Individual, Interpersonal, and Structural Power: Associations With Condom Use in a Sample of Young Adult Latinos.

Health Care for Women International

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Individual, Interpersonal, and Structural Power: Associations With Condom Use in a Sample of Young Adult Latinos Lynissa R. Stokes, S. Marie Harvey & Jocelyn T. Warren To cite this article: Lynissa R. Stokes, S. Marie Harvey & Jocelyn T. Warren (2015): Individual, Interpersonal, and Structural Power: Associations With Condom Use in a Sample of Young Adult Latinos, Health Care for Women International, DOI: 10.1080/07399332.2015.1038345 To link to this article: http://dx.doi.org/10.1080/07399332.2015.1038345

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Health Care for Women International, 00:1–21, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2015.1038345

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Individual, Interpersonal, and Structural Power: Associations With Condom Use in a Sample of Young Adult Latinos LYNISSA R. STOKES, S. MARIE HARVEY, and JOCELYN T. WARREN School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA

Interviews were conducted with 480 sexually active Latino young adults from four rural counties in Oregon. We examined relationships between three levels of power (individual, interpersonal, and structural) and consistent condom use. Condom use self-efficacy and sexual decision-making, examples of individual and interpersonal measures of power, respectively, were associated with increased odds of consistent condom use among both men and women. Among men only, increasing relationship control, an interpersonal measure of power, was associated with lower odds of consistent condom use. Among women only, increasing medical mistrust, a structural measure of power, was associated with increased odds of consistent condom use. HIV/AIDS and sexually transmitted infections (STIs) are public health problems that affect millions of people around the world (Kaiser Family Foundation, 2013; World Health Organization, 2013). In the United States, the burden of HIV infections and STIs is disproportionately high among communities of color, including Latinos (Centers for Disease Control and Prevention [CDC], 2011a, 2012b). For example, rates of STIs among Latinos range from two to nearly three times the rate among Whites (CDC, 2012b). In 2009, Latinos accounted for 20% of new HIV infections in the United States (CDC, 2011a). During that same time period, the rate of new HIV infections among Latino men was two and one-half times higher than that experienced by White men Received 28 May 2013; accepted 2 April 2015. Address correspondence to Lynissa R. Stokes, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, 466 Waldo Hall, Corvallis, OR 97331, USA. E-mail: [email protected] 1


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(CDC, 2011a). Among Latinas, the rate of new HIV infections was more than four times that experienced by White women (CDC, 2011a). Latinos in Oregon experience disproportionately high rates of STIs and HIV infections similar to the disproportionate rates seen among Latinos across the United States. Based on 2009 data, the rates of STIs among Latinos ranged from almost two times greater than that reported among Whites for gonorrhea to two and one-half times greater than the rate reported among Whites for chlamydia (U.S. Department of Health and Human Services, 2011). Latinos’ rate of HIV infection is nearly two times higher than for Whites residing in Oregon (Oregon Health Authority [OHA], 2011). Between 2005 and 2009, Latinos comprised a greater proportion of newly diagnosed HIV cases in Oregon than they had in previous time periods (OHA, 2011). These national and state data support an ongoing critical need to understand the factors that contribute to the disproportionately high rates of HIV/AIDS and STIs among Latinos. Heterosexual contact is the second largest risk category for young adult men and the largest risk category for young adult women across racial and ethnic groups in the United States (CDC, 2011b). Among Latinas, for example, recent data indicate that 87.8% of HIV infections were due to heterosexual contact (CDC, 2012a). Male condoms remain the most widely available and accessible means for controlling the transmission of STIs and HIV for sexually active couples. Decision making regarding STI and HIV/AIDS prevention, including whether or not to use condoms, occurs in the context of a sexual relationship. Condom use is, therefore, an interdependent behavior in that it requires the participation and cooperation of both members of a couple. Issues of power and control are particularly important when considering interdependent behaviors (Thibaut & Kelley, 1959) such as condom use. Lack of power in heterosexual relationships is an issue that women face worldwide and has implications for their ability to protect themselves from acquiring heterosexually transmitted HIV infection and STIs. In previous research on HIV/AIDS risk in both the United States and internationally, researchers have found that condoms are used inconsistently and the negotiation of their use is more difficult when women report low levels of power (Gómez & Mar´ın, 1996; Langen, 2005; Pettifor, Measham, Rees, & Padian, 2004; Pulerwitz, Amaro, DeJong, Gortmaker, & Rudd, 2002; Ragsdale, Gore-Felton, Koopman, & Seal, 2009). For example, Langen (2005) found that among South African women, experiencing abuse was an impediment to suggesting condom use. In a study done by Pettifor and colleagues (2004), South African women who reported inconsistent condom use were more likely to report low levels of condom use self-efficacy than women who were consistent condom users. In an ethnically diverse sample of women in the United States, most of whom were Latina, Pulerwitz and colleagues (2002) found that women with high levels of sexual relationship power were almost five times more likely


