural equation modelling, a confirmatory
factor analysis (CFA) was conducted on the items meas- Confirmatory Factor Analysis
uring AIDS-related knowledge, alcohol and drug use, risky
The initial factorial model was specified and tested using
sexual behaviour, and condom use. Four critical fit indices
CFA. Output indices for the CFA model indicated a poor fit
were applied to determine the degree of fit of the struc-
to the data (χ2/df ratio = 3.812, CFI = 0.828, RMSEA = 0.074,
tural equation models (Kline 2011) as follows (with index
and Hoelter (95%) = 165), though all factor loadings were
values reflecting good model fit indicated in parenthesis):
statistically significant (p  <  0.001). Examination of the
χ2/df ratio (less than 4); Comparative Fit Index (CFI of 0.95
modification indices indicated a correlation between the
and greater); Root-Mean-Square Error of Approximation
error terms of the men-to-women and women-to-men
(RMSEA 0.06 and less); and Hoelter critical N (CN index 200
 CONSTRUCTION MANAGEMENT AND ECONOMICS   7

Table 2. Regression models for the prediction of condom use (n = 512).

Model Dependent variable Independent variables β p-value R2 F-ratio
1. AIDS-related knowledge (AK)
Demographic factors, and alcohol and drug use as AIDS-related knowledge Age −.002 .965 0.170 23.058**
predictors of AIDS-related knowledge Gender .048 .293
Education .366 .000**
Alcohol and drug use .136 .003**
2. Alcohol and drug use (AD)
Demographic factors and AIDS-related knowledge as Alcohol and drug use Age −.270 .000** 0.111 14.008**
predictors of alcohol and drug use Gender −.169 .000**
Education −.002 .960
AIDS-related knowledge .145 .003**
3. Life risk (LR)
Demographic factors, AIDS-related knowledge, and Life risk Age −.171 .001** 0.071 6.759**
alcohol and drug use as predictors of life risk Gender −.121 .012*
Education −.049 .348
AIDS-related knowledge −.068 .180
Alcohol and drug use .133 .006**
4. Condom use (CD)
Demographic factors as predictors of condom use Condom use Age −.090 .078 0.058 4.451**
Gender .076 .123
Education −.114 .031*
AIDS-related knowledge −.062 .225
Alcohol and drug use −.117 .018*
Life risk .136 .005**

*Significance level at p < 0.05; **Significance level at p < 0.01.

transmission items (r  =  0.76, p  <  0.01). With this path
specified, model fit proved excellent (χ2/df ratio = 1.562,
CFI = 0.966, RMSEA = 0.033, and Hoelter (95%) = 403). This
final measurement model was significantly different to the
initial measurement model χ2Δ(1) = 255.83, p < 0.01, and
all factor loadings were significant (p < 0.001) – thus con-
firming the psychometric validity of the individual scalar
instruments.
Developing the theoretical model
Multiple linear regression analysis was used to, firstly,
explore demographic characteristics (age, gender, and
education level) as predictors of each of AIDS-related
knowledge, alcohol and drug use, and risky sexual
behaviour; and secondly, demographic characteristics,
AIDS-related knowledge, alcohol and drug use, and risky
sexual behaviour as predictors of condom use. The various
models are shown in Table 2.
Predictors of AIDS-related knowledge
Model 1 explored age, gender, education and alcohol and
drug use as determinants of AIDS-related knowledge. This
model was significant, F(4, 449) = 23.06, p < 0.01, R2 = 0.17,
with education (β = 0.37, p < 0.01) and alcohol and drug
use (β  =  0.14, p  <  0.01) as significant determinants of
AIDS-related knowledge (see Table 2). Higher levels of
AIDS-related knowledge were positively associated with
higher levels of education and greater consumption of
alcohol and drugs.
Predictors of alcohol and drug use
Model 2 examined the impact of the three demographic
factors and AIDS-related knowledge on alcohol and drug
use. This model was significant, F(4, 449) = 14.01, p < 0.01,
R2  =  0.11. Age (β  =  −0.27, p  <  0.01), gender (β  =  −0.17,
p < 0.01), and AIDS-related knowledge (β = 0.15, p < 0.01)
proved significant predictors of alcohol and drug use (see
Table 2). Females, older workers and workers with lower
levels of AIDS-related knowledge reported significantly
lower levels of alcohol and drug use.
Predictors of risky sexual behaviour
Model 3 explored the demographic variables, AIDS-related
knowledge, and alcohol and drug use, as predictors of
risky sexual behaviour. This model was significant, F(5,
443) = 6.76, p < 0.01, R2 = 0.07. Age (β = −0.17, p < 0.01),
gender (β  =  −0.12, p  <  0.05), and alcohol and drug use
(β = 0.13, p < 0.01) were significant predictors of risky sex-
ual behaviour (see Table 2). Younger workers, male workers
and workers reporting higher levels of alcohol and drug
use reported significantly higher levels of risky sexual
behaviour than did workers in other categories.
8   P. BOWEN ET AL.

