AIDS Education and Prevention, 25(6), 480–494, 2013 © 2013 The Guilford Press XIAO ET AL. CONDOM USE AMONG YOUNG CHINESE MIGRANTS

SEXUAL COMMUNICATION, SAFER SEX SELF-EFFICACY, AND CONDOM USE AMONG YOUNG CHINESE MIGRANTS IN BEIJING, CHINA Zhiwen Xiao, Xiaoming Li, Danhua Lin, Shulin Jiang, Yingjie Liu, and Shuming Li

Mediation effect of sexual communication on the relationship between safer sex self-efficacy and condom use was tested among 307 homosexually active migrant men, 376 heterosexually active migrant men, and 265 heterosexually active migrant women. The study found certain aspects of sexual communication mediated the effect of self-efficacy on condom use among the three samples. The findings underscored the importance of including components that promote safer sex self-efficacy and sexual communication in HIV prevention interventions for Chinese migrants.

Social cognitive theory (SCT; Bandura, 1992) states that human behavior is the result of interactions among personal factors, environmental factors, and the behavior itself. Self-efficacy, an individual’s confidence in performing a specific behavior, has been identified as one of the most salient personal factors that influence behavior. Sexual communication is a social environmental factor that exchanges sexual information (such as issues relating to risk of HIV infection and STDs, past sexual practice) and requests/negotiate condom use between individuals in a significant relationship such as between sexual partners, between parents and their children, and between health care professionals and their patients or clients (Byers, 2011; Noar, Carlyle, & Cole, 2006; Zamboni, Crawford, & Williams, 2000). Previous research has long and consistently demonstrated that safer sex self-efficacy is an important determinant of condom use among Western populations (e.g., Heeren, Jemmott, Mandeya, & Tyler, 2007; Sheeran, Abraham, & Orbell, 1999) and Chinese populations (Zhao, Wang, Fang, Li, & Stanton, 2008). A meta-analysis

Zhiwen Xiao is affiliated with the Valenti School of Communication, University of Houston, Houston, Texas. Xiaoming Li is affiliated with Wayne State University School of Medicine, Detroit, Michigan. Danhua Lin is affiliated with the Institute of Developmental Psychology, Beijing Normal University, Beijing, China. Shulin Jiang, Yingjie Liu, and Shuming Li are affiliated with the Chaoyang District Center for Disease Control and Prevention, Beijing, China. The study was supported by NIH Research Grant R01NR10498 by the National Institute of Nursing Research and National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research and National Institute of Mental Health. Address correspondence to Z. Xiao, Valenti School of Communication, University of Houston, 101 Communication Bldg., Houston, TX 77204-3002. E-mail: [email protected]

480

XIAO ET AL. 481

of 134 estimates of the relationships between safer sex self-efficacy and condom use as well as between response-efficacy (belief that condom use will be effective) and condom use found both safer sex self-efficacy and response-efficacy are correlated with condom use but self-efficacy is more predictive of intended and actual condom use (Casey, Timmerman, Allen, Krahn, & Turkiewicz, 2009). The results of the meta-analysis indicate “the importance of a prevention message focusing on raising self-efficacy to increase condom use” (p. 57). Sexual communication, especially negotiation on use of condoms between couples or partners, is another fundamental concern for research on HIV risk prevention (Allen, Emmers-Sommer, & Crowell, 2002). An increasing body of literature demonstrates that sexual communication is an important factor associated with condom use (Morokoff et al., 2009). Condom use during sex typically is a mutual act between partners and the partners must first communicate/negotiate about condom use to make it happen. “The need for communication between the couple becomes not just a matter of convenience but a matter of safety” (Allen et al., 2002, p. 264). The meta-analysis by Sheeran and colleagues (1999) concluded that sexual communication about condom use was the strongest correlate of condom use. Another meta-analysis study (Allen et al., 2002) found that couples who talked about HIV and condoms before sex were more likely to use condoms during sex than those who did not talk. And there was 38% increase in the likelihood of condom usage if such a conversation occurred. A more recent meta-analysis conducted by Noar and colleagues (2006) indicated that the mean sample-size weighted effect size was r = .22 for the relationship between sexual communication and condom use. Given the relative broad definition, most measurements of this construct have been adopted, adapted, or developed specifically for particular studies. For instance, one aspect of sexual communication associated with condom use is an individual’s assertiveness (Crowell, 2004). Ross (1988) noted that an individual’s ability to talk about condom use in sexual encounters without fear or rebuff is the most important assertive personality. A growing number of researchers found that assertive communication strategies play significant roles in successful safer sex negotiation and compliance among different populations (e.g., Edgar, Freimuth, Hammond, McDonald, & Fink, 1992; Wingood & DiClemente, 1998). Willingness to communicate about sex-related topics, another aspect of sexual communication, has been considered as the most important and powerful predictor of condom use (Edgar et al., 1992). In addition, frequency of sexual communication (Crosby, DiClemente, Wingood, Rose, & Lang, 2003; Crosby et al., 2002; Oakley & Bogue, 1995), communication self-efficacy (Dilorio, Dudley, Lehr, & Soet, 2000), quality of sexual communication (Catania et al., 1989), and specific sexual topics discussed (Cline, Johnson, & Freeman, 1992) were associated with condom use in heterosexual or homosexual encounters among diverse populations. Noar and colleagues’ meta-analysis (2006) demonstrated that different ways of operationalization of the construct had significantly different impact on the relationship between sexual communication and condom use, with a weighted mean effect size of r = .29 for behavioral format, r = .18 for intention format, and r = .13 for self-efficacy format. Limited studies have examined sexual communication among Chinese samples (e.g., Cottrell et al., 2005; Xiao, 2012; Xiao, Li, Liu, Li, & Jiang, 2013; Yang et al., 2005). However, some of the studies did not intend to examine the association between sexual communication and condom use. For example, Cottrell et al. (2005) investigated the relationship between attitudes toward condom use and communication with partners about sexual history and ways to prevent AIDS/STDs/pregnancy

