ARTICLES

 

Using activity theory to understand contradictions in the safe sex practices of married people in a rural area of the Eastern Cape, South Africa

 

 

Tendani Gabakaiwe^I; Mary van der Riet^II

^IDepartment of Business Management, BA ISAGO University, Private Bag BR 94, Gaborone, Botswana tdgabakaiwe@gmail.com
^IIDiscipline of Psychology, School of Applied Human Sciences, College of Humanities, University of KwaZulu-Natal, South Africa VanDerRiet@ukzn.ac.za

 

 

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ABSTRACT

HIV/AIDS is a significant public health issue in South Africa. Drawing upon activity theory, this study investigated the prevailing contradictions, tensions and dilemmas related to safe sex practices in the sexual activity systems of heterosexual married people in a rural area of the Eastern Cape in South Africa. This study used secondary data obtained from a National Research Foundation (NRF) funded qualitative project on responses to HIV/AIDS. Nine individual semi-structured interviews (5 women and 4 men) and two focus group discussions (one with women and one with men) were analysed. The findings identify primary and secondary contradictions within two sexual activity systems (that of the married woman, and that of the married man). Tertiary level contradictions between the object of each activity system (specifically sexual pleasure versus safe sex practice) are exacerbated by contradictions between the division of labour components of the two activity systems. These tertiary contradictions are enabled because of the primary contradiction within the married women's sexual activity system, specifically within the division of labour component. This is a contradiction between being responsible for sexual safety, but submissive in the negotiation of sexual activity. A significant finding of this study is that these contradictions within and between the activity systems are at an early start of maturity, as they have not yet lead to a crisis in, and collapse of, the systems. This analysis contributes to understanding the lack of change in behaviour related to safe sex practices.

Keywords: Activity theory, activity system, contradictions, HIV/AIDS, marriage

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Despite substantial efforts at prevention and intervention, South Africa is among the countries with the highest rates of HIV in the world, with approximately 7.9 million people currently HIV positive (Human Sciences Research Council [HSRC] 2018). Sexual activity is a complex behaviour "deeply embedded in individual desires, social and cultural relationships, and environmental economic processes" (United Nations Programme on HIV/AIDS (UNAIDS) 1999: 5). Despite a high level of HIV/AIDS awareness, people continue to engage in risky sexual behaviour such as not using condoms with a person whose HIV status is unknown. In a national survey, 55.6% of people aged 15-64 years with two or more intimate partners self-reported condom use at last sex. In those aged 25-49 years, condom use rates were similar for both men (53.0%) and women (53.4 %). Just 33.3% of older adults aged 50-64 years, with multiple partners, used condoms at last sex (HSRC, 2018). Without a cure for HIV/AIDS, it is crucial to understand why people continue to engage in risky sexual practices despite the HIV prevention interventions already put in place.

The need for condom use within heterosexual marriage relationships has been neglected despite the fact that many new infections occur in marriage unions (Madiba & Ngwenya, 2017). Marriage is portrayed by many as an institution where sexual intimacy is a necessity for a couple (Giddens, Duneier & Appelbaum, 2006). Giddens et al.. (2006: 284) state that marriage is "a socially acknowledgeable and approved sexual union between two adult individuals". This focus on sex, and procreation makes it difficult for heterosexual married couples to negotiate condom use and use condoms. Condoms are believed to threaten sexual intimacy and sexual satisfaction (Williamson, Liku, McLoughlin, Nyamongo, & Nakayima, 2006). Several studies have found that heterosexual married couples are less likely to use condoms as an HIV prevention strategy (Adejoh & Uchenna, 2011; Chirwa, Malata & Norr, 2011; Maharaj & Cleland, 2004; Osuafor & Mturi, 2014).

However, condoms are the best form of protection against HIV and other sexually transmitted diseases (Maharaj & Cleland, 2004) especially in socially disadvantaged communities where HIV awareness, and access to HIV pre-exposure prophylaxis (PrEP), are already limited (Calabrese et al.., 2017). Antiretroviral treatment (ART) is also an effective way to prevent the spread of HIV by suppressing the viral load (Bogoch Scully & Zachary, 2012; Rodger et al, 2016), However, at the time of this study and in this rural context, not many married people were on ART or had access to PrEP.

Studies show that although relationships may begin with condom use, this stops once trust is gained (Hattori, Richter & Greene, 2010). Marriage is often associated with values such as trust, monogamy and faithfulness, leading to the assumption that HIV risk, when married, is low (Maia, Guilhem & Freitas, 2008; Osuafor & Mturi, 2014). Chimbiri (2007) argues that the introduction of condom use in the marriage relationship is likely to be difficult, irrespective of HIV risk. In several studies with heterosexual couples, both married men and women say that requesting a spouse to use a condom is like acknowledging one's own infidelity, or accusing one's partner of being unfaithful, making it problematic to negotiate condom use (Bauni & Jarabi, 2003; Chirwa et al, 2011; Maharaj & Cleland, 2005). One of the dominant approaches to HIV prevention in South Africa emphasised the abstain, be faithful and condomise (ABC) options (Burman, Aphane, & Delobelle, 2015). However, this message potentially undermines condom use by linking the use of a condom to not being able to be faithful. This association with infidelity makes it difficult to negotiate condom use in long term relationships. Studies of heterosexual relationships have shown that both married men and women, but particularly women are aware of the risk of HIV presented by their partners' behaviour (Maharaj & Cleland, 2005; Watkins, 2004). According to Hattori et al.. (2010), many people enter relationships with the assumption that they are both HIV negative. However, having premarital sex and multiple sexual partners are common practices in South Africa (HSRC, 2018; Shisana et al, 2014), increasing the risk of HIV infection.

