JADACK, ROSEMARY A. PhD, RN*†; FRESIA, ANNE BS‡; ROMPALO, ANNE M. MD‡§; ZENILMAN, JONATHAN MD‡§
A MAJOR FOCUS of sexually transmitted disease (STD) prevention programs is to increase condom use among sexually active people.1 Nevertheless, many people at high risk for STD continue to report inconsistent or no condom use.2 Although much research has evaluated the characteristics of condom users and nonusers, the reasons for inconsistent condom use in at‐risk populations are not well understood. Focusing on reasons for inconsistent condom use from the point of view of people at risk may be important in furthering the development of effective prevention interventions. Therefore, the purpose of this analysis was to ascertain what at‐risk people who present to STD clinics identify as reasons for unprotected sex.
Self‐reported reasons for not using condoms have been addressed in the literature, and several reasons have been reported. These include the belief that the respondent knew a partner's history,3,4 because another form of birth control was being used,4,5 the belief that condoms limit sexual pleasure and enjoyment,6,7 and trust in the partner.6,8 Other reasons for not using condoms include the inaccessibility of condoms,8–11 partner dislike of condoms,12,13 and personal condom dislike.7,12,14
Most of the studies just reviewed are the result of research that has predominantly used college students, adolescent samples, and samples of homosexual men. Few studies address reasons for not using condoms among young, urban adults attending STD clinics who are a population at high risk for heterosexual STD and human immunodeficiency virus transmission.15,16 The purpose of this study was to explore reasons for not using condoms among people presenting for care at inner‐city STD clinics. The following research questions were addressed:
1. What reasons do at‐risk sexually active people give for failing to use condoms during sexual activity?
2. Are there gender differences in reasons for failing to use condoms?
3. Are reasons that people give for not using condoms related to consistency of condom use?
4. Are reasons that people give for not using condoms related to beliefs about condoms?
Setting and Sample
Participants for this analysis were drawn from a larger prospective study of behavioral aspects of condom use and STD conducted at two Baltimore City Health Department STD clinics, and have been previously described.17 These clinics serve approximately 20,000 individual patients at 35,000 visits annually. Baltimore is a gonorrhea epicenter; about half of all gonorrhea cases in the city are identified in these clinics.18 In 1992, over 18,000 human immunodeficiency virus tests were performed, and the seroprevalence rate was 4%.
The data presented here are from a second wave of baseline data collection in which a series of open‐ended questions were used to address issues related to condom use. Participants who presented for evaluation of a new clinical problem or for a check‐up, or had been referred as a sexual contact to an individual with an STD, were systematically recruited from the clinic registration rosters. Overall, 61.4% of eligible participants agreed to enroll. Most common reasons for refusal included work commitments, fear of needles, no desire for additional swabs, and plans to move out of the area. Participants were selected for the current analysis if, at baseline, they reported that at least 1 of their last 10 episodes of sexual activity was unprotected.
After obtaining written, informed consent, each participant received a baseline face‐to‐face interview administered by one of two dedicated study interviewers. Questions used for this analysis were part of the larger survey, and consisted of open‐ and closed‐ended questions that assessed self‐reported condom use, beliefs related to condom use, and reasons for not using condoms. After the interview, clients received a directed physical examination and a comprehensive laboratory evaluation for STD.
Self‐Reported Condom Use. A calendar instrument corresponding to the 30‐day period before the clinic visit was used to collect information about sexual activity and condom use, and has been described previously.17,19 Study participants provided partner‐specific information on which days they had engaged in sexual activity, the type of sexual activity (vaginal, oral, or anal), the number of episodes of each type of sex on each day, and whether a condom was used for each sexual encounter. From these data, a trichotomized variable of condom use was created. The three categories of condom use included: used condoms all the time in the previous month, used condoms sometimes in the previous month, and did not use condoms during the previous month. Finally, a variable was created from the calendar that represented percentage condom use during the past 30 days.
Beliefs Related to Condom Use. Two behavioral concepts related to condom use were measured. These included condom self‐efficacy and perceived barriers related to condom use.
Condom Self‐Efficacy. Condom self‐efficacy was measured with a 10‐item scale designed for this study. Respondents were asked how able they felt they were to initiate and engage in condom behaviors. Behaviors included going to store and buying condoms, going to clinic and getting free condoms, putting a condom on correctly, making sure a partner uses a condom correctly, talking to friends about condoms, talking to sex partners (regular and new) about using condoms, persuading sex partners (regular and new) to use condoms, and ability to refrain from having sex if partner refuses to use a condom. Items on this scale had values ranging from 1 to 3, with 3 indicating greater perceived personal control. Cronbach's alpha for this scale was 0.74.