482

CONDOM USE AMONG YOUNG CHINESE MIGRANTS

among Chinese college students. Yang et al. (2005) assessed the relationship between perceived gatekeeper support for condom use and communication with sexual partners about condom use among FSWs (Yang et al., 2005). Xiao and colleagues, however, did find that sexual communication with partners about topics such as condom use and HIV/STDs prevention were associated with condom use among Chinese MSM and college students sampled (e.g., Xiao, 2012; Xiao et al., 2013). The existing literature shows that sexual communication along with safer sex self-efficacy are important factors associated with condom use in both heterosexual and homosexual populations. However, prior research has focused on the associations between self-efficacy and safer sex or between sexual communication and safer sex; few studies have examined the relationship between safer sex self-efficacy and sexual communication. According to Bandura, Barbaranelli, Caprara, and Pastorelli (1996), individuals with high social self-efficacy will seek to cultivate relationships while individuals with low self-efficacy will envision rejection even before they cultivate relationships. Based on this theoretical logic, some researchers demonstrated that social self-efficacy influences communication skills that are critical in development of relationships; and individuals with higher self-efficacy were more likely to demonstrate a higher job readiness level, which was measured by levels of communication skills and other life skills (Chan, Rubin, Lee, & Prutt, 2003). Some other researchers documented that general self-efficacy could have a positive impact on communication skills (Meneses, Miyazaki, & Pais-Ribeiro, 2010). Therefore, the current study hypothesized that safer sex self-efficacy is associated with sexual communication and condom use, and sexual communication is associated with condom use. In other words, sexual communication mediates the relationship between safer sex self-efficacy and condom use among Chinese migrants. In China, sexual transmission has become the primary mode of HIV transmission (The Joint United Nations Programme on HIV/AIDS [UNAIDS], 2010). There is a sexual revolution going on in China (Pan, 2006). Therefore, there has been increasing premarital, extramarital, and commercial sex among both men and women (Pan, 2006). These factors put Chinese at increased risk of HIV infection. However, condom use is not a common practice among at-risk Chinese populations because “condoms are often seen as an obstacle to intimacy. In China, under strict family planning policies, condoms were primarily used for birth control within the context of a marriage in urban areas” (Choi & Holroyd, 2007, p. 499). Among these at-risk populations, the rural-to-urban migrant population plays a particularly important role in increasing the sexually transmitted HIV epidemic (Qian, Vermund, & Wang, 2005). HIV prevalence among rural-to-urban migrants is almost twice that of rural dwellers (Yang et al., 2009). In addition, compared to their rural peers, migrants are less constrained in terms of seeking recreational opportunities or purchasing sex (Tucker et al., 2005). It is estimated that nearly 30% of migrants have had multiple sexual partners or paid for sex at least once (Li et al., 2004). However, Chinese migrants usually do not have protected sex with their sexual partners when they travel back to their hometowns, and this floating population bridges the risk of HIV transmission between the high-risk urban populations and rural residents (Thompson, 2005). Accordingly, there is a great need to promote condom use to serve the dual purpose of birth control and disease prevention among Chinese migrants. Understanding the antecedents of condom use behavior can be very important in designing effective behavioral intervention programs that aim at promoting condom use. However, little has been documented about these antecedents among Chinese migrants, “which constitutes a serious gap in the knowledge base to formulate ap-

XIAO ET AL. 483

propriate responses” (Li, Morrow, & Kermode, 2007, p. 1289). The current study therefore aimed to fill this gap in the literature by exploring the associations among safer sex self-efficacy, sexual communication, and condom use and testing the mediation role of sexual communication between self-efficacy and condom use among a diverse group of young Chinese migrants.

METHODS PARTICIPANTS A cohort of 948 young Chinese migrants (307 homosexually active men, 376 heterosexually active men, and 265 heterosexually active women) was surveyed in Beijing. Migrants were defined as individuals who worked in Beijing without an official Beijing residence. Beijing has a population of 22 million, which includes 5.09 million migrants at the end of 2009 (National Bureau of Statistics of China, 2010). These participants were 18–30 years of age and did not have permanent residency registration in Beijing. The heterosexually active sample included men and women who were either single, or married but lived apart from their spouse. The homosexual male sample was recruited through peer outreach, snowballing, the Internet outreach, and venue-based outreach (see Guo et al., 2011). The heterosexually active male and female migrants were recruited through venue-based outreach (see Li et al., 2006). All the participants were ensured of confidentiality. Participants provided written informed consents before participating in the survey.

SURVEY PROCEDURE The questionnaire of the study was self-administered via paper-and-pencil. The participants completed their surveys privately in local CDC or a community medical center in Beijing. The interviewers were trained graduate students and faculty members in psychology at a local university and trained health workers from a local CDC. The questionnaire took about 45 minutes to complete. The participants received a small monetary incentive (equivalent to U.S. $2) for their participation and reimbursement for their transportation expenses (up to U.S. $5) upon the completion of the survey. The research protocol received clearance from the Institutional Review Boards at Wayne State University and Beijing Normal University.

