UNIVERSIDADE DE LISBOA
FACULDADE DE PSICOLOGIA
UNIVERSIDADE DE COIMBRA
FACULDADE DE PSICOLOGIA E CIÊNCIAS
DA EDUCAÇÃO
CONDOM USE AMONG HETEROSEXUAL YOUNG MEN:
AN EXAMINATION OF VOLITIONAL PREDICTORS AND A STAGE-BASED
INTERVENTION
PROGRAMA DE DOUTORAMENTO EM PSICOLOGIA
(PSICOLOGIA DA EDUCAÇÃO)
TELMA ANDREIA DE SOUSA CARVALHO
TESE ORIENTADA PELA PROFESSORA DOUTORA MARIA JOÃO ALVAREZ,
ESPECIALMENTE ELABORADA PARA A OBTENÇÃO DO GRAU DE DOUTOR
2015
Ao António, my love
Agradecimentos
Este grande capítulo da minha história ensinou-me “na pele” o verdadeiro significado
de perseverança. Mas este caminho, não seria possível sem as pessoas que somam a minha
vida, que trazem mundo até mim, que de uma forma tão generosa me apoiam, me escutam,
me dão paciência, tempo, ânimo, mimo, coragem, força, silêncio e luz.
Em primeiro lugar, à minha orientadora, Professora Doutora Maria João Alvarez o
agradecimento que tenho a fazer-lhe não cabe nestas linhas, nem tão pouco se reflete em
palavras apenas… mas aqui fica um muito obrigado pelo seu carinho e apoio incondicional
em todos os momentos da minha vida nos últimos anos. Pelo exemplo de verdadeiro
profissionalismo e de inesquecível dedicação, pela sabedoria otimismo e criatividade que
tem sido, por todos os ensinamentos, rigor e exigência que me fizeram crescer pessoal e
profissionalmente. Pelo tanto que me ensinou e me ajudou a crescer neste caminho sintome feliz e honrada que tenha entrado desta forma na minha vida.
I would like to thank Professor Ralf Schwarzer, who has shown huge availability and
generosity towards me since my first visit to Berlin. Many thanks first of all for helping me
define my project and for accompanying my work over the years, and for having taught me
so many important things about research. Thank you for all your support over these long
years. It means a lot to me. I really admire your intelligence, wisdom and humanity.
Um obrigado especial à Professora Alexandra Marques Pinto que me permitiu contar
com a sua enorme experiência e conhecimento, que foram determinantes nas decisões
importantes deste projeto. Ao Professor Cícero Pereira, por me ajudar nas questões
i
estatísticas.
Agradeço
ainda
à
coordenação
do
Programa
de
Doutoramento
Interuniversitário e aos seus professores.
Gostaria ainda de agradecer ao grupo de colegas que fazem parte dos seminários de
doutoramento e que contribuíram com inúmeras propostas de melhoria ao meu trabalho. À
Susana Ramalho agradeço todo o mimo e partilha ao longo destes anos.
À Cristina Godinho, uma das pessoas que este doutoramento me trouxe e a quem
agradeço pela ajuda, primeiro no Qualtrics e depois de forma constante, e por todos os
reforços e incentivos.
Ao David Ralo pela indispensável ajuda na programação do questionário. À minha
prima Daniela a preciosa ajuda e incentivo. À Tânia Gregg por rever o meu inglês.
Ao CENFIM por contribuir para a minha constante formação, pela possibilidade que,
ao longo destes anos, me proporcionou para conciliar da melhor forma trabalho com
estudo. Um agradecimento especial à minha agora diretora, mas à pessoa que a Dra.
Alexandra Pousada é para mim, aquela pessoa que tem sempre a serenidade e o conselho
que me acalma o coração e a mente. Aos meus colegas Amélia e Pedro, por aturarem os
meus desabafos e terem agarrado as pontas quando as deixei mais soltas. À Edite que
entrou recentemente na minha vida mas que ocupa um lugar muito especial no meu
coração e que com o seu otimismo e generosidade me ajuda no trabalho com os jovens.
Um agradecimento especial aos jovens formandos, que
participaram no
preenchimento dos questionários. São vocês que foram o meu motor inicial e que dão
sentido a este trabalho!
ii
Agradeço também às outras instituições que permitiram a recolha dos dados, à Casa
do Gaiato, CINEL e Casa Pia.
Ao meu núcleo duro dos afetos, aqueles que estão sempre lá para nós, às amigas do
coração que tantas vezes aturaram os meus desabafos, as minhas frustrações e
transformaram-nos em momentos fantásticos que dão outra cor à vida. Quem tem
verdadeiros amigos, tem tudo!
Aos meus pais e irmão que são o meu “porto seguro”, que me fazem perceber que
quem tem as pessoas certas do lado esquerdo do peito, quando temos um amor
incondicional para a vida inteira, tem tudo.
Ao meu LOVE, (António) sem ti e sem a tua energia e o otimismo, este doutoramento
não seria possível. Contigo aprendo todos os dias o verdadeiro significado de resiliência isto
porque lutar, como só tu lutas, exige muitas vezes a força sobrenatural de nos mantermos
firmes às nossas crenças, desejos e propósitos, mesmo quando tudo à volta nos diz que é
muito difícil. Nós lutamos juntos e vamos continuar a lutar para concretizar “os nossos”
sonhos. Ao meu querido Afonso por nas alturas certas conseguir fazer pouco barulho para
eu me concentrar e à minha Mel, minha companhia incondicional de quatro patas.
iii
iv
Resumo
O uso consistente do preservativo entre jovens adultos sexualmente ativos é de suma
importância para a saúde sexual, sendo o método mais eficiente e disponível para reduzir a
transmissão sexual do VIH e de outras infeções sexualmente transmissíveis (IST’s). Apesar
dos avanços nos programas de prevenção de ISTs e promoção do uso do preservativo em
jovens adultos, os preservativos são utlizados ainda com pouca frequência e de forma
inconsistente (Alvarez & Garcia-Marques, 2008; Reis, Ramiro, Matos, & Dinis, 2013). A
inconsistência no uso deste comportamento protetor traz graves consequências para a
saúde, sendo uma delas ilustrado pelo número de 1089 pessoas infetadas em 2013 com o
VIH em Portugal, sendo 70.7% dos quais homens com idades compreendidas entre os 32 e
os 51 anos, indicando que alguns destes foram infetados durante a sua juventude (CVEDT,
2013).
O não uso de preservativo como causa do elevado número de jovens adultos infetados
com IST’s permanece até hoje como um problema de saúde pública e implica a necessidade
de mudanças nas estratégias de prevenção direcionadas a essa população. A idade adulta
emergente é um estádio de desenvolvimento que inclui os indivíduos entre 18 a 25 anos
(Tanner, Arnett, & Leis, 2009). Neste período de transição, podem ocorrer inúmeras
oportunidades de comportamentos sexuais de risco devido, sobretudo, à falta de
informação em relação à prevenção de ISTs (Ramiro et al., 2014) e à existência de múltiplos
parceiros sexuais sem o uso de proteção consistente, o que pode influenciar trajetórias da
saúde sexual ao longo da vida (Meier & Allen 2008).
v
O principal objetivo dos estudos realizados no âmbito desta dissertação foi o de
identificar os mecanismos pelos quais determinados preditores sociocognitivos afetam o
uso do preservativo, avaliando a sua importância na promoção deste comportamento.
Defendemos que as teorias psicológicas de mudança de comportamentos de saúde podem
ajudar a discriminar esses mecanismos e a fornecer mais informações sobre o
desenvolvimento de intervenções educacionais eficazes, contribuindo para aumentar as
possibilidades de alcançar o objetivo principal, isto é, o uso consistente do preservativo.
Investigações anteriores têm atestado a relevância dos preditores psicossociais para a
explicação de diferentes comportamentos de saúde, incluindo o uso do preservativo
(Sheeran, Abraham, & Orbell, 1999). Contudo, a motivação, por si só, não é suficiente para a
mudança de comportamento, sendo necessários processos de autorregulação para
transformar a motivação em ação. Por esta razão, mais recentemente, os fatores volitivos,
isto é, os fatores que ajudam os indivíduos a comprometer-se na prossecução dos objetivos
estabelecidos, passando da intenção à ação, têm sido estudados na tentativa de
compreender os processos de autorregulação envolvidos no comportamento de uso do
preservativo (Teng & Mak, 2011).
Os estudos realizados sustentam-se no modelo do Health Action Process Approach
(HAPA; Schwarzer, 2008), o qual inclui explicitamente processos volitivos para além dos
processos motivacionais, sendo considerado um modelo híbrido, uma vez poder ser
utilizado na sua versão contínua (Capítulos 2 e 3) ou como um modelo por estádios
(Capítulo 4), dependendo do objetivo de prever as mudanças de comportamento ou o
desenvolvimento de intervenções (Schwarzer, 2008a). Na sua versão por estádios, o modelo
vi
sustenta que o processo de mudança pode ser subdividido em três etapas ou estádios
psicológicos, qualitativamente distintos, ao longo dos quais os indivíduos progridem até ser
bem-sucedidos e conseguir manter as mudanças desejadas. O primeiro estádio, não
intencional, diz respeito aos indivíduos que não realizaram a mudança, nem estão ainda
motivados para o fazer, o segundo estádio, intencional, corresponde aos indivíduos que,
apesar de ainda não terem realizado a mudança, encontram-se já motivados (i.e., com
intenção) para o fazer e, por último, o terceiro estádio, de ação, engloba os indivíduos que
já conseguiram realizar a mudança desejada. Uma premissa comum aos modelos por
estádios é a de que as intervenções serão mais eficazes quando adequadas ao estádio de
mudança em que o indivíduo se encontra (Weinstein, Rothman, & Sutton, 1998). De facto,
têm sido encontrados bons resultados das intervenções adaptadas aos estádios de mudança
(Noar, Benac, & Harris, 2007) e os diferentes conjuntos de preditores do modelo HAPA têmse mostrado importantes para as diferentes transições entre estádios (Schuz, Wiedemann,
Mallach, & Scholz, 2009).
Nesta dissertação foram realizados três estudos empíricos, descritos em três capítulos,
com jovens adultos masculinos entre os 18 e os 25 anos e as hipóteses formuladas
alicerçaram-se no modelo HAPA (Schwarzer, 2008). No estudo longitudinal (N = 150)
apresentado no Capítulo 2, investigou-se a utilidade teórica do modelo para o uso do
preservativo e verificou-se que comportamentos preparatórios, como comprar o
preservativo e trazê-lo consigo, desempenham um papel mediador entre motivação e ação.
As expectativas de resultados positivos foram determinantes das intenções de usar o
preservativo e mostraram-se responsáveis por 44% da sua variância. Para além disso, as
vii
intenções e as crenças otimistas sobre a capacidade pessoal para lidar com possíveis
obstáculos que possam surgir durante o envolvimento no comportamento (autoeficácia de
manutenção)
foram
determinantes
para
o
desempenho
dos
comportamentos
preparatórios. Sem o comportamento passado, os construtos sociocognitivos considerados
permitiram explicar 40% da variabilidade no uso do preservativo. No estudo longitudinal (N
= 203) apresentado no Capítulo 3, demonstrou-se serem os comportamentos preparatórios
o único preditor e o mais próximo do uso do preservativo, estudando-o em articulação com
outras variáveis autorregulatórias, como o planeamento de ação e de coping e a
autoeficácia volitiva, na passagem da intenção de usar ao uso do preservativo. Estas
variáveis volitivas mostraram ser preditoras dos comportamentos preparatórios e, em
conjunto com o comportamento passado, explicaram 32% da variância do uso do
preservativo. No Capítulo 4, apresentou-se um estudo experimental e longitudinal (N = 159)
que teve como principal objetivo testar duas intervenções realizadas por computador,
adaptadas a dois estádios de mudança preconizados pelo HAPA, isto é, a indivíduos com
pouca motivação para usar preservativo ou já com intenção, mas ainda sem o utilizarem de
forma consistente. No estudo foi analisado se a intenção de usar preservativo e o seu uso
foram influenciados pelo tratamento psicológico direcionado para os aspetos motivacionais
ou volitivos, de acordo com o estádio em que os participantes se encontravam. Assim, de
acordo com o HAPA, foi postulado que indivíduos “sem intenção” beneficiariam de uma
intervenção motivacional que ajudasse a antecipar resultados positivos que podiam
decorrer da mudança, i.e. estimulasse o pensamento sobre os benefícios da adoção do
comportamento (expectativas de resultados positivos) e fortalecesse a crença de que o
indivíduo seria capaz de iniciar a mudança pretendida (autoeficácia), a qual se esperou
viii
aumentar a intenção de uso do preservativo. Já para os indivíduos “com intenção” postulouse que beneficiariam de uma intervenção volitiva focada no planeamento da mudança,
nomeadamente no quando, com quem e onde usar preservativo (planeamento de ação) e
no planeamento de estratégias a utilizar no caso de surgirem barreiras à execução do plano
inicial (planeamento de coping), antecipando-se um aumento no uso do preservativo. De
acordo com as hipóteses formuladas, os indivíduos “sem intenção” apresentaram níveis
mais elevados de intenção de usar o preservativo duas semanas após a intervenção e
relataram usar mais o preservativo, um mês depois, em comparação com os indivíduos
“sem intenção” na condição de controlo. Do mesmo modo, os indivíduos “com intenção”
relataram níveis mais elevados no uso do preservativo quatro semanas após a intervenção
comparativamente aos indivíduos da condição controlo. Foi, assim, mostrado que não só os
indivíduos “sem intenção” aumentaram os níveis de intenção de uso do preservativo, mas
também, os indivíduos “sem intenção” e “com intenção” aumentaram os níveis de uso do
preservativo, avaliado por autorrelato.
