Self-efficacy in protecting oneself against HIV transmission : A qualitative study of female university students in Malawi by Corresponding

This article deals with the complexity of health behaviour from a self-efficacy perspective, and shows the naivety in assuming knowledge as the main guide to better protection against HIV. The authors accentuate the importance of local knowledge when developing health strategies as in the case of protection against HIV, in this case for female university students in Malawi. Being part of a transition period, these students have to handle complex and at times opposing expectations. This makes HIV protection into a complex social- and health issue. However, the close association between universities and rational thinking has for long made public health see self-efficacy as one of the main determinants in general health behaviour. By seeing health behaviour as complex, this study explores into how female university students perceive their own self-efficacy in protecting themselves against HIV in Malawi with a HIV score of approximately 12%. The study is based on data from Chancellor College in Zomba, Malawi. The authors point to the potential of a closer collaboration between social work and public health in issues of both a social and a health nature, as in the case of HIV protection.


Introduction
I mean, pretty much we are told "'no boys", right?And one day you are expected to have a boyfriend.So you don't catch that link from "no boys" to "have a boyfriend."(Mary,Group interview 3) This article deals with Malawian female university students and self-efficacy in protecting themselves against the transmission of HIV.The aim is to contribute to improved public health by identifying factors that can influence young women to make safe and healthy choices during college.Though social work and public health are organized as separate educations with their own concerns, and tend to operate in separate organizations, we often find a close collaboration across these borders for the well-being of the general public, as in the case of the work with HIV and Aids (Ryen et al., 2010).This invites a wider readership on board, e.g. when we explore into what degree the female students perceive their own self-efficacy to be, through among others, contraceptive use and relational negotiation about sex with boyfriends.Self-efficacy is defined as the belief in one`s ability to handle tasks or reach a desired outcome (Maddux, 2000).It was originally a key concept in Social Cognitve Theory by Albert Bandura, but later on has been intergrated into several theories of health behaviour (Glanz, 2008).Multiple studies have linked self-efficacy to health-promoting behaviour (Bandura, 1997), and also as an important determinant when chosing sexual health behavour such as whether or not to use condoms (Albarracín et al., 2005;Bandura, 2012).Self-efficacy is a central concept in the field of public health, and is also fundamental in strengthbased social work by empowering people to enhance their well-being (Parrish, 2014).We present a more thorough definition and the theory below.HIV has assumed a substantial public health burden in Africa, and is one of the major causes of death.In 2010, 34 million people worldwide were living with HIV (UNAIDS, UNICEF, & WHO, 2011), with the first person diagnosed with HIV in Malawi being in 1985.The number of people transmitting the disease has been decreasing over the last few years, but the prevalence is still very high at 10.6%.
The main route of transmission is heterosexual unprotected sex with multiple and concurrent partners (UNAIDS et al., 2011).
Public actions to prevent the transmission of HIV have primarily focused on giving out information (Bandura, 2012), and this is also the case in Malawi (Yeatman, 2011).Previous studies have found that most young people have a basic knowledge of HIV and how to protect themselves against transmission (Barden O`Fallon et al., 2004;Mwale, 2008;Ntata, 2008;Smith & Watkins, 2005).Still, only 43% of the sexually active males and 56% of the sexually active females reported using a contraceptive method in a survey conducted in 2004 (Munthali et al., 2006).
Why do the young female Malawians, despite knowledge, not protect themselves against the risk of HIV (Gobo & Ryen, 2011)?
There are many psychosocial theories about how different factors contribute to make us change our habits and choose a more health-promoting behaviour.The first behavioural theorists emphasized the importance of knowledge and skills (Earle, Lloyd, Sidell, & Spurr, 2007), claiming that if people only had knowledge about a health hazard and skills to behave differently, they would choose to avoid it.A huge amount of research has proven that this classic rational thinking is too simple to account for an actual choice of behaviour (Bunton & Macdonald, 2002).
According to Albert Bandura (1977), the use of knowledge and skills are not sufficient to achieve a change in behaviour, as other factors also play a role in determining our actions.This is illustrated by well-informed smokers who continue smoking, and by people who continue having unprotected sexual relationships with a partner with an unknown HIV status.Self-efficacy is considered by many to be one of the most important determinants in health behaviour.Apart from a core construct in Social Cognitive Theory, the concept is also included in many of the different models of behaviour change such as the Stages of Change (Prochaska & DiClimente, 1984) and the Health Belief Model (Becker, 1974).
Higher education is associated with more knowledge about HIV and AIDS (Barden O`Fallon et al., 2004).At Chancellor College in Zomba, 98% of the students report knowledge about the routes of transmission, and that this knowledge is gender equal (Ntata, 2008).Nonetheless, education does not fully act as a protection against the transmission of HIV, and as a paradox, the prevalence is higher between women with more than a secondary school education (National Statistical Office & ICF Macro, 2011).These women are argued to have a more masculine view on sexuality, have multiple partners and are highly vulnerable to HIV infection due to the lack of power to negotiate the use of condoms (Leclerc-Madlala, 2009).
Malawi being a collectivistic society, the evaluation and modelling of group members (called "vicarious experiences" by Bandura) such as family and neighbours are important sources of self-efficacy (Oettingen, 1995).For girls in particular, this collectivity is closely associated with an internationalization of patriarchal control and does not stop at the gate to the campus.However, when it comes to the communication about sex between parents and children in Malawi, it suffers from a lack of openness.According to a study by Limaye et al. (2012), parents find it immoral to talk to their children about sex, and that they believe it may encourage them into having sexual relationships.As a result, they are advised to abstain from sex, but not told about the use of protection.This creates a lack of openness and stigma barriers for healthy behaviour, and therefore major drives of the epidemic by demotivating to seek information or check their own status (Munthali & Bannerman, 2012).So, there is still a need for reducing the HIV-related stigma in Malawi (Munthali & Bannerman, 2012;Rimal & Creel, 2008).
The use of condoms is supported by the national policy, and the availability is in general very high (Chimbiri, 2007).Male condoms are given out for free at places such as hair salons, bars and restrooms at various public offices.In their extensive research on the use of condoms in Malawi, Tavory and Swidler (2009) did find that many Malawians characterized their relationship by whether or not condoms were being used.In a serious relationship based on love, asking for the use of condoms would be seen as a sign of a lack of trust.
Growing evidence shows an inequality in gender-driven HIV vulnerabilities and the AIDS epidemic (Gibbs, 2008;UNAIDS et al., 2011).Economic and social factors are heightening women's vulnerability (Woodsong & Alleman, 2008), and over 60% of people living with HIV and AIDS in Sub-Saharan Africa are women.Because of economic dependency, many Malawian women do not have the opportunities to negotiate for condom use with their husbands.Paradoxically, their dependency supports the men's high-risk behaviour (Woodsong & Alleman, 2008).This can be illustrated by a study from Chirwa and Chisimbi (2009), who found it culturally acceptable in both urban and rural communities for men to have multiple sexual partners.
This referred to study was conducted at Chancellor College in Zomba, the third biggest city in Malawi, and the analysis aims at understanding the self-efficacy of female university students in protecting themselves against HIV transmission.