MEASURES Condom Use During First Time Sex. Respondents were asked to indicate if they used a condom when they had sexual intercourse for the first time. Frequent Condom Use in the Past Three Sexual Episodes. Respondents were asked how many times they used condoms in their last three sexual episodes with regular/ casual partners. The response options ranged from 1 (0 time) to 4 (all 3 times). For the homosexual sample, in addition to the aforementioned questions, more specific questions were asked about condom use in the last three anal sex. The questions were “In the last three anal sexual episodes with regular/casual partners, how many times did you use condoms?” A composite score of frequent condom use in the last three sexual episodes was created for each sample by counting those who used condoms all three times. The composite score for each sample was included in the data analysis.

484

CONDOM USE AMONG YOUNG CHINESE MIGRANTS

Safer Sex Self-Efficacy. Respondents were asked to indicate how much they disagree or agree with a set of 6 statements. Sample statements include “If my sexual partner refuses to use condoms, I won’t have sex with them” and “I would insist to use condoms even if I was affected by alcohol or drugs.” These items were adapted from the five-item, full alternative version A of the Confidence in Safer Sex (CSS) scale (Redding & Rossi, 1999). Each item was indicated by a four-point scale ranging from 1 = strongly disagree to 4 = strongly agree. Crohbach alpha was .84, .83, .91 for the homosexual male, the heterosexual male and the heterosexual female samples, respectively. Sexual Communication. Respondents were asked to indicate whether each of the 10 statements related to discussion of sex and condom use with their partners was true to them. These items were adopted and adapted from studies conducted by Cline et al. (1992), Guzman et al. (2003), and Milausen, Sales, Wingood, DiClemente, Salazer, & Crosby (2007). Sample statements include “I definitely would talk to my partners about sex-related topics,” “If my partners don’t want to use condoms, I would talk with him/her,” “I talk frequently with my partners about condom use,” and “I can comfortably talk with my partners about sex-related topics.” Response options were “very untrue,” “untrue,” “neither untrue nor true,” “true,” and “very true.” Items were recoded when necessary so that a higher score reflected higher level of sexual communication. Exploratory factor analysis revealed a three-factor structure for the 10 items: assertiveness of communication (3 items, e.g., I would talk to my partners if I have concerns or questions about sex-related topics), communication about condom use (4 items, e.g., I talk frequently with my partners about condom use), and comfort with sexual communication (3 items, e.g., it’s embarrassing to talk about the use of condoms with my partners) for the three samples. Crohbach alpha was .77, .84, and .78 for the three factors for the heterosexual female sample, .80, .77, and .73 for the heterosexual male sample, and .63, .73, and .70, for the homosexual male sample. Demographics. Respondents were also asked to respond to questions related to their demographic information, including age, ethnicity, township, monthly income, education level, and employment.

DATA ANALYSIS First, descriptive statistics were reported to describe characteristics of demographics, safer sex self-efficacy, and sexual communication as well as the rate of condom use among the study samples. Second, bivariate correlations were examined among demographics, sexual communication, self-efficacy, and frequent condom use. Third, path analyses were used to test the mediation effects of sexual communication on the relationship between safer sex self-efficacy and frequent condom use. The effect of self-efficacy on frequent condom use is completely mediated by sexual communication if the effect of self-efficacy on frequent condom use approaches zero while controlling for sexual communication. Otherwise, it is partially mediated by sexual communication if the total effect of self-efficacy on frequent condom use equals to the sum of direct effect and indirect effect; and if the direct effect is greater than zero but smaller than the zero-order correlation between self-efficacy and frequent con-

XIAO ET AL. 485 TABLE 1. Demographic Characteristics of Study Samples Homosexual Male

Heterosexual Male

Heterosexual Female

N

307 (100%)

376 (100%)

265(100%)

Age

23.73 (2.86)

24.52 (3.32)

23.52 (3.17)

49.27 (30.98)

60.28 (30.74)

53.94 (33.13)

2.71 (2.95)

1.99 (1.40)

1.87 (1.09)

Total migration times (month) # of cities stayed Time in Beijing (month)

39.50 (30.56)

46.42 (34.45)

38.32 (28.03)

Monthly Income (100 yuan)

22.08 (16.80)

25.39 (13.42)

23.24 (10.26)

282 (92%)

349 (95.6++++%)

252 (96.2%)

32 (12.3%)

Han Ethnic Hometown Type

102 (33%)

41 (11.6%)

County seat

City

63 (21%)

44 (12.4%)

47 (18%)

Township

44 (14%)

82 (23.2%)

51 (19.5%)

Rural

98 (32%)

187 (52.8%)

131 (50.2%)

Education ≤ Middle School

51 (17%)

183 (51.1%)

108 (42.5%)

High School

121 (39%)

146 (40.8%)

110 (43.3%)

≥ 3yr college

135 (44%)

30 (8.3%)

36 (14.2%)

Never Married

287 (94%)

237 (64.8%)

185 (70.3%)

93 (30.3%)

111 (30.2%)

72 (27.7%)

4 (1.3%)

61 (16.6%)

25 (9.6%)

Employment Company Construction Entertainment

99 (32%)





Freelance

68 (22%)





School Other/No stable employment



14 (3.8%)

9 (3.5%)

43 (14%)

182 (49.5%)

154 (59.2%)

Frequency of Visiting Home Never Once/2–3 yrs Once/year 2–3 times/year

23 (8%)

3 (.8%)

4 (1.6%)

40 (13%)

61 (16.4%)

22 (8.6%)

148 (48%)

231 (62.1%)

149 (58%)

95 (31%)

77 (20.7%)

82 (31.9%)

dom use while controlling for sexual communication (Hayes, 2009). SPSS 20 and Amos were used for the statistical analysis.