Walker, Reid and Cornell (2004) argue that the use of condoms within marriage is difficult because one of the main objectives of marriage is to bear children. Beyeza-Kashesya et al (2009: 10) argue that "childbearing is a socio-cultural practice involving the person and (and is also) the concern of other members of the person's social environment". Condoms are thus rarely used in heterosexual marriage relationships due to the desire, and social pressure, to have children (Adejoh & Uchenna, 2011; Chimbiri, 2007; Preston-Whyte, 1999). However, the desire to have children cannot fully account for non-use of condoms within marriage because condom use is also low among married couples who do not seek to have children (Anglewicz & Clark 2013; Williamson et al, 2006).

Men's control over sexual decision-making in heterosexual relationships is seen as normal by many societies (Chimbiri, 2007; Mash, Mash & De Villiers, 2010). Osuafor and Mturi (2014) argues that the cultural practice of the payment of lobola (bride price) sustains the subordination of women in marriage relationships because when a man pays lobola it is assumed that he 'owns' his wife. Dube et al (2017) argue that this translates into a power imbalance compromising women's sexual decision-making and increasing women's vulnerability to HIV infection. Whether or not these cultural practices always create inequality between men and women in sexual relationships, the gendered social organisation of South Africa society means that men are accorded greater power in decision-making in sexual relationships (Sofika & Van der Riet, 2017). According to Mash et al (2010) safe sex behaviour, particularly condom use, is not simple because it has to be negotiated between unequal partners. Pettifor et al (2004 cited in van der Riet, 2009) argue that gender roles and power dynamics make it difficult for women to manage the risk of HIV. For many women, safe sex practice depends on their spouses' attitudes towards sexual risk (Mash et al, 2010).

Shisana et al's (2014) survey found a 9.8% HIV prevalence amongst married people in South Africa. According to Madiba and Ngwenya (2017), over half of the new HIV infections in South Africa occur in marriage relationships. A number of studies have focussed on understanding the nature of heterosexual marriage and HIV risk in South Africa (Dube et al, 2017; Maharaj & Cleland, 2004; Madiba & Ngwenya, 2017; Osuafor & Ayiga, 2016; Osuafor & Mturi, 2014). These studies have found significant resistance to the use of condoms in heterosexual marriage relationships.

Married men and women in a rural area of the Eastern Cape Province of South Africa formed part of a broader study on responses to HIV. This study worked with the data related to these participants, to examine how heterosexual married men and women engaged with sexual activity and the risk of HIV. This study used Engeström's (1987) model of human activity to explore and understand tensions and contradictions that married men and women experience in relation to sexual activity related to safe sex practices.

 

Activity theory and its principle of contradictions

Activity Theory has its roots in the writing of Marx and Engels, and the work of Vygotsky, Leontiev and Luria from the Soviet Russian cultural-historical school (Roth & Lee, 2007). The significant contribution of this theory is its core assumption that humans are constituted through, and in, their participation in practices (particularly their social and historical practices) (Van der Riet, 2009; 2012). This has significant implications for how we study 'problems' of human behaviour, such as behaviour change in response to HIV risk. Kaptelinin, Kuutti and Bannon (1995: 190) first make the point that the "human mind comes to exist, develops" within activity, but they continue arguing "and (it) can only be understood within the context of the meaningful, goal-oriented, and socially determined interaction between human beings and their material environment" (emphasis added). Yrjö Engeström (1999), one of the founders of activity theory argues that human consciousness, or thinking, emerges through and is shaped by participation in practical activity in a social context. As Van der Riet (2012: 24) argues, this means that human practices such as sexual activity, and safe sex practices in heterosexual marriages, need to be examined as practical social activities, in relation to the broader systems which ascribe their meaning, rather than merely as cognitive decisions about risk. Assuming that activity is "a collective systemic formation" (Daniels, 2001: 86), Engeström (1987) directs this analysis of human behaviour through his development of a model of human activity, in the form of the activity system. Integral to this modelling is the representation of the structure of activity as complex and mediated, echoing Vygotsky's (1978) focus on the mediated nature of human action, and the dialectical relationship between individual and society.

Engeström's (1987) model of the activity system (depicted in figure 1) consists of several interacting components: subject, object, mediating artefacts (tools), norms, community, division of labour, and outcome (Engeström, 1987). The 'subject' in this model is the individual or group of individuals whose activity is being analysed or who are involved in the central activity (Engeström 1999), for example, a married woman, or a married man. The 'object' is the motive of the activity for that subject, for example, attaining sexual pleasure. In the activity system the object is changed into outcomes "with the help of physical and symbolic external and internal tools" (Engeström 1999: 67). An example of an 'outcome' of sexual activity is pregnancy, or becoming HIV positive. 'Mediating artefacts' refer to everything used in the transformation process, including both material tools and tools for thinking (Engeström, 1999). For example, a condom is a material tool, while HIV knowledge is a set of conceptual tools.