Dagga Tik Cocaine

Alcohol 0.82 0.44 Mandrax

0.54 0.75
-0.16** 0.18
-0.15*
Alcohol & Drug
Age Condom Use
Use

0.70 0.84
-0.14*
Condom Condom
0.36*** Last Like
-0.26***
-0.18*** -0.11*

-0.18** 0.18* Chi-Sq / df = 1.977

Gender p = 0.000
CFI = 0.926
-0.10 ns RMSEA = 0.044
0.24***
Hoelter = 308
ns: not significant
*P <0.05
**p<0.01
***p<0.001

0.46*** -0.16* Note. All factor-item

AIDS Risky Sexual loadings: p <0.001
Education
Knowledge Behaviour
0.65
0.48 0.38
0.46 Traditional 0.72 0.56
0.71 Medicines
Sex Gifts Gifts
Men-Women Women-Men 0.64 Partners Received Given
0.39 0.51
Washing Vitamins
Partners Pregnant
0.70***

Figure 2. The final structural model.

Predictors of condom use the interests of parsimony, the non-significant path from
education to condom use was omitted, as its inclusion did
In Model 4, the determinants of condom use were examined
not contribute significantly to the model.
(see Table 2). This model was significant, F (6, 436) = 4.45,
With this path omitted, the resultant model was a good
p < 0.01, R2 = 0.06. Level of education (β = −0.11, p < 0.05),
fit to the data (χ2/df ratio = 1.977, p = 0.000, CFI = 0.926,
alcohol and drug use (β = −0.12, p < 0.05), and risky sexual
RMSEA = 0.044 and Hoelter (95%) = 308). All paths were
behaviour (β = 0.14, p < 0.01) were all statistically signifi-
now significant at p < 0.05, except for gender to risky sex-
cant predictors of condom use. None of the other factors
ual behaviour, which was significant at p < 0.10. Given the
in this model were significant. Workers reporting higher
importance of gender in the literature as a predictor of
levels of education, higher levels of alcohol and drug use,
risky sexual behaviour, this path was retained in the model.
and lower levels of risky sexual behaviour reported signif-
The final structural model, regression weights and asso-
icantly less condom use than did less educated workers,
ciated levels of significance are shown in Figure 2.
workers consuming less alcohol and drugs, and workers
A number of significant direct pathways were identified
reporting higher levels of risky sexual behaviour.
in the SEM. Gender was significant in predicting levels of
Based on the conceptual model (Figure 1) derived from
alcohol and drug use (β = −0.11, p < 0.05) and risky sexual
the literature and the regression analyses described above,
behaviour (β = −0.10, p < 0.10). Female workers were less
an initial structural model specifying the antecedents of
likely than males to report higher levels of alcohol and
risky sexual behaviour and condom use was postulated.
drug use or to engage in risky sexual behaviour. Level
of education had a direct role in predicting AIDS-related
Testing the structural model knowledge (β  =  0.45, p  <  0.01), with better-educated
workers being more likely to possess better AIDS-related
An initial structural model (with correlated error terms
knowledge. Age was found to be significant in predicting
for the men-to-women and women-to-men items as sug-
alcohol and drug use (β = −0.16, p < 0.01) and risky sexual
gested by the CFA) was specified and tested. The output
behaviour (β = −0.18, p < 0.01). Older workers were less
revealed good model fit (χ2/df ratio  =  1.976, p  =  0.000,
likely than younger workers to engage in either alcohol
CFI = 0.927, RMSEA = 0.044, and Hoelter (95%) = 309). In
and drug use or risky sexual behaviour.