RESULTS DEMOGRAPHIC CHARACTERISTICS The study consisted of 307 homosexual male migrants recruited in 2009, 376 heterosexual male migrants recruited in 2011, and 265 heterosexual female migrants recruited in 2010. Participants’ age ranged from 18–30 years with a mean of 23.73 years (SD = 2.86) for the homosexual male sample, a mean of 23.5 years (SD = 3.17) for the heterosexual female sample, and a mean of 24.5 (SD = 3.32) for the heterosexual male sample. Ninety-eight (32%) homosexual male migrants, 131 (50.2%) heterosexual female migrants, and 187 (52.8%) heterosexual male

486

CONDOM USE AMONG YOUNG CHINESE MIGRANTS TABLE 2. Characteristics of Condom Use Among the Study Samples Homosexual Male

Heterosexual Male

(n = 307)

First time sex

Heterosexual Female

(n = 376)

(n = 265)

Valid response

Condom use

Valid response

Condom use

Valid response

(N)

n (%)

(N)

n (%)

(N)

Condom use n (%)

307

133 (43.3)

342

108 (31.6)

244

95 (38.9)

Recent 3 episodes Regular partner

200

122 (61)

319

54 (16.9)

237

61 (25.7)

Casual partner

304

212 (69.7)

136

28 (20.6)

73

15 (20.5)

T-test

–9.52***

Anal sex

1

306

268 (87.6)

–3.46*** n/a

n/a

6.25*** n/a

n/a

Note. 1Questions were not available for the heterosexual samples.

migrants were from rural areas. Table 1 presents the demographic characteristics of the study samples.

CONDOM USE BEHAVIOR Table 2 presents the summary statistics of respondents’ condom use with their regular and casual sexual partners in their last three sex episodes. Among those homosexual male migrants who reported that they had regular sexual partners, 122 (61%) used condoms all three times with regular partners, and 212 (69.7%) with casual partners (t = -9.52, p < .001). Among the heterosexual male sample, 54 (16.9%) used condoms all three times with regular partners, and 28 (20.6%) with casual partners (t = -3,46, p < .001). Among those females who reported they had regular/ casual partners, (25.7%) used condoms all three times with regular partners, and 15 (20.5%) with casual partners (t = 6.25, p < .001).

BIVARIATE ANALYSIS Table 3 presents the Pearson r correlations among frequent condom use, safer sex self-efficacy, and factors of sexual communication. None of the demographic variables was associated with frequent condom use. For the homosexual male sample, the heterosexual male and female samples, significant correlations were observed between frequent condom use in the last three sexual episodes and safer sex self-efficacy (r = .177, p < .01; r = .205, p < .01; r = .258, p < .01, respectively)

PATH ANALYSIS Figures 1­–3 represent the path analysis models of mediation effects for the three samples. In the path model of condom use in the last three sexual episodes for the heterosexual female sample (see Figure 1), safer sex self-efficacy was significantly associated with condom use in the last three episodes (β = .192, SE = .056, p < .01), assertiveness of sexual communication (β = .339, SE = .074, p < .001), and communication about condom use (β = .345, SE = .074, p < .001). Assertiveness of sexual communication (β = .184, SE = .066, P < .05) was significantly associated with condom use in the last three sexual episodes. However, safer sex self-efficacy was not significantly associated with comfort with sexual communication (β = .038, SE = .074); communication about condom use (β = -.001, SE = .074) and comfort with sexual communication (β = .073, SE = .044) were not significantly associated with frequent condom use in the last 3 sexual episodes. The proposed path model

Heterosexual Male Sample 1 2 3 4 5 Homosexual Male Sample 1 2 3 4 5

5

1 2 3 4

Heterosexual Female Sample

.398** 1

.111 1

1

.340** 1

2. Assertiveness

1

1

1. Safer Sex Self-Efficacy

.190** .610** 1

.126* .514** 1

.346** .770** 1

3. Communication About Condom Use

.171** –.125* –.025 1

–.072 –.374** –.315** 1

.038 –.283** –.240** 1

4. Comfort With Sexual Communication

TABLE 3. Correlation Matrix Among Safer Sex Self-Efficacy, Factors of Sexual Communication, and Condom Use

.177** .025 .150** –.037

.205** .202** .087 –.021 1

1

.258** .228** .190** .029

5. Condom Use in Past 3 Episodes

1

XIAO ET AL. 487

488

CONDOM USE AMONG YOUNG CHINESE MIGRANTS

FIGURE 1. Path Model for Heterosexual Female Migrant Sample.

