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Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
Modelling condom use: Does the theory of planned behaviour explain condom use in a low risk, community sample? a
a
a
Joanna Thomas , Chris Shiels & Mark B. Gabbay a
Department of Health Services Research, University of Liverpool, Liverpool, UK. Published online: 05 Aug 2013.
To cite this article: Joanna Thomas, Chris Shiels & Mark B. Gabbay (2014) Modelling condom use: Does the theory of planned behaviour explain condom use in a low risk, community sample?, Psychology, Health & Medicine, 19:4, 463-472, DOI: 10.1080/13548506.2013.824592 To link to this article: http://dx.doi.org/10.1080/13548506.2013.824592
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychology, Health & Medicine, 2014 Vol. 19, No. 4, 463–472, http://dx.doi.org/10.1080/13548506.2013.824592
Modelling condom use: Does the theory of planned behaviour explain condom use in a low risk, community sample? Joanna Thomas*, Chris Shiels and Mark B. Gabbay Department of Health Services Research, University of Liverpool, Liverpool, UK
Downloaded by [University of Birmingham] at 17:36 02 September 2014
(Received 27 May 2012; final version received 7 July 2013) To date, most condom research has focused on young or high-risk groups, with little evidence about influences on condom use amongst lower-risk community samples. These groups are not risk free and may still wish to negotiate safer sex; yet the considerations involved could be different from those in higher-risk groups. Our research addresses this gap: We report a cross-sectional questionnaire study enquiring about recent condom use and future use intentions in community settings. Our sample (n = 311) purposively included couples in established relationships, known to be condom users. Items included demographics, sexual history and social-cognitive variables taken from the theory of planned behaviour. The strongest association with condom use/use intentions amongst our respondents was sexual partner’s perceived willingness to use them. This applied across both univariate and multivariate analyses. Whilst most social-cognitive variables (attitudes; self-efficacy and peer social norms) were significant in univariate analyses, this was not supported in multivariate regression. Of the social-cognitive variables, only “condom-related attitudes” were retained in the model explaining recent condom use, whilst none of them entered the model explaining future use intentions. Further analysis showed that attitudes concerning pleasure, identity stigma and condom effectiveness were most salient for this cohort. Our results suggest that, in community samples, the decision to use a condom involves different considerations from those highlighted in previous research. Explanatory models for established couples should embrace interpersonal perspectives, emphasising couple-factors rather than individual beliefs. Messages to this cohort could usefully focus on negotiation skills, condom advantages (other than disease prevention) and reducing the stigma associated with use. Keywords: condoms; sexual health; theory of planned behaviour; community questionnaire study; interpersonal factors
Introduction New HIV infections more than doubled in the UK between 2001 and 2006 (UNAIDS, 2011; UNAIDS & World Health Organisation, 2008). Other STI rates, particularly chlamydia, also continue to rise (Family Planning Association, 2010; Health Protection Agency, 2011a; Hughes et al., 2007). Condoms protect against HIV/AIDS and other infections (Holmes, Levine, & Weaver, 2004; National Institute of Allergy and Infectious Diseases, 2001). Yet unprotected sex is common, with only 24% of sexually active UK women ever, and 14% always using condoms (Lader & Hopkins, 2008). Condoms are mostly used by young people (Lader & Hopkins, 2008; Taylor, Keyse, & Bryant, 2006) in new, casual or short-term relationships (Plichta, Weisman, *Corresponding author. Email: [email protected] Ó 2013 Taylor & Francis
464
J. Thomas et al.
Nathanson, Ensminger, & Robinson, 1992; Raj, 1996; Upchurch et al., 1992) engaging in relatively infrequent intercourse (Glor & Severy, 1990). Condoms are often considered incompatible with love and trust (Abbott Chapman & Denholm, 1997; Willig, 1995), being abandoned for other contraceptive methods as relationships develop (Civic, 1999).