Self-efficacya belief in your own ability
Self-efficacy is considered to be one of the most important determinants in many theories about health behaviour, and is defined as a personal belief that he or she is actually capable of performing a behaviour that will lead to a desired outcome.It is not concerned with the amount of skills a person possesses, and it does not predict behaviour (Maddux, 2000).Instead, the focus is on the person's perception on what he or she actually can do with his or her skills (Bandura, 1986, p. 391).In return, a high or low self-efficacy will influence the intention or willingness to behave in a certain way.A person with a high self-efficacy will set higher goals for him/herself, invest more effort into it and have a better persistence when facing obstacles.On the contrary, a person with a low self-efficacy is argued to set lower goals and to invest less effort in handling difficulties, while a person who thinks of him/her as being unable will tend to do so.
Two of the most important sources of self-efficacy beliefs are enactive mastery experiences and vicarious experiences.These sources will interact, and have a different value in influencing a person's self-efficacy (Bandura, 1997).A person will gain enactive mastery experiences from personal successes or failures, with experience being the most powerful source to a high or low self-efficacy.If a person has not been able to handle a situation well, it may give the person a lower selfefficacy.Even so, a person can gain a heightened self-efficacy by being guided by health programmes to achieve a mastery experience.Vicarious experiences are achieved through comparing one's results with others and by modelling.People will often compare themselves with someone they perceive to be similar, such as the same age and gender.This can have different effects on their self-efficacy.A person will have a heightened self-efficacy if he or she experiences better results than the norm.Still, if someone you compare yourself with is struggling with a task, it may lower your belief that you will handle the same task with success.
Prior research has shown that self-efficacy is an important determinant when people are deciding on their sexual behaviour, such as whether or not to use a condom (Albarracín et al., 2005).HIV-related sexual situations are interpersonal.Bandura (2012) claims that to be able to successfully translate knowledge about HIV into a healthy and safe behaviour, it is necessary to feel in control of this interpersonal situation.This is not easily accessed, since feelings such as shame, embarrassment and fear of being rejected can be included and even dominate.A person with a high self-efficacy holds a bigger chance that he or she will be able to handle those difficult feelings and still choose healthy behaviour.
People are constantly being influenced and interacting with people in their surroundings (Glanz, Rimer, & Viswanath, 2008).Bandura argues that people still have more self-efficacy if they have the freedom to affect behaviour by selfinfluence, such as knowledge and reflections, and will experience less self-efficacy if he or she is controlled by the environment (Bandura, 1997).Even though Malawi is considered to be a collectivistic country, whereas Rohregger (2006) argues that the cultural dualism between the rural/traditional in the villages and the urban/modern in the cities is still very much in existence (Rohregger, 2006).People tend to be members of both traditional and urban societies, and this will necessarily invite conflicts on board (Martinussen, 2008).