for condom use in the last three sexual episodes produced significant a chi-square (χ2 = 28.193, df = 2, p < .001 respectively). The values of the selected fit indices were: NFI = .914, and CFI = .916, indicating a good fit of the model. The direct effect between safer sex self-efficacy and frequent condom use remained significant after controlling for sexual communication factors. The direct effect (β = .192) is smaller than the zero-order correlations between safer sex self-efficacy and condom use in the last three episodes (r = .258). Also, the standardized total effect of self-efficacy on condom use (.257) equals to the sum of the standardized direct effect (.192) and the standardized indirect effect (.065). Therefore, there is a partial mediation effect of assertiveness of sexual communication on the relationship between safer sex selfefficacy and condom use in the last three sexual episodes. In the path model for the heterosexual male migrant sample (see Figure 2), safer sex self-efficacy was significantly associated with frequent condom use in the last three episodes (β = .143, SE = .054, p < .01), assertiveness of sexual communication (β = .408, SE = .077, p < .001), and communication about condom use (β = .125, SE = .076, p < .05), but not with comfort with sexual communication (β = -.072, SE = .078). Assertiveness of sexual communication (β = .159, SE = .038, p < .05) was significantly associated with frequent condom use in the last three episodes, but communication about condom use (β = .001, SE = .038) and comfort with sexual communication (β = .051, SE = .034) were not significantly associated with frequent condom use in the last three episodes. The proposed path model for condom use in the last three sexual episodes produced a significant chi-square (χ2 = 37.344, df = 1, p < .001). The values of selected fit indices were NFI = .863, and CFI = .859. The direct effect (β = .143) remained significant and is smaller than the zero-order correlation (r = .205). Also, the standardized total effect of self-efficacy on condom use (.204) equals to the sum of the standardized direct effect (.143) and the standardized indirect effect (.061). Thus, there is a partial mediation effect of assertiveness of sexual communication on the relationship between self-efficacy and condom use. In the path model for the homosexual male migrant sample (see Figure 3), safer sex self-efficacy was significantly associated with frequent condom use in the last three episodes (β = .167, SE = .133, p < .01), assertiveness of sexual communication (β = .111, SE = .076, p < .05), communication about condom use (β = .190, SE = .07, p < .001) and comfort with sexual communication (β = .171, SE = .083, p < .01). Communication about condom use was significantly associated with frequent condom use in the last three sexual episodes (β = .188, SE = .132, p < .01), but assertiveness of sexual communication (β = -.117, SE = .121) and comfort with sexual

XIAO ET AL. 489

FIGURE 2. Path Model for Heterosexual Male Migrant Sample.

communication (β = -.076, SE = .089) were not significant predictors of condom use. The proposed path model for condom use in the last three sexual episodes produced a significant chi-square (χ2 = 7.164, df = 2, p < .05). The values of selected fit indices were NFI = .961, CFI = .970. The selected fit indices indicate a good fit . The standardized total effect of self-efficacy on condom use (.177) equals to the sum of the standardized direct effect (.167) and the standardized indirect effect (.01). Also, the significant direct effect of self-efficacy on condom use (β = .167) is smaller than the zero-order correlation (r = .177). Therefore, for this sample, communication about condom use partially mediated the effect of self-efficacy on condom use. However, assertiveness had an inverse relationship with condom use among the homosexual male migrants.

Discussion One of the major findings in the current study is that the relationship between safer sex self-efficacy and condom use was partially mediated by sexual communication for all three samples. Although we cannot definitely assert the flow of causality based on this finding, we theorize that sexual communication is an important intermediate step between safer sex self-efficacy and the initiation and maintenance of safer sex behavior. Practicing safer sex involves believing in one’s ability to engage in safer sex and the interpersonal communication skills necessary to negotiate safer sex with a partner (Lear, 1995). If interpersonal communication about condom use is not effective, then safer sex might not be practiced (Edgar, Hammond, & Freimuth, 1989). Another important finding is that certain aspects of sexual communication partially mediated the effects of safer sex self-efficacy on condom use. For the heterosexual male and female samples, assertiveness had significant mediation effects on the relationship between safer sex self-efficacy and condom use. And communication about condom use was found to partially mediate the relationships between selfefficacy and condom use for the homosexual male migrant sample. These findings indicate that assertiveness is a critical important factor of sexual communication to be considered in increasing actual condom use and decreasing HIV-related sexual risk among heterosexually active Chinese migrants, which is consistent with findings of previous studies (e.g., Noar, Morokoff, & Harlow, 2002). However, it is important to note that the association between assertiveness and condom use was negative among the homosexually active Chinese migrants (although it was not significant). This might indicate that assertiveness might not act as a protective factor, rather, it

490

CONDOM USE AMONG YOUNG CHINESE MIGRANTS

FIGURE 3. Path Model for Homosexual Male Migrant Sample.

might function as an underlying accusation of mistrust among the homosexually active sample (Allen et al., 2002) because the homosexual male community “may have developed a norm through socialization that makes such conversation unnecessary” (Allen et al., 2002, p. 274). “The social pattern may be such that sexual behavior provides a script or expectation that involves a condom” for homosexual males (Allen et al., 2002, p. 274). However, the current study found communication about condom use did predict condom use among the homosexually male migrants, which is consistent with previous studies that found sexual communication about condom use was a strong correlate of actual heterosexual condom use (e.g., Allen et al., 2002; Sheeran et al., 1999). According to Edgar and Fitzpatrick (1988), direct communication about condom use might make partners feel the least amount of manipulation when compared to other condom influence strategies, which might explain why assertiveness of sexual communication had a negative but communication about condom use had a positive relationship with condom use; that is, the levels of manipulation in these two aspects of sexual communication might be perceived differently by the homosexual male migrants surveyed. These findings support Lear’s (1995) argument, which states that communication is the medium to explore the complicated relations between behavior and sexual culture. In addition, this result supports and extends the previous research conducted among both homosexual and heterosexual samples in Western countries (e.g., Noar, Morokoff, & Redding, 2002). The mediation effect of sexual communication has important implications for HIV prevention interventions that promote condom use among migrant Chinese populations. Most of the HIV prevention interventions in China focus on improving HIV knowledge, awareness of HIV, attitudes towards condom use, and condom use (Hong & Li, 2009), few emphasize improving the assertiveness and the frequency of communication about condom use among target audience (Zhang, Li, Shah, Baldwin, & Stanton, 2007). It is important to understand the characterisitcs of assertive sexual communication of Chinese migrants so that variations in safer sex negotiation skills can be discovered. It is also very important to include the intervention components designed to promote safer sex communication in effective HIV prevention interventions. One of the strengths of the current study is the inclusion of a diverse group of young migrants including homosexual male, heterosexual male and female. While it is unclear from the current data why the relationship between assertiveness of sexual communication and condom use was negative and why only sexual communication about condom use was significantly correlated with condom use among the homo-