Downloaded by [University of Birmingham] at 17:36 02 September 2014
What influences the decision to use condoms? The theory of planned behaviour (TPB) (Ajzen & Madden, 1986) is useful for explaining condom use. Each of its components has received substantial support from meta-analysis (Albarracin, Johnson, Fishbein, & Muellerleile, 2001; Sheeran, Abraham, & Orbell, 1999; Sheeran & Taylor, 1999) and it is superior to earlier models in explaining condom use intentions (Sheeran & Taylor, 1999). The TPB proposes that behavioural intentions are influenced by: Attitudes; “perceived behavioural control” and “social norms”. “Perceived behavioural control” is similar to “self-efficacy” (Bandura, 1977). These terms are used almost interchangeably in studies of condom use. “Social norms” can include descriptive norms (what others are perceived to think and do) and subjective norms (perceived social pressure to comply). In studies of condom use, descriptive norms are more important (Fazekas, Senn, & Ledgerwood, 2001; Rivis & Sheeran, 2003; Sheeran et al., 1999). Rationale Previous condom research into the TPB has used mainly undergraduate/adolescent samples or participants from high STI risk groups (e.g. sex workers, drug users or deprived minority communities) (Albarracin et al., 2001; Sheeran et al., 1999; Sheeran & Taylor, 1999). Studies amongst lower-risk populations rarely measure social norms or self-efficacy. Recent community-based studies that included these variables focussed on populations with high STI rates or condom use in first or casual sexual encounters (Beadnell et al., 2008; Gredig, Nideroest, & Parpan-Blaser, 2006). Whilst “stable” relationships reduce STI risk, they are not necessarily risk-free. Honesty between partners is not guaranteed (Cochran & Mays, 1990; Seal & Palmer Seal, 1996), and judgements regarding STI risk are often flawed (Wendt & Solomon, 1995). Estimates suggest that a quarter of UK people with HIV (over 20,000 individuals) are unaware they are infected (Health Protection Agency, 2011b). For some people, condom use may therefore be advisable even if their relationship is “stable”. Others may prefer to use condoms, but find negotiation difficult. We investigated recent condom behaviour and future intentions in a varied UK sample, in which long-term relationships were common. We hypothesised that TPB variables would explain much of the variance in condom use, with the sexual partner’s perceived willingness to use condoms likely to be more important than peer social norms. Method Sampling and recruitment Half our respondents were recruited through primary care and family planning waiting rooms. A further 18% were postgraduate volunteers and patients recruited through campus health centres. These respondents were not necessarily condom users; therefore,
Psychology, Health & Medicine
465
Downloaded by [University of Birmingham] at 17:36 02 September 2014
participants in our condom trial (Gabbay & Thomas, 2004; Gabbay, Thomas, Gibbs, & Hold, 2008) were invited to complete questionnaires, to ensure we included regular condom users (32%). Measures Our cross-sectional questionnaire covered age, gender, sexuality, marital status, recent sexual history, condom use at first intercourse, experience of condom failure and our two outcome variables: recent condom use and condom use intentions. Attitudes and self-efficacy were measured using the multi-dimensional condom attitudes scale (MCAS) (Helweg-Larsen & Collins, 1994) and condom use self-efficacy scale (CUSES) (Brafford & Beck, 1991). Subscales within these validated questionnaires enable detailed analysis of condom attitudes and self-efficacy. Sample items are shown in Figure 1. Responses were measured using five-point ordinal scales; “strongly agree” – “strongly disagree”. Following piloting, CUSES item 25 (I feel confident that I would remember to use a condom even if I were high) was removed because it was considered ambiguous. The remaining 27-item scale had high internal reliability (α = .8999), as did the 25-item MCAS scale (α = .8782). We developed two additional items measuring descriptive social norms and one measuring partner’s willingness to use condoms (see Figure 2).
MCAS:
“Condoms are an effective method of birth control.” “Condoms ruin the sex act.” CUSES
“I feel confident in my ability to put a condom on myself or my partner.” “If I were unsure of my partner’s feelings about using condoms, I would not suggest using one.”
Figure 1.
Sample items for MCAS and CUSES.
Social norms
“as far as you know, do your friends and other people who are important to you think condom use is a good idea?” “as far as you know, do your friends and other people who are important to you use condoms themselves?” Partner attitude
“how willing is your current partner to use condoms?”
Figure 2.
Additional questionnaire items.