Individual, Interpersonal, and Structural Power

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to report consistent condom use compared with women in the study who reported low sexual relationship power. Each of these studies highlights the importance of power or lack thereof in condom negotiation and use. Although sexual risk behaviors that contribute to HIV/AIDS and STI risk have been the focus of previous research, evidence for the contribution of social determinants and structural inequalities to these behaviors is growing and necessitates additional research. In this study, we posit that in order to tease apart the complicated relationship between power and condom use in heterosexual relationships among Latinos, it is important to consider a broader conceptualization of power that reflects that power occurs at the individual, interpersonal, and structural level (Gutiérrez, 1990). Thus, we focused on the influence of multiple measures of power on condom use behavior among Latino young adult men and women and (a) investigated if different measures of power were related; (b) determined whether perceptions of power varied by gender; and (c) examined which measures of power were more strongly associated with condom use among the women and men in our sample.

BACKGROUND Many conceptual models used by researchers to investigate sexual risk and risk reduction behaviors include mostly individual determinants of sexual risk-taking and protective behaviors (e.g., Gazabon, Morokoff, Harlow, Ward, & Quina, 2007; Mausbach, Semple, Strathdee, & Patterson, 2009; Walsh, Senn, Scott-Sheldon, Vanable, & Carey, 2011). Missing from such models are the diverse cultural, contextual, interpersonal, and societal factors related to gender (e.g., power differentials, gender role attitudes) that likely influence sexual behaviors and have been identified elsewhere as contributors to both sexual risk and risk reduction behaviors (Amaro, 1995; ´ Amaro & Raj, 2000; Castañeda, 2000; Gomez & Mar´ın, 1996; Gutiérrez, Oh, & Gillmore, 2000; Rosenthal & Levy, 2010; Ulibarri, Raj, & Amaro, 2012; Wingood & DiClemente, 2000). Although the reasons for the disproportionately high rates of STIs and HIV/AIDS among Latinos are very complex, gender-based power imbalances may help to explain some of these disparities. Power imbalances are not experienced exclusively by Latinos in heterosexual relationships. Latino cultural values such as machismo, in which men are expected to control and dominate sexual relationships, however, may contribute to a range of risky sexual behaviors including unprotected sex (Hillman, 2008; Moreno, 2007; Tross, 2001; Weidel, Provencio-Vasquez, Watson, & Gonzalez-Guarda, 2008). An examination of the factors that may underlie the ability of a particular individual in a sexual relationship to exert more control over condom use is, therefore, an important area for further empirical examination.

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A Multilevel Approach to Understanding Power and HIV/AIDS Risk Gutiérrez (1990), in describing her clinical work with women of color, provides a useful framework that can be applied to understanding how levels of power (individual, interpersonal, and structural) are related to sexual risk behaviors. She notes that “the process of empowerment occurs on the individual, interpersonal, and institutional levels, where the person develops a sense of personal power, an ability to affect others, and an ability to work with others to change social institutions” (p. 150). With increasing personal, interpersonal, or political power, an individual is better able to take action to improve his or her life situations (Gutiérrez, 1990). Viewing power in heterosexual relationships as a combination of individual, interpersonal, and structural forces better reflects Amaro and Raj’s (2000) exhortation that cultural and contextual factors be examined in any study of HIV/AIDS risk in heterosexual relationships.