'Norms' are procedures which are followed conventionally, that prescribe action and interaction within activity system (Engeström, 1999). For example, in many contexts, women do not initiate sexual interaction, it is the prerogative of the male partner. Another expectation in sexual relationships, is that partners should be faithful to each other. This is not written down or prescribed anywhere, but it is accepted as a convention. 'Community' refers to all participants in the activity system with a common object (Engeström, 1999), for example, other married men in the same context who also engage in sexual activity to demonstrate a particular identity investment. 'Division of labour' refers to the roles and responsibilities on vertical and horizontal dimensions (Engeström, 1999). The horizontal dimension refers to the division of roles in the activity, for instance women are usually responsible for sexual safety in a relationship. The vertical dimension refers to hierarchical power relations and authority (Engeström, 1999), for instance men often initiate and control sexual activity.

Using an activity system as the unit of analysis allows one to be able to see the processes through which people shape and are shaped by the social context (Engeström, 1999). In this study, activity system analysis enabled an understanding of the relationship between the individual and their context, and the dynamics of risky sexual behaviour. It also potentially provides an understanding of how and why married people engage in risky sexual behaviours. An analysis of the sexual activity systems of people who are married provided a means to understand the potential change and transformation within the activity systems (Engeström, 2001).

The concept of 'contradictions' is critical to examining the research problem of this study. Engeström (2001:137) comments that contradictions refer to "historically accumulating structural tensions within and between activity systems". In every activity, tensions arise within and between the components of the system (Engeström, 2001, Kaptelinin et al 1995). These tensions indicate systemic contradictions within the activity. The significance of these contradictions are that they are a source of change, innovation and development. According to Engeström (1996), tensions and contradictions of the activity system are aggravated over time, and will inevitably lead to a crisis in the activity system. He argues that it is this crisis which lead to change in the activity. An analysis of the sexual activity systems of people who are married is thus one way to understand the 'status' of the system, specifically through defining the tensions and contradictions within these activity systems.

According to Engeström (1987), there are four levels of contradictions. Primary contradictions exist within components of an activity system (e.g., within the subject), secondary contradictions are between the components of an activity system (e.g., between the subject and mediating artefacts/tools within an activity system), tertiary contradictions occur between components of one activity system and components of another system (for example, between the object of a married women's sexual activity, such as maintaining the relationship, and that of a married man, for example, sexual activity for pleasure). Finally, quaternary contradictions take place between the components of a central activity and its neighbouring activities (e. g. a young girl engaging in sexual activity, and a parenting context where youth engaging in sex is prohibited and talking about sex is taboo). It is in the identification of the tensions and contradictions within an activity system that the status of the system can be understood and change can potentially be facilitated (Engeström, 1987).

 

Method

This paper is based on a master's dissertation which used secondary data from a larger NRF funded qualitative study (conducted between the years 2012 and 2013). This study used a qualitative research design to examine the sexual activity systems of married men and married women. An activity theory framework was used to guide the development, analysis and interpretation of the data.

Sampling and participants

The research site consisted of 14 villages in a rural area of the Eastern Cape province of South Africa. It is a resource-constrained setting with few opportunities for formal employment and a high dependence on government social grants (e.g. pensions) and, or remittances from family members who work in towns. Data was collected between 2011 and 2013 and the census data for that period indicated that 23.6% of the population had no annual income and 65% earned below R38200 ($2616) per year (Statistics, 2011). There are no HIV or sexual health non-governmental organisations operating in this area, apart from government programmes in the high school and the one primary health care clinic.

Data for this study was selected from the broader NRF dataset using purposive sampling to select transcripts of heterosexual married participants. The married men and women who participated in the study were not necessarily married to each other. There were nine transcripts from individual interviews, five with married women (one aged 26-34, three aged 35-45, and one aged 45-60) and four with married men (one aged 35-45 and three 45-60). There were also two transcripts from focus group discussions (one with married women aged between 46 and 60 which had six participants, and one with married men aged between 46 and 60 which had seven participants). Therefore, the total number of participants was twenty-two (eleven female participants and eleven male participants), although there was some overlap between the participants in the focus groups and those in the individual interviews. For the focus groups participants of similar ages, and the same gender, were grouped to encourage participation and reduce power differences between participants.

Ethical clearance for the study was granted by the University of KwaZulu-Natal's Humanities and Social Science Research Ethics Committee (HSS/0367/013M). The broader NRF project obtained permission from the local Chief to conduct the study in the research site. The project research team also liaised with the chairpersons of the local residents' associations to approach residents who met the criteria for participant selection, for example being resident in the area, and being male or female within a particular age range. The research was explained to potential participants, and if they agreed to participate, arrangements were made for an interview or focus group time. In these sessions, formal consent processes were discussed and finalised. The potential participants were also informed about the option of being referred to psycho-social support services for those who might experience unanticipated distress related to the research process.

Data collection

The interviews and focus groups were conducted using semi-structured schedules to provide some consistency across the data collection processes. The questions focused on awareness of HIV/AIDS, HIV prevention methods, dynamics of relationships, and risks in sexual activity. The interviews and focus groups were conducted in isiXhosa, by bilingual researchers. The interviews and focus group discussions were audio-recorded, and translated from isiXhosa into English during the transcribing process. Sections of the translations were then checked for validity through a process of back-translation (Brislin, 1970).