466
J. Thomas et al.
Downloaded by [University of Birmingham] at 17:36 02 September 2014
Data analyses Missing responses on the MCAS and CUSES were randomly distributed with no item being missed by >5% of respondents; therefore, mean substitution was used for missing data. MCAS and CUSES scores were assumed to approximate normal distribution (Kolmogorov-Smirnov: p > .05). The t-test was used to compare differences in mean scores across different outcome groups (see Table 1). To simplify the main analysis, a number of explanatory and the two outcome variables were transformed into dichotomous variables. Positive outcomes were defined as “always” or “mostly” using or intending to use condoms; whilst negative outcomes were defined as “sometimes”, “rarely” or “never”. Univariate and multivariate logistic regression models were constructed to explore associations between explanatory variables and the two outcomes. In the univariate analysis, the explanatory variable was entered alone in the model. In the multivariate analysis, variables with an association of p < .25 at the univariate level were entered into each model as covariates. The explanatory variables are listed in Tables 2 and 3. Significance was set at p < .05. Results Sample A total of 311 respondents completed the questionnaires. The majority (78%) were female, and 73% were in relationships of more than a year. The mean age was 27 (range: 16–59, SD: 8.6). Attitudes, self-efficacy and outcomes Mean MCAS and CUSES scores were 95.6 (SD 12.6) and 111.7 (SD 14.0), respectively. (Possible range: 25–125 on MCAS; 27–135 on CUSES. Higher scores indicate more positive attitudes and greater self-efficacy.) Table 1. Mean MCAS and CUSES sub-scale scores for outcome groups. Mostly or usually used condoms in previous 3 months No Mean score
Yes Mean score
MCAS sub-scales Reliability/effectiveness Pleasure Identity stigma Embarrassment about negotiation and use Embarrassment about purchase
18.1 14.7 21.4 20.6 18.3
CUSES sub-scales Mechanics Partner’s disapproval Assertiveness Intoxicants
16.0 21.8 13.3 7.6
Intention to mostly or usually use condoms
p
No Mean score
Yes Mean score
p
20.2 16.0 22.8 20.1 18.4
< .001 .002 < .001 < .001 .93
18.3 14.8 21.7 21.1 18.6
19.7 15.9 22.6 21.4 17.8
.003 .005 .008 .45 .17
17.0 22.7 13.7 8.3
.005 .03 .16 .002
15.9 22.1 13.4 7.7
16.7 22.4 13.6 8.2
.04 .52 .53 .02
Note: Higher scores = more positive attitudes and greater self-efficacy. Significantly different results in bold. p = 1 year duration No (26% of sample, n = 67) 41.8 Yes (74% of sample, n = 190) 47.9
1.3 (.73–2.3)
.39
.81 (.33–1.9)
.63
Partner willing to use condoms No (53% of sample, n = 139) Yes (47% of sample, n = 125)
6.1 (3.6–10.4)
< .001
25.9 68.0
4.5 (2.4–8.5)
< .001
Friends/significant others think condom use good idea No (30% of sample, n = 85) 42.4 1.3 (.77–2.2) Yes (70% of sample, n = 195) 48.7
.33
.60 (.27–1.3)
.21
Friends/significant others use condoms No (56% of sample, n = 152) 39.5 Yes (44% of sample, n = 120) 55.0
.01
1.03 (.53–2.0)
.94
Condom used at first intercourse No (37% of sample, n = 102) Yes (63% of sample, n = 172)
48.0 47.7
Previous condom failure: No (20% of sample, n = 54) Yes (80% of sample, n = 218)
40.7 50.0
1.9 (1.2–3.0)
.98 (.60–1.61)
.95
.74 (.37–1.48)
.39
1.5 (.80–2.7)
.22
1.3 (.56–3.0)
.55
Total MCAS attitudes score (+10 points)
1.5 (1.3–1.9)
1 year duration No (27% of sample, n = 70) Yes (73% of sample, n = 188)
45.7 48.9
1.1 (.66–1.9)
.65
1.1 (.46–2.8)
.79
Partner willing to use condoms No (52% of sample, n = 138) Yes (48% of sample, n = 128)
29.7 69.5
5.4 (3.2–9.1)
< .001
5.7 (2.9–11.2)
< .001
Friends/significant others think condom use good idea No (29% of sample, n = 86) 50.0 1.1 (.65–1.8) Yes (71% of sample, n = 210) 51.9
.77
.55 (.24–1.3)
.15
Friends/significant others use condoms No (53% of sample, n = 154) 42.9 Yes (47% of sample, n = 134) 61.9
.002
Downloaded by [University of Birmingham] at 17:36 02 September 2014
Independent variables
Condom used at first intercourse No (37% of sample, n = 106) Yes (63% of sample, n = 179)
56.6 49.2