XIAO ET AL. 491

sexual male sample, the finding itself underscored the importance of examining the issue among different groups of migrants, as they might differ from each other in terms of safer sex behaviors, perception, and characteristics of sexual communication. The current study provides further empirical evidence for the importance of promoting more frequent, open, and assertive communication between heterosexual Chinese migrants and their sex partners. Intervention programs could aim to promote frequent communication with sex partners about condom use as normative and socially-desired behaviors for homosexual Chinese migrants. Health education programs could also promote Chinese migrants’ openness and willingness to engage in sexual communication with both regular and casual sexual partners. Programs may promote Chinese migrants’ motivation to communicate and negotiate condom use with their partners. Meanwhile, intervention programs should make efforts to build Chinese migrants’ communicative self-efficacy to talk about and negotiate condom use and other important risk reduction skills. Focus group methodology and indepth interviews could also be used to find out why Chinese migrants don’t engage in more frequent, more open, and more voluntary sexual communication with their sexual partners. Safer sex campaign programs among Chinese migrants may then benefit from addressing these areas of concern. In addition, safer sex self-efficacy is found to be an important determinant of condom use in the migrant samples studied. This finding is consistent with previous studies on the relationship between self-efficacy and condom use (e.g., Heeren et al., 2007; Sheeran et al., 1999). Self-efficacy is also found to be a predictor of assertive sexual communication and communication about condom use among the heterosexual migrant sampels and a predictor of all three aspects of sexual communication among the homosexual sample. These findings indicate that promoting safer sex self-efficacy is one of the most important steps when promoting condom use targeting both homosexual and heterosexual Chinese migrants. Safer sex self-efficacy and sexual communication should be promoted hand-in-hand. Consistent with global literature regarding condom use with different types of partners (e.g., Misovich, Fisher, & Fisher, 1997; Noar, Zimmerman, & Atwood, 2004), condom use behavior among homosexual and heterosexual migrants differed by types of sexual partners. In general, the homosexual male migrants studied were more likely to use condoms with their casual partners than with their regular partners. This finding is consistent with Lear’s (1995) observation that people in homosexual relationships tend to increase condom use with casual partners and decrease condom use when the relationship becomes steady. The heterosexual male migrants were also more likely to use condoms with their casual partners than with their regular partners. On the contrary, the heterosexual female migrants, with relatively lower rates of condom use with both types of partners, was more likely to use condoms with their regular partners than with their casual partners. These findings are partially consistent with those of de Visser and Smith’s (2001) and Lear’s (1995), who found that condom use was less likely with regular partners than with casual partners in samples of heterosexual adults. One possible explanation is that “regular partnership” among the heterosexual female migrants in the current study was also in the context of multiple partnership and extra- or premarital relationship (based on the inclusion criteria). Compared to the male samples, the heterosexual female sample might be less aware of the risk of HIV infection. Seeking sexual gratification or sexual pleasure was their major purpose with casual partners (e.g., one-night stand, commercial sex workers, etc.). Therefore, they might be less likely to use

492

CONDOM USE AMONG YOUNG CHINESE MIGRANTS

condoms with their casual partners. However, because of the nature of pre-marital or extra-marital sexual encounters, pregnancy prevention might be their major concern. Based on the findings in the current study, promoting condom use should be one of the top priorities of HIV preventive intervention programs targeting both homosexual and heterosexual Chinese migrants. Future research is needed to find out whether different groups of migrants (e.g., homosexual vs. heterosexual; male vs. female) hold different perceptions regarding condom uses for different sexual partners (i.e., regular/casual partners) and tailor the intervention messages accordingly. Our research must be interpreted within the context of some methodological limitations. First, due to the fact that all participants were migrants in a large city (which is also the cultural and political center of the nation), participants in this study might not be representatives of migrants in other areas of China. Second, assessment of condom use, self-efficacy, and sexual communication were self-reported, which was subject to a self-reporting bias. Third, the results of this cross-sectional study only indicate associations between the studied variables and condom use, and are inadequate for identifying causal effects despite the causal directions specified in the models tested. Fourth, the study included perspectives from only one partner (the participants) regarding sexual communication, safer sex self-efficacy, and condom use. Future research could examine data from both partners to examine the associations among these factors because condom use is agreement and cooperation of both partners rather than an individual action. Fifth, the surveys were administered via paper-and-pencil (rather than computer-based methodologies), which might have increased the likelihood of obtaining socially-desirable responses. In conclusion, the findings support the practice of promoting safer sex selfefficacy, increasing frequency and effectiveness of sexual communication, and teaching partner communication skills to young Chinese migrants (including both homosexual and heterosexual migrants) who participate in programs designed to promote safer sex behaviors. The findings also suggest that HIV prevention programs may benefit by addressing issues of sexual communication, including more frequent communication, willingness to engage in sexual communication, and assertive sexual communication.

