Worldwide, a number of factors associated with migration place migrant populations at higher risk for HIV infection, including extreme poverty, substance and alcohol abuse, obstacles with different language and culture, migration patterns, immigration status, disparities in access to health care, segregation and social exclusion, and lack of education [9, 10].
Furthermore, migration has been associated with higher levels of depression, loneliness, and isolation as well. The sense of solitude and isolation experienced by migrants may be the driving force behind embracing unhealthy behaviors, such as practicing risky sexual practices [11, 12]. These populations may become a reservoir of latent infections because of poor health care in their native Countries or because of social and ethnic marginalization [13,14,15,16,17].
Efforts to prevent the transmission of HIV have largely focused on education and behavior change, but several studies reported scarce use of condom among migrants [18,19,20,21].
HIV/STI prevention interventions should focus on promoting consistent as well as correct use of condoms because their improper use is associated to failure rate, due to improper application or removal, or both, other than breakage or slippage and timing of application and removal (as well as the skills involved) .
Studying the general level of Condom Use Skills in our sample, composed of migrants recently landed in Italy, we find no significant differences in the level of Condom Use Skills between African and Middle Asian migrants.
We find that level of education and age are associated with better answers to the questionnaire and an high skill score. For these reasons, we suppose that education level can influence the quality of advice and knowledge imparted and have contributed to condom use behaviours and level of Condom Use Skills. Furthermore, other studies underline the role of better-educated friends or acquaintances’ communication in improving Condom Use Skills .
Single or married men of our sample don’t show relevant differences in the answers: this is an important remark because other studies suggest that low condom skill score may be related to single status or living as temporary single condition .
Although a low skill score may not predict absolute failure of HIV infection prevention, it would be advisable to proceed with caution in using this score as a means of predicting real-life condom use, about 30% of our sample results in class C or D, an alarming percentage. It would be important to have a comparative norm, but literature about vulnerable populations is scarce, while other categories, such as female sex worker (FSW), reached important goals in the prevention of STIs and HIV with a higher condom use [29,30,31,32]. On the other side, a longitudinal research in an urban canadian setting highlights the persistent challenges faced by migrant sex workers in terms of accessing and using condoms .
Our sample is only composed of asylum-seekers: although Italian residence permit requests are justified mainly by business employment (48%) or familiar reunification (41%), in 2014 the third most frequent cause is asylum-seeking and humanitarian aid (5%), overtaking studying reasons . The observed skills of condom use among our participants may be different from other populations, such as foreigner sex workers, and this could be a limitation of our study.
Another critical issue is the presence of only men in our sample, but another study that performed additional analyses for males and females separately showed no significant differences in demonstrated condom skills . However, it would be interesting to carry out a new study to make comparisons between male and female migrants.
As peer reviewers had suggested, different methods for classifying and analyzing data in this study could have be adopted. We have chosen to assign one point for each value in the questionnaires used to evaluate the attitudes, knowledge and skills to simplify statistical analysis. According to the assumption that all items are equally important, the dichotomist classification reduced the variability and gave the immediate overview on the critical targets to be included in specific and rapid interventions. Nevertheless, further evaluations using quantitative methods, alongside scrutiny of each item on the skill scales, will be able to supply more nuanced and detailed insight into this complex situation and to identify more tailored health promotion requirements.
After all, recent researches are also focusing on the timing of condom application (late application or early removal as being crucially important aspects), but we don’t include these features because it’s difficult to see how they could be with a wooden penile model [27, 28].