A investigação apresentada nesta tese pretende contribuir para aprofundar o
conhecimento em torno dos processos psicológicos envolvidos no uso do preservativo. O
seu principal contributo teórico reside sobretudo no estudo dos comportamentos
preparatórios para o uso do preservativo em homens jovens heterossexuais, contribuindo
para o atual debate sobre a importância dos fatores volitivos na mudança de
comportamentos de saúde. Os resultados contribuem para a compreensão do papel dos
comportamentos preparatórios no hiato entre o planeamento e o comportamento. Tendo o
modelo HAPA uma arquitetura aberta (Schwarzer & Luszczynska, in press), pode esperar-se
ix
encontrar alterações ao modelo original. No caso presente, tal manifestou-se através da
análise da relevância dos comportamentos preparatórios, mostrando como estes
contribuem, em conjunto com outras variáveis volitivas, tais como o planeamento de ação e
de coping e a autoeficácia volitiva, para a transformação das intenções comportamentais
em utilização do preservativo. A compreensão dos mecanismos presentes nos
comportamentos sexuais mais seguros são um importante contributo para
o
desenvolvimento e avaliação de intervenções educacionais destinadas a aumentar o uso de
preservativo entre os jovens adultos. Intervenções educacionais devem, portanto, prestar
especial atenção aos comportamentos de preparação para o uso do preservativo e facilitar a
sua ocorrência entre os jovens adultos. A nível aplicado, o desenho de uma intervenção
breve realizada por computador, adaptada aos estádios de mudança, eficaz na promoção de
mudanças na intenção e no uso do preservativo, contribui para novas opções com vista a
mudanças mais efetivas em comportamentos de saúde. Estes resultados têm implicações
importantes para iniciativas de educação para a saúde que pretendam utilizar uma
intervenção através de computador destinada a indivíduos num determinado estádio de
preparação para a mudança, com vista a promover o uso do preservativo.
Esperamos que este trabalho permita uma melhor articulação entre a teoria e a prática
da educação para a saúde e estimule intervenções eficazes que ajudem a reduzir o número
de jovens infetados com ISTs, e em especial VIH, inspirando investigações futuras.
Palavras-chave: jovens adultos; uso do preservativo; estádios de mudança; intervenção
por computador; comportamentos preparatórios; prevenção do VIH.
x
Abstract
Consistent condom use among sexually active individuals, particularly young adults, is of
paramount importance for sexual health. The central aim of this dissertation was to identify
the relevant mechanism by which key psychological antecedents affect male condom use, in
addition to contributing to the design of educational interventions and evaluating their
effectiveness in the promotion of this behaviour. Three on-screen studies were conducted
with samples of heterosexual young men, assessed by a self-report questionnaire, and
which are described in three chapters. The theoretical underpinning of the hypotheses was
based on the Health Action Process Approach (Schwarzer, 2008), and on the potential of
computer-delivered interventions to provide tailored health education treatment to boost
condom use. The study described in Chapter 2 (N = 150) provided confirmation of the
mediating role of preparatory behaviours as a volitional factor between intention and
condom use within the HAPA framework. The study described in Chapter 3 (N = 203)
demonstrated the contribution of preparatory behaviours, added to the set of volitional
variables of the HAPA model (volitional self-efficacy, action planning and coping planning). It
particularly revealed how these variables sequentially mediated the relationship between
intention and condom use, serving to bridge the intention-behaviour gap, and further
revealing that preparatory behaviours were the more proximal volitional predictors of
condom use. Chapter 4 (N = 159) highlighted the proof that a brief computer intervention
would be useful in the promotion of condom use adapted to the stages of change,
envisioned by the HAPA, both for individuals with little motivation and those already
intending to use condoms. The contributions support the use of psychological theories for
xi
the development of health education interventions by revealing the mechanisms involved in
condom use, placing the focus on the planning-behaviour gap.
Keywords: young adults; condom use; stages of change; computer-delivered interventions;
preparatory behaviours; HIV prevention.
xii
Table of Contents
Resumo ............................................................................................................................. v
Abstract ........................................................................................................................... xi
Table of Contents ........................................................................................................... xiii
Index of Tables ...............................................................................................................xvii
Index of Figures ...............................................................................................................xix
Chapter 1: Introduction ........................................................................................................ 3
1. Condom Historical Roots ............................................................................................... 6
2. Sexually Transmitted Infections and Condom Use ...................................................... 13
2.1 Inconsistent condom use among young adults ....................................................... 19
2.2 Barriers to condom use .......................................................................................... 23
3. Predictors of Condom Use........................................................................................... 25
3.1 Social-demographic predictors ............................................................................... 26
3.2. Contextual psychosocial predictors ....................................................................... 29
3.3 Individual psychosocial predictors .......................................................................... 31
4. Condom Use Promotion .............................................................................................. 34
4.1 Social cognitive models of health behaviour change............................................... 36
4.2 The Health Action Process Approach (HAPA) .......................................................... 41
4.3 Computer-targeted stage intervention ................................................................... 47
5. Overview of the empirical studies .............................................................................. 50
Chapter 2: Preparatory Behavior For Condom Use Among Heterosexual Young Men: A
Longitudinal Mediation Model ........................................................................................... 55
1. Abstract ....................................................................................................................... 57
2. Introduction ................................................................................................................ 59
Sexual risk behavior and condom use........................................................................... 59
The health action process approach (HAPA) ................................................................. 60
Predictors of condom use: The role of preparatory behaviors ...................................... 63
Aims of the study ......................................................................................................... 64
3. Method ....................................................................................................................... 65
Participants and Procedure .......................................................................................... 65
Measures ..................................................................................................................... 66
xiii
Data analysis ................................................................................................................ 67
4. Results......................................................................................................................... 68
Drop-out analysis ......................................................................................................... 68
Preliminary Analysis ..................................................................................................... 68
Main Results ................................................................................................................ 68
5. Discussion ................................................................................................................... 71
Chapter 3: Preparing For Male Condom Use: The Importance Of Volitional Predictors ..... 75
1. Abstract ....................................................................................................................... 77
2. Introduction ................................................................................................................ 79
The Health Action Process Approach (HAPA) ................................................................ 80
Aims of the present study ............................................................................................ 84
3. Method ....................................................................................................................... 86
Participants and Procedure .......................................................................................... 86
Measures ..................................................................................................................... 87
Data Analysis................................................................................................................ 90
4. Results......................................................................................................................... 92
Dropout Analysis .......................................................................................................... 92
Confirmatory Factor Analysis ....................................................................................... 92
Descriptive statistics .................................................................................................... 93
Mediational Analyses ................................................................................................... 94
5. Discussion ................................................................................................................... 97
Chapter 4: Stage-Based Computer-Delivered Interventions To Increase Condom Use In
Young Men ....................................................................................................................... 101
1. Abstract ..................................................................................................................... 103
2. Introduction .............................................................................................................. 105
Interventions ............................................................................................................. 106
Computer-delivered stage-based interventions ......................................................... 107
Aims and hypotheses ................................................................................................. 109
3. Method ..................................................................................................................... 110
Participants ................................................................................................................ 110
Measures ................................................................................................................... 110
xiv
Procedure .................................................................................................................. 111
Intervention ............................................................................................................... 112
Analytical Procedures ................................................................................................. 114
4. Results....................................................................................................................... 114
Motivational intervention for non-intenders .............................................................. 115
Volitional intervention for intenders .......................................................................... 116
5. Discussion ................................................................................................................. 117
Chapter 5: General Discussion .......................................................................................... 121
1. Summary of Findings................................................................................................. 125
2. Discussion of the Findings and Main Implications .................................................... 126
3. Limitations and Future Directions ............................................................................. 134
4. Concluding Comments .............................................................................................. 138
References ........................................................................................................................ 141
Appendices ....................................................................................................................... 177
Appendix A. Questionnaire on Condom Use Among Young Portuguese Adults (Chapters
2 and 3) ......................................................................................................................... 179
Appendix B. Intervention ON- SCREEN (Chapters 4) ..................................................... 187
Motivational intervention for non-intenders .............................................................. 187
Volitional intervention for intenders .......................................................................... 189
xv
xvi
Index of Tables
Table 1. Correlations of latent variables. ............................................................................ 69
Table 2. Means, standard deviations and correlations of the latent variables ..................... 93
Table 3. Overall fit of the three models tested and comparisons between models ............. 94
Table 4. Decomposition of the effect of intention on condom use at Time 3,
controlling condom use at Time 1 .......................................................................... 96
Table 5. Means and (standard deviations) for intention and behavior in non-intenders ... 115
Table 6. Means and (standard deviations) for behavior in intenders ................................ 116
xvii
xviii
Index of Figures
Figure 1. The Health Action Process Approach (adapted from Schwarzer, 2008). ................ 43
Figure 2. Health Action Process Approach (HAPA) Model .................................................... 62
Figure 3. Structural equation model with standardized parameter estimates...................... 70
Figure 4. Model 1 with standardized coefficient estimates .................................................. 95
Figure 5. Flow diagram of participants .............................................................................. 112
Figure 6. Intention and behavior level for non-intenders in experimental and
control group ............................................................................................................. 116
Figure 7. Behavior level for intenders in experimental and control group.......................... 117
xix
1
INTRODUCTION
CHAPTER 1: INTRODUCTION
Introduction
Consistent condom use among sexually active individuals, particularly young adults, is
of paramount importance for sexual health. Nowadays, the concept of sexual health
corresponds to a broader way of thinking and acting actively in promoting rewarding,
informed and safe experiences in the field of sexuality of both sexes (WHO, 2006). In fact,
hardly anyone would deny the relevance of condom use as the single most efficient,
available method to reduce the sexual transmission of HIV and other sexually transmitted
infections (STIs) and some, the physical and psychological well-being it can provide. Despite
advances in prevention and promotion programs targeting increased condom use in young
adults, male condoms are still used infrequently and inconsistently (Alvarez & GarciaMarques, 2008; Reis et al., 2013). Such risk behaviour contributes to serious health
consequences, one of which is the estimated 1089 people who became newly infected in
2013 with HIV in Portugal, 70.7% of whom were men between the ages of 32 and 51 years,
which means that some were infected during their youth (CVEDT, 2013).
Unsafe sex is believed to be the second most important risk factor for disease,
disability and death in poor countries, and the ninth most important factor in developed
countries (WHO, 2001). Each year, an estimated 500 million people acquire one of four
sexually transmitted infections: chlamydia, gonorrhea, syphilis and trichomoniasis (WHO,
2013). The non-use or inconsistent use of condoms as a contributory factor in the high
number of STI infected young adults, is still a public health problem and therefore, calls for
changes in preventive strategies targeting this population. Emerging adulthood is a
3
CHAPTER 1: INTRODUCTION
recognized developmental stage that includes individuals between the ages of 18 to 25
years (Tanner, Arnett, & Leis, 2009). In this transition period, more opportunities for
vulnerability to risky sexual health outcomes may present themselves due to a lack of
information on STI prevention (Ramiro et al., 2014). In addition, there is greater likelihood of
young people being involved in risky sexual practices as they often have multiple partners,
without consistent protection, which may influence future paths in sexual health
throughout their life course (Meier & Allen 2008).