Individual Power Individual power involves experiencing oneself as a capable person. One’s power in a heterosexual relationship may reflect the extent of an individual’s power. For example, perceived self-efficacy, defined as people’s belief that they can exert control over their motivation and behavior and over their social environment (Bandura, 1993), is a form of individual power. Perceived self-efficacy in general and condom use self-efficacy, specifically, have emerged as strong predictors of safer sex behaviors in numerous stud´ ies (e.g., Gomez & Mar´ın, 1996; Gutiérrez et al., 2000; Knipper et al., 2007; ´ Mar´ın, Tschann, Gomez, & Gregorich, 1998; Soler et al., 2000). Individual power in heterosexual relationships may also depend on relative interest in the relationship. The “principle of least interest” posits that the partner with the least interest in the relationship has more power and, conversely, the partner with the most interest has less power (Agnew, 1999; Huston, 1983). In their study of power in romantic heterosexual relationships, Sprecher and Felmee (1997) found that less emotional involvement was associated with greater power. Least interest can be defined in ways other than emotional attachment. In his study of power over condom use, Agnew (1999) measured relative interest in the relationship in terms of the desirability of perceived alternatives to the current relationship. He found that the dyad member who was least dependent on/least committed to the relationship (e.g., the one who had the most attractive relationship alternatives to the current relationship) was the member whose own intentions were significantly more likely to be adopted by the overall dyad. This suggests that the more highly committed partner may be more dependent on the other partner and thus less powerful in sexual decision making. Relationship commitment is not a common measure of power, but it has been included as


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such in a number of studies (e.g., Billy, Grady, & Sill, 2009; Grady, Klepinger, Billy, & Cubbins, 2010; Saul et al., 2000).


Interpersonal Power Interpersonal power has been defined as the ability to influence another person in order to achieve desired ends (Balswick & Balswick, 1995; Connell, 1987; Huston, 1983). In a recent qualitative study with young adult Latinos (Zukoski, Harvey, Oakley, & Branch, 2011), both men and women described relationship power as relationship control and decision-making dominance. These findings are consistent with those of Pulerwitz, Gortmaker, and DeJong (2000), who defined relationship power as the ability of one partner to dominate decision making, to engage in behaviors against the other partner’s wishes, to control a partner’s actions, or some combination of these behaviors. Both of these conceptualizations of interpersonal power, relationship control and decision-making dominance, have been associated with condom use among young adults in heterosexual relationships. In such studies, when the female partner reports equal or greater relationship control than her partner, condom use is generally more consistent than among those women who report that they have less control than their partner (Knudsen et al., 2008; Pettifor et al., 2004; Wingood & DiClemente, 1998). Similar results have been found for those women who report greater participation in sexual decision-making (Billy et al., 2009; Harvey, Bird, Galavotti, Duncan, & Greenberg, 2002; Soler et al., 2000).

Structural Power Structural power refers to power that relies on hierarchies that exist in society, hierarchies based on individual characteristics such as race, gender, or class that are linked to inequality in the larger social structure. This form of power has been described in the literature using a range of terms including institutional, societal, contextual, and group-based power (Guinote & Vescio, 2010; Sumartojo, 2000). Racism is a form of structural power that “create[s] or perpetuate[s] power differences among racial groups” (Henry & Pratto, 2010, p. 344) by conveying privilege or advantage to one group based solely on race (Jones, 1997). Structural power and the resultant advantages afforded to some and disadvantages experienced by others are important to consider in the context of HIV/AIDS risk given that “vulnerability to HIV is influenced by broad social structural characteristics that impact individual’s lives through racism, sexism and discrimination” (Sumartojo, 2000, p. S3).


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Few researchers, however, have examined the relationship between racism and HIV/AIDS risk, perhaps because of the complexity of the relevant issues (Williams & Prather, 2010). Some exceptions include the research done by Ayala, Bingham, Kim, Wheeler, and Millett (2012), D´ıaz, Ayala, and Bein (2004), and Mizuno and colleagues (2012), who have studied links between discrimination and sexual risk behaviors among Latino and Black men who have sex with men (MSM). Latino MSM who reported experiencing racism were more likely to report engaging in risky sexual situations, including sex with partners who do not use condoms (D´ıaz et al., 2004; Mizuno et al., 2012). Among both Latino and Black MSM, racism was associated with unprotected sex with serodiscordant or sero-unknown partners (Ayala et al., 2012). Minorities’ experiences with race-based discrimination can foster a level of mistrust of mainstream institutions that has a number of negative implications for their engagement in HIV prevention activities (Newman, Williams, Massaquoi, Brown, & Logie, 2008). This mistrust likely has a negative effect on access to sexual and reproductive health services, satisfaction with services, consistent use of contraceptives, and ultimately the prevention of unintended pregnancy, HIV/AIDS, and STIs (Bird & Bogart, 2003). For example, in a study about HIV/AIDS conspiracy beliefs of African Americans, Bogart and Thorburn (2005) found that among the men sampled, those who expressed a greater mistrust of medical, public health, and government institutions, believing that these organizations were responsible for the creation and spread of HIV in the community, reported inconsistent condom use. Our study is part of a larger project, Proyecto de Salud Para Latinos, which examined the social and cultural factors related to contraceptive use, sexual risk behavior, and STI prevention behavior among young adult Latinos, primarily of Mexican heritage, living in rural Oregon. For this article, we focused on the influence of multiple measures of power on condom use behavior. Our goal was to address some of the limitations in previous research on power and condom use by analyzing both global and domainspecific measures of power, including partner-specific measures of power, and measuring power at three levels—individual, interpersonal, and structural. In addition, our sample was focused on and limited to individuals who identified as Latino. As a result, this study is intended to contribute to a fuller understanding of the multiple and intersecting forms of power that can influence sexual health in young adult Latino men and women.