Data analysis

The application of activity system analysis used a two phased approach. Firstly, the transcripts were analysed in relation to the components of the activity system as identified in Engeström's (1987) model of the activity system. Secondly, the relationships between, and within, components and systems were analysed for contradictions. In reading through the transcripts, text that referred to components of the activity system, and the presence of tensions or dilemmas, were noted. The tensions and dilemmas were grouped according to the components involved in the contradiction.

 

Findings

In this section the analysis is captured by presenting the sexual activity system of a married woman and that of a married man. In employing this analysis, all the transcripts were reviewed and analysed in relation to the components of the activity system and the principle of contradictions. The identification of these components and their interaction is illustrated through extracts from the data (where "P" is participant, and "I" is Interviewer, Figure 2 is the focus group for married women aged 45-60 and Figure 3 is the focus group for married men aged 45-60). The extracts presented here were chosen based on how well they represented the data, as well as how they matched the study questions. Figure 2 presents the activity system of married woman highlighting the contradictions (lightning lines) in the activity system.

In this activity system, a married woman is presented as the subject of the activity system. One of the main objects of a married woman's sexual activity is to have children, as expressed in the focus group extract 1 below linking sexual activity to the need to procreate. The participant assumed that the purpose of marriage for a woman is to procreate and raise the children.

Extract 1:

P: People who are married must have sex because they were allowed to by God. When God was speaking in the book of Genesis telling them to procreate.

Another object of this activity is to maintain the relationship. This object was more pronounced when participants were asked about the risk of unprotected sex. Some married women argued that they put up with the risk of HIV infection through unprotected sex in order to maintain a good relationship with their husbands. In extract 2 one of the participants argued that married women avoid the conflict ('battle') with their husbands because refusing unprotected sex might end the marriage, or encourage the male partner to be unfaithful ('go there'). She commented that they know the need for condoms in sex ('it's really meant to be a condom'), and another participant highlights the negative outcome of this condom negotiation, 'a marriage can end'.

Extract 2:

P1: ...we don't, all do it because we will be in battle with these men

I: ((laughs))

P1: and if he doesn't, want it he doesn't, want it and he will leave you here in the home and go there and you reckon yhu you will lose your husband just because you want to use a condom. Hhh otherwise its really meant to be a condom even if we don't, do it, because hhh a person, I want to say that a person who is saying that they use a condom all the time is lying there is no such thing, in marriage

P2: another thing, a marriage ends, a marriage can end with some people.

The discussion in extract 2 also illustrates another object of this activity, safe sex practice. The extract shows that a married woman is willing to engage in protected sex, however the husband refuses to use condoms. The participants in the above extract argued that refusing to engage in unprotected sex might result in them losing their partners. Similar dynamics are illustrated in extract 6, 7 and 8.

The discussion in extracts 1 and 2 also illustrate some of the norms that guide married woman's sexual activity such as the inappropriateness and impossibility of condom use, the imperative to procreate, and the importance of maintaining the marriage. Other norms of the activity system are that a married woman should be trusted. Trust means believing a sexual partner is not engaging in risky sexual behaviour, such as sex with other partners outside of the marriage relationship. Trust is perceived as a substitute for condom use. Condom use amongst married people was not a norm in this context. Requesting condom use raised concerns about the fidelity of the partner. If one of the partners suggested using a condom, the other partner would assume that she or he is accusing her/him of having an outside relationship. This can be seen in the next extract from an interview with a married woman 46-60 years of age:

Extract 3:

I: If perhaps you have said to him "I think we should use a condom" what do you think he would have said?

P: He'd first ask me why is it that I am suggesting that we use a condom? Isn't. it

((Laughter))

I: I also don't, know;;;

P: "↑Why is it now that you think we should use a condom?" He'll want to know

I: Alright

P: "Why are you telling me to use a condom?"

I: What would you say if he were to ask you to use a condom?

P:I'd also ask him: "why is it that you are asking me to use a condom"?

I: So what kind of people use these condoms?

P: People who do not trust each other

I: Oh people who do not trust each other.

Another norm is that married women should tolerate their husband's infidelity. Some of the married women were aware that their partners might have sex outside the marriage relationship and had accepted this behaviour and resorted to requesting them to use condoms in the outside relationship. In the next extract from an interview with a married woman aged between 35-45 years, she said:

Extract 4:

P: I just explained to him the issues of cheating and that if he is cheating he should please use a condom

I: Alright

P: I just put it that way because there's this disease called AIDS

I: Yes

P: He should always use a condom and not forget to get tested.

As stated above, the community involves individuals who share the same general object of the activity, in this case other married women. This community is significant because it constructs "the individual's repertoire of possible actions in relation to sexual activity through articulating the norms, expectations and conditions that create or constrain the possibility of sex happening in a particular way" (van der Riet, 2009: 128). It is in this sense that a married woman is afforded opportunities to act only in particular ways, for example, tolerating infidelity.

However, married women expressed concern for sexual safety and seemed to take the risk of HIV infection seriously. The physical tools that are available to mediate sexual activity and risk are condoms, the conceptual tools are safe sex knowledge and messages. All of the married women in the sample were aware of HIV/AIDS and related prevention strategies. They were aware that condom use is the main way to protect oneself from the risk of HIV/AIDS. This was apparent in extract 5.

Extract 5:

I: like what would you say it is, this HIV?

P: this virus, firstly it is infectious, it infects people in relationships, through sex. To protect yourself from it you must use a condom.