In this dissertation, the aim is to identify the relevant mechanism by which key
psychological antecedents affect condom use in addition to presenting the design of
educational interventions and evaluating their effectiveness in promoting this health
behaviour. The main focus will be to identify the mechanisms by which social cognitive
predictors affect condom use, and to evaluate their effectiveness in promoting this
behaviour. The perspective put forward in this dissertation is that psychological theories of
health behaviour change may help to refine such mechanisms and provide more
information on the development of effective educational interventions, thus contributing
towards an increase in the odds of attaining the ultimate goal, namely consistent condom
use.
This dissertation is organized into five chapters. The present chapter presents the
general background, an overview of different determinants related to condom use, and the
theoretical framework supporting our hypotheses. The following three chapters (Chapters 2,
3, and 4) are empirical chapters, based on published or submitted articles resulting from the
research developed. Following the empirical chapters, Chapter 5 provides a summary and
4
CHAPTER 1: INTRODUCTION
comprehensive discussion of the main findings, as well as their main contributions at both
theoretical and applied levels. It further draws conclusions as to their implications and
pinpoints issues that have yet to be addressed.
The following introduction begins by portraying the general background of this
research study. The first section focuses on the historical roots of the behaviour under study
in this dissertation: condom use. The second section starts by defining what may be
considered sexually transmitted infections and their link to condom use. The available data
regarding condom use in different countries, including Portugal, is highlighted, as is its
inconsistency among young adults and some barriers hindering its use, thus aiming to show
the need for its promotion. In the third section, the social-demographic, contextual and
individual psychosocial predictors accounting for differences in levels of condom use are
then reviewed, with special emphasis on the socio-cognitive factors, given that they are our
primary target by virtue of their important influence on behaviour. In the fourth section, the
theoretical underpinnings of the thesis are presented. A brief historical overview of models
of health behaviour change is provided, followed by a detailed description of the theoretical
framework underlying the present research, the Health Action Process Approach
(Schwarzer, 2008). In the following section, the potential of computer interventions is
examined by regarding them as opportunities to provide tailored health education
interventions to change condom use. Finally, the fifth section provides an outline of the
empirical chapters, discussing how the aims of the different studies have been achieved,
and how they set out to contribute to the current state of the literature on the motivational
and volitional mechanisms involved in condom use and their implications for targeted
interventions.
5
CHAPTER 1: INTRODUCTION
1. Condom Historical Roots
As legend has it, the semen of King Minos, son of Zeus,
swarming with snakes and scorpions, was fatal to his many
concubines, until one of them, Procris, had the idea of
protecting herself from the royal sperm with a goat bladder
Translated and Adapted from Fontanel and Wolfromm, 2010
There are many legends or stories that narrate the origin of the condom. Procris
managed to protect her own life by using a goat bladder to isolate the sperm of King Minos,
avoiding self-contamination. So, this small tale expresses the idea of preservation of life.
Therefore, condoms were presented as skin protectors to guard from infectious diseases
before serving contraceptive purposes (Martos, 2010). According to records, the emergence
of the first condom seems to date back to somewhere between 1354 and 1345 b.c., which
was made of animal intestines and is exhibited in the Cairo Museum and found in the
tumulus of a Pharaoh.
This mythological legend on the king’s semen putting at risk the health of his lovers, is
illustrative of the current problem of infections from sexual transmission, which may
compromise the health of the individual. Formerly, as emphasised by many authors, the
Romans manufactured condoms with the guts of lambs and used them to rape the women
of the places they conquered to prevent the danger of becoming infected with venereal
diseases, hence the so-called "Venus" shirts.
The current designation for condoms may be found in the Latin verb servare (save,
conserve), which, preceded by the prefix prae (before), changes its direction to avoid or
6
CHAPTER 1: INTRODUCTION
save from something damaging or bad, preserve. The word condom in Portuguese
(preservativo) is associated with the same idea of preservation. This may be its origin, which
has taken many forms throughout history (Fontanel & Wolfromm, 2010). Only in 1717 did
the word condom have its first reference in the work of Daniel Turner on venereal diseases,
who used the condom expression. According to Fontanel and Wolfromm (2010), it was
claimed that the name came from a physician of the English court of King Charles II "the
insatiable", Dr. Condom (or Cockburn). Supposedly this doctor developed a method for the
king's protection against illegitimate offspring, which proliferated. At that time condoms
were described as small bags, made out of lamb casings, and scrubbed with bran and
almond oil to make them soft and flexible. Although the name has endured over time,
neither the name of Dr. Condom, nor descriptions to prove his existence have ever been
found. However, there are those who ensure that the name derives from the Latin word
"condum" which means “hide and protect”.
An accurate fact, however, is that the first clear and scientific description of the
design, manufacture and use of condoms corresponds to the sixteenth century and is
named after Gabriel Fallopio, the first to consider the condom as a prophylactic measure.
So, the condom was born (or reborn) in Europe in the sixteenth century, more precisely in
1560, as a protective measure against syphilis. Fallopio was the doctor who first published a
medical treaty setting out the need for protection from syphilis through condom use
(Martos, 2010). He claimed to have invented a linen sheath, made to fit the glans and it was
worn for protection against syphilis. He experimented it with 1100 men, no more, no less not one of them became infected (Youssef, 1993). According to Collier (2007), Fallopio had
obviously made the connection between covering the man’s member and disease
7
CHAPTER 1: INTRODUCTION
prevention, as he believed that the “fluids” exchanged between the man and the woman
were directly connected to contagion. With that in mind, he also soaked his condoms in a
chemical solution, which inadvertently acted as a spermicide—a technique that would
remain popular for hundreds of years. Fallopio’s goal was to keep men safe from disease; he
kept no records on the women with whom his patients had sex.
By the late fifteenth century, the Japanese were also subject to an outbreak of
syphilis, which they called mankabassam (the Portuguese sickness), referred to as such
since they believed—and accurately so—that it was Vasco da Gama’s Portuguese sailors
who had brought the disease to Japan. Either way, syphilis meant the condom served the
purpose in the Japanese society, of disease prevention (Collier, 2007).
Casanova’s lewd story adds an interesting footnote to the history of the condom.
Youssef (1993) mentions that Casanova (1725-1798) referred to condoms several times in
his exhaustive memoirs. However, he was not enthusiastic about them, and he did not
appreciate the value of the condom until later in life. He used the condom more frequently
for contraceptive purposes than as protection against infection. This illustrates why condom
use was deemed a taboo for many years and frequently associated with underground and
debauchery.
According to Lord (2010), Americans began using the condom in the 18th century to
protect themselves against the so called “venereal diseases”, despite during the 19th century
the main focus shifted to chastity, abstinence and continence as the only effective form of
STIs prevention. Throughout the 20th century, battles over sex education were at the centre
of broader discussions on the health of the US nation. At that time, sex education and
8
CHAPTER 1: INTRODUCTION
condom use were widely regarded as a crucial tool in fighting sexually transmitted
infections, and continue to be so today.
The condom stood triumphant with its recognition by the World Health Organization
(WHO), when Margaret Sander, a family planning mother, managed to create legislation in
1924, authorizing women to use condoms as a method of birth control (Bailey, 2013). It was
in the 30s that people were finally prepared to accept advice that the use of rubber
(condom) during sexual intercourse protected both the man and the woman. During World
War II, the US Public Health Service took active steps to ensure that soldiers and sailors
learned about the effectiveness of the condom in preventing the spread of venereal
diseases and around 50 million condoms were distributed on a monthly basis to US troops.
European and Asian soldiers on both sides of the conflict also provided condoms to their
troops throughout the war (Collier, 2007).
The latex condom, the most common and more commercialized form, was a follow up
of Thomas Hancock's idea of using the viscous juice secreted by cahutchu trees - latex - for
waterproofing fabrics, and the vulcanization invention of Charles Goodyear, which brought
elasticity and flexibility to the stiffness of the rubber. It was in 1843 that the production of
rubber condoms began, which continued to rival with the condom originating from animal
intestines, since the latter was cheap and accessible to most of the impoverished
population. The first reusable vulcanized version followed, and condoms were sold along
with instructions for their cleaning and maintenance, until they final broke from wear.
Moreover, rubber condoms were described as being unpleasant to use, hard and took some
time to put on (Fontanel & Wolfromm, 2010). The London Rubber Company, later known as
9
CHAPTER 1: INTRODUCTION
Durex (Durability, Reliability, Excellence), began the process of moulding liquid latex that
enabled condoms to become thinner, comfortable and odourless. Therefore, during the 20s
the introduction of automated technology enabled manufacturers to produce condoms
cheaply, quickly and on an unprecedented scale. As condoms became more readily
available, concerns developed regarding their use.
The technical evolution of the condom had not ended by the end of the twentieth
century and is still constantly adapting, not only to health needs, with the emergence of
polyurethane to prevent allergies produced in some people, to latex, but also to the times
and social customs. This has been achieved through the production of hundreds of condom
varieties, using different combinations of size, shape, texture and material, which contribute
to different sensations and increased perceptions of pleasure experienced throughout its
use (O’Neal & Berteau, 2015).
A big step was taken during the post World War II era, when many married couples
used condoms as their primary method of birth control. For example, 42% of Americans, at
a reproductive age, relied on condoms for birth control and 60% of British married couples
used condoms from 1950–1960 (Collier, 2007). Condoms, which had gingerly been
advocated as a means of preventing venereal disease in the 30s, were also sold from 1947
as a contraceptive means, enabling couples to buy them anonymously without a medical
prescription.
For Martos (2010), the contraceptive method, described more in-depth in history, is
undoubtedly the use of spermicides as "concoctions for killing sperm." Moreover, the three
venereal diseases that became epidemics, namely gonorrhoea, syphilis, and AIDS,
10
CHAPTER 1: INTRODUCTION
determined the use of condoms in different periods of history, since they affected all social
classes. It was only in the twentieth century, when the use of penicillin kept the phantom of
venereal diseases at bay, that condoms began to be used mainly as a contraceptive method
to prevent pregnancy.
Before the worldwide acknowledgement of the benefits of condom use, despite the
love hate relationship it arouses - for many, condoms were considered immoral, as a device
interfering with the commandments of God and were associated with debauchery due to
their association with venereal diseases and prostitution. The condom use faded out in the
60s, with the sexual revolution and especially with the introduction of penicillin. The
emergence of the sexual revolution, characterised by free love without limits, was
fashionable at that time, thus advocating sexual relations without protection, with the
added guarantee that penicillin would help in the event of subsequent infections by offering
treatment for gonorrhoea and syphilis (Azevedo, 2008).
A less embarrassing, more convenient and controlled form of contraception than
condom use, was the pill, a revolution for women. It entered the market in 1960 and its
popularity over the following years enabled this generation of women to acquire a new
power: the control of reproduction. By dissociating sexuality and procreation, the revolution
brought by the pill, disturbed relations between men and women. The condom continued
on its path, despite the growing popularity of the pill, in addition to a weakening of this
market in the early 80s (Almeida & Vilar, 2008).
During the late 60s, researchers uncovered some disturbing trends, such as the fact
that when younger men became sexually active, they more easily engaged in risky sexual
11
CHAPTER 1: INTRODUCTION
behaviour with multiple partners. However, the most disturbing revelation of all was the
discovery that the problems associated with unprotected sex were not confined to any sex,
race, social group or section of the country (Lord, 2010).
The advent of AIDS would transform the way in which the world looked upon
infectious diseases, public health and sex education. With this twentieth century plague,
which began in the 80s, when the world had the prospect of a new and unknown threat,
governments, on a worldwide scale, recommended that the only way for people to protect
themselves against this fatal infection was by adopting the same method that guaranteed
protection in former times against the plague of syphilis, by using the condom. Therefore,
the condom re-emerged and from the 90s on, it began to be marketed in very accessible
places such as pharmacies, supermarkets, and bars to broaden its use to a widespread level.