METHODS Sample We recruited participants from farms, health clinics, health fairs, and other community locations in each county using both passive (e.g., posters and



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fliers) and active (e.g., recruiters approaching potential participants) strategies. A toll-free number was advertised on all print materials and provided participants with an opportunity to contact the study team directly to ask questions or enroll in the study. Recruiters briefly described the study to potential participants, explained that they would need to be screened for eligibility, and asked if they were willing to be screened. Recruiters were directed to exclude the partners of participants from enrolling in the study. To be eligible for the study, participants had to be between the ages of 18 to 25, self-identify as Latino, and report sexual intercourse within the past 3 months with a member of the opposite sex. We excluded those who were pregnant/had a pregnant partner or were planning to become pregnant/get a partner pregnant in the next year, were unable to understand informed consent or other aspects of the project description, and were not fluent in either English or Spanish. Of the 952 individuals screened, a total of 615 (65%) met the eligibility criteria. Of these, 116 (19%) declined to participate and 499 (254 women and 245 men) completed interviews. For this manuscript we excluded participants who did not have a current sexual partner (n = 17) and two participants with missing data on key variables, for a total of 480 participants (246 women and 234 men).

Data Collection Participants were recruited and enrolled in the study over a 4-month period between July 1, 2006, and November 1, 2006. Bilingual, bicultural staff members conducted interviews using a computer-assisted survey interviewing (CASI) system. Participants and interviewers were matched according to gender. Recruiter/interviewers (RIs) participated in an initial 2-day training as well as two short follow-up trainings to reinforce skills. RIs also received ongoing training and supervision through weekly team meetings to discuss recruitment and interviewing strategies, quality assurance issues, and problem solving. The instrument was available in English and Spanish; the Spanish version was prepared using forward-translation and back-translation by different translators (Aday, Chiu, & Andersen, 1980). The measures included validated scales from previous studies as well as items developed for this study based on formative work with the population of interest. Most measures were partner specific, asking about current boyfriend/girlfriend, husband/wife or lover. For constructs measured with multi-item scales, we computed Cronbach alphas to assess internal reliability. All interviews were approximately 60 minutes in length, and participants were paid for their time and compensated for travel and child care costs. The research protocol was approved by the institutional review board of the university where the authors work and each participant provided written informed consent.