REFERENCES Allen, M., Emmers-Sommer, T., & Crowell, T. (2002). Couples negotiating safer sex behaviors: A meta-analysis of the impact of conversation and gender. In M. Allen, R. Preiss, B. Gayle, & N. Burrell (Eds.), Interpersonal communication research: Advances through meta-analysis (pp. 263–280). Mahwah, NJ: Lawrence Erlbaum. Bandura, A. (1992). A social cognitive approach to the exercise of control over AIDS infection. In R. J. DiClimente (Ed.), Adolescents and AIDS (pp. 89–116). Newbury Park, CA: Sage. Bandura, A., Barbaranelli, C., Caprara, G. V., & Pastorelli, C. (1996). Self-efficacy beliefs as shapers of children’s aspirations and career

trajectories. Child Development, 67(3), 1206–1222. Byers, S. (2011). Beyond the birds and the bees and was it good for you?: Thirty years of research on sexual communication. Canadian Psychology, 52(1), 20–28. Casey, M. K., Timmerman, L., Allen, M., Krahn, S., & Turkiewicz, K. L. (2009). Response and self-efficacy of condom use: A metaanalysis of this important element of AIDS education and prevention. Southern Communication Journal, 74, 57–78. Catania, J., Dolcini, M., Coates, T., Kegeles, S., Greenblatt, R., & Puckett, S. (1989). Predictors of condom use and mulitple partnered sex among sexually-active adolescent women: Implications for AIDS-related

XIAO ET AL. 493 health interventions. Journal of Sex Research, 26 (4), 514–524. Chan, F., Rubin, S. E., Lee, G., & Prutt, S. R. (2003). Empirically derived life skill factors for program evaluation in rehabilitation. Journal of Applied Rehabilitation Counseling, 34(4), 15–22. Choi, S.Y.P., & Holroyd, E. (2007). The influence of power, poverty and agency in the negotiation of condom use for female sex workers in mainland China. Culture, Health & Sexuality, 9(5), 489–503. Cline, R.J.W., Johnson, S. J., & Freeman, K. E. (1992). Talk among sexual partners about AIDS: Interpersonal communication for risk reduction or risk enhancement. Health Communication, 4, 39–56. Cottrell, L., Li, X., Stanton, B., Harris, C., D’Alessandri, D., Sun, Z. . . . Zhang, H. (2005). Perceptions regarding preventive sexual practices and communication with sexual partners among Chinese college students. Preventive Medicine, 40(2), 189­ –196. doi:10.1016/j.ypmed.2004.05.019. Crosby, R. A., DiClemente, R. J., Wingood, G. M., Cobb, B. K., Harrington, K., Davies, S. L., … Oh, M. K. (2002). Condom use and correlates of African American adolescent females’ infrequent communication with sex partners about preventing sexually transmitted diseases and pregnancy. Health Education & Behavior, 29(2), 219–231. Crosby, R. A., DiClemente, R. J., Wingood, G. M., Rose, E., & Lang, D. (2003). Correlates Of continued risky sex among pregnant African American teens: Implications for STD prevention. Sexually Transmitted Diseases, 30(1), 57–63. Crowell, T. (2004). Seropositive individuals willingness to communicate, self-efficacy, and assertiveness prior to HIV infection. Journal of Health Communication, 9, 395–424. de Visser, R., & Smith, A. (2001). Relationship between sexual partners influences rates and correlations of condom use. AIDS Education and Prevention, 3, 413–427. DiIorio, C., Dudley, W. N., Lehr, S., & Soet, J. (2000). Correlates of safer sex communication among college students. Journal of Advanced Nursing, 32, 658–665. Edgar, T., & Fitzpatrick, M. A. (1988). Compliance-gaining in relational interaction: When your life depends on it. Southern Speech Communication Journal, 53, 385–405. Edgar, T., Freimuth, V. S., Hammond, S. L., McDonald, D. A., & Fink, E. L. (1992). Strategic sexual communication: Condom use and resistance and response. Health Communication Research, 4, 83–104. Edgar, T., Hammond, S. L., & Freimuth, V. S. (1989). The role of mass media and interpersonal communication in promoting

AIDS-related behavioral change. AIDS and Public Policy Journal, 4, 3–9. Guo, Y., Li, X., Fang, X., Lin, X., Song, Y., Jiang, S., & Stanton, B. (2011). A comparison of four sampling methods among men having sex with men in China: implications for HIV/STD surveillance and prevention. AIDS Care, 23(11), 1400–9. Guzman, B. L., Schlehofer-Sutton, M. M., Villanueva, C. M., Stritto, M. E., Casad, B. J., & Feria, A. (2003). Let’s talk about sex: How comfortable discussions about sex impact teen sexual behavior. Journal of Health Communication, 8, 583–598. Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76, 408–420. Heeren, G. A., Jemmott, J. B., Mandeya, A., & Tyler, J. C. (2007). Theory-based predictors of condom use among university students in the United States and South Africa. AIDS Education and Prevention, 19, 1–12. Hong, Y., & Li, X. (2009). HIV/AIDS behavioral interventions in China: A literature review and recommendation for future research. AIDS & Behavior, 13, 603–613. Joint United Nations Programme on HIV/AIDS. (2010). China 2010 UNGASS Country Progress Report (2008–2009). Retrieved September 22, 2011, from http://www.unaids.org/en/dataanalysis/monitoringcountry progress/2010progressreportssubmittedbyc ountries/china_2010_country_progress_report_en.pdf Lear, D. (1995). Sexual communication in the age of AIDS: The construction of risk and trust among young adults. Social Science Medicine, 41(9), 1311–1323. Li, X., Fang, X., Lin, D., Mao, R., Wang, J., Cottrell, L., & Harris, C. (2004). HIV/STD risk behaviors and perceptions among rural-tourban migrants in China. AIDS Education and Prevention, 16(6), 538–556. Li, L., Morrow, M., & Kermode, M. (2007). Vulnerable but feeling safe: HIV risk among male rural-to-urban migrant workers in Chengdu, China. AIDS Care, 19(10), 1288–1295. Li, X., Stanton, B., Chen, X., Hong, Y., Fang, X., Lin, D. . . . Wang, J. (2006). Health indicators and geographic mobility of young rural-to-urban migrants in China. World Health Population, 8(2), 5–21. Meneses, R., Miyazaki, C., & Pais-Ribeiro, J. (2010, July). Relationship between self-efficacy and communication skills. Paper presented at the 27th International Congress of Applied Psychology, Melbourne, Australia. Milhausen, R. R., Sales, J. M., Wingood, G. M., DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2007). Validation of a partner sexual