Previous condom failure No (23% of sample, n = 65) Yes (77% of sample, n = 218)
47.7 53.7
2.2 (1.4–3.5)
.74 (.46–1.2)
.23
Multivariate OR (95% CI)
1.5 (.75–2.9)
.51 (.25–1.03)
p
.26
.06
1.3 (.73–2.2)
.40
1.8 (.77–4.4)
.17
Total MCAS attitudes score (+10 points)
1.2 (1.01–1.5)
.04
1.3 (.92–1.9)
.13
Total CUSES self-efficacy score (+10 points)
1.1 (.96–1.4)
.13
1.05 (.75–1.5)
.78
Model R2 = .29
Table 1 summarises the relationship between our outcome variables and MCAS and CUSES subscales results. More positive attitudes on four of the MCAS sub-scales (“reliability and effectiveness” [ p < .001], “identity stigma” [ p = .002], “pleasure” [ p < .001] and
Psychology, Health & Medicine
469
“embarrassment about negotiation and use” [ p < .001]) were significantly associated with recent condom use. “Reliability and effectiveness” ( p = .003), “pleasure” ( p = .005) and “identify stigma” ( p = .008) had positive significant associations with intentions to use condoms in the future. On the CUSES, recent condom use was significantly associated with higher scores on the “mechanics” ( p = .005), “intoxicants” ( p = .03) and “partner’s disapproval” ( p = .002) sub-scales. Higher “mechanics” ( p = .04) and “intoxicants” ( p = .02) scores were significantly associated with intention to “mostly or always” use condoms in the future.
Downloaded by [University of Birmingham] at 17:36 02 September 2014
Association between respondent characteristics and outcomes Univariate analysis In univariate analysis, recent regular condom use was significantly associated with partner’s willingness ( p =
Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
Modelling condom use: Does the theory of planned behaviour explain condom use in a low risk, community sample? a
a
a
Joanna Thomas , Chris Shiels & Mark B. Gabbay a
Department of Health Services Research, University of Liverpool, Liverpool, UK. Published online: 05 Aug 2013.
To cite this article: Joanna Thomas, Chris Shiels & Mark B. Gabbay (2014) Modelling condom use: Does the theory of planned behaviour explain condom use in a low risk, community sample?, Psychology, Health & Medicine, 19:4, 463-472, DOI: 10.1080/13548506.2013.824592 To link to this article: http://dx.doi.org/10.1080/13548506.2013.824592
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychology, Health & Medicine, 2014 Vol. 19, No. 4, 463–472, http://dx.doi.org/10.1080/13548506.2013.824592
Modelling condom use: Does the theory of planned behaviour explain condom use in a low risk, community sample? Joanna Thomas*, Chris Shiels and Mark B. Gabbay Department of Health Services Research, University of Liverpool, Liverpool, UK
Downloaded by [University of Birmingham] at 17:36 02 September 2014
(Received 27 May 2012; final version received 7 July 2013) To date, most condom research has focused on young or high-risk groups, with little evidence about influences on condom use amongst lower-risk community samples. These groups are not risk free and may still wish to negotiate safer sex; yet the considerations involved could be different from those in higher-risk groups. Our research addresses this gap: We report a cross-sectional questionnaire study enquiring about recent condom use and future use intentions in community settings. Our sample (n = 311) purposively included couples in established relationships, known to be condom users. Items included demographics, sexual history and social-cognitive variables taken from the theory of planned behaviour. The strongest association with condom use/use intentions amongst our respondents was sexual partner’s perceived willingness to use them. This applied across both univariate and multivariate analyses. Whilst most social-cognitive variables (attitudes; self-efficacy and peer social norms) were significant in univariate analyses, this was not supported in multivariate regression. Of the social-cognitive variables, only “condom-related attitudes” were retained in the model explaining recent condom use, whilst none of them entered the model explaining future use intentions. Further analysis showed that attitudes concerning pleasure, identity stigma and