In 1987, with the permission of advertising, the condom gained a new impetus. It has been
globalized for many years, and was strongly promoted following the official recognition of
institutions instigated by the government of Buenos Aires, which marked the International
Day for the fight against AIDS on 1 December 2005, by launching a new slogan for condom
use: “Do not hesitate, take care. I take care of myself”, and since then, governments all over
the world have shown similar concern in encouraging condom use.
The barriers hindering condom use seem to be consistently “imported” from former
times: loss of pleasure and sensation (Adebiyi & Azuzu, 2009), lack of trust in the
effectiveness of the condom (Kaneko, 2OO7), and the difficulty in negotiating or talking
about its use (Manuel, 2005).
12
CHAPTER 1: INTRODUCTION
2. Sexually Transmitted Infections and Condom Use
As defined by the World Health Organization (2013), sexually transmitted infections
refer to all possible infections that are transmitted from person to person through sexual
contact, with over 30 identified infectious agents such as bacteria, viruses and parasites
responsible for these diseases. Sexually transmitted infections occur in homo and
heterosexual relationships and are the result of close contact with the genitals, mouth or
rectum. Amongst them, the most well known are syphilis, chlamydia, gonorrhea, herpes,
and the human immunodeficiency virus (HIV), which is the classic example of the new
generation of STIs (WHO, 2013). Despite some STIs being incurable, treatment is available
for most of them, but prevention is the preferred option, since these diseases may, in the
long term, lead to serious implications for health and society. According to the World Health
Organization (2014), the prevalence of the most frequent STIs (Chlamydia infection and
gonorrhea) have increased in several European countries in the last decade, resulting in
serious long-term morbidity and mortality, with an impact on female fertility and the
facilitation of HIV transmission. In Portugal, little is known about the occurrence of STIs in
adults and even less about their prevalence in young people, which may, indeed, contribute
to the low rates presented in official documents. Even if the notification of STI cases were
made by clinicians, only recently, since 2002, have syphilis, gonorrhea infection and HIV
become diseases of mandatory notification, while the prevalence of other STIs such as
chlamydia, genital herpes and HPV infections is still unknown (Azevedo, 2008). According to
the European Centre for Disease Prevention and Control, in 2010, 32.028 gonorrhea cases,
with an overall rate of 10.4 per 100 000 people and 17.884 syphilis cases with an overall rate
of 4.4 per 100 000 people, were reported from 29 European Member Countries (ECDC,
13
CHAPTER 1: INTRODUCTION
2010). In Portugal, 1830 cases of gonorrhea (< 5 per 100 000), and 1792 cases of syphilis (<
1.7 per 100 000) were reported in 2010 (ECDC, 2010).
Overall, literature claims that prevention is the best way to control STIs and condom
use is generally acknowledged as the best preventive behaviour regarding STIs among
sexually active individuals. Latex condoms provide a quasi-impermeable barrier to HIV
(Carey, Lytle, & Cyr, 1999), and epidemiological studies of HIV-discordant heterosexual
couples indicate that correct and consistent condom use is highly effective in preventing HIV
infection (Weller & Davis, 2002). In their review of 14 cohort studies, Weller and Davis
(2002) found that consistent condom use ("always" users) accounted for an estimated 1.14
[95% C.I.: .56, 2.04] per 100 person-years. When not using condoms ("never" users) the
infection incidence rate was 5.75 [95% C.I.: 3.16, 9.66] per 100 person-years, without taking
gender into account. Overall effectiveness, namely the proportionate reduction in HIV
seroconversion with condom use is approximately 80%, though the confidence intervals
mean that ‘true’ efficacy could be as low as 35.4% or as high as 94.2%. Recently, the World
Health Organization (2012) confirmed that with the consistent and correct use of quality
condoms, there is a near-zero risk of contracting HIV. It also shares some important data
that enable better understanding of the effectiveness of condom use: studies on couples, in
which one partner is infected with HIV show that with consistent condom use, HIV infection
rates for the uninfected partner are below 1% per year; STIs dropped from 400,000 to
30,000 per year among Thai sex workers who used condoms; the success of the 100%
condom use programme designed for commercial sex workers in Thailand, revealed a very
strong correlation between the percentage of male condom use and the decline of the
national incidence of STIs; also in Cambodia, condom use has resulted in a decline in of over
14
CHAPTER 1: INTRODUCTION
80% of HIV rates since the peak of the epidemic, and comprehensive condom programmes
have kept HIV prevalence very low among sex workers in China.
Other data were gathered showing that the condom provides effective protection
against HIV and other sexually transmitted infections for both men and women (Holmes,
Levine, & Weaver, 2004) and that it extends its action to syphilis, chlamydia, herpes simplex,
and gonorrhea for both sexes (Steiner & Cates, 2008). For example, the condom offers
protection in the range of approximately 50 to 66% against syphilis, protection rates varying
from 26 to 85% against chlamydia, and providing protection of 80 to 85% against gonorrhea
(NAM, 2015; Holmes, Levine, & Weaver, 2004). Neto, Araújo, Doher and Haddad (2009)
conducted a review of the efficacy of condoms in protecting against STIs. The result of this
study suggests that latex condoms are considered to be more effective than the natural
membrane condoms, namely those made of processed sheep intestines, since the latter
were shown to be permeable to smaller viruses such as HIV. However, condom
effectiveness (actual use or typical use that includes all condom users, including
inconsistent-use and incorrect application of condoms) is lower than condom efficacy
(perfect use that includes people who use condoms properly and consistently) (Free,
Roberts, Abramsky, Fitzgerald, & Wensley, 2011). For instance, studies have shown that
98% of women relying on condoms as their sole form of contraception remain pregnancy
free if condoms are used perfectly, meaning that they are used consistently and correctly
during every act of sexual intercourse. However, since they are not used correctly, even if
they are used consistently, studies have found efficacy rates of 85 to 87% when young
women use condoms as their sole form of contraception (NAM, 2015). Evidence shows that
15
CHAPTER 1: INTRODUCTION
male latex condoms have an 85% efficacy rate, or a higher protective effect against HIV and
other sexually transmitted infections (WHO, 2014).
Young people and emerging adults, namely those between 15 and 24 years of age
(Tanner et al., 2009), are particularly vulnerable to STIs and to sexual health problems as the
initiation of sexual activity may increase the risk of unintended pregnancy or sexually
transmitted infections (STIs). This is due to their lack of information in relation to STIs
prevention, less proneness to search for correct information or treatment (as a result of
fear, introversion or inexperience) and greater likelihood of being involved in risky sexual
practices, as they often have multiple partners (without consistent protection), so they are
considered a priority bracket in terms of prevention (WHO, 2012). Furthermore, condom
use at the beginning of sexual life is particularly relevant considering it is associated with its
ensuing use (Shafii, Stovel, & Davis, 2004; Shaffi, Stovel, & Holmes, 2007). Thus, early sexual
initiation has been pinpointed as an important indicator of future sexual health (CDC, 2014;
UNAIDS, 2013; WHO, 2014) and, therefore, an important moment for introducing
interventions in order to increase condom use.
HIV is an infectious agent which, after a varying prolonged period of time, leads to the
Acquired Immune Deficiency Syndrome (AIDS), and eventually the death of the affected
individual. HIV prevalence in developed countries does not present the worrying levels
found in most countries in Africa or in other countries with a similar socio-economic
structure. However, the fact that the number of new HIV cases continues to gradually
increase, mainly among the younger sections of the population, through unprotected
heterosexual contact, makes the World Health Organization (2014) continue to classify the
16
CHAPTER 1: INTRODUCTION
HIV infection as the greatest challenge to world public health, requiring rapid and capable
interventions more than ever, to slow down the progression of this epidemic.
Globally, AIDS has claimed more than 39 million lives so far, around 35.3 million
people were living with HIV by the end of 2013 and an estimated 2.1 million people became
newly infected with HIV in 2013. Individuals between the ages of 15 and 24 years comprised
around one third of the population who had acquired HIV infection globally (WHO, 2014).
Although the number of new HIV infections has declined among young people (15–24
years), and the number of people newly infected with HIV has fallen to the lowest level in
over two decades, according to the latest available data (WHO, 2014), global figures still
suggest that around one third of young people are estimated to be newly infected with HIV.
Nevertheless, these trends are mixed among different regions and data is still scarce
(especially concerning adolescents), so they still represent a group requiring special
surveillance (WHO, 2014). The annual number of people newly infected with HIV decreased
by 15% between 2009 and 2013 across all ages and by 14% among young people in the
same period. At such a pace, the targeted 50% reduction by 2015 proposed by the UNAIDS
(2013), is unattainable, and prevention efforts need to be considerably intensified.
According to the latest results provided by the Department of Infectious Diseases
(CVEDT, 2013) in Portugal, the total cumulative number of infected cases of HIV/AIDS in
December 31, 2013 was 47.390 (19.075 of these AIDS cases). Sexual intercourse was at the
root of the infection in most cases, with 61.1% referring to heterosexual transmission. In
Portugal, 72.8% of the people diagnosed with HIV were men, and the highest rate of HIV
infection was through heterosexual unprotected sex (45.7%), and intravenous drug users
17
CHAPTER 1: INTRODUCTION
who had shared unclean needles (36.4%), and approximately 15.4% of all infections were
transmitted via homosexual and/or bisexual unprotected sex [data refer to the cumulative
percentage of HIV transmissions from 1983 to 2013 (CVEDT, 2013)]. Thus, the statistics of
2013 have confirmed the epidemiological pattern recorded annually since 2000, that is, a
proportional increase in the number of cases of heterosexual transmission among the 20 49 year old cohort has been observed (CVEDT, 2013), which means that some were infected
during adolescence or youth. Nevertheless, HIV prevalence is diminishing in a considerable
number of countries, as people have less sexual risk behaviours, such as unprotected sexual
intercourse, i.e. sex without condom use (UNAIDS, 2013). This is also the case in Portugal,
where HIV infection has declined and presents an average (8.9%) below the averages
calculated by the European Centre for Disease Prevention and Control (ECDC) for EU
countries (11.0%) (CVEDT, 2012), however HIV continues to represent a major challenge for
public health.
Guidelines from the WHO (2014) recommend that the world can only achieve an AIDSfree generation if it succeeds in protecting successive generations of adolescents and young
adults against HIV. Despite progress in recent years, the full preventive potential of
condoms is still not being fully accomplished. One study assessing condom use among
university students reported that 83.1% had engaged in unprotected sex in the past
(Bontempi, Mugno, Bulmer, Danvers, & Vancour, 2009). Although currently there are very
effective drugs for HIV/AIDS treatment that have improved the quality of life of those
infected with the disease, and increased life expectancy after infection, so far the efforts to
develop a cure or vaccine for HIV have proven to be fruitless, hence, it continues to be
extremely important that risky behaviours are changed, in order to reduce exposure.
18
CHAPTER 1: INTRODUCTION
Notwithstanding, even if a cure for HIV/AIDS is found, the cost of an infection to health
continues to make male condom use relevant, particularly to protect against other STIs such
as herpes, which does not have a cure.
2.1 Inconsistent condom use among young adults
The global pandemic of STIs, including HIV, and unintended pregnancy, requires an
accelerated emphasis on consistent male condom use. Among adolescents in Western,
Central and Eastern Europe who have already had intercourse, up to 40% did not use
condoms during their last act of sexual intercourse (Avery & Lazdane, 2010). Condom use is
also markedly lower among sexually active adults, where 20% overall, and less than 50% of
adults with multiple partners, report having used a condom the last time they had
intercourse (Warner, Gallo, & Macaluso, 2012).
Some studies conducted in Portugal suggest inconsistent condom use among young
adults (Alvarez & Garcia-Marques, 2008; Amaro, Frazão, Pereira, & Teles, 2004; Gomes &
Nunes, 2011). Upon analysis of a number of studies conducted on the inconsistent use of
contraception and condoms, it appears that young people, in general, use contraception
irregularly or they do not use any contraceptive method, exposing themselves to unwanted
pregnancies and the risk of contracting a STI (Reis et al., 2012). In a Portuguese
representative sample of adults (between 18 and 65 years of age), condom use has been
integrated in sexual intercourse but also inconsistently (Aboim, 2010). Men tend to have
greater oversight and inconsistency in condom use with casual partners (47.9%) than with
regular partners (26.7%). According to this author, the relationship between sexual risk
19
CHAPTER 1: INTRODUCTION
behaviour and masculinity is very strong, so gender is a strong variable that should be
studied. In the same representative sample, Vilar (2010) refers to low frequency of regular
condom use (16%) associated with other forms of contraception, which confirms the lower
preoccupation of Portuguese couples with STIs and the dissociation between contraceptive
practices and practices related to sexual health.