Barriers Related to Condom Use. Barriers to condom use were measured with a 12‐item scale. Content validity was established by a panel of clinicians and behavioral scientists. The scale includes five items related to physical sensation (e.g., sex with condoms does not feel natural, sex does not feel as good when you use a condom), five items related to partner barriers (e.g., my partner would not like it if I had a condom with me, my sex partner would break up with me if I said we should use a condom), and two items related to disease prevention (e.g., condoms prevent disease/infection, condoms protect against the virus that causes AIDS). For each statement, respondents indicate on a five‐point scale to what extent they agree with each item (1 = strongly disagree, 5 = strongly agree). Items are summed for each subscale. Cronbach's alphas for this sample were 0.65 for physical barriers, 0.71 for partner barriers, and 0.73 for the disease prevention subscale.
Reasons for Not Using Condoms. Participants responded to an open‐ended question that asked, “When you have sex without using a condom, what is the main reason why you don't use one?” Responses were written verbatim on the questionnaire.
Content analysis was used to analyze responses to the open‐ended reason for not using condoms question.20 First, responses to the open‐ended question were written on index cards. Next, the index cards were sorted into categories that shared similar themes. These categories were named and defined. Finally, an independent rater resorted the index cards into the named categories. The group of coders met to discuss difficulties with coding and revised the coding categories.
Once the categories were revised, two independent raters coded the cards using the revised categories. The percentage agreement between the two raters was 92%. Five reasons were uncodable. Once the data were coded, frequencies of responses were computed.
The Mantel‐Haenzel chi‐square was used with categorical variables and the student's t test and analysis of variance was used with continuous variables to evaluate factors associated with reasons for not using condoms during the last occurrence of unprotected intercourse.
Participants were 260 male and female clients; most presented for evaluation of symptoms (61.9%), for a check‐up (29.6%), or as a sexual contact of another patient (5.0%). There were 163 (62.7%) men and 97 (37.3%) women; their average age was 30.2 years (SD = 10.5 years; Table 1). Most respondents were African American (84.2%) and single (76.9%). There were no significant demographic differences between participants attending the two clinics17; the demographic characteristics of the sample were representative of overall clinic attendance.
Reasons for Not Using Condoms
Reasons given for not using condoms during sexual activity are shown in Table 2. The content analysis revealed six major areas of reasons. The first category of reasons was related to partner relationships (45.0%). The most frequently given reason in this category related to trust in the partner (19.6%). The next three most frequently cited reasons for not using condoms in this category were related to the nature of the sexual relationship with the partner (referring to the partner as a “main,” long‐time, or only partner).
The second category of reasons was related to sexual sensation (18.5%). Reasons in this category related to whether participants and their partners liked the feel, fit, or sensation related to condom use. In this category, 31 (11.9%) of the respondents stated that sex felt better without a condom.
The third category of reasons (39 respondents; 15.0%) related to situational constraints. These constraints included condom availability at the time of intercourse, as well as the spontaneous nature of the situation leading up to unprotected intercourse.
Only 12 (4.6%) people stated reasons related to perceptions about condom products. In this category, four (1.5%) people gave reasons related to condom fit, and three (1.2%) stated condom breakage as a reason not to use condoms. Few people (3.8%) related reasons of wanting to get pregnant or being on other forms of contraception. Finally, 16 (6.2%) people simply could not give a reason for not using condoms, and stated that they did not know why they did not use a condom.
Reasons for Not Using Condoms and Gender
Gender was compared with condom reason categories and the six most frequently cited reasons for not using condoms (Table 2). Overall, significant gender differences in condom reason categories emerged [χ2(6, N = 255) = 13.0, P < 0.05]. Individual chi‐square analyses showed that more men (22.7%) than women (11.3%) reported reasons related to sexual sensation. More women (7.2%) than men (1.8%) reported reasons with regard to pregnancy.
When examining the six most frequently cited reasons, two significant gender differences emerged. Women were more likely to state that they did not know why they did not use a condom [χ2(1, N = 260) = 7.2, P < 0.01]. Men were more likely to state that they did not use condoms because they believed that sex felt better without a condom [χ2(1, N = 260) = 6.8, P < 0.01].
Reasons for Not Using Condoms and Consistency of Condom Use
Condom use data were available for the 30 days before the clinic visit. Overall, 219 (84.2%) people reported an episode of sexual activity in the previous 30 days. All but 20 people (n = 199) reported vaginal‐penile sexual activity and completed the calendar; of these, 18 (9.0%) reported using condoms for each episode of intercourse, 47 (23.6%) reported using condoms sometimes, and 134 (51.5%) reported never using condoms in the previous month. These results are similar to the self‐reported condom use of other samples drawn from these clinics. 17 There were no gender differences. Percentage of self‐reported condom use was also computed. Overall, respondents reported using condoms an average of 17.0% of the time in the past month.
Table 3 compares data for condom use and reasons for not using condoms for the 194 people who gave codable reasons for not using condoms and completed calendar data. There were significantly different reports of condom use by type of reported reason [F(6, 187) = 3.67, P < 0.01]. People who reported reasons related to type of sexual activity and people who reported reasons related to situational constraints used condoms most consistently in the past month. Conversely, people who cited reasons related to condoms (breakage, fit) reported using condoms least, only 2.4% of the time.