condom effectiveness were most salient for this cohort. Our results suggest that, in community samples, the decision to use a condom involves different considerations from those highlighted in previous research. Explanatory models for established couples should embrace interpersonal perspectives, emphasising couple-factors rather than individual beliefs. Messages to this cohort could usefully focus on negotiation skills, condom advantages (other than disease prevention) and reducing the stigma associated with use. Keywords: condoms; sexual health; theory of planned behaviour; community questionnaire study; interpersonal factors
Introduction New HIV infections more than doubled in the UK between 2001 and 2006 (UNAIDS, 2011; UNAIDS & World Health Organisation, 2008). Other STI rates, particularly chlamydia, also continue to rise (Family Planning Association, 2010; Health Protection Agency, 2011a; Hughes et al., 2007). Condoms protect against HIV/AIDS and other infections (Holmes, Levine, & Weaver, 2004; National Institute of Allergy and Infectious Diseases, 2001). Yet unprotected sex is common, with only 24% of sexually active UK women ever, and 14% always using condoms (Lader & Hopkins, 2008). Condoms are mostly used by young people (Lader & Hopkins, 2008; Taylor, Keyse, & Bryant, 2006) in new, casual or short-term relationships (Plichta, Weisman, *Corresponding author. Email: [email protected] Ó 2013 Taylor & Francis
464
J. Thomas et al.
Nathanson, Ensminger, & Robinson, 1992; Raj, 1996; Upchurch et al., 1992) engaging in relatively infrequent intercourse (Glor & Severy, 1990). Condoms are often considered incompatible with love and trust (Abbott Chapman & Denholm, 1997; Willig, 1995), being abandoned for other contraceptive methods as relationships develop (Civic, 1999).
Downloaded by [University of Birmingham] at 17:36 02 September 2014
What influences the decision to use condoms? The theory of planned behaviour (TPB) (Ajzen & Madden, 1986) is useful for explaining condom use. Each of its components has received substantial support from meta-analysis (Albarracin, Johnson, Fishbein, & Muellerleile, 2001; Sheeran, Abraham, & Orbell, 1999; Sheeran & Taylor, 1999) and it is superior to earlier models in explaining condom use intentions (Sheeran & Taylor, 1999). The TPB proposes that behavioural intentions are influenced by: Attitudes; “perceived behavioural control” and “social norms”. “Perceived behavioural control” is similar to “self-efficacy” (Bandura, 1977). These terms are used almost interchangeably in studies of condom use. “Social norms” can include descriptive norms (what others are perceived to think and do) and subjective norms (perceived social pressure to comply). In studies of condom use, descriptive norms are more important (Fazekas, Senn, & Ledgerwood, 2001; Rivis & Sheeran, 2003; Sheeran et al., 1999). Rationale Previous condom research into the TPB has used mainly undergraduate/adolescent samples or participants from high STI risk groups (e.g. sex workers, drug users or deprived minority communities) (Albarracin et al., 2001; Sheeran et al., 1999; Sheeran & Taylor, 1999). Studies amongst lower-risk populations rarely measure social norms or self-efficacy. Recent community-based studies that included these variables focussed on populations with high STI rates or condom use in first or casual sexual encounters (Beadnell et al., 2008; Gredig, Nideroest, & Parpan-Blaser, 2006). Whilst “stable” relationships reduce STI risk, they are not necessarily risk-free. Honesty between partners is not guaranteed (Cochran & Mays, 1990; Seal & Palmer Seal, 1996), and judgements regarding STI risk are often flawed (Wendt & Solomon, 1995). Estimates suggest that a quarter of UK people with HIV (over 20,000 individuals) are unaware they are infected (Health Protection Agency, 2011b). For some people, condom use may therefore be advisable even if their relationship is “stable”. Others may prefer to use condoms, but find negotiation difficult. We investigated recent condom behaviour and future intentions in a varied UK sample, in which long-term relationships were common. We hypothesised that TPB variables would explain much of the variance in condom use, with the sexual partner’s perceived willingness to use condoms likely to be more important than peer social norms. Method Sampling and recruitment Half our respondents were recruited through primary care and family planning waiting rooms. A further 18% were postgraduate volunteers and patients recruited through campus health centres. These respondents were not necessarily condom users; therefore,