In the activity system, roles and responsibilities are taken on by subjects in achieving the object and generating an outcome of the activity. The analysis of this division of labour in sexual activity shows that married women have acknowledged their powerlessness in sexual relationships (the vertical dimension of the division of labour). This was indicated by their yielding and submitting to their husbands' sexual desires even when they were not willing to engage in unprotected sex. An example of this comes from extract 7 and an interview with a married woman in the age range 26-34 years (extract 8). These extracts show how a man turns the request for condom use into blaming the woman, casting aspersions on her fidelity ('I see that you are unfaithful' in extract 6) and 'he thinks that there is this man that you are having an affair with' (in extract 7). This undermines the need to practice safe sex and shows how men have power over women in deciding how the sexual activity will take place. Even though the woman is aware that he might be unfaithful 'he does not come home or he comes late' (in extract 6), the suggestion is that she has to 'endure' this.

Extract 6:

I: And so here you are as a woman, you want to use a condom, what do you say to the man, why do you want to use a condom as a married person?

P: It's not easy because whenever you want to - use a condom, no I see that you are unfaithful. It's not easy even though he sometimes does not come home or he comes late, even if we use a condom in the house because we have agreed on it, he will not sleep in the house. He is going to tell you that no I went to look for sex outside because I am not feeling your sex.

Extract 7:

I: so when you are already in a marriage. Mm, as married people, are you able to speak to your husband about the risks of sex...?

P: ((laughs)) I talk about it, but then a man does not like to talk about those things. It is usually you as the woman that usually talks about that.

I: m mm

P: Mm, but then eish, it becomes hard, it becomes hard ((shuffling)) for a man to understand that, I mean a man understands that with much difficulty.

I: mm

P: That there are these diseases that you can contract through sex.

I: mm

P: And then your husband then just does not trust you then, he thinks that there is this man that you are having an affair with when you keep on telling him that, yhu there is this disease that is...

I: like this.

P: Eh, so rather let us use a condom most of the time.

I: mm

P: And he thinks then that there is another man that you are having an affair with.

The married woman's 'role' was to take responsibility for initiating condom use (the horizontal dimension of division of labour), it 'is usually you as the woman that usually talks about that'. This was most clear in extract 8 from an interview with a married woman (35-45 years). This extract shows a woman initiating condom use in an attempt to take responsibility for safe sex practice, however the husband 'doesn't agree'.

Extract 8:

P: but he doesn't, want that. He asks: why is it as my wife you ask that we use a condom?

I: use a condom]

P: What is it that you are trying to tell me? What are you telling me? Then he doesn't, agree.]

Identity is a significant outcome of this activity system. Being able to maintain a marriage is essential for a married woman's social identity. A married woman who is able to maintain her relationship has social status and maintains her reputation. The analysis shows that there is a concern for sexual safety, but an inability to act on this (see extract 6 and 7 above) because of the risk of the marriage ending 'marriage ends' (in extract 2), or of being accused of infidelity. If the use of condoms symbolises infidelity, and undermines the relationship, condom use does not enhance a married woman's identity. However, this also increases the risk of becoming HIV positive as a negative outcome of this activity system.

In the next section we present a brief description of the nature of the contradictions within, and between, the components of the activity system of sex of a married woman.

Contradictions observed in the activity system of sex of a married woman An analysis of the data showed the presence of tensions and contradictions within the activity system of sex of a married woman. A primary contradiction rooted in the division of labour arises between the women's responsibility for sexual safety and her yielding and submitting to the man's object of the activity. Married women initiated condom use in an attempt to take responsibility for safe sex but they were usually not successful because of the power dynamics (seen in the division of labour) within the relationship. This creates a strong tension or a dilemma in the activity system of the married woman because she is concerned about sexual safety but at the same time does not have the power to enact this in the sexual activity. In Engström's (1987) theory tensions can accumulate over time, and lead to significant contradictions in the activity system. Ultimately this can lead to the collapse of the system, and thus change or development (van der Riet, 2009). However, if the sexual activity system of the married woman stays as it is, it means the tension is present but not significant enough to disrupt the activity.

In marriage, one of the objects of sexual activity for both men and women is procreation. However, the use of a condom to prevent HIV transmission also prevents conception. This tension seems to be experienced particularly by married women, in their initiation of condom use, towards the object of safe sexual activity. The tension is a secondary contradiction between the object of the activity (child- bearing) and the mediating tool of the condom. This is also a manifestation of a secondary contradiction between the object of the activity (child-bearing) and division of labour (the married woman's responsibility for safe sex practice). This also reflects a tension between the object of the sexual activity system (child- bearing), and the object of engaging in safe sex. Another secondary contradiction was observed between the norms and the mediating artefacts of the activity system. The tolerance of a husband's infidelity was in tension with the married woman's knowledge of safe sex practices (a set of conceptual mediating artefacts). This gendered norm related to men's practices was in tension with the 'norm' created in HIV prevention messaging. However, this tension had not led to significant contradictions in the system. A secondary contradiction was also observed between the outcome of identity (retaining their married status) and the object of safe sex practice. Married women in this study were invested in maintaining their relationship because being married was an essential part of a woman's social identity. Although these tensions exist, the sexual activity system continues to function without condom use, suggesting that they have not matured into contradictions which could then lead to the collapse of, or a change in, the activity system.

In sexual activity in the heterosexual marriage, there are two activity systems at work. The data analysis also generated a model of the sexual activity system of a married man. Figure 3 presents the activity system of married man highlighting the contradictions (lightning lines) in the activity system.