Reasons for Not Using Condoms and Condom Self‐Efficacy
Overall, participants reported a moderately high level of perceived condom self‐efficacy. Of a possible score of 30, participants had a mean score of 28.3 (SD = 2.5). There were no gender differences in reported condom self‐efficacy. There were no significant differences between condom self‐efficacy and condom use. However, the relationship between condom self‐efficacy and reasons for not using condoms approached significance [F(6,241) = 2.0, P = 0.06]. People who did not know why they did not use a condom had the lowest level of self‐efficacy, whereas people who did not use condoms because of pregnancy/contraceptive and partner relationship reasons had the highest levels of condom self‐efficacy. However, the means ranged from 27.0 to 28.7, reflecting high levels of self‐efficacy across groups.
Reasons for Not Using Condoms and Barriers to Condom Use
Overall, people reported beliefs that posed barriers to their condom use. Three aspects of condom barriers were measured: beliefs related to disease prevention, beliefs related to partners, and beliefs related to condom sensation. Overall, people tended to believe that condom use helps prevent the transmission of STD. Of a possible range of scores from 2 to 10, where 2 represents few disease‐related barriers, respondents reported a mean score of 3.84 (SD = 1.63). Of a possible score of 25, where 25 represents a high level of perceived barriers, respondents gave a mean score of 11.88 (SD = 3.39) with respect to partner barriers (e.g., partner would be angry if a condom was used, partner would not like it if I had a condom with me). Further, of a possible score of 25, respondents gave a mean score of 15.32 (SD = 3.18) with respect to barriers related to sexual sensation (e.g., sex with a condom does not feel natural, sex does not feel as good with a condom). There was one gender difference. Men had a significantly higher score on the sexual sensation barrier subscale than women [F(1, 255) = 14.65; P < 0.01]. There were no significant correlations between scores on the barrier subscales and condom use.
Finally, beliefs about condom barriers were compared to reasons for not using condoms (Table 3). Overall, there was no significant difference between reasons for not using condoms and disease prevention barriers. There was, however, a significant difference between reasons for not using condoms and partner barriers [F(6, 245) = 2.42; P < 0.05]. Inspection of the means shows that people who gave reasons related to condoms (e.g., breakage, fit) gave higher partner barrier scores (e.g., partner does not like condoms, partner would be angry to use a condom). Further, there was a significant difference between reasons for not using condoms and physical sensation barriers [F(6,245) = 2.21, P < 0.05].
This research provides insight into ideas about sexual risk‐taking in young, urban adults. When asked to communicate why condoms are not used, most respondents cite trust in partner. The frequency of trust as a reason not to use condoms confirms findings in other studies among homosexual men,14 and raises serious concerns. It is dangerous to assume that one's sexual partner will be up‐front if the possibility of an STD exists, especially in light of research that indicates that people often have difficulty disclosing the existence of STD.21 Furthermore, placing trust in a partner may dilute personal responsibility with respect to STD prevention.22
Another frequent group of reasons for not using condoms is related to the nature of the sexual relationship. For example, people frequently state that they do not use a condom because the partner is either their only partner, or their “main” partner. The issue of an “only” partner versus a “main” or “regular” partner provides interesting insight into how people define their relationships, and suggests implications for intervention. When assessing sexual behavior of clients, clinicians and researchers need to be sensitive to how people characterize their relationships, and that clients may consider themselves safe with a well known partner even if both partners are not necessarily monogamous.
The issue of condom availability was a reason given by 11.5% of the respondents. Interestingly, these people were the most consistent in their overall condom use in the past month. Although inexpensive and free condoms are widely available in the area where the respondents live, these condoms may not be readily available at the time of intimacy. This issue of availability presents a challenge to prevention efforts. Although strides have been made to make condoms available and visible, interventions may be needed to stress the importance of consistent availability at the time of intercourse.
There were few gender differences with respect to condom nonuse reasons. Most notably, men were more apt to give reasons related to condom dislike with respect to sexual arousal and feeling. This finding supports other researchers who have found that men tend to have more negative attitudes about condom use.13 These people tended to use condoms only 12% of the time in the past 30 days. Innovative strategies are needed to promote condom use among those who have negative attitudes about condoms. Programs that show promise include those that eroticize condoms and promote the positive aspects of condom use.23
There is limited generalizability of these results because of the small sample size and the fact that the respondents were actually attending an STD clinic. Therefore, they may represent a group of people who are at higher risk for STD and engage in more risky behaviors than the general inner‐city population. However, this sample represents a cross‐section of people who are at highest risk for STD and are the very people that clinicians see daily in STD clinics. Although an appropriate central focus of STD prevention efforts continues to be to promote and encourage the positive aspects of condom use, it is also important to explore the reasons and rationale that clients give for electing not to use condoms. It is vital to examine and understand the context from which people who acquire STD live their lives, the framework from which people make decisions about condom use, and target interventions accordingly.
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