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Measures The interview guide included questions on participants’ age, education, employment status, and U.S. nativity status. We also collected data on perceived power using six different measures of individual, interpersonal, and structural power. Condom use self-efficacy, an individual domain specific measure, was assessed using a six-item scale adapted from the condom use self-efficacy scale developed by Brafford and Beck (1991). This scale assesses confidence in using condoms. For example, participants were asked how confident they were that they “could put a condom on correctly” and “could use condoms every time they had sex.” Respondents rated each item on a 5-point scale ranging from 1 (not at all confident) to 5 (extremely confident). A mean score on the entire scale was computed, with higher scores indicating greater selfefficacy. The Cronbach alpha for our study was .77. Relationship commitment, an individual and nondomain-specific measure, was assessed with eight items adapted from the commitment component of the Investment Model Scale (Rusbult, Martz, & Agnew, 1998) to be partner specific. Participants were asked how much they agreed with each of eight statements “with respect to your relationship with [name of partner].” Examples include the following: “I want our relationship to last a very long time” and “I feel very attached to our relationship.” Items were rated on a 9-point Likert-type response scale ranging from 0 (do not agree at all) to 8 (agree completely). A mean score for the scale was computed, with higher scores indicating greater commitment. Alpha reliability for our sample was .94. Sexual decision making, an interpersonal and domain-specific measure, was assessed with six items adapted from the PARTNERS Project (Harvey et al., 2009). Participants were asked, “In your relationship with [name of partner], how much have you taken part in deciding such things as: 1) whether or not to use a condom; 2) whether or not you protect yourselves from HIV and other STDs; 3) whether or not to have sex; and 4) what kinds of things you do when they have sex.” Items were rated on a 5-point Likerttype response scale, ranging from 1 (not at all) to 5 (a great deal). A mean score for the entire scale was computed, with higher scores indicating greater participation in sexual decision making. Alpha reliability for our sample was .82. Relationship control, an interpersonal and nondomain-specific measure, was assessed using the Relationship Control Scale (RCS) developed by Pulerwitz and colleagues (2000) that asked participants the extent to which they agreed on items describing their current relationship (response items ranged from 1 [strongly disagree] to 4 [strongly agree]). We used the modified version of the RCS that eliminates three condom-use-related items (e.g., “If I asked my partner to use a condom, he would get violent”) from the subscale. Sample items for the RCS included, “My partner will not let me wear



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certain things” and “My partner always wants to know where I am.” Because the 12-item modified scale, with condom-related questions eliminated, had good reliability (Cronbach alpha = 0.82 for our study), we created a relationship power scale by averaging scores across items, with higher scale scores indicating that participants perceived that they had greater control in their relationship. Experience of Discrimination (EOD) in Specific Situations, a structural and nondomain-specific measure, was used to explore experiences of discrimination. Participants were asked, “Have you ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following situations because of your race, ethnicity, or color?” We used nine specific experiences (e.g., at school, getting medical care, getting housing) adapted from the EOD scale (Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005). Response categories were as follows: never, rarely, sometimes, most of the time, always. We created an index of the number of situations in which participants experienced discrimination. The scale has been found to have good reliability and validity when used with African American and Latino subjects (Krieger et al., 2005). Medical Mistrust, a structural and domain-specific measure, was assessed using the Group-Based Medical Mistrust Scale (GBMMS; Thompson, Valdimarsdottir, Winkel, Jandorf, & Redd, 2004). Participants were asked to rate their agreement with 11 items on a 5-point response scale, ranging from 1 (do not agree at all) to 5 (completely agree). Sample items included, “People of my ethnic group cannot trust doctors or health care providers,” “People of my ethnic group should be suspicious of information from doctors and health care workers,” and “People of my ethnic group should be suspicious of modern medicine.” A mean score for the entire scale was computed, with higher scores indicating greater levels of medical mistrust (alpha = .79 for our study). Consistency of condom use was the dependent variable in our study. We asked participants how many times in the past 90 days they had vaginal or anal intercourse with their primary partner and how many times they used a condom when they had vaginal or anal sex. We constructed a proportional measure of consistency of condom use by dividing the number of times a participant had used a condom for vaginal or anal sex in the past 90 days (with a specific partner) by the number of times she/he had vaginal or anal sex (with that partner). We dichotomized condom use in the past 90 days into use of condoms 100% of the time (consistent condom use) and use of condoms less than 100% of the time (inconsistent condom use).

Statistical Analysis We generated means and proportions for the study variables to describe the sample and assessed differences between the men and women on the


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variables using Pearson’s chi-square test for categorical variables and t statistics for continuous variables. To determine whether and the extent to which the variables conceptualized as measures of power at the individual, interpersonal, and structural levels were related to one another, we calculated Spearman rank correlation coefficients. Finally, we used multiple logistic regression to model the associations between the conceptual measures of power and consistent condom use among our study sample, controlling for age, country of origin, education, employment status, and whether or not effective birth control was used. All of these control variables have been associated with differences in condom use rates among Latinos in other studies (Hillman, 2008; Ibañez, Van Oss Mar´ın, Villarreal, & Gomez, 2005; Moreno & El-Bassel, 2007; Roye, 1998; Saul et al., 2000). We stratified the logistic regression analyses by gender. Interactions among the variables were tested; however, no significant interactions were identified and none were included in the final models. We conducted sensitivity analyses to determine whether the strength or direction of effects of any of the power variables changed significantly with the removal of each variable. Because there were no significant changes, we report here the full models. There was no evidence of multicollinearity in postestimation analyses. All analyses were conducted using SPSS version 18.