Risky sexual behaviour was also predicted by alcohol
and drug use (β = 0.36, p < 0.01) and level of AIDS-related
knowledge (β = −0.16, p < 0.05). Workers with higher levels
of alcohol and drug use and lower levels of AIDS-related
knowledge were more likely to indulge in risk sexual
behaviour.
Finally, condom use was determined by alcohol and
drug use (β  =  −0.15, p  <  0.05), risky sexual behaviour
(β = 0.18, p < 0.05), and extent of AIDS-related knowledge
(β = −0.14, p < 0.05). In essence, use of condoms was sig-
nificantly less likely amongst workers with higher levels of
alcohol and drug use, workers engaging in riskier sexual
behaviour, and workers with lower levels of AIDS-related
knowledge.
The regression analyses had determined that AIDS-
related knowledge was a significant predictor of alcohol
and drug use, and that education was a direct predictor
of condom use. These relationships were not found in the
SEM analysis. In the SEM model, education predicted con-
dom use indirectly via its direct relationship with AIDS-
related knowledge (itself a direct predictor of condom
use). The SEM found no relationship (direct or indirect)
between AIDS-related knowledge and alcohol and drug
use.
The final structural model vindicated the inclusion of
the paths between AIDS-related knowledge and each of
the risky sexual behaviour and condom use factors. These
paths were not identified in the regression analyses.
Discussion
Deriving from a public health perspective and impera-
tive, the aim of this study was to examine the condom
use of construction workers as a function of demographic
factors (age, gender, and education), AIDS-related knowl-
edge, alcohol and drug use, and risky sexual behaviour.
The importance of the focus on the construction industry
is underscored by the disproportionately higher impact
of the pandemic on this sector, the industry-specific char-
acteristics contributing to this estimated higher rate, and
the importance of consistent condom use as an effective
barrier to infection.
The modelling of the construction worker survey data
shows that, when controlling for age and gender, knowl-
edge about HIV/AIDS is predicted directly by education
level, with lower levels of education consistently associ-
ated with lower levels of AIDS-related knowledge. While
this result appears immediately obvious, in that lower edu-
cation attainment renders a person less likely to properly
comprehend media and communication messages, a less
obvious link is that related to the correspondence between
lower education attainment and likely adherence to tradi-
tional beliefs about the cause of HIV/AIDS. In this regard,
CONSTRUCTION MANAGEMENT AND ECONOMICS   9
the observed relationship between lower education and
poor HIV knowledge references another considerable
challenge for public health efforts to improve levels of
transmission knowledge, particularly so in societies and
communities where such non-scientific or traditional
beliefs about HIV and AIDS are commonplace (Yamba
1997, Kalichman and Simbayi 2004, Govender et al. 2016).
Alcohol consumption and drug use among construc-
tion workers are predicted by age and gender, but not
by education level. Older workers, and female workers,
reported significantly lower levels of substance use than
did younger, and male, workers. This finding corroborates
Kader et al. (2014), who found that males were significantly
more likely than females to engage in hazardous and
harmful use of alcohol and problematic drug use. Kader
et al. (2014) also reported that alcohol use was predicted
by age, as did the study by Peltzer et al. (2010), where alco-
hol and drug use were found to be more likely amongst
predominantly younger persons.
The determinants of risky sexual behaviours among
construction workers were found to be age, gender, AIDS-
related knowledge, and substance use. Specifically, work-
ers reporting lower levels of AIDS-related knowledge and
those engaging in higher levels of substance use, reported
significantly riskier sexual behaviour. This finding resonates
with the literature (Stein and Nyamathi 2000, Shisana et al.
2004, Kalichman et al. 2006, Shisana et al. 2014).
The determinants of condom use among construc-
tion workers were found to be AIDS-related knowledge,
substance use and risky sexual behaviour. Lower levels
of AIDS-related knowledge, lower levels of substance use
and higher levels of risky sexual behaviour were associ-
ated with more positive disposition towards and frequent
use of condoms. The negative association between AIDS-
related knowledge and condom use was surprising, given
that other research has indicated a positive link between
level of AIDS-related knowledge and condom use (Kline
2014). A possible explanation for this anomaly might be
that being more knowledgeable lures individuals into a
false sense of confidence regarding the risk of infection,
and consequently directs them towards riskier behaviours.
This finding corresponds with the concept of “lower per-
ceptions of risk” noted by MacPhail and Campbell (2001)
and Ndugwa Kabwama and Berg-Beckhoff (2015). That
is, increased knowledge results in greater perceptions of
risk up to a point, where after further knowledge instills
a greater (false) sense of confidence and thereby actually
decreases the risk perception. This finding, however, would
require greater confirmation in future research.
Finally, the associations between condom use and
risky sexual behaviour (positive) and alcohol and drug use
(negative) support previous research (Parkes et al. 2007,
Scott-Sheldon et al. 2009, Shisana et al. 2014). Our findings
10   P. BOWEN ET AL.
reinforce the argument that alcohol consumption and