Methods
Traditionally, self-efficacy has been measured through quantitative surveys.To understand how the female university students themselves experience their own ability to protect themselves against HIV, there are calls for a qualitative approach that offers to explore the interviewees' own perspectives, as well as the young Malawian women's own understanding of their self-efficacy.
As previously referred to, the study was conducted by van Pelt in August -November 2012 at Chancellor College in Zomba, conducting 17 semi-structured interviews and three group interviews.This is the biggest university in the country, and student enrolment is increasing.The decision to carry out this study at the university was based on the argument above that knowledge is not sufficient to create healthy sexual behaviours.Ntata and Biruk (2009) state: In Malawi, gender also seems confined to the village; it is often assumed that only the poor of those who live in rural areas need to be enlightened about gender or suffer from health or social problems that emanate out of gender inequality.In reality, Malawi is much more complex (…) (p.12) In this article, we will primarily draw on the interview data though the interviews that are part of a bigger data set.In her fieldwork van Pelt lived close to the campus, spent her days sitting on the lawn talking with the students, participating in classes and doing everyday things such as eating lunch on the premises and going on the bus to town like students do.In this way, many students came to know about her study, which often made asking for an interview a natural continuation of their conversation.To talk about sex is often seen as a delicate issue, though in this case it was most often unproblematic.This could be due to practical matters such as the minimal age difference between van Pelt and the students, or the cultural constructions of what can be seen as "delicate" or not (for more discussion about emotions in certain African settings, see Ryen, 2008).Female students from all age groups, both with and without sexual experience, were asked to participate to ensure maximum disparity.All the women were in the age range between 18-27 years old, and though motivation to participate in the study did vary, only a very few turned down the invitation.Almost all the interviews were conducted on the premises of the university, the purpose of the study and the process of the research were explained in English and all interviewees consented both verbally and in writing to participate in the individual-and group interviews.All the interviews that took place in English were recorded to ensure reliability.The interviews lasted for 30-45 minutes, with the main focus on relationships and sex in general in Malawi, and on campus in All data were transcribed verbatim and analysed by classic content analysis.This is an inductive process, in which all meaningful text was first coded into descriptive units, and then into analytic categories (for a detailed description of the analytical process with a full overview over all descriptive units, see Skiftun 2013 1 ).This means that the analysis was built from transcripts to analytic categories, as opposed to filling in transcripts to pre-selected categories.In our discussion below, we organize the thematic presentations in accordance with these categories as reflected in the subtitles of the section, as each category is illustrated with data extracts.To protect interviewees' identities, we use fictitious names throughout the article, which is in accordance with the Western research ethical codes we are obliged to follow, though at times theses are controversial in East-African settings (Ryen 2004(Ryen , 2007)).

The students' self-efficacy in protecting themselves against HIV
The data analysis yielded three analytic categories or themes, and the presentation of our data follows these categories.

Relational communication
Since one of the most important sources to self-efficacy is argued to be through communication with others, we will first look into how the students perceive their communication with parents and friends.
Counter to expectations, almost all the students report that they had a conversation about sexuality and relationships with their mothers.But, consistent with prior research, the content of the conversation had normally focused on the importance of abstaining from sex.Almost none of the parents have talked with their daughters about how to protect themselves against HIV transmission.Many of the girls believe that their parents hesitate to talk about the use of condoms for fear of encouraging them to have sex: Extract 1 Ennettie: They will think like they are encouraging you to practice sex… "You know when you are having sex, use condoms…".They will think like they are encouraging you.Priscilla: They tell you just to abstain from sex.That's all.Not to say to use a condom.No. (Group interview 1) and Extract 2 Blessing: My mum can´t tell me to protect myself (laughs).She feels like she's telling me "go have sex!"These extracts illustrate the delicacy of condoms as a topic in talks between parents and their daughters, as captured here in the lack of openness and feeling of immoral similar to what Limaye et.al ( 2012) also found in their study.Most of the girls would not tell their parents about a boyfriend at the start of the relationship.
Many expressed that it is only appropriate to bring home a boyfriend when they are about to think about marriage.Despite this, several girls claim that the parents probably know about both relationships and sex, but still "don't want to know": This extract deals with the privacy of the taken for granted.It shows the girls talking about parental assumptions, but without parents making it explicit.Parents seem to take for granted that their daughters may enjoy campus life as an arena devoid of parental control, as Joyce, who Ellen agreed with, says on parents' expectations that they do protect themselves.Mary's "a mixed thing going on" was an expression that came up in different interviews.Some girls believe that their parents expect their daughters to find a boyfriend during their time at the university as presented below under the section "social expectations".However, the sex is never an explicit topic in parental talks.Almost all the students report that they can talk to their friends about sexuality and relationships, but most of them would pick their interlocutor carefully for fear of gossip.They choose one or a few very close friends:

Extract 4
Atupele: Well it depends on what kind of friend you have.Cause some people are not comfortable just talking about anything.They´ll judge you when you break up such topic, right.But there are some friends you can always just talk to about anything, like anything at all.And you´ll be surprised to find that they can give you better advice than anybody else.I:So you can have friends that can even give you advises on these issues?Atupele: Yeah, "how-to's"…How to prevent… Several girls believe they have learned much from their friends in these conversations.Other girls claim in turn that a bad quality to the advice is the reason for only talking to close friends.This points to the delicacy of this type of conversation with friends, though friends may be a dubious category.They represent a risky territory because of the threat of disloyalty ("they`ll judge you"), as well as a potential source of valuable guidance ("they can give better advice than anybody else").It takes a careful amount of work to assess this territory to help master the balance as we see in the following section, in which one girl is talking about how some friends were reacting when they heard that she did not want to have sex: Extract 5 Pamela: I remember someone telling me like, "Why didn´t you do it?"So… (Short laugh) I was like: "Hey, mind your business" (with laughter in her voice) I: Yeah… Pamela: Yeah, so that's why I do… Okay, I keep it to myself, and I only tell my best friends this because only I tell someone, and then someone will like say "okay, you have to do it", you know.Like, convince me to… like… I: Pressure you… Pamela: Pressure me like to do it, yeah.So... I'd rather tell my best friends only.
The border between advice and pressure may become blurred.It also demands skills to handle.Some of the girls are emphasizing that it is not appropriate to talk with friends about HIV testing because it can be offensive:

Extract 6
Mwipie: It doesn't really get into the whole "do you use protection" part of it.They never really discuss that part.Like, they only tell each other ways they can prevent getting pregnant, like morning-after pill and stuff like that.They never really bring that issue of the HIV, because they don't want their friends to be feeling like you are accusing their boyfriend of being infected, or something like that.
As illustrated in this excerpt, many of the girls are concerned with other girls` judgements.Mwipie claims girl-talk tends to escalate into talk about protecting oneself against pregnancy rather than against HIV.Though related and delicate, talk about protection against HIV may implicitly be heard as an accusation against someone`s boyfriend.Consequently, friends may take care of each other by redirecting their talk to avoid bad feelings or cluttering up friendships.This highlights the social complexities associated with HIV talk and how the female students may handle such dilemmas.A few of the students name girls` judgements as the main reason for not wanting to talk to anyone about sexuality:

Extract 7
Sellah: I think it is the boys who have that mind to disclose it to others, but girls choose not to disclose that I am having a boyfriend Rachel: Or you know so much about sex, and things like that…they think people will think bad about them I: If you know too much about sex? Rachel: Yeah.See? Sellah: They call you a "bitch" Rachel: They will be calling you names I: Mm.Rachel: So most of them will just keep it to themselves (Group interview 2) The fear of others` opinions was very alive during the interviews, and having too much knowledge was often referred to as something negative associated with the talker`s own practice as a girl.The students talk about knowledge of sexual behaviour as contributing to their own vulnerability.Hence, knowledge about sexual behaviour and protection falls into the classic trap that female knowledge causes social disorder and should be kept personal and private out of the public space.In this way girls, discipline other girls, which moves social control into the very midst of the female spaces on campus.Protecting one`s image makes talk about protection against HIV highly complex.The image of purity still rules, and female students protect themselves by framing their talk into the public discourse of female morality.Nevertheless, this finding is not coherent with many of the other social expectations in their surroundings, as they seem to confront conflicting discourses.

Social expectations
We will now look into the female students' expectations for relationships and for sex in the relationship while at Chancellor College.
Many of the students said that they had heard stories about Chancellor College before they came to campus, and they did have expectations to what the coming years should bring.It is a common saying that the girls come from a life under the rules of their parents, and are now able to live independently: Extract 8 Blessing: They just sort of think that here it's free, and it's okay to do certain things… and the society might say "no", but they think "oh, it's okay, its college."

Extract 9
Gloria: (…) cause when you come here people mostly talking about just "let's have fun", "its uni, let's have fun, let's be young, let's be wild".
Blessing and Gloria both talk from the wider campus life by their comments: "its college" (Extract 8) and "its uni, let's have fun" (Extract 9).A few of the first-year students said that they were inexperienced with relationships, but because the college is seen as a space of its own, as illustrated by Blessing and her talk about the difference between society and college, nearly all the girls believe that it is highly expected to be in a relationship when at college.Several girls feel that there is some degree of group pressure, and that your peers can easily tease you if you have never had a boyfriend.One student said that girls are named bindery girl if they do not have a boyfriend throughout university, as in "(…) old tattered books that need to go the bindery".Many students report that it can be very important for a girl to have a boyfriend before she finishes her fourth year, and they often refer to the importance of marriage and the need for safety.Many tell stories from their families about how very difficult it can be to find a man after college, which they sum up by their "now or never" attitude.They have many thoughts related to not finding a boyfriend:

Extract 9
Blessing: Chancellor College is known to be one of the big campuses in Malawi, and you´re thinking: "Okay, I am I gonna go out after four year with no boyfriend?What are people gonna think?"Like, what are people gonna think?They think that I was playful, like maybe jumping from one guy to another.Like maybe none of the guys at my school didn't like me, they didn't pick me.
In her narrative, Blessing conveys her ideas about expectations to find a boyfriend at the college.She also says (not shown here) that mothers and aunts in particular send such messages to their daughters.A few girls say that even though the parents do not accept a sexual relationship, they still expect their daughters to have a boyfriend before leaving university.Here is Mary from our opening extract: Extract 10 Mary: "I mean, pretty much we are told "no boys", right?And one day you are expected to have a boyfriend.So you don't catch that link from "no boys" to "have a boyfriend."(Group interview 3) From these excerpts one can assume that the parents do know about their daughters relationships when at college, but are still avoiding talking about sexuality.More than half the students interviewed reported they had no sexual experience.The majority were first-year students and others who had chosen not to have sex before marriage based on their religion.Still, almost all the students think that it is expected to have sex if you are in a relationship.

Extract 11
Mwipie: I think nowadays it's like girls get into relationships for love.And the guys get into it I guess for sex and for fun.But then girls use sex to get love, and guys use love to get sex.
As illustrated, many of the girls think sex is the main aim for a boy who goes into a relationship.They also report that whether or not it is expected to have sex is dependent on the boy.Parents have an interest in seeing their daughters with a boyfriend when finishing their studies, as expressed by Mary and her complaint in Extract 10, preferably without talking about protection.The girls interpret their parents' hesitation to raise this issue as a fear of being misunderstood, potentially protecting their daughters' health and image in search of an acceptable partner when reaching the social stage of marriage.But no one tells them how to get into a relationship and remain there apart from the boys in their demand for sex.This is illustrated by Mwipie, who in Extract 11 believes that girls would use sex to get love.That is, a relationship emerges as a gendered social phenomenon, but without guidance the social gendered order of patriarchy seems to be invited on board.The question then is how to protect oneself?

Practical protection
Let us now look into the recurrent answers on how the girls perceive they are able to protect themselves against HIV transmission via HIV tests, the use of condoms and the ability to say no to sex.
Most of the students think it is acceptable for a girl to ask her boyfriend for a HIV test.A high self-efficacy in asking their recent or future boyfriend for a HIV test is a common finding in the interviews: Extract 12 Alinafe: You can do it!You also have to do it!It's your body!You can also take part, let's go for HIV test.It's not the boy's law only, it's for both of us.
Alinafe is 24 and through with the first tricky years on campus.She is also a Christian, and is one out of two who mention that their pastors are preaching the importance of HIV testing.Despite this, many believe that it can be very difficult for other girls to do the same, as illustrated in the following excerpt: Extract 13 I: Would you ask him for a HIV test?Pamela: Yes!I would ask him.Definitely.I think that would be the first thing before getting married.Yeah, to have a HIV test before like we get married.Yeah.I: Would it be okay for a girl to ask a boy for a HIV test?Pamela: Ehm… Yeah... Ehm… But then nowadays….Okay… whenever they ask a guy to have a HIV test, I would think that maybe… Ehm… maybe there is no trust in him, or something.So, many people do of course keep it in their minds, and are not telling the guy to have a… I: because they're scared that… Pamela: Yeah, yeah… But as for me, I think I can tell that guy.
Pamela expresses a firm belief that she is confident to ask for a HIV test before getting married.However, when she is asked a question outside the preached narrative, Pamela becomes less self-assured as seen in her, "Ehm…Yeah…Ehm…But then…".Asking for a HIV test could be seen as a sign of lack of trust, which also found by Tavory and Swidler (2009).Importantly, Pamela is not yet in a relationship, so she is talking in general terms without having faced the cross-pressure.A question about condoms may also make the relationship more fragile: Extract 14 Ellen: It is not a great start of the relationship, in some way.I: Cause then you`re kinda starting with…?
Ellen: "I doubt you."(Group interview 3) More girls refer to doubt and a lack of trust as a reason for not asking about the use of condoms, but are somewhat divided in their opinion about the acceptance of condom use in a relationship.Some of the girls claim that it is unacceptable to have a sexual relationship without using condoms.They give two reasons: One is that there is a culture at Chancellor where people have multiple partners, which makes it very unsafe not to protect yourself against HIV.Another more frequently given reason is to avoid the risk of pregnancies, as one of the girls believes that this fear is more present in their daily life because of the shame: Extract 15 Mwipie: Cause they go like: "Ooh, with HIV I can even live like 10 years.How many more years…20 more years… but then when I am pregnant, I could be embarrassed and what, what".
The visibility of HIV and a pregnancy is different, and the immediate embarrassment associated with giving birth outside marriage is a tough sanction for Mwipie, who imagines HIV can be hidden for a decade or two.
It is not unlikely that sexual experience may influence the students' self-efficacy through their first-hand experience with the associated difficulties in negotiation from meeting boyfriends' expectations in a sexual setting: Many girls expressed that a boy is in behavioural control over whether or not to use a condom.If the boy says "no", it would be very difficult to argue.The girls also say that many other girls will then have unprotected sex, in fear of losing the boy.The condom issue means boy power.One girl puts it this way: Extract 17 Eniette: Most girls, they do sex without condom.Without wanting themselves to do that.They just make it for the sake of making him happy Several girls: To the boy.To the man.(Group interview 1) The fear of losing the boy, as well as the importance of "making him happy", are both repeated in almost all the interviews.The talk about "they" may refer to the master narrative about girls' sexual behaviour faced by personal male power and the image of girls pleasing men.The girls do not need to buy condoms because they are free at many locations, such as the women's bathroom, but the students revealed a strong conviction against girls picking up condoms and putting them in their purses.Several of the students claimed that it would be smart for a girl to bring her own protection, but that it would ruin her reputation.If someone sees a girl picking up a condom, she will get the image of someone who is "loving sex too much" or "always ready to have sex".Many say that it is the same as the behaviour of a prostitute, as in the following illustration when a girl was asked what she would think if she saw a girl with a condom in her purse:

Extract 18
Alinafe: I would say (whispers) she's a bitch.(…).I would think that she's a bad girl.Why is she carrying all this… That's my point of view, eh?
This 24-year-old girl's opinion captures many of the interviewees' views, as illustrated by one girl who pointed a finger to show how girls are judging each other:

Extract 19
Florence: It would be better if girls would sort of stick together and not say anything bad about a girl who picks up a condom (…).But it actually comes from girls and guys.The pressure is a little too much I think.
All interviewees report that the opinion of other girls does matter, as does the opinion of the boy.Most of them see it as the boy`s responsibility to bring a condom.
To avoid bringing her own protection will also protect the girl from giving the boy a bad impression of her.

Extract 20
Amena: It's not [okay to bring condoms].Yeah.And because girls expect that the boys will just take a condom… it's like the girl produces the condom and say, "Let's use this condom"… Of course she can negotiate about the condom, but producing a condom… "I have the condom, let's use it"… the boy will think, "Oh, so she can do it with everybody else"… The only time it would be okay for a girl to bring a condom is when it is agreed upon with her boyfriend.But again, this also depends on the boy's willingness to use protection.So either way, girls can best protect their social honour by rejecting the leadership in decisions about their own sexual behaviour, thereby increasing the risky behaviour.Most of the students expressed that it is very hard for a Malawian girl to turn a boyfriend down: Extract 21 Joyce: I think a person who have the most chance to not really have sex is the single.(Group interview 3) Almost all the students believe that for a girl to refuse to have sex comes with costs: Extract 22 Amena: I can say that there is two options.The relationship can be ended up, or that boy will have multiple partners.Cause you have that person… maybe he likes that girl muchhe cannot lose the girl.But because the girl is refusing to have sex, he will look for another person who would be having sex with him.
Many of the girls were explicit that the boy is only be in the relationship to get sex, and that to refuse would cause him find another girl.A few of the girls who choose to say "no" got reactions from their friends.In the following excerpt, we follow Gloria`s friends and her reactions: Extract 23 Gloria: Like a lot.Even some of my own friends, like "Serious!That's you decision?"Like, "Trust me, if he is not gonna get it from you then he get it from someone else".My own friends.
Gloria talks about a group pressure from within the peer group itself by portraying sex with your boyfriend as a remedy to make him refrain from having sex with other girls.If you do not, then you only have yourself to blame.
Despite parental advice, it is still not always expected for a girl to say "no" to sex, which brings nuances into the previous narratives about chastity.However, the focus of the friends in Gloria's narrative is on how to keep the boyfriend, or the fear of losing him, rather than on safe sex.Again, this shows how girls' advice to each other, such as in Extract 4 with Atupele and her talk about what kind of friends you have, may influence a girl's health behaviour in a more problematic and unsafe way.This brings us back to public health.

Discussion
As previously referred to, the main purpose of this study was to understand the self-efficacy of young female students at Chancellor College in protecting themselves against HIV transmission.Let us now look into the results and later discuss how they relate to Bandura's concept of self-efficacy.