RESULTS Characteristics of Sample The average age in the study was 21.7 years for women and 21.2 years for men (see Table 1). A little over a third of the sample was born in the United States. Sixty-two percent of women and 54% of men had completed high school. Men were more likely than women to be employed (68% versus 51%). There were no significant gender differences in reported consistent condom use or effective birth control use. A third of the men (33.3%) reported consistent condom use in the past 3 months, and 26.4% of the women reported consistent condom use during that time period. Over 50% of the women and slightly less than 50% of the men reported using an effective method of birth control other than condoms in the past 3 months. There were significant gender differences for all of the measures of power included in the study. Women reported greater relationship commitment, sexual decision making, and relationship control than men. Men reported greater condom use self-efficacy, medical mistrust, and perceived discrimination. Of the nine situations in which respondents could report ever having experienced discrimination, women reported an average of four situations and men an average of five.

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Individual, Interpersonal, and Structural Power TABLE 1 Characteristics of Study Participants, by Gender Women (N = 246) Variable


a

Age (in years) U.S.-borna Completed high schoola Employeda Effective birth controla Consistent CONDOM USE Measures of power Condom use self-efficacyb Relationship commitmentb Sexual decision makingc Relationship controlc Discriminationd Medical mistrustd

Men (N = 234)

Range

Mean or %

SD

Mean or %

SD

18–25 yrs y/n y/n y/n y/n y/n

21.7 35.77 62.20 51.22 58.13 26.42

2.19 — — — — —

21.2 38.46 54.27 67.95 49.57 33.33

2.24 — — — — —

t = −2.30∗ χ 2 (1) = .27 χ 2 (1) = 2.78 χ 2 (1) = 13.23∗∗∗ χ 2 (1) = 3.20 χ 2 (1) = 2.42

1–5

3.91

0.80

4.05

0.74

t = 2.07∗

1–8

6.77

1.53

5.32

2.34

t = −8.00∗∗∗

1–6

4.33

0.70

4.09

0.88

t = −3.33∗∗∗

1–12 1–9 1–5

3.43 4.02 2.02

0.50 3.07 0.59

3.33 5.01 2.24

0.46 2.84 0.68

t = −2.15∗ t = 3.68∗∗∗ t = 3.69∗∗∗

∗p

≤ .05, ∗∗ p ≤ .01, ∗∗∗ p ≤ .001. variables included in regression analyses. bIndividual measure of power. cInterpersonal measure of power. dStructural measure of power. aControl

Relationships Between Predictor Variables The measures of individual, interpersonal, and structural power were, with one exception, significantly related to one another (see Table 2). None of the correlations, however, were large. There was no significant association between experiences of discrimination and condom use self-efficacy. The TABLE 2 Reliability Coefficients and Spearman Rank Correlation Coefficients for Power Variables (N = 480) Variables 1. 2. 3. 4. 5. 6.

Condom use self-efficacya Relationship commitmenta Sexual decision-makingb Relationship controlb Discriminationc Medical mistrustc

∗p

≤ .05,

∗∗ p

≤ .01, ∗∗∗ p ≤ .001. measure of power. bInterpersonal measure of power. cStructural measure of power. aIndividual

1

2

3

4

5

6

(.77) .12∗∗ .46∗∗∗ .29∗∗∗ −.06 −.10∗

(.94) .20∗∗ .22∗∗∗ −.10∗ −.11∗

(.83) .32∗∗∗ −.10∗ −.12∗∗

(.82) −.18∗∗∗ −.20∗∗∗

(na) .49∗∗∗

(.79)

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strongest association was between the two measures of structural power, but the correlation was only a moderate one (rho = .49). The measures of structural power exhibited weak, inverse relationships with the remaining individual and relationship measures of power. Condom use self-efficacy was moderately, positively associated with sexual decisionmaking (rho = .46); there were weak positive correlations between the remaining individual power and relationship power variables.


Consistent Condom Use Consistent condom use was reported by 26.4% of the women and 33.3% of the men in our study. In the stratified logistic regression analyses (see Table 3), we found that condom use self-efficacy and sexual decision making were associated with increased odds of consistent condom use for both women and men. Among women only, increasing medical mistrust was associated with increased odds of consistent condom use. Among men only, increasing relationship control was associated with lower odds of consistent condom use.