494

CONDOM USE AMONG YOUNG CHINESE MIGRANTS

communication scale for use in HIV/AIDS prevention interventions. Journal of HIV/ AIDS Prevention in Children & Youth, 8(1), 11–33. Misovich, S. J., Fisher, J. D., & Fisher, W . A. (1997). Close relationships and elevated HTV risk behavior Evidence and possible underlying psychological processes. Review of General Psychology, 1, 72–107. Morokoff, P. J., Redding, C. A., Harlow, L. L., Cho, S., Rossi, J. S., Meier, K. S., … BrownPeterside, P. (2009). Associations of sexual victimization, depression, and sexual assertiveness with unprotected sex: A test of the multifaceted model of HIV risk across gender. Journal of Applied Biobehavioral Research, 14, 30–54. National Bureau of Statistics of China. (2010). 2009 Surveillance reports of rural-tourban migrants in China. Retrieved from http://www.stats.gov.cn/tjfx/fxbg/ t20100319_402628281.htm. Noar, S. M., Carlyle, K., & Cole, C. (2006). Why communication is crucial: Meta-analysis of the relationship between safer sexual communication and condom use. Journal of Health Communication, 11(4), 365–90. Noar, S. M., Morokoff, P. J., & Harlow, L. L. (2002). Condom negotiation in heterosexually active men and women: Development and validation of a condom influence strategy questionnaire. Psychology and Health, 17(6), 711–735. Noar, S. M., Morokoff, P. J., & Redding, C. A. (2002). Sexual assertiveness in heterosexually active men: A test of three samples. AIDS Education & Prevention, 14, 330– 342. Noar, S. M., Zimmerman, R. S., & Atwood, K. A. (2004). Safer sex and sexually transmitted infections from a relationship perspective. In J. H. Harvey, A. Wenzel & S. Sprecher (Eds.), The handbook of sexuality in close relationships (pp. 519–544). Mahwah, NJ: Lawrence Erlbaum. Oakley, D. & Bogue, E. (1995). Quality of condom use as reported by female clients of a family planning clinic. The American Journal of Public Health, 85, 1526–1531. Pan, S. (2006). Transformations in the primary life cycle: The origins and nature of China’s sexual revolution. In E. Jeffreys (Ed.), Sex and sexuality in China (pp. 21–42). New York: Routledge. Qian, H. Z., Vermund, S. H., & Wang, N. (2005). Risk of HIV/AIDS in China: subpopulations of special importance. Sexually Transmitted Infections, 81(6), 442–447. Redding, C. A., & Rossi, J. S. (1999). Testing a model of situational self-efficacy for safer

sex among college students: Stage of change and gender-based differences. Psychology and Health, 14, 467–486. Ross, M. W. (1988). Personality factors that differentiate homosexual men with positive and negative attitudes towards condoms. Journal of Sex Research, 4, 411–433. Sheeran, P., Abraham, C., & Orbell, S. (1999). Psychosocial correlatesofheterosexual condom use: A meta-analysis. Psychology Bulletin,125(1), 90–132. Thompson, D. (2005). China confronts HIV/ AIDS. Washington, DC: Population Reference Bureau. Tucker, J. D., Henderson, G. E., Wang, T., Huang, Y., Parish, W., Pan, S. . . . Cohen, M. S. (2005). Surplus men, sex work, and the spread of HIV in China. AIDS, 19, 539– 547. Wingood, G. M., & DiClemente, R. J. (1998). Partner influences and gender-related factors associated with noncondom use among young adult African American women. American Journal of Community Psychology, 26, 29–51. Xiao, Z. W. (2012). Correlates of condom use among Chinese college students in Hunan Province. AIDS Education & Prevention, 24(5), 469–482. Xiao, Z. W., Li, X., Liu, Y., Li, S., & Jiang, S. (2013). Sexual communication and condom use among Chinese men who have sex with men in Beijing. Psychology, Health, & Medicine, 18(1), 98–106. Yang, H., Li, X., Stanton, B., Fang, X., Zhao, R., Dong, B., ... Hong, Y. (2005). Condom use among female sex workers in China: Role of gatekeepers. Sexually Transmitted Diseases, 32(9), 572–580. Yang, T., Wang, W., Abdullah, A., Beard, J., Cao, C., & Shen, M. (2009). HIV/AIDS-related sexual risk behaviors in male rural-to-urnan migrants in China. Social Behavior & Personality, 37(3), 419–432. Zamboni, B. D., Crawford, I., & Williams, P. G. (2000). Examine communication and assertiveness as predictors of condom use: Implications for HIV prevention. AIDS Education and Prevention, 12(6), 492–504. Zhang, L., Li, X., Shah, I., Baldwin, W., & Stanton, B. (2007). Parent–adolescent sex communication in China. European Journal of Contraception and Reproductive Health Care, 12(2), 138–147. Zhao, R., Wang, B., Fang, X., Li, X., & Stanton, B. (2008). Condom use and self-efficacy among female sex workers with steady partners in China. AIDS Care, 20(7), 782–790.

Copyright of AIDS Education & Prevention is the property of Guilford Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Sexual communication, safer sex self-efficacy, and condom use among young Chinese migrants in Beijing, China.

Mediation effect of sexual communication on the relationship between safer sex self-efficacy and condom use was tested among 307 homosexually active m...
480KB Sizes 0 Downloads 0 Views