In Portugal, in the Health Behaviour in School-aged Children study (HBSC, 2014), with
a sample of 3869 young Portuguese people attending grades 8 and 10 of schooling, an
average of 83.9% of adolescents were shown to have not had sexual intercourse, and those
who had already initiated sexual activity reported their first sexual intercourse occurrence at
the age of 14 or later, and condom use at the time of their last sexual intercourse (82.5%).
The percentage of male condom use was higher (70.4%), followed by the pill (31%). Boys
(69.1%) and girls (72.9%) were found to report condom use during their last act of sexual
intercourse, while 22.6% of girls and 19.1% of boys were not.
Among university students, condoms (87%) and oral contraceptives (21%) were the
most commonly used contraceptive methods, with 33% mentioning having had occasional
partners (Ramiro et al., 2014). As far as young adults are concerned, the condom is the most
used contraceptive method (51%), followed by the pill (45.7%), while the situation is
reversed among those in a higher age bracket (Vilar, 2010). Although 64.7% of university
students reported not having had sexual intercourse under the effect of alcohol or drugs,
35.3%, which is a relevant percentage, reported the contrary (Ramiro et al., 2014). Results
for adolescents also showed that the majority (84.1%) had not had sexual intercourse under
the effect of alcohol or drugs. In the afore-mentioned Health Behaviour School Children
20
CHAPTER 1: INTRODUCTION
study (HBSC, 2014), 82.5% of middle and high school students reported having used a
condom during their last act of sexual intercourse compared to 81.6% of university students
(Ramiro et al., 2014).
The data presented showed that there is still a significant number of adolescents and
young adults who do not use condoms and they are used to an even lesser extent among
individuals with less schooling. Furthermore, one third of young adults have casual partners,
and condom use tends to decrease in older ages, thus, young people engage in sexual
behaviours that place them at risk of contracting STIs, including HIV.
Recent evidence suggests that STI risk varies according to sexual orientation identity
(homosexual or heterosexual) and also behaviours among young adult men (Everett, 2013).
Sexual minority groups are assumed to have an increased likelihood of reporting not using a
condom during their last act of sexual intercourse compared with heterosexual groups
(Everett, Schnarrs, Rosario, Garofalo, & Mustanski, 2014), although in Portugal the highest
rate of HIV infection is through heterosexual unprotected sex (CVEDT, 2013). Besides the
need to increase consistent condom use, research has also shown that there are different
dynamics in heterosexual and homosexual relationships that may justify separate
intervention (Kelly, 1995), and the benefits of such protection are equally necessary for
heterosexual men, who have a higher rate of infections than women. Thus, different
messages may be required for men and women within interventions that focus on the use
of contraceptives, since, for example, the reasons for, and barriers to carrying and using
condoms may differ between the genders (Courtenay, 2000; Davis, et al., 2014).
21
CHAPTER 1: INTRODUCTION
A report from the WHO (2012) highlights that men tend to use more condoms, since
they do not always know whether their female partner is on the pill, which may explain the
tendency for women to report the use of oral contraceptives at the time of their last sexual
intercourse more frequently than men. The report also refers to the fact that men are more
likely than women to use condoms during their last sexual intercourse act, possibly as they
feel less embarrassed buying and/or carrying them, and as they are more receptive to
messages related to HIV/AIDS, while women are more likely to respond to pregnancy
prevention interventions. Previous research has already suggested that men and women
hold different beliefs (and consequently behaviours) in relation to their health (Courtenay,
2000) and many men, for instance, appear reluctant to engage in preventative health
behaviours (Springer & Mouzon, 2011). In a study developed among tertiary and
heterosexual young students (Newton, Newton, Windisch, & Ewing, 2012), condom use
remained a source of embarrassment, and within the context of sexual intimacy, men were
often reluctant to use condoms (Davis et al., 2014), leaving themselves (and their sexual
partner) vulnerable to STIs. Thus, these studies have shown that although men use condoms
more often than women, they continue to be reluctant to do so. Therefore, it has been
suggested that safe sex interventions should equip young men with the necessary skills to
effectively mitigate many of the condom use barriers.
From a health education standpoint, the correct and consistent use of condoms
should be emphasized as it continues to be one of the most efficient methods for
preventing the transmission of HIV and other sexually transmitted infections, and for
preventing unplanned pregnancies. Despite progress in recent years, the full potential
benefits of condoms are still not being accomplished, since the condom is not always used
22
CHAPTER 1: INTRODUCTION
by most interveners (Warner et. al., 2012), despite being widely acknowledged as a possible
preventive barrier. Johnson, Michie and Snyder (2014) conducted a meta-review of metaanalyses on the effects of behaviour intervention content on HIV prevention, which aimed
to reduce risk behaviours. The review suggests that these interventions have a positive and
significant effect on reducing sexual risk behaviours, and an effective mean in reducing
infection rates by HIV.
2.2 Barriers to condom use
In an attempt to understand the psychological phenomena associated with condom
use, and before presenting the different predictors and several models of health psychology
that have been adapted to explain its variance, knowledge of the main obstacles to condom
use has also been extremely helpful in understanding the specificity of this protective
behaviour’s impact on its actual use.
The main barriers identified for using condoms can be summarized as the possibility of
a condom transmitting a lack of trust in a partner; loss of sexual pleasure; use of another
type of contraception; feelings of love and closeness to the partner; loss of spontaneity; its
proposal in the context of a monogamous relationship, and embarrassment in buying and
carrying condoms (e.g. Adebiyi & Azuzu, 2009; Kaneko, 2007; Kelly, 1995; White, Terry, &
Hogg, 1994). Some studies have identified the reluctance of the partner to use condoms as a
barrier (Bogart et al., 2005), and by staying in regular relationships with a strong sense of
security (Manuel, 2005). However, Edwards and Barber (2010) found that some of the
barriers stem from the expectations individuals have that their partners do not want to use
23
CHAPTER 1: INTRODUCTION
a condom. Indeed, in this study it is claimed that most participants did not introduce the
issue of condom use, believing that the male partner did not intend to use it, especially
women in romantic relationships, who thought that their partners were less receptive to
using condoms than the male participants in romantic relationship experiences actually
reported to be. Heuristics in relation to partners also contributes as a barrier, based on the
belief that known partners are safe, trustworthy and reliable, thus leading to a decrease in
condom use (Thorburn, Harvey, & Ryan, 2005). Having thoughts that are in opposition to
these barriers may sometimes be constituted predictors of condom use, for example,
Heeren, Jemmott, Mandeya and Tyler (2009) showed that the intention of condom use is
predicted by beliefs in hedonistic behaviour that the condom does not interfere with
pleasure, and by the belief that the partner will accept the condom.
The types of barriers encountered that hinder condom use have contributed to a more
systematic study of new variables/predictors and the development of models on this
protective behaviour.
24
CHAPTER 1: INTRODUCTION
3. Predictors of Condom Use
The male condom is used as a means of individual protection against sexually
transmitted infections, and also has a contraceptive function (WHO, 2014). The data
presented earlier indicate that the majority of people still use condoms inconsistently,
however, some individuals do actually use them in a more consistent manner. Therefore,
one may question precisely which of the factors can predict and / or explain consistent use
or non-use of condoms. In line with other behaviours, condom use is also multi-determined,
and is affected by demographic, social, situational and cognitive factors (for a review see
Sheeran, Abraham, & Orbell, 1999).
Three types of predictors were taken into consideration: social-demographic,
contextual and individual psychosocial. The social–demographic predictors seek to address
the relationship of condom use with variables used to differentiate groups or samples, such
as socio-economic status, type of commitment relationship, age, level of schooling, gender
and culture or cultural subgroups. Contextual psychosocial predictors include the social
influence that affects condom use, the norms and values of primary socialization groups,
such as parents or peers, and secondary groups such as couples, and also integrate those
other variables that can influence the use of condom, such as the link between condom use
and the hormonal contraceptive or the use of soft drugs or alcohol, capable of altering the
state of consciousness or judgement. Finally, the individual psychosocial variables refer to
the provisions, beliefs, expectations and responsibilities of the individual, in a direct or
indirect relationship with condom use such as attitudes, self-efficacy, planning, preparatory
25
CHAPTER 1: INTRODUCTION
behaviours, such as, buying and carrying them, and communication/negotiation between
partners regarding their use.
3.1 Social-demographic predictors
The socio-economic status, type of relationship, age, level of schooling, and gender
are determinants of condom use.
Poverty hampers access to information on risks, contraceptive methods and the
prevention of STIs, also making it difficult to acquire the necessary skills for personal
protection (Bull & Shlay, 2005). Lower socio-economic status also seems to be associated
with an increased number of partners and a reduced use of condoms (Dinkelman, Lam, &
Leibbrandt, 2007, 2008; Sanders et al., 2010).
Condom use appears to vary more according to the type of relationship (casual or
regular) than to the participant's gender. There is greater consistency of condom use in
casual than in regular relationships (Broaddus, Schmiege, & Bryan, 2011; Reynolds, Luseno,
& Speizer, 2013). There are numerous studies, finding a close relationship between sex with
a primary or regular partner and not using condoms, and their more frequent use with a
casual or secondary partner (Xiao, Palmgreen, Zimmerman, & Noa, 2010). Mercer et al.
(2009) conducted a study on the characteristics of heterosexual relationships, suggesting
that men have more casual or shorter relationships, which could explain why in some
samples condom use is more associated with men than with women. They also observed a
statistically significant reduction in condom use at around 21 days of a relationship, at which
point the utilization rate becomes similar to that of regular couples. Individuals in regular
relationships are found to be less likely to use condoms, have a lower perception of risk and
26
CHAPTER 1: INTRODUCTION
to be more geared towards preventing unwanted pregnancies than STIs (Mehrotra, Noar,
Zimmerman, & Palmgreen, 2009). Nevertheless, the idea of fidelity and the increase of
confidence among young partners appears to be a risk factor, since one of the main reasons
for couples ceasing to use condoms when their relationship moves from casual to
established, is that perceptions of trust and intimacy increase, while the perceived risk of
contracting an STI from their partner decreases (Brady, Tschann, Ellen, & Flores, 2009;
Umphrey & Sherblom, 2007). Therefore, relationship status has proved to be one of the
most important predictors of condom use.
Age also seems to influence condom use behaviour. Condom use is higher among the
younger than the older population, and longitudinal analyses have confirmed this finding
(Sheeran et al., 1999). The less likelihood of reporting condom use was shown to be more
common among older individuals (Adefuye, Abiona, Balogun, & Lukobo-Durrell, 2009).
University students tend to use condoms more frequently than those who do not
attend university (Bailey, Fleming, Henson, Catalano, & Haggerty, 2008), and, by the same
token, more educated individuals have more consistent contraceptive standards, such as
the joint use of the pill and condoms (Martin, 2005). Inconsistent condom use, early sexual
initiation, high levels of sexual activity and greater instances of multiple partners were
found among the non-student population (Burke, Gabhainn, & Young, 2015)
There is a higher likelihood of non-use of condoms among cultures where there is a
greater divergence in behavioural expectations associated with the gender roles of men and
women. As an example, Stutterheim, Bertens, Mevissenc and Schaalma (2013) report that
in Curaçao there is an important disconnection between what is considered culturally
27
CHAPTER 1: INTRODUCTION
appropriate sexual behaviour for men and women and condom use. It was established that
condom use is inconsistent with culturally embedded notions of masculinity in which men
are perceived to be impulsive, promiscuous sexual beings who should father many children,
and health which is regarded the woman’s domain. However, condom use negotiation by a
woman is inappropriate as it either suggests her own promiscuity or implies distrust in her
partner. On the other hand, the cultural ideals of Native American communities have social
values that lead to a reduction in the use of condoms (Gilley, 2006). The study suggests that
when there is an adaptation of the HIV protection message through the condom, having
taken the cultural symbols into account, better results are achieved in terms of prevention.
Noting that cultural norms may be protective, Lee and Hamn (2010) observed that the
acculturation of Hispanic women in the United States increases the likelihood of sexual risk
behaviours.