DISCUSSION In this study, we extend previous research on power and condom use by examining different levels of power (individual, interpersonal, and structural) and their associations with condom use, an HIV/AIDS and STI protective behavior. Power has been described in previous research primarily in terms of women’s perceptions of power and condom use behavior. We included young adult men who reported recent heterosexual involvement, to better understand the context of condom use for both Latino men and women in TABLE 3 Odds Ratios From Logistic Regression Analyses Assessing Associations Between Measures of Power and Consistent Condom Use, by Gender Women OR Condom use self-efficacya Relationship commitmenta Sexual decision makingb Relationship controlb Discriminationc Medical mistrustc ∗p

2.16∗∗ .85 2.10∗ 1.53 .90 2.00∗

Men

95% CI

OR

95% CI

(1.26, 3.69) (.67, 1.08) (1.10, 4.00) (.71, 3.29) (.80, 1.02) (1.09, 3.67)

1.72∗ 1.07 2.84∗∗∗ .37∗∗ 1.03 .61

(.99, 2.96) (.94, 1.23) (1.66, 4.85) (.17, .81) (.91, 1.18) (.35, 1.07)

≤ .05; ∗∗ p ≤ .01, ∗∗∗ p ≤ .001. Analyses controlled for age, nativity, high school completion, employment status, and use of effective birth control. aIndividual measure of power. bInterpersonal measure of power. cStructural measure of power.



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heterosexual adult relationships. The inclusion of men may allow for a more refined understanding of the dynamics involved in condom use and provide information for prevention programs and counseling for women, men, and couples. We found that the six measures of power were related to one another, with one exception, and that the structural power items (which actually measure lack of power) were negatively associated with the individual and interpersonal items. The measures were not, however, strongly correlated, suggesting that each captures a different dimension of power. This finding confirms that researchers interested in studying power as it relates to reported condom use should consider measurement issues including the level at which the type of power is expressed. There were gender differences for all of the power measures included in the study, with women reporting higher levels of relationship commitment, sexual decision making, and relationship control. It is important to note that the men and women in this study were recruited individually and not as couples; therefore, we cannot draw conclusions about relative commitment, decision making, or relationship control experienced by the men and women in their relationships. Consistent with findings from other researchers (Armstrong, Ravenell, McMurphy, & Putt, 2007), we found that medical mistrust was higher among the men in our sample. Mistrust of doctors and the medical system has not been extensively assessed among Latinos, especially rural Latinos. Although distrust of physicians and the health care system appears to vary widely in the United States, men tend to report greater mistrust than women across regions and communities (Armstrong et al., 2007). It should be noted that men and women in this study, in general, indicated low overall agreement with the medical mistrust items. Less than one-third of the women and approximately one-third of the men in this study reported consistent condom use in the previous 3 months. We found that measures of individual, interpersonal, and structural power were associated with consistent condom use. Further, we found that significant factors related to reported consistent condom use tended to be domainspecific rather than global measures. Relationship commitment, for example, a global measure, was not a significant factor in predicting condom use. Researchers have suggested that individuals with high commitment or interest in the relationship may have less power and be less willing to jeopardize a valued relationship by insisting on condom use (e.g., Logan, Cole, & Leukefeld, 2002, Wingood, Hunter-Gamble, & DiClemente, 1993). It may also be that trust and commitment are related and that those with higher commitment do not perceive themselves to be at risk of contracting HIV/AIDS or STIs from their partner (Agnew, 1999). In our study, however, relationship commitment was not a significant predictor when included in a model with measures that were domain specific.