Psychology, Health & Medicine
465
Downloaded by [University of Birmingham] at 17:36 02 September 2014
participants in our condom trial (Gabbay & Thomas, 2004; Gabbay, Thomas, Gibbs, & Hold, 2008) were invited to complete questionnaires, to ensure we included regular condom users (32%). Measures Our cross-sectional questionnaire covered age, gender, sexuality, marital status, recent sexual history, condom use at first intercourse, experience of condom failure and our two outcome variables: recent condom use and condom use intentions. Attitudes and self-efficacy were measured using the multi-dimensional condom attitudes scale (MCAS) (Helweg-Larsen & Collins, 1994) and condom use self-efficacy scale (CUSES) (Brafford & Beck, 1991). Subscales within these validated questionnaires enable detailed analysis of condom attitudes and self-efficacy. Sample items are shown in Figure 1. Responses were measured using five-point ordinal scales; “strongly agree” – “strongly disagree”. Following piloting, CUSES item 25 (I feel confident that I would remember to use a condom even if I were high) was removed because it was considered ambiguous. The remaining 27-item scale had high internal reliability (α = .8999), as did the 25-item MCAS scale (α = .8782). We developed two additional items measuring descriptive social norms and one measuring partner’s willingness to use condoms (see Figure 2).
MCAS:
“Condoms are an effective method of birth control.” “Condoms ruin the sex act.” CUSES
“I feel confident in my ability to put a condom on myself or my partner.” “If I were unsure of my partner’s feelings about using condoms, I would not suggest using one.”
Figure 1.
Sample items for MCAS and CUSES.
Social norms
“as far as you know, do your friends and other people who are important to you think condom use is a good idea?” “as far as you know, do your friends and other people who are important to you use condoms themselves?” Partner attitude
“how willing is your current partner to use condoms?”
Figure 2.
Additional questionnaire items.
466
J. Thomas et al.
Downloaded by [University of Birmingham] at 17:36 02 September 2014
Data analyses Missing responses on the MCAS and CUSES were randomly distributed with no item being missed by >5% of respondents; therefore, mean substitution was used for missing data. MCAS and CUSES scores were assumed to approximate normal distribution (Kolmogorov-Smirnov: p > .05). The t-test was used to compare differences in mean scores across different outcome groups (see Table 1). To simplify the main analysis, a number of explanatory and the two outcome variables were transformed into dichotomous variables. Positive outcomes were defined as “always” or “mostly” using or intending to use condoms; whilst negative outcomes were defined as “sometimes”, “rarely” or “never”. Univariate and multivariate logistic regression models were constructed to explore associations between explanatory variables and the two outcomes. In the univariate analysis, the explanatory variable was entered alone in the model. In the multivariate analysis, variables with an association of p < .25 at the univariate level were entered into each model as covariates. The explanatory variables are listed in Tables 2 and 3. Significance was set at p < .05. Results Sample A total of 311 respondents completed the questionnaires. The majority (78%) were female, and 73% were in relationships of more than a year. The mean age was 27 (range: 16–59, SD: 8.6). Attitudes, self-efficacy and outcomes Mean MCAS and CUSES scores were 95.6 (SD 12.6) and 111.7 (SD 14.0), respectively. (Possible range: 25–125 on MCAS; 27–135 on CUSES. Higher scores indicate more positive attitudes and greater self-efficacy.) Table 1. Mean MCAS and CUSES sub-scale scores for outcome groups. Mostly or usually used condoms in previous 3 months No Mean score