The religious aspects, as part of an individual's culture, also seem to affect, in part,
their choices in the area of health protection (Hirsch, 2008). Burris, Smith and Carlson (2009)
observed that religion was negatively associated with the number of partners and frequency
of vaginal sex, but not the use of condoms. However, these authors also observed that the
degree of spirituality, regardless of religion, had a positive correlation with the frequency of
unprotected sex. In this particular case, religion (understood as belonging to a specific group
of values and beliefs) is seen to be protective, while spirituality (as a means for seeking a
meaning to life and a personal form of connection to others) is identified as a risk factor for
condom use.
28
CHAPTER 1: INTRODUCTION
The relationship between demographic variables and condom use has received the
greatest amount of attention in psychosocial research (Sheeran et al., 1999). However,
Sheeran et al., have shown that all the social-demographic variables presented have small
associations with condom use (less than r= .10), thus, undermining a simple deterministic
view of the contribution of these demographic factors to condom use.
3.2. Contextual psychosocial predictors
Research has shown the importance of interpersonal aspects to explain the use of
condoms (see Widman, Noar, Choukas-Bradley, & Francis, 2014). In selected studies, a
tendency for issues related to communication with parents about sex, communication with
the relationship partner and standards of peers and partners have been found to have an
effect on condom use behaviour.
Communication with parents about sex in adolescence is associated with fewer
episodes of unprotected sex (Hadley, et al., 2009; Njau, et al., 2007). The likelihood of fewer
sexual risks has been observed in such cases when parents teach their children to refuse
unprotected sex, provide clear rules on sex, and when they encourage them to discern
properly (Aspy et al., 2007).
The perception of social approval for the adoption of a given behaviour increases the
likelihood of an individual engaging in such behaviour. Subjective social norms, i.e. an
individual's beliefs about whether significant others think he/she should engage in a
particular behaviour, which is influenced by their judgement (Ajzen, 1991), were shown as
an influential factor in the adoption of the condom (Albarracín, Johnson, Fishbein, &
Muellerleile, 2001). The attitudes of peers or the perception that they value and use
29
CHAPTER 1: INTRODUCTION
condoms (descriptive norms) are also a powerful predictor of their use, particularly the
perception that this behaviour is approved of by the sexual partner (McMillan & Worth,
2011; Sheeran et al., 1999).
Research on sexual risk behaviour increasingly finds support for variables that take
into account the context of the sexual situation (Zimmerman, et al., 2007), such as whether
a hormonal contraceptive or alcohol and other substances are used in a sexual situation.
The fear of an unwanted pregnancy seems to remain the main motivational factor for
condom use among heterosexual and university students in particular (Sheeran et al., 1999).
However, as what is highlighted is contraception, condom use is often considered
unnecessary when another contraceptive, usually the pill, is used (Milhausen et al., 2013).
Hoefnagels, Hospers, Hosman, Schouten and Schaalma (2006) found that the way
individuals relate to using the condom, for protection against sexually transmitted
infections, pregnancy, or both, differentiates the inconsistent from the consistent users.
Individuals who focus on protection against infections are more likely to consistently use the
condom.
A meta-analysis of studies that examined the relationship between alcohol and
condom use (Leigh, 2002), showed that the ingestion of alcohol was related to the non use
of condoms at first intercourse, with a trend among adolescents, in general, toward non use
of condoms when drinking. Drinking prior to sex with casual partners increases the
likelihood of unprotected sex for men, and for women influences not using condoms with
both casual and regular partners (Kiene, Barta, Tennen, & Armeli, 2009). Those who do not
use condoms under the influence of alcohol appear to be men, generally older, who submit
30
CHAPTER 1: INTRODUCTION
to more episodes of intoxication and report a higher number of sexual partners (Randolph,
Torres, Gore-Felton, Lloyd, & McGarvey, 2009). Brown and Vanable (2007) note that
although high rates of alcohol and inconsistent condom use among university students
coexist, the relationship between the variables is not straightforward, as unprotected
vaginal intercourse occurs in identical proportions in groups with and without alcohol.
With regard to drug use, it appears to be consensual that individuals who consume or
have consumed any drugs are less likely to use condoms consistently in their sexual
relationships (Bertoni et al., 2009; Galvez-Buccollini, Delea, Herrera, Gilman, & PeaceSoldan, 2009). The combination of alcohol and drugs also implies a decrease in condom use
(Adefuye et al. 2009).
In short, knowledge concerning the social-demographic and contextual psychosocial
factors associated with levels of condom use may be relevant for the selection of specific
audiences in greater need of intervention, since it seems to bring out a pattern of condom
use, e.g. less educated people, with regular partners. However, it is important to bear in
mind that these factors are hardly likely to be direct causes of condom use. Their effect is
dependent upon individual factors and largely mediated by cognitive factors, such as those
presented in the following section.
3.3 Individual psychosocial predictors
Despite the undeniable relevance of social demographic and contextual psychosocial
predictors, humans are self-determined and have the ability to exercise control over their
behaviour. In this section we look at the factors of a motivational nature, those that lead to
the establishment of goals or intentions, and at the factors of a volitional type, namely those
31
CHAPTER 1: INTRODUCTION
that help individuals to commit to furthering the objective established, moving from
intention to action.
Attitudes and self-efficacy are considered to have an important motivational influence
on the development of an intention to use condoms (Zimmerman et al., 2007). Attitudes
have proven to be major predictors of a number of behaviours extended to the use of
condoms (Ajzen & Fishbein, 1977; Fisher & Fisher, 1992; Sheeran et al., 1999). In a general
manner, favourable attitudes towards condoms are associated with their more consistent
use. Sanchez-Garcia and Batista-Foguet (2008) observed that the explanatory power of
attitude towards condom use intention increases when its components, both affective and
cognitive, are congruent. According to these authors, the cognitive component, understood
as the knowledge and beliefs about the object in question, has a direct impact on the
intention to use condoms.
The concept of perception of self-efficacy, defined by Bandura (1997), emphasizes that
the individual is able to maintain consistent behaviour over time, whether accomplished by
rules and external reinforcement, or by means of patterns and self-imposed reinforcement.
In the context of sexual risk behaviour, self-efficacy can be defined as the belief that one is
capable of using condoms during sexual intercourse (Farmer & Meston, 2006). It is therefore
related to individual beliefs of having the skills and expertise to use condoms. Studies seem
to agree by stating that high self-efficacy for condom use is a predictor of intention and
condom use behaviour. (Farmer & Meston, 2006; Hendriksen, Pettifor, Lee, Coates, & Rees,
2007).
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CHAPTER 1: INTRODUCTION
Another variable strongly linked to the use of condoms is the intention to use them.
Intention has proven to be a reliable predictor of condom use (Ajzen and Fishbein, 1977;
Sheeran et al., 1999). However, changing sexual behaviours like condom use is a complex
process and requires considerable self-regulatory efforts, besides the formulation of an
intention to change. This is empirically revealed by what is acknowledged in the literature as
the intention-behavior gap, in other words, successful changes in intention engender only
small-to-medium change in behaviour (Webb & Sheeran, 2006).
One of the psychological mechanisms that operates in the translation of an intention
into action is planning. Action planning can be considered synonymous with implementation
intentions (Gollwitzer, 1999) as it involves a mental simulation regarding when, where and
how one intends to perform the behaviour. It is a task-facilitating strategy that helps link the
desired end state, formulated through an intention consolidated by specific situational cues
and may, therefore, be especially important for the initiation of behaviour. Thus, planning
may encompass both action planning and coping planning, i.e., the anticipation of possible
barriers that might hinder fulfilment of the action plans and the establishment of plans to
overcome the identified barriers (Sniehotta, Schwarzer, Scholz, & Schüz, 2005a). Action
planning and coping planning have been shown to facilitate condom use behaviour (Teng &
Mak, 2011).
The meta-analysis by Sheeran, et al. (1999) concluded that three preparatory
behaviours were among the strongest determinants of condom use: discussing condom use
with a sexual partner, purchasing condoms and having them available.
33
CHAPTER 1: INTRODUCTION
Individuals who plan the use of condoms in advance seem more likely to talk to their
partner and discuss the issue successfully (Gebhardt, Kuyper, & Dusseldorp, 2006).
Communication with the partner about condom use is also an important predictor of its use
(Sheeran et al., 1999; Xiao, 2012). Communication with the first sexual partner about
condom use appears as a strong predictor of condom use in future situations (Hendriksen et
al. 2007; Stulhofer, Graham, Bozicevic, Kufrin, & Ajduković, 2009).
Preparatory behaviours “emerge as medium-to-strong predictors of condom use”
(Sheeran et al., 1999, p. 118), and some studies have tested the hypothesized mediating
role of preparatory behaviours in condom use and have demonstrated that adolescents who
intended to use condoms and prepared themselves to do so were more likely to actually use
them (Bryan, Fisher, & Fisher, 2002; van Empelen & Kok, 2006, 2008; Gebhardt et al., 2006;
Zimmerman et al., 2007). In fact, forming implementation intentions for the preparatory
actions preceding actual condom use has been found to involve the planning of separate
concrete actions, such as buying, carrying and discussing condoms (de Vet et al., 2011).
Despite general neglect of preparatory actions in most health behaviour theories, they
constitute an obvious proximal predictor of action (Koring et al., 2013).
4. Condom Use Promotion
Condom use should be integrated into prevention programs for reducing the risk of
STIs. Sexually active individuals should be aware that condoms are effective in STI protection
when packaged properly, and correctly and consistently used. Self-reported measures of
34
CHAPTER 1: INTRODUCTION
condom use are a quick and affordable way to measure the risk to which individuals are
exposed, although in conjunction with this, some objective measures, such as regarding the
outcome of ‘any STI’, should be increased (Free et al., 2011). Thus it is essential to identify
condom use behaviour patterns in order to improve the strategies that lead to their
consistent use.
Since vulnerability to contracting HIV is mainly linked to behaviour, the best way to
combat this epidemic has proven to be through behaviour change, such as through a
preventive action of sexual risk behaviour or the promotion of sexual protection such as
condom use. The need to develop programs in the prevention of HIV/AIDS, has, on the one
hand, used what is already known about the predictors of condom use, and on the other
has led to further investigation of other factors responsible for social, psychological and
situational risks. These programs are extremely important, as we cannot expect individuals
to protect themselves if they are not educated to avoid or protect themselves from certain
behaviours. Nevertheless, according to Johnson et al., (2014) in their meta-review of metaanalyses about the effects of behavioural intervention content on HIV prevention outcomes,
most research has taken an interest in the dimensions that are actively responsible for
behaviour change resulting from interventions. In other words, the focus is more on
whether HIV prevention interventions significantly decrease risk behaviour and for whom,
rather than on the content of such interventions that might be related to success. Increased
attention to the content of interventions and mechanisms of behaviour change may be
regarded as a sign of progress in this field of intervention, since they strongly suggest that
fully incorporating behavioural change technique (BCTs) taxonomies would, in the long run,
improve both the application to HIV prevention and to care.
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CHAPTER 1: INTRODUCTION
4.1 Social cognitive models of health behaviour change
Identifying predictors of the behaviour through empirical research is a task that not
only enables one to understand the psychological processes behind the behaviour, but also
encourages the development of theories and behaviour change models that may help
individuals to adopt healthier behaviours (Schwarzer & Luszczynska, 2008). Most health
behaviours are hard to change (Lippke, Wiedemann, Ziegelmann, Reuter, & Schwarzer,
2009), so a number of theoretical models have been used to describe, explain, and predict a
variety of health behaviours with various degrees of success. Social cognition models
examine various social and/or cognitive constructs in order to predict future health-related
behaviours, and also provide knowledge that is useful for planning and designing
intervention programs for health behaviour change (see Conner & Norman, 2005 for a
review).
Several behavioural change models have been found to particularly produce
meaningful results in the area of HIV prevention (Alvarez, 2005). The evolution of forms of
understanding and their intervention in preventive behaviours, particularly in condom use,
has been characterized by the primacy given to information and its role in the adoption of
the behaviour, followed by demographic and psychosocial variables that might be
associated with the use of condoms and, finally, by the application of psychological
decision-making models to this protective behaviour, such as the Protection Motivation
Theory and the Theory of Planned Behavior (Sheeran et al., 1999).