The campus as an arena of conflicting expectations
According to Bandura, self-efficacy can be developed by four primary sources, and will be influenced by different strengths: enactive mastery, vicarious experiences, social persuasion and physiological arousal (emotional status).In this article the authors will focus on enactive mastery and vicarious experiences, hence, our interest would be in the local mediating mechanisms of such experiences.In their discussions, the female students refer to both of Bandura's categories by intersecting their own past experiences from relationships and their talks with parents, friends and peers.It takes clever manoeuvering to master dealing with complex and conflicting surroundings.
Most of the girls in the sample have been talking to their parents about sex.The girls report that abstinence is the main parental advice and with hardly any talk about the use of protection, which is consistent with prior research.So when Bandura refers to modelling as one of the most important sources of self-efficacy, one may wonder if the parents are playing out the roles that they expect their daughters to show society to avoid the stigma.In that case, one may say that mothers who themselves have experienced the tricky age of the "in-betweeners" may now from the parental perspective heighten their daughter's self-efficacy by their advice to stay away from sex.By expressing it in this way -do stigma and social norms also have a protective side?In a strongly ordered society where it is not socially accepted for girls to have a sexual relationship with a boyfriend, one could assume that there may be a preventive side of preaching abstinence.The girls did express concern about their reputation and the fear of being looked upon as "liking sex too much" or being called names (Extracts 7 and 18).Does it make them reflect more on sexual activity and its possible consequences?This leads us to the problematic side of this way of thinking.
The girls are not only surrounded by parental expectations, but also by talk about the campus as an arena of conflicting expectations.This becomes very much alive in their search for a partner or a future candidate to present for their parents and their expectations associated with life at a university -safeguarding both their ownand their family's position.Oettingen (1995) states that culture has an impact on what sources of self-efficacy we chose to emphasize or reject.Despite being a collectivistic society, it would be a simplification to believe that the parents are the main source of self-efficacy.What "culture" do the girls emphasize?
The girls are living in several worlds and cultures at the same time.The village, their family, neighbours and the surrounding society constitute the wider arenas.
Here, we partly find an alternative set of rules such as in the traditional communities, where there is more control in hierarchical relationships.This is different from the more modern and urban campus, where the girls have wider networks and less social control.This difference is expressed by Blessing when she talks about the campus: "… and the society might say "no", but they think "oh, it's okay, it's college" (Extract 8).How do they juggle the different rules and arenas?Many of the girls like Atupele and Pamela (Excerpts 4 and 5) report that they share experiences about relationships and sex with very close friends only.This makes us see how the girls seek advice in their very practical everyday life as female students mediating between conflicting parental advice and their boyfriends' lust.Does this mean that the girls rank their female co-students as role models when at college above their parents?Almost all the students see it as expected for a girl to be in a relationship at college, and that staying single can make other people think there is something wrong with you being captured by the description of being "a bindery girl"an expression that seems to mean that the girl is "outdated" and in need of a change in her look.If this is the norm among the peers, it will be difficult for the girls to believe they can have success by staying single without getting a negative evaluation, which will lower their self-efficacy.
Still, there seems to be a crossing point between the expectations from friends and family.Many girls expressed the importance for Malawian students to find a boyfriend before they leave university.They are planning for the future, meaning getting married in a societal context with marriage as the only legitimate status, especially for a woman whose legitimate womanhood depends on male protection.How can parents be a part of an environment that makes it easier for the girls to choose a less risky behaviour when their daughters (and sons, too) frequent what for their parents would be unknown territories?Maybe transforming contexts within collective cultures calls for renewing health workers policies by widening up the target groups of health behaviour by offering both "parental classes" and "student classes".
The students did express different levels of self-efficacy when talking about using condoms with a boyfriend.To help give this nuance, when some girls without any sexual experience express a higher self-efficacy in asking a to use a condom and take HIV tests than girls with some sexual experience, we may wonder how come?Girls with sexual experiences may have been in situations where they faced male power and failed to succeed, as expressed by Sellah in Extract 16: "If he says yes, it's yes.But if he says no, it's no".On the other hand, "our" nonexperienced girls referred to another external source, the preacher in their church.This other collectivity to which they also belonged may influence them by vicarious experiences.Some of the students believed that asking a boyfriend to use condoms or take a HIV test would indicate a lack of trust and thereby support prior research (Tavory & Swidler, 2009).Several girls pinpoint the acceptance of using condoms as a protection against pregnancies, which is a classic worry.If the experiences of other students are seen as the most important source of self-efficacy, it follows from this that the fear for something as visible as a pregnancy has a high impact.It takes a longer time to detect that someone is contaminated by HIV, and the long-term consequences are not so easy to worry about (Glanz et al., 2008).

The relational aspects of condoms
Both the government and different NGOs have prioritized making condoms easily available for girls in Malawi, as all the students know that condoms are easy to find and free to pick up.Nonetheless, most of the girls said that it is not easy to take advantage of this offer.It seems to be very hard for a Malawian to maintain an image of being a good girl if you are found carrying a condom in your bag.The consequences of being caught with condoms are huge.What would other girls think (Amena in Extract 20)?What would the boy think?Many girls also said that it is the boy who should be concerned about condoms since too much knowledge about this could make others believe that she likes sex too much.This attitude was also expressed by other girls, who described a girl with a condom as a "bitch" (Alinafe in Extract 18).Availability does not easily make people change their behaviour because the link between attitudes and availability is more complex.Condoms available at women's salons will not make women more self-sufficient in bringing condoms in their purse.If we want to make women to bring condoms in their purse, we need to change the connotations associated with this as a sign of health care, and not prostitution.Access to a condom is just half the job.Health workers need to shift their concern from the condom itself to the social aspects of picking up and carrying a condom in their bag as a sign of a responsible person.The issue at stake is how to make it legitimate for a young person to see a condom as a marker between enjoyment and disaster.It seems as if the strategy started in the wrong place.If we want our behaviour to change, we need to start by changing our beliefs and our culture in our everyday doings.
Bandura claims that a person will feel less self-sufficient if she or he is controlled by their environment.Our study does indeed show that their environment strongly interacts with young girls' decisions.He reminds us of the mastery experience as the primary source of self-efficacy.However, we argue for a need for nuancing this category.In our case, maybe the self-efficacy can be low in protecting oneself against HIV, but high in dealing with the expectations of the surrounding environment.This leads to another vital question, what does it take to be successful?If the female student's preference for being successful on campus is to master her social arena and avoid rumours and shame by choosing risky behaviour such as not using a condom, it will be a serious danger to her health.