The subject of the above activity system (figure 3) is the married man. A married man engages in sexual activity with the object of sexual pleasure, to maintain the marriage, to be sexually active, and to demonstrate virility through having children. The male participants in the study emphasised the object of having children. This was most clear in a comment in extract 9. In this extract a male participant links the activity of sex to procreation ('we are trying to expand the family') and suggests that not being able to produce children within the marriage ('here in the family') and possibly being 'infertile', is stigmatised. One of the norms that mediate the activity system for married men is therefore that they should show their virility through having children.

Extract 9:

I: So do you have sex in your marriage?

P: Yes we do have sex. Because if you not do that, then there will be trouble here in the family.

I: ((laughs)), Okay.

Participants: ((laughter))

P: It will be like there is one of you who is infertile.

P: on top of all that is going on during sex, one of the things that we are doing is that we are trying to expand the family.

In extract 10 below a married man commented that the other object of a married man's sexual activity is to keep the marriage intact. According to the participant in extract 10, sex helps to maintain a healthy relationship. He assumes that if there is sex within the marriage, sex outside the marriage relationship is less likely to happen. However, if 'they are not getting it here in the house' then there will be infidelity as "one of you is going to be forced to go outside in the street".

Extract 10:

I: so Sipho is saying that if there is no sex in the marriage it becomes kinda hard. Mm

P: uh you see if you are not going to have sex, there is one, if you have a fight here in the house, one of you is going to be forced to go outside in the street, uh, and go look for this thing in the street if they are not getting it here in the house

I: mm, ok, ok, ok (.)

P: there in the street where they will get it

I: ok, so so so sex prevents people from?

P: not to go out onto the street

I: ok, ok

Participants: uh

P: when they are already in marriage

Another norm of this activity is that married men have 'desires' and often meet these through relationships outside of the marriage. There was a normalisation and tolerance of men's extramarital relations. This was most clear in extract 11. In this extract, two points are illustrated. Firstly, the male participant acknowledges that women take responsibility for sexual safety (it is 'usually my wife' who raises the issue of safe sexual practice and condom use), as highlighted in the married woman's sexual activity system. Secondly, men are portrayed as having physical desires (iminqweno), which drive them to engage in sex outside of the marriage. In this statement there is an acceptance of sexual pleasure and fulfilling sexual needs as the 'object' of a married man's sexual activity. In the way this participant narrates the interaction, his wife is resigned to men's behaviour, but requests that he act responsibly and use a condom.

Extract 11:

P: With me it is usually my wife who usually tells me that, no my husband, whatever happens, you see a man has what are called iminqweno [desires] you see that, and she tells me that even if you are out there and you are doing something there, please use a condom.

I: Ok.

P: Uh, and she tells me like that, that please, whatever happens please use a condom.

Condom-less sex is a norm in this sexual activity system. In extract 12, a male participant also indicates that it is 'usually the woman' who initiates condom use which he then refuses because he needs a particular kind of sex ('skin on skin'). This extract also illustrates an example of the division of labour, how the activity is defined by the way in which men control sexual interactions and women have to yield ('she will end up giving in') to his object in the activity system.

Extract 12:

P: It is usually the woman who says me, I use a condom. Then I say that I do not use a condom, I want skin on skin.

I: And then what happens?

P: She will end up giving in.

In extract 13 a participant argues that married men refuse protected sex because it is their 'right' to have a particular kind of sexual interaction ('this thing'). This suggests that condom use is not expected in a marriage relationship. The findings also suggest that condom use might not be the norm in relationships outside of the marriage (see extract 4). A female participant in extract 13 comments that her request for condom use can lead to conflict with her husband. She implies that the request is to use a condom is made often, and that 'every time' a condom is not used during sex, this builds up and can develop into a more significant conflict ('something big'), which could then also involve the extended family ('it involves families'), or those to whom the couple in a traditional marriage are accountable. Even though the object in her sexual activity system might be safe sex, a norm and expectation for men is the 'right' to sex, and possibly condom-less sex.

Extract 13:

I: So when he does not want to use a condom, does that mean that it will not be used?

P: even if he does not have the final word, but ultimately you will fight about it. Every time it does not happen in the end you will fight and then it ends up being something big and it involves families, that so and so is like this. Even if he does that he knows that it is his right to get this thing and he does not care how he gets it.

The community in this activity system is comprised of other married men. As with the activity system of a married woman, it is this community which constructs the range of possible actions in a particular setting, through articulating the norms around sexual activity and marriage. This then affords the married man a particular set of possible actions in the activity system of sex. The implication of this is that the norms mediating the sexual activity system of both men and women are thus defined in the broader social context. There are expectations of men and women and their behaviour in the marriage, and only particular 'actions' of the individual are given affordance in any particular context.

The tools which mediate this activity include condoms, and safe sex knowledge. All married men in this study seemed aware of HIV/AIDS and HIV prevention. This was most clear in the extract from an interview with a married man aged 46-60 years (extract 14). In this extract the participant sees condom use and abstinence as the only ways to practice safe sex, that is they mediate the activity of sex.

Extract 14:

I: alright. Are there ways that a person can protect themselves from these diseases besides using a condom?

P: ey, I don't, see another way beside you abstaining. That's the way to protect yourself but if you want to be with another person then better that you use a condom because if you are just going to sleep with someone then it will be hard for you.