Yes Mean score
MCAS sub-scales Reliability/effectiveness Pleasure Identity stigma Embarrassment about negotiation and use Embarrassment about purchase
18.1 14.7 21.4 20.6 18.3
CUSES sub-scales Mechanics Partner’s disapproval Assertiveness Intoxicants
16.0 21.8 13.3 7.6
Intention to mostly or usually use condoms
p
No Mean score
Yes Mean score
p
20.2 16.0 22.8 20.1 18.4
< .001 .002 < .001 < .001 .93
18.3 14.8 21.7 21.1 18.6
19.7 15.9 22.6 21.4 17.8
.003 .005 .008 .45 .17
17.0 22.7 13.7 8.3
.005 .03 .16 .002
15.9 22.1 13.4 7.7
16.7 22.4 13.6 8.2
.04 .52 .53 .02
Note: Higher scores = more positive attitudes and greater self-efficacy. Significantly different results in bold. p = 1 year duration No (26% of sample, n = 67) 41.8 Yes (74% of sample, n = 190) 47.9
1.3 (.73–2.3)
.39
.81 (.33–1.9)
.63
Partner willing to use condoms No (53% of sample, n = 139) Yes (47% of sample, n = 125)
6.1 (3.6–10.4)
< .001
25.9 68.0
4.5 (2.4–8.5)
< .001
Friends/significant others think condom use good idea No (30% of sample, n = 85) 42.4 1.3 (.77–2.2) Yes (70% of sample, n = 195) 48.7
.33
.60 (.27–1.3)
.21
Friends/significant others use condoms No (56% of sample, n = 152) 39.5 Yes (44% of sample, n = 120) 55.0
.01
1.03 (.53–2.0)
.94
Condom used at first intercourse No (37% of sample, n = 102) Yes (63% of sample, n = 172)
48.0 47.7
Previous condom failure: No (20% of sample, n = 54) Yes (80% of sample, n = 218)
40.7 50.0
1.9 (1.2–3.0)
.98 (.60–1.61)
.95
.74 (.37–1.48)
.39
1.5 (.80–2.7)
.22
1.3 (.56–3.0)
.55
Total MCAS attitudes score (+10 points)
1.5 (1.3–1.9)
1 year duration No (27% of sample, n = 70) Yes (73% of sample, n = 188)
45.7 48.9
1.1 (.66–1.9)
.65
1.1 (.46–2.8)
.79
Partner willing to use condoms No (52% of sample, n = 138) Yes (48% of sample, n = 128)
29.7 69.5
5.4 (3.2–9.1)
< .001
5.7 (2.9–11.2)
< .001
Friends/significant others think condom use good idea No (29% of sample, n = 86) 50.0 1.1 (.65–1.8) Yes (71% of sample, n = 210) 51.9
.77
.55 (.24–1.3)
.15
Friends/significant others use condoms No (53% of sample, n = 154) 42.9 Yes (47% of sample, n = 134) 61.9
.002
Downloaded by [University of Birmingham] at 17:36 02 September 2014
Independent variables
Condom used at first intercourse No (37% of sample, n = 106) Yes (63% of sample, n = 179)
56.6 49.2
Previous condom failure No (23% of sample, n = 65) Yes (77% of sample, n = 218)
47.7 53.7
2.2 (1.4–3.5)
.74 (.46–1.2)
.23
Multivariate OR (95% CI)
1.5 (.75–2.9)
.51 (.25–1.03)
p
.26
.06
1.3 (.73–2.2)
.40
1.8 (.77–4.4)
.17
Total MCAS attitudes score (+10 points)
1.2 (1.01–1.5)
.04
1.3 (.92–1.9)
.13
Total CUSES self-efficacy score (+10 points)
1.1 (.96–1.4)
.13
1.05 (.75–1.5)
.78
Model R2 = .29
Table 1 summarises the relationship between our outcome variables and MCAS and CUSES subscales results. More positive attitudes on four of the MCAS sub-scales (“reliability and effectiveness” [ p < .001], “identity stigma” [ p = .002], “pleasure” [ p < .001] and
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“embarrassment about negotiation and use” [ p < .001]) were significantly associated with recent condom use. “Reliability and effectiveness” ( p = .003), “pleasure” ( p = .005) and “identify stigma” ( p = .008) had positive significant associations with intentions to use condoms in the future. On the CUSES, recent condom use was significantly associated with higher scores on the “mechanics” ( p = .005), “intoxicants” ( p = .03) and “partner’s disapproval” ( p = .002) sub-scales. Higher “mechanics” ( p = .04) and “intoxicants” ( p = .02) scores were significantly associated with intention to “mostly or always” use condoms in the future.
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Association between respondent characteristics and outcomes Univariate analysis In univariate analysis, recent regular condom use was significantly associated with partner’s willingness ( p =