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For both men and women, increasing condom-use self-efficacy, a domain-specific individual measure of power, was positively associated with consistent condom use. Confidence in one’s ability to use condoms has been a robust predictor of condom use across diverse populations and settings (e.g., Gutiérrez et al., 2000; Knipper et al., 2007; Pettifor et al., 2004; Shai, Jewkes, Levin, Dunkle, & Nduna, 2010; Soler et al., 2000). The same was true with our study in that self-efficacy remained a significant factor when included in a model with multiple measures of power measured at the individual, interpersonal, and structural level. Among both men and women, participation in sexual decision making, a domain-specific interpersonal measure of power, was also associated with a greater likelihood of consistent condom use. Although not as widely investigated as self-efficacy, the association between sexual decision making and condom use among women also has support in the literature (e.g., Pulerwitz, Amaro, DeJong, Gortmaker, & Rudd, 2002; Soler et al., 2000). Results from our study also add to the body of literature (Harvey & Henderson, 2006) that men’s involvement in sexual decision making increases the likelihood of consistent condom use in heterosexual relationships. Although the association between sexual decision making and consistent condom use was positive, the association between the other interpersonal variable, relationship control, and condom use among men was negative. High levels of relationship control have been associated with a greater likelihood of condom use among women. Based on the results from our study, it appears that unlike participation in sexual decision making, greater relationship control among men has negative implications for HIV/AIDS and STI protective behavior. It may be that participation in sexual decision making is a characteristic of more egalitarian relationships, and the participation of one partner does not necessarily limit the participation of the other partner. Relationship control, on the other hand, by definition limits the control or power of the other partner. HIV/AIDS and STI prevention programs that emphasize equitable gender norms and communication in sexual decision making, therefore, may be effective in increasing condom use among men and women in their relationships. One final difference between the men and women in our sample was the influence of the measures of structural power on consistent condom use. Bird and Bogart (2003) found that greater perceived discrimination was associated with more negative attitudes toward contraceptive methods, contraceptive behavior, and intentions among African American men and women. We found no association, however, between experiences of discrimination and consistent condom use among our sample of young adult Latinos. Among men, medical mistrust was also not significantly associated with condom use. Among women, however, greater medical mistrust was associated with a greater likelihood of using condoms consistently. The fact that women with greater mistrust were more likely to use condoms was an unexpected



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finding. Given previous research, we had expected that the association between exposure to discrimination and feelings of medical mistrust on health protective behavior would be negative. Condom use does not, however, require interaction with medical professionals or with a health care system, as with most of the other health care behaviors studied with respect to discrimination and medical mistrust. The increased likelihood of condom use among women may mean that women with greater medical mistrust are more likely than other women to use condoms as a method of birth control rather than seek prescription contraceptives from family planning or other medical providers. Because most contraceptives must be obtained from health care providers, obtaining contraception involves seeking family planning services. As such, negative expectations about providers may affect use of contraceptive services resulting in a greater reliance among women on nonprescription methods for birth control.

Limitations This study has a number of limitations that should be considered. The first is that participants, primarily of Mexican descent, were recruited using convenience sampling methods, and thus the findings may not be widely generalized to other Latino young adults in general or even to those living in rural areas. Second, all data are self-reported and are subject to potential biases. To encourage accurate reports of sexual behavior and other sensitive topics, however, we used computer-assisted interviewing techniques, with the participants entering answers to potentially sensitive questions directly on the laptop computers themselves, blinded to the interviewer. Interviewers were bilingual/bicultural and matched to participants on gender to increase the comfort of participants. Another limitation is that the data are cross sectional, and we are unable, therefore, to make causal inferences from the data. Finally, although we included multiple measures of power, there are additional measures not included here, including interpersonal violence and economic dependence, which have also been shown to be relevant in HIV/AIDS protective behaviors. Although they are beyond the scope of this study, it is possible that the estimates of effects would be different if we could consider these variables.

Conclusions We found that measures of individual, interpersonal, and structural power explained variations in condom use among the men and women in our sample, and that the significant predictors tended to be domain-specific rather than global measures. Increasing power, however, was not always associated with increased condom use in that, for men, higher levels of reported


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relationship control were associated with lower levels of consistent condom use. Future research on the associations between power and condom use should include men and specify both the level at which power is experienced or expressed and whether the measures of power used are specific to condom use or more general. Programs and counseling to prevent heterosexually acquired HIV/AIDS and STIs among Latinos should address power imbalances among couples as potential barriers to condom use and, where possible, include male partners or men, individually, to increase condom use self-efficacy and sexual decision-making participation among both men and women. Finally, we believe that the results of our study are relevant not only for Latino young adults residing in the United States, but for men and women of diverse backgrounds internationally. For example, Kershaw and colleagues (2006) found that decision-making power predicted condom use intentions of Haitian women. In addition, Sayles and colleagues (2006) found that for both South African men and women, those with high levels of self-efficacy were more likely to report condom use with their most recent sexual partner than those with low levels of self-efficacy. Our study, as well as those cited above, highlights the importance of power (or the lack thereof) in negotiating condom use for both men and women of diverse nationalities.

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