The crucial outcome of this activity system is identity, particularly a virile identity. This outcome is demonstrated through having children as indicated in extract 9 above. Children are perceived as a crucial outcome of marriage and being seen as 'infertile' may lead to a negative social identity. Another, negative outcome of this activity system is the risk of becoming HIV positive. However, married men preferred condom-less sex despite their knowledge about HIV/AIDS prevention.

The essence of the tensions and contradictions within and between the components of the activity system of sex of a married man are discussed in the subsection below.

Contradictions observed in the activity system of sex of a married man

The analysis in this study identified tensions and contradictions in the sexual activity system of a married man. A secondary contradiction exists between the object of the activity, to have children (which relates to identity and reputation), and the mediating tool of the condom. A married man's virility is demonstrated through procreation. However, condom use to prevent HIV infection also prevents conception. This creates a tension for a married man particularly with the expectation that in marriage sex is for procreation, and being unable to demonstrate this is potentially stigmatising. In this situation, the individual may have a particular object in the activity (to procreate), but the desire has its origins within the gendered social organisation (Sofika & van der Riet, 2017) of the context. In this broader activity system, performing a particular type of manhood (through procreation) is a significant object of sexual activity. It is in this sense that the 'individual' desire originates in the system rather than the individual. As the analysis illustrated, the social expectation to have children, and the personal desire to demonstrate masculinity through procreation, are in conflict with the use of condoms. However, although this tension is present, it does not generate a contradiction which could lead to the collapse of the activity system of sex. It seems that the tension is not significant enough to generate a crisis in the system.

Another secondary contradiction was observed between the norms which mediate the activity, and the mediating artefacts of the married man's sexual activity system. Two norms which mediate sexual activity for men create a contradiction. The acceptance of men's extra-marital relationships (a norm), and the acceptance of condom-less sex as a convention within marriage, are in tension with safe sex knowledge and messages (a set of conceptual mediating artefacts). This tension is however, not necessarily experienced as a strong contradiction. The tension is present, but it does not generate a contradiction which could lead to the collapse of the activity system of sex. Despite men being aware of how to prevent HIV infection, they prefer contact and condom-less sex, which is perhaps linked to their experience of sexual pleasure as an object, and their concept of themselves as manly.

In the analysis of the data each activity system is separated out and the system is viewed (for the purpose of analysis) from the point of view of the acting subject. In this analysis this led to the modelling of the married man's sexual activity system and that of the married woman. However, the activity they engage in is with another person, and tertiary level contradictions exist between these two activity systems. Figure 4 presents the activity system of a married woman and the activity system of a married man highlighting the tertiary contradictions (lightning lines) between the two activity systems.

In this analysis there is a clear tension between the women's object of safe sex, and their husbands' object of sexual pleasure. For example, in extracts 6, 7 and 8 the husbands persuaded their wives to have unprotected sex by using the notion of being faithful. The married woman initiates condom use with the object of safe sex but the married man, aware of the risk of unprotected sex, still insists on condom-less sex. The power dynamics in the division of labour in which a married man controls the sexual activity while a married woman submits to his control, sustains this tension. What is significant in this analysis is that the tension is present, but does not lead to a significant contradiction which disrupts the activity system. There is no change in sexual behaviour, possibly because women have less power in deciding the terms of the sexual activity.

 

Discussion

Over the years there have been developments in the treatment of HIV and the prevention of HIV infection. For example, PrEP for HIV has been developed as an effective strategy for prevention. However, some studies show that it may also encourage risky sexual behaviour contributing to high rates of other sexually transmitted infections (Kojima et al, 2016). Condom use thus remains the dominant strategy to prevent HIV transmission. However, condom use within marriage remains very low (Chirwa et al, 2011). In this study, married participants considered condoms as the best form of protection against HIV infection. However, they are not a simple or neutral mediating artefact in sexual activity because of their association with infidelity. The expectations of trust and sexual fidelity created tensions and dilemmas which made it difficult for many married couples to negotiate condom use. These findings are consistent with those of Chirwa et al (2011), Chimbiri (2007) and Maharaj and Cleland (2005), who found that condom use was not acceptable in marriage. This dilemma is captured in the finding in this study that although some married women felt at risk of HIV infection due to their husband's infidelity, they continued to have unprotected sex because it was difficult to insist on condom use. However, this tension between the norms (practices of infidelity) and the mediating tool (of the condom) in the sexual activity system has not led to a change in the system, possibly because it is latent. The tension puts married woman at risk of contracting HIV and other sexually transmitted infections.

Although many married women attempted to initiate condom use, they did not persist in their request when their male partner refused to use a condom, fearing the conflict that this would generate in the marriage. One might ask how could a relationship be more valuable than protection of one's health? It seems that for both men and women, there is an identity investment in marriage, just as for younger men and women, there are identity investments in sexual relationships (Van der Riet, Sofika, Akhurst & Daniels, 2019). Maintaining the marriage, and the status this accrues (be it 'being married', or 'producing children'), means that the conflict between the object of safe sex practice, and the object of sexual pleasure has to be tolerated. Having the positive social reputation of being linked to, and keeping, a partner, restricts married women in terms of acting upon their sexual safety. This is a clear tension between being in a relationship and having to engage in unprotected sex. Similarly, Hattori et al (2010) also found that women may refrain from insisting on condom use if they saw it as keeping the relationship stable. This suggests that a married woman could be at an increased risk of HIV infection in the process of trying to maintain the relationship. The risk of HIV as an outcome of sexual activity is thus in tension with the married woman's reputation.