Despite the number of social cognitive models for health behaviour change, there is,
however, a great degree of overlap among the different models (Armitage & Conner, 2000).
36
CHAPTER 1: INTRODUCTION
One important distinction is whether they conceptualize behaviour change as a continuum
or rather as a staged process (Weinstein et al., 1998), continuum models may be further
subdivided into motivational models and behavioural enaction models.
In motivational models, integrating the Theory of Planned Behavior (TPB; Ajzen, 1991),
the Theory of Reasoned Action (TRA; Fishbein & Ajzen, 1975), the Health Belief Model (HBM;
Janz & Becker, 1984; Rosenstock, 1974), the Social Cognitive Theory (SCT; Bandura, 1986),
and the Protection Motivation Theory (PMT; Rogers, 1983), the common characteristic is the
fact that the determinants of motivation to change are studied, considering motivation as
being sufficient to initiate a behavioural response, and intention as being the most proximal
predictor of behaviour (Armitage & Conner, 2000).
Several criticisms of motivational models have been identified (Adams & White, 2005;
Schwarzer, 2008).
The fact that motivational models do not take into account the
interaction that may exist among variables that predict behaviour, and therefore do not
propose an explanation for how this interaction can influence the targeted action has been
criticized (Armitage & Conner, 2000). Furthermore, these models can better explain the
variance of the behavioural intention than the actual behaviour, and have left out volitional
processes that help individuals to translate their intentions into action (Abraham, Sheeran,
& Johnston, 1998; Schwarzer, 2008). Thus, these models have been criticized for not taking
into account a post-intentional phase, helping to explain how the objectives or goals are
translated into action (Schwarzer, 2008).
Hence, attention has more recently been drawn to the self-regulatory processes
involved in the initiation, monitoring and maintenance of health behaviours, besides the
37
CHAPTER 1: INTRODUCTION
motivation underlying behaviour change. The observation that people often fail to act on
their intentions has been designated as the intention-behavior gap (Sheeran, 2002; Webb &
Sheeran, 2006).
Criticism of the motivational models has led to the emergence of
behavioural enaction models, which are mostly concerned with how intentions are
translated into behaviours, in an attempt to improve this relationship. Gollwitzer's
Implementation Intentions and Bagozzi's Goal Theory (Armitage & Conner, 2000) are
examples of these models. The former defends that implementation intentions are formed
for the purpose of enhancing the translation of goal intentions into action and are if-then
plans that link situational cues (i.e., good opportunities to act, critical moments) with
responses that are effective in attaining goals or desired outcomes (“If situation Y is
encountered, then I will initiate behaviour Z in order to reach goal X”). The latter examines
motivational influences on goal intentions and actual trying, which is the process that
initiates and regulates instrumental action.
Another model that attempts to explain the mechanisms that operate after individuals
have formed a behavioural intention is the Health Action Process Approach (HAPA;
Schwarzer, 2008), which explicitly includes volitional processes besides motivational
processes in its conceptualization, and which will be described in detail further ahead.
In their review article, Albarracín, Durantini, and Earl (2006) reported that among
behavioural change theories, the TPB (Ajzen & Fishbein, 2005), the SCM (Bandura, 1994),
and the Information-Motivation-Behavioural Skills (IMB) model (Fisher & Fisher, 1992) were
generally supported in the HIV intervention literature. The main variables detected in these
models revealed the importance for condom use of attitudes, social norms, perceived self38
CHAPTER 1: INTRODUCTION
efficacy, communication skills, the obstacles and benefits of protective measures and
behavioural intentions for condom use (as mentioned in section 3 on the predictors of
condom use). Comparatively, they also made it possible to pinpoint the least important role
of knowledge on the disease, the perception of threat (i.e. perception of vulnerability,
perception of disease severity and concern about infection) and demographic variables for
condom use (Sheeran et al., 1999). Therefore, the applications of socio-cognitive models in
the interventions to promote condom use has brought about important advances in
addition to the simple dissemination of information and changes to the level of beliefs and
attitudes towards HIV/AIDS.
The afore-mentioned socio-cognitive models and similar motivational models also
assume that behavioural changes occur in a linear manner, thus being continuous models.
Hence, associated interventions are of a one-size-fits-all type, which do not take into
account the changes that may have been made by the individual (Schwarzer, 2008).
Stage models, on the other hand, defend that some discontinuities exist in the
process of behaviour change, where people go through several mindsets (stages) with
specific cognitive and behavioural characteristics. Thus, some predictors will be relevant for
particular stage transitions, but might be irrelevant for others. Since people at the same
stage are likely to face similar barriers, and different barriers must be overcome by people
at different stages, interventions should be adapted to fit the needs of people at different
stages of change (Weinstein et al., 1998). Progress throughout the stages, i.e., forward
transitions between the stages, is thus considered a valid intervention goal in stage theories.
In each of these stages, changes are expected to occur in the individual’s perception and
39
CHAPTER 1: INTRODUCTION
cognition, through the manipulation of variables that characterize the stage, allowing
transition to the next stage (Schwarzer, 2008; Schüz, Sniehotta, Mallach, Wiedemann, &
Schwarzer, 2009). Some examples of stage models in the health context (see, Schüz et al.,
2009 for a review) are the Transtheoretical Model of Change (TTM; Prochaska &
DiClemente, 1983), the Precaution Adoption Process Model (Weinstein, 1988; Weinstein &
Sandman, 1992), the I-Change model (de Vries, Mesters, van de Steeg, & Honing, 2005) and
the Health Action Process Approach (HAPA; Schwarzer, 2008).
Unlike continuous models, where all individuals are subject to the same type of
intervention, stage-model intervention is adapted to the stage of change of the individual. In
other words, different interventions are appropriate at different stages of health behaviour
change. One of the most apparent distinctions among different stage theories is the number
of proposed stages. Whereas the TTM (Prochaska & DiClemente, 1983) defines five stages
(pre-contemplation, contemplation, preparation, action and maintenance), and the PAPM
(Weinstein, 1988) provides seven stages (unaware, disengaged, undecided, decided not to
act, decided to act, action and maintenance), the HAPA model (Schwarzer, 2008) establishes
only three fundamental distinctions (non-intending, intending, and action). Despite
important differences, all stage theories share the assumption that health behaviour change
processes evolve through a sequence of qualitatively different stages or mindsets (Sutton,
2005). They sustain that people at different stages should benefit from distinct treatment in
order to progress to the following stage (Weinstein et al., 1998).
Stage models also differ from continuous models in that they take into account other
criteria besides the probability of performing a behaviour. Therefore, based on the
40
CHAPTER 1: INTRODUCTION
assumption that an individual moving from one stage to the next increases the likelihood of
reaching the final stage of change, the quality of the intervention, according to these
models, is evaluated on the basis of the transition between stages. Some studies suggest
that this type of approach that takes into account the stage at which the individual finds
him/herself increases the effectiveness of interventions (Prochaska & Velicer, 1997; Schüz et
al., 2009).
According to this stage perspective, behaviour change, including condom use, is not
seen as a discrete or drastic move, of an all or nothing type, but is, rather, a gradual process
of advances and setbacks for which the adaptation of the type of intervention to the stage
of change can facilitate the effect of interventions (Noar, 2008).
4.2 The Health Action Process Approach (HAPA)
The HAPA model (Schwarzer, 2008) may be considered a hybrid model as it might be
used in its continuum version or as a stage model, depending on whether the purpose is to
predict behavioural changes or to guide interventions (Schwarzer, 2008).
What makes the HAPA distinct from other models is its five main principles
(Schwarzer, Lippke, & Luszczynska, 2011). The first principle suggests that one should divide
the health behaviour change process into two phases. There is a switch of mindsets when
people move from motivation to action. First is the motivational phase in which people
develop their intentions, and afterwards they enter the volitional phase where they
translate their intentions into action. The second principle is that within the volitional phase,
individuals can be grouped into two stages, those who have not yet translated their goals
41
CHAPTER 1: INTRODUCTION
into action, and those who already have. According to Schwarzer et al. (2011), there are,
therefore, three categories of individuals, depending on their readiness within the course of
health behaviour change: pre-intenders, intenders, and actors. The third principle includes
planning as a mediator between intention and behaviour; planning facilitates the transition
from intention to tangible behaviour. Intenders who are at the volitional pre-actional stage
are motivated to change, but do not act because they might lack the appropriate skills for
translating their intention into action. Planning is a key strategy at this point. The fourth
principle assumes that planning can be divided into action planning and coping planning.
Action planning pertains to the when, where, and how of intended action. Coping planning
includes the anticipation of barriers and the design of alternative actions that help to attain
one’s goal despite hindrances. The last principle is based on the importance of self-efficacy,
which is required throughout the entire behaviour change process. However, the nature of
self-efficacy differs as different challenges arise, and as people progress from one phase to
the next. Goal setting, planning, initiative, action, and maintenance all pose unique
challenges. Therefore, perceived self-efficacy and volitional self-efficacy are specifically
distinguished terms.
According to Conner and Norman (2005) the main feature of the HAPA lies in the
explicit distinction between a motivational and a volitional stage. Within the two phases,
different patterns of social–cognitive predictors may emerge (see Figure 1).
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CHAPTER 1: INTRODUCTION
Figure 1.The Health Action Process Approach (adapted from Schwarzer, 2008).
In the motivational phase the individual develops an intention to change. Three
variables are considered to play a major role in this process: risk perception, outcome
expectancies, and self-efficacy. The process of forming an intention often starts with some
level of risk perception that is considered a distal predictor in the motivational phase, in the
sense that it might instigate thoughts about change, yet it is not sufficient for intention
formation (Luszczynska & Schwarzer, 2003). In recent research on condom use, risk
perception was also found to be less important in determining one’s intention to take action
(Teng & Mak, 2011). Weighing the pros and cons, namely holding positive outcome
expectancies (i.e., anticipating positive consequences from change), and action self-efficacy
(i.e., beliefs about one’s own ability to accomplish a certain task by one’s own actions and
resources) are considered the main predictors of intention. Therefore, interventions aiming
to move individuals from a non-intentional to an intentional stage of change should target
at least some of these constructs.
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CHAPTER 1: INTRODUCTION
After forming an intention, the individual enters the volitional phase. When someone
is inclined to adopt a particular health behaviour, the “good intention” has to be
transformed into detailed instructions on how to perform the desired action. Once an action
has been initiated, it has to be maintained. This is not achieved through a single act of will,
but involves self-regulatory skills and strategies. Planning covers both action planning (i.e., a
mental simulation of when, where and how the behaviour will be performed) that can be
considered synonymous with implementation intentions (Gollwitzer, 1999) and coping
planning (i.e., the anticipation of barriers and the generation of alternative behaviours to
overcome them). The combination of action and coping plans have been found to be highly
effective for physical exercise (Sniehotta, Scholz, & Schwarzer, 2005). Besides planning,
volitional self-efficacy refers to the perceived ability to cope with unexpected barriers
(maintenance self-efficacy) and maintain difficult behaviours (recovery self-efficacy), many
of which may turn out to be far more challenging to adopt than initially anticipated.
Maintenance self-efficacy refers to optimistic beliefs about one's own ability to deal with
the barriers that might present themselves during the maintenance phase, and recovery
self-efficacy is related to optimistic beliefs about one's own ability to get back to the
previous behavioural pattern after a setback or a failure. Both facets of volitional selfefficacy have been found to exert an important influence on several health behaviours, such
as healthy eating (Renner et al., 2008) and physical activity (Luszczynska et al., 2010). Teng
and Mak (2011) attest the relevance of maintenance and recovery self-efficacy for condom
use. High confidence in the ability to use condoms encourages people to try harder to seek
alternative strategies when one of them fails. Interventions aiming to shift individuals from
44
CHAPTER 1: INTRODUCTION
an intentional to an action stage of change should target at least some of these volitional
constructs.
The continuum version of the HAPA model has been tested in longitudinal and
experimental studies that have used the model in its entirety or focused on some of its
constructs for a range of health behaviours, such as breast self-examination (Luszczynska &
Schwarzer, 2003), physical activity (Barg et al., 2012; Koring et al., 2013a; Renner, Spivak,
Kwon, & Schwarzer, 2007), condom use (Teng & Mak, 2011), eating a healthy diet
(Guttiérez-Dõna, Lippke, Renner, Kwon, & Schwarzer, 2009; Renner et al., 2008), and fruit
and vegetable intake (e.g., Godinho, Alvarez, Lima, & Schwarzer, 2014; Kreausukon, Gellert,
Lippke, & Schwarzer, 2012).