The embeddedness of self-efficiency: Asking the bigger questions
For a health worker, a student's feeling of self-efficacy should come from a feeling of being able to protect yourself from the risk of being HIV infected, which may not be a priority for a female Malawian university student.It may be much more important to feel capable of performing a behaviour that will lead to keeping a boyfriend -without losing her image and reputation.It is important for the girls to know how to look ignorant about sex, as this is crucial information when creating a strategy for increasing knowledge about sexual health.The reality is complex, and if health is created where we live it is important to learn about the arenas where we operate.This includes the boys who are in behavioural control over the use of condoms and HIV tests.Bandura (2012) reminds us that: "Problems arise in following safer sex practises because self-protection often conflicts with interpersonal pressure and sentiments" (p.10).It is not possible to only focus on the girls' behaviour without identifying the enormous impact the environmentally nested social structures have on them.The danger is if the struggles to avoid a negative evaluation from the surroundings override the judgement based on knowledge.According to Bandura (2012), the most effective health communication is to maximize peoples' belief in their own capability to change their behaviour.Our data show that this is more complex if the students are weighing the risk of contracting HIV against the stigma associated with asking for condoms, saying "no" to sex or staying single.Both are as rational as they are emotional.To better get at this, we need to ask ourselves, where does self-efficiency come from?If contextual, then what if the context changes?Changes tend to be partial and take place across a long time.Malawi now undergoes profound transformations as reflected in the current increase of female students.As opposed to their male counterparts on campus whose life will be accepted as just moderately different, these female students are the first generation to prepare for a full-time job in the formal sector.
Hence, their economic dependency on a male breadwinner is different from that of their mothers (Temba et al., 2009).However, norms change less rapidly, which leaves female students in a squeeze between the old and the new gendered female lives that prompts the question: Self-efficiency towards what desired outcome as defined above?It is these questions that young women now face and which demand that health workers redirect their attention and practice.

Conclusion
Our data tell us that health policies to protect against HIV transmission cannot be reduced to merely a health issue.Though factual knowledge about how the virus is transmitted is crucial, so is the acknowledgment that sex is embedded in a profound symbolic complexity of social relationships, presentation of self and power in highly gendered spaces.As mentioned, female Malawian students are part of a community undergoing profound change, and going to university makes them part of both the traditional and modern society, arenas with partly conflicting norms.The girls report that their parents also see university as a place to find a partner, but without telling them how to handle the more practical, not to mention emotional work, that comes with it.On the other side, being the first generation in many families going to university, we may wonder how parents would even be able to guide in an unfamiliar setting.To grasp the social of the phenomenon is a crucial insight for public health workers, and the condom maze illustrates this well.It deals with much more than health and free access to condoms.It also deals with dignity and honour, which makes the simple act of picking up a condom into a massive risk zone.

Moving forward
Our study suggests that health workers need to offer guidance as how to handle the practical side of negotiating power in sexual relationships.By health workers, we also mean both practitioners in public health and social work.Despite somewhat different approaches, the two fields have a shared mission on enhancing the wellbeing of the communities and social justice (Ruth & Sisco, 2008:2).Jennifer van Pelt (2009) claims that collaboration between the two professions offers to bridge prevention and intervention, individual and community.In this study, we have found that the girls are caught in the crossfire of different expectations from family, boyfriends and friends.Since this deals with relationships, practitioners need to include both partners individually or as couples to make sure attitudes toward a healthy sexual practice become legitimate common goods.Boys, friends, family and the surrounding environment are an integral part of female students' health behaviour, and not simply disturbing elements.Hence, they should be a part of the solution.

Endnote
1. Van Pelt's former family name particular, in relation to the perception of control and protection, and talking about sex with friends and family.Ethical approvals for the study were obtained by the Ethics Committee of the Faculty of Health and Sports Science at the University of Agder in April 2012 and the National Health Science Research Committee (NHSRC) in Malawi in August 2012.Van Pelt has previously been in Malawi several times as part of her education in social work, and this time also worked with the late professor Ntata, while Ryen has been doing research in East Africa for two decades.
Joyce: No… Parents do know that we do actually have sex; they just expect you that you do protect yourself.
If he says yes, it's yes.But if he says no, it's no (all laughing).