drug use has an adverse effect on risky sexual behaviour
in general, and condom use in particular.
Limitations
Results emanating from this study provide new informa-
tion about the inter-relationship between AIDS-related
knowledge, alcohol and drug use, risky sexual behaviour,
and condom use. However, these must be tempered by
limitations of the study that include the cross- sectional
nature of the survey, the geographical bias of the sam-
ple (Western Cape), and the potential under-reporting of
risk behaviours. Caution should therefore be exercised
before generalizing the results to other geographical
regions, other demographic groups or other industries.
Additionally, condom use was only measured for the last
sex act and for respondents’ attitudes towards condoms,
but not for consistency of condom use over a specified
period.
Despite these limitations, this research has identified
that condom use by construction workers is strongly and
positively associated with risky sexual behaviour, but
strongly and negatively associated with alcohol and drug
use.
Conclusions
The purpose of this study was to better understand how
demographic characteristics, AIDS-related knowledge,
alcohol and drug use, and risky sexual behaviour of
construction workers are associated with their attitudes
towards and use of condoms.
A number of important relationships were identified
in this research. Age, gender and level of education were
indirect determinants of condom use, with higher levels
of education predicting better AIDS-related knowledge.
Increased HIV transmission knowledge was inversely asso-
ciated with sexual risk behaviour, and higher levels of risky
sexual behaviour were associated with more frequent use
of condoms, suggesting greater awareness of risk of HIV
transmission. Construction workers reporting higher use
of alcohol and drugs reported higher levels of risky sex-
ual behaviour, but lower use of condom use. The inverse
relationship between levels of HIV transmission knowl-
edge and condom use was surprising. We postulated that
improved knowledge of HIV transmission may act contrary
to safe sexual behaviour if it lulls the person into a false
sense of confidence, but this requires deeper investigation.
While these findings generally support those indicated
by research conducted among the general population,
they present some challenges and provide clear pointers
for proactive HIV/AIDS intervention management by con-
struction firms. Firstly, AIDS-related knowledge is clearly
a strong influencing factor on risky sexual behaviour,
and hence on condom use. However, acquisition of any
knowledge is to a great extent influenced by literacy and
education, and this poses some challenges for an industry
characterized where the majority of the workforce is poorly
educated and/or have low levels of literacy. How can AIDS-
related knowledge be improved in the face of these edu-
cational and literacy limitations of workers? To address the
dilemma, the construction industry needs to consider the
efficacy of media and communication interventions that
are minimally dependent on both formal education and
literacy. For instance, mixed media such as live action and
animated videos and theatre may provide better results
because of reduced reliance on text and comprehension
of the written word. Some of these initiatives have been
delivered successfully, albeit not in a construction industry
context, though they may provide lessons for the sector.
This requires a participatory process that truly engages
with the culture of the target population which, while it
may lack literacy skills, is likely to be adept in using these
technologies. Workers should also be involved in discus-
sions surrounding HIV/AIDS and the knowledge delivery
essential to addressing it, in order to minimize assump-
tions, and ensure that workers’ values are adequately con-
sidered, and so that traditional beliefs, myths and customs
are dealt with in non-confrontational ways.
We have shown the significant inverse relationship
between alcohol and drug use and condom use. This also
raises additional challenges for workplace programmes
seeking to promote more frequent and consistent condom
use. Such programmes cannot ignore or discount worker
habits with regard to alcohol and drug use, and need
to account for these by way of content and targeting of
messages and behaviour change, including interventions
designed for venues where alcohol is consumed such as tav-
erns and beerhalls. In addition to the likely improved safer
sexual behaviours and lower risk of HIV infection that more
prudent alcohol and drug use can bring, integrating alco-
hol and drug use issues into worker education has wider
positive impacts such as reduced worker absenteeism,
enhanced job performance, and improved safety records.
Acknowledgements
The authors wish to express their appreciation to the South
­African Human Sciences Research Council (HSRC) for permitting
them to draw on relevant HSRC questionnaires in the compila-
tion of the survey questionnaire employed in this study.

Disclosure statement
The authors reported no potential conflicts of interest. Ethical
clearance was obtained from the Faculty Research Ethics Com-
mittee of the University of Cape Town.
Funding
This work is based on research supported by the National Re-
search Foundation of South Africa [grant number (UID) 85,376].
The Grantholder acknowledges that opinions, findings and
conclusions or recommendations expressed in any publication
generated by the NRF supported research are those of the au-
thors, and that the NRF accepts no liability whatsoever in this
regard.
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