In the HAPA as a stage model, the volitional phase may be further divided into a preaction phase and a post-action phase, thus enabling a distinction among three qualitatively
different stages: the non-intentional, comprising the individuals who are not yet in
possession of an intention to change their behaviour, the intentional, encompassing the
individuals who have already entered the volitional phase but have not yet initiated action
and, finally, the action stage, where individuals are already acting upon their intentions.
Some studies have used the stage version of the HAPA, either to examine the predictors
associated with specific stage transitions (e.g., Wiedemann et al., 2009, for fruit and
vegetable intake), or to test the stage assumptions by means of matched-mismatch
interventions (e.g., Lippke, Schwarzer, Ziegelmann, Scholz, & Schüz, 2010; Luszczynska, Goc,
Scholz, Kowalska, & Knoll, 2011). Some have demonstrated that interventions targeting
determinants of intention are only effective among pre-decisional individuals (Luszczynska
45
CHAPTER 1: INTRODUCTION
et al., 2011; Reuter, Ziegelmann, Wiedemann, & Lippke, 2008) and that interventions
targeting predictors that are important at the intentional phase are only effective when
applied to individuals at that stage (e.g., Lippke et al., 2010; Reuter et al., 2008; Schüz,
Sniehotta, & Schwarzer, 2007; Wiedemann, Lippke, Reuter, Ziegelmann, & Schwarzer,
2011a).
One of the main assumptions of the HAPA is that a different set of processes is
relevant for different stage transitions (see Figure 1). This is done by identifying individuals
who are either at the motivational or volitional stage. When it comes to the design of
interventions, each group receives specific, tailored treatment. In interventions for preintenders, one needs risk and resource communication, for example by addressing the pros
and cons of a critical behaviour. Interventions aiming to move individuals from an
intentional to an action stage of change should target constructs such as action planning,
coping planning and maintenance self-efficacy. On the other hand, interventions targeting
actors should foster behavioural maintenance by reinforcing coping planning, maintenance
and recovery self-efficacy. In short, it is a clearly-specified and parsimonious model,
establishing which predictors are relevant for each of the stage transitions, and defining the
stages by means of psychologically meaningful differences in intention and behaviour
In the present dissertation the HAPA as a continuum layer is tested in Chapters 1 and
2 and as a stage layer in Chapter 3.
46
CHAPTER 1: INTRODUCTION
4.3 Computer-targeted stage intervention
Theoretical models provide a logical framework for designing behavioural
interventions (Lawrence & Fortenberry, 2007), offering a road map for studying a health
problem, enabling explanation of the relationships between variables, and specifying the
measurement that will provide useful outcome evaluations from an intervention.
In fact, current interventions for sexual risk reduction are largely influenced by models
that address social–cognitive factors (Johnson et al., 2014; Noar, 2008), which offer a useful
way to conceptualize and change health behaviours and provide a theoretical framework for
evaluating how interventions work— or why they do not work (Rothman, 2004).
According to Lawrence and Fortenberry (2007), behavioural interventions are
characterized by a specified theoretical model, an intervention using evidence-based
methods of behaviour change, a rigorous outcome evaluation, a sound research design, a
measurement of multiple domains such as cognitions (e.g., self-efficacy beliefs) and
behavioural skills (e.g., condom use).
From a health education intervention standpoint, depending on the degree of
individualization, interventions may be generally classified as targeted when the same
message is provided to large audiences, or tailored when they are adapted to the
characteristics of one individual (Kreuter, Strecher, & Glassman, 1999). Targeting is a way of
improving the efficacy of interventions through a combination of strategies and information
based on the identification of similarities in a group or sub-group of individuals, and further
adapting the communication to meet those characteristics (Noar, Harrington, & Aldrich,
2009).
47
CHAPTER 1: INTRODUCTION
The use of new information and communication technologies (ICT’s) in health has
increased exponentially, bringing new possibilities and tools for healthcare professionals.
ICTs, on the one hand, have the unique opportunity for online interactivity, i.e., the Internet
can deliver sophisticated messages tailored to specific individual risk behaviours in a way no
other broadcast message can, and on the other hand, can reach a far higher number of
people online than through any face-to-face campaign. Over the past decade, in particular,
the Internet has presented an ample potential to facilitate interventions that can promote
STI/HIV control and prevention (McFarlane & Bull, 2007). Therefore, an increasing number
of interventions, designed to promote health behaviour change, has been delivered via the
Internet, and meta-analyses have shown that Internet-based interventions have positive
effects on behaviours such as physical activity, healthy eating, and smoking cessation (e.g.
Lustria et al., 2013; Webb, Joseph, Yardley, & Michie, 2010).
Content matching is one of the strategies that can be used to target interventions to
the group level and consists of adapting constructs theoretically associated with the
outcome of interest (e.g. attitudes, self-efficacy, behavioural intentions) to group scores
(Hawkins, Kreuter, Resnicow, Fishbein, & Dijkstra, 2008).
Thus, prior to the computer-targeted interventions, the individual has to be evaluated
according to each selected variable, usually through answering a computerized / online
questionnaire. In order to develop this computer-targeted intervention, first, it is important
to identify and select the relevant psychosocial, behavioural and demographic variables that
will serve as the basis for customizing the intervention, then, with a view to attributing a
specific intervention to the previously assessed individual parameters, an algorithm, i.e., a
48
CHAPTER 1: INTRODUCTION
non-ambiguous set of decision rules, must then be defined. The creation of a database
containing all the messages/intervention options that will correspond to each identified
profile is also important. Thus, depending on individual answers to the questionnaire, a
specific message/intervention is presented (for a detailed explanation see Godinho, Araújo,
& Alvarez, in press).
Stage models, therefore, offer a useful template for adapting interventions to
individuals´ needs, as they provide guidance for the selection of a parsimonious set of
relevant determinants upon which they may be tailored (Godinho, Alvarez, & Lima, 2013).
Furthermore, the availability of behavioural change techniques (BCTs) (Michie at al., 2013)
helps to determine what should be manipulated in each intervention.
Computer-targeted interventions may be based on a virtually infinite number of
variables, but the most common approach is the use of demographic variables, such as
gender, age, ethnicity and income (Slater, 1995). Although this type of tailoring / targeting
may contribute to increased persuasion (Noar et al., 2007), one arguably more sophisticated
approach would be to target the major motivational and volitional variables that are known
to influence health behaviours, according to the individual’s stage of change (Godinho, et
al., in press).
Most behaviour change interventions for HIV/AIDS prevention have attempted to
increase condom use by boosting intentions towards its use (Bauman, Karasz, & Hamilton,
2007; Mevissen, Ruiter, Meertens, Zimbilec, & Schaalma, 2011). However, few have focused
upon helping those who have already formed strong intentions to use condoms to actually
carry out these intentions (Althoff, et. al., 2014; von Haeften, Fishbein, Kaspryzk, &
49
CHAPTER 1: INTRODUCTION
Montano, 2000). Although a variety of Internet-based safer sex interventions exist with
varying rates of cost-effectiveness (Pinkerton, Johnson-Masotti, Holtgrave, & Farnham,
2002), hardly any of the studies have specifically addressed a computer intervention for
condom use, targeted to different stages of change.
5. Overview of the empirical studies
The aim of this dissertation is to provide a more in-depth understanding of the
psychological processes that are relevant for condom use, in addition to understanding the
pertinence of a stage-based intervention in the promotion of condom use.
Previous research has attested the relevance of the psychosocial predictors for the
explanation of the practice of different health behaviours, including condom use (e.g.,
Sheeran et al., 1999). It is also now known that despite motivational factors being good
predictors of behavioural intention (Ajzen, 1991), they provide only a partial account when
it comes to predicting behaviour change (Webb & Sheeran, 2006). Therefore, volitional
factors have been more recently studied in an attempt to understand the self-regulation
processes involved in the behavioural enaction of condom use (e.g., Teng & Mak, 2011).
Cumulatively, good results of stage-matched tailored interventions have been attested
(Noar et al., 2007) and different sets of predictors of the HAPA model have been shown to
be important for different stage transitions (Schüz et al., 2009). Thus, evidence has been
found on the value of cognitive social constructs for the understanding of condom use, as
well as the usefulness of interventions adapted to the individual's stage of change. However,
several important issues are yet to be analysed. Some ideas are presented on how to further
50
CHAPTER 1: INTRODUCTION
understand self-regulatory factors and intervention in the promotion of condom use and
efforts will be addressed in the present dissertation in the following three empirical
chapters.
As noted above, the role of motivational factors in intention formation has been
extensively studied and is now better established (Armitage & Conner, 2000). A
considerable part of the research on volitional determinants has used the HAPA model as a
theoretical backdrop, and has shown that volitional determinants, such as planning, is more
proximal and better more capable of explaining variability in behaviour than motivational
variables (Guttiérez-Dõna et al., 2009). However, whereas inclusion of the planning
construct has received significant empirical support and has been studied as a cognitive
antecedent of action (Schwarzer, 2008), preparatory behaviours, which may help initiate
and maintain behaviours (Sheeran et al., 1999), have been less studied as a salient aspect of
planning up to now. Planning, as a preparatory behaviour, has proven to facilitate the
adoption of a health behaviour, as barriers are minimized and cues for action are
encountered more frequently (Koring et al., 2013). Some studies have tested the
hypothesized mediating role of preparatory behaviours in condom use and have
demonstrated that adolescents who intended to use condoms and prepared themselves to
do so (buying, carrying, and discussing condom use with a sexual partner) were more likely
to actually use them (Bryan et al., 2002; van Empelen & Kok, 2006, 2008). However, there
appears to be a lack of studies investigating the applicability of both pre-intentional factors,
such as positive outcome expectancies, and post-intentional factors, such as preparatory
behaviours, in condom use behaviour. Therefore, in Chapter 2, this new variable which,
according to the literature, might influence the predictive value of the HAPA model for this
51
CHAPTER 1: INTRODUCTION
particular behaviour has also been explored. Thus, we have tested the mediating role of
preparatory behaviours as a volitional factor between intention and condom use within the
HAPA framework.
Self-regulatory processes have proven to be useful in condom use however, whenever
volitional variables have been studied, preparatory behaviours were not taken into
consideration in the explanation of condom use. As the HAPA is an open architecture
framework, one should not expect to find a single acid test of the entire model as displayed
in Figure 1, and instead, in Chapter 3, the further contribution of preparatory behaviours
added to the set of volitional variables of the HAPA model (volitional self-efficacy, action
planning and coping planning) was investigated, and a test was performed to ascertain
whether these variables sequentially mediate the relationship between intention and
condom use.
A variety of web-based safer sex interventions with varying rates of cost-effectiveness
is readily available (Pinkerton et al., 2002), however hardly any of the studies have
specifically addressed a computer intervention for condom use, targeted to stages of
change. Thus, in Chapter 4, evidence for the utility of a brief computer-targeted intervention
for promoting condom use and adapted to the stages of change envisioned by the HAPA for
individuals with little motivation to use condoms or already with the intention, but not using
them consistently, will be presented.
It is the aim of this research study to clarify the relevant psychological mechanisms for
condom use, in particular the importance of the preparatory behaviours, and the usefulness
of a stage-based intervention, in a heterosexual sample, underscoring the findings by Teng
52
CHAPTER 1: INTRODUCTION
and Mak (2011) that the HAPA could be applied successfully to condom use in homosexual
men. Three studies with different samples (although there is some overlap among the
samples) were conducted: two longitudinal survey studies (Chapter 2 and 3), and one
experimental/longitudinal study (Chapter 4), all with Portuguese samples. These studies will
be presented in the following three chapters, which are based on published articles
(Chapters 2 and 3) and a submitted manuscript (Chapter 4). Since these chapters were
written for publication in scientific journals, the underlying rationale is provided in each
chapter, as well as the specific aims, so they can be read independently of each other. In
Chapter 2, a longitudinal analysis of data collected over a one-month period, by means of an
on-screen questionnaire (Appendix A) is presented, which sets out to understand the
psychological mechanisms that operate in condom use. The role of preparatory behaviours
with pre-intentional and volitional variables is specifically examined, looking at the
mediating role of preparatory behaviours, such as