The participants of this study, especially men argued that they engage in sexual activity for sexual pleasure (iminqweno), but also to demonstrate their virility. This finding is consistent with those of studies by Adejoh and Uchenna (2011), Chimbiri (2007), Maharaj and Cleland (2005) and Preston-Whyte (1999), who found that the need and desire to have children in marriage is in conflict with the use of condoms. Condom use undermines the man's identity because of the gendered expectation that men must prove their virility through having children. Even though married couples have the knowledge to prevent HIV infection, the desire to have children may put them in a dilemmatic situation. The need to demonstrate their potential to have children overrides their concerns about the possibility of HIV infection. In this sample of married men and women, in this rural context of South Africa, there was a clear tension between the use of condoms and identity. However, it was clear that sexual activity was also about sexual pleasure. Physical desires (expressed by the male participants as iminqweno), also lead to sex outside of the marriage. Interestingly although this male sexual desire was acknowledged by female participants, there was no mention of female sexual desire. Chimbiri's (2007) study found that married people in Malawi perceived condom use as interfering with the 'purpose' of marriage in the sense of facilitating sexual pleasure and satisfaction. In this study the need, or desire, for sexual gratification outweighs the risk of HIV infection. This indicates a tension between the object of sexual activity, in the form of sexual pleasure, and the mediating tool of the condom.

The participants in this study live in a context in which a man is the main decision-maker in sexual interactions. In this study, married women were reluctant to challenge their husbands' power to control sexual decision making. In Pettifor et al's (2004) study, limited and unequal sexual power was also significantly linked with inconsistent condom use. Hollway (1984) has found that women invest differently in relationships, and one way of retaining the relationship is to be submissive to male decision making. In this study there was a clear tension between the object of a married man's sexual activity system (sexual pleasure) and that of a married woman (safe sexual practice). Women were responsible for sexual safety (in the division of labour) but had less authority and power in the relationship to ensure sexual activity was safe.

The sexual activity systems of both married men and women seem to be relatively stable. This suggests that the existing tensions and contradictions are not significant enough to create a crisis in the sexual activity system. Although married people acknowledge the presence of HIV and AIDS, and conceptualise it as a negative outcome of activity, they continue to engage in risky sexual behaviour. The married women in the study commented several times on the tensions they experience in their sexual activity system related to sexual safety, specifically how they appealed to their husbands to engage in condom use. The married men in the study did not focus on the practice of safe sex, but rather spoke about sexual activity in relation to pleasure and procreation. It is clear that the tensions and contradictions which do exist in these sexual activity systems are not very strong, as they have not led to sexual behaviour change, or any significant disruption of the sexual activity system, for example, a suspension of sexual interaction between husband and wife. In this research context the conceptualisation of HIV and AIDS as a risk in married peoples' sexual activity systems does not seem to generate a significant enough contradiction to disrupt the system. However, there are some changes in the system. The condom is a relatively new mediating artefact for couples who have been married for twenty years or more (for example, the participants who were over the age of 40). It seems that married women have brought the concept of the condom into the sexual activity system, where it might not have been conceptually present before, although with not much effect. Another factor which would work against significant behaviour change in sexual activity in marriages, and a significant change in mediating artefacts since this study was conducted, is the option of antiretroviral treatment for those with HIV. Having this as mediating artefact within the sexual activity system might also lessen the urgency of changing sexual activity to 'safe sexual' activity.

 

Conclusion

This study illustrates a fairly unique use of activity theory in understanding some of the problematics of sexuality activity, HIV, and safe sex, in marriage. The study also brings into focus the experiences of a relatively vulnerable population in South African society, married men and women living in a rural context who have limited access to healthcare and opportunities for socioeconomic development. This study contributes to understanding why behaviour change in sexual activity does not happen. This study identified significant tensions and contradictions experienced by married women and men related to safe sex practices. However, the existence of tensions and contradictions within activity systems does not mean that change in the systems is possible. The tensions as described above are present, but do not lead to significant contradictions. No significant changes to the sexual activity systems, and thus no 'change' in behaviour is observed, rather 'risky' sexual activity in the sense of condom-less sex takes place. There are also undoubtedly other systems at play, and in interaction with, these systems, for example, the health care system, the system of service provision in a rural context, as well as socio-economic systems which affect men and women's status and opportunities. It might be that changes in some of these systems, for example, greater economic empowerment of married women, would affect their position within the marriage and thus increase tensions which could then lead to a more dramatic change in the system.

Although this study used secondary data and this means that the data was adapted to this study rather than collected with this specific research focus in mind, the focus groups and interviews provided rich accounts of the experiences and views of married men and women in this particular rural context. As a qualitative study with a fairly small sample size, transferability of the study findings is limited to similar people in similar contexts. The findings of this study could potentially be used in the conceptualisation of more effective HIV and AIDS interventions, which could focus on exacerbating the tensions and contradictions in the activity system to bring about changes in, or generate new, sexual activity systems in marriages.

 

Acknowledgements

This work is based on research supported by a National Research Foundation (NRF) Thuthuka Grant (grant number: 73647). Any opinion, finding and conclusion or recommendation expressed in this material is that of the author(s) and the NRF does not accept any liability in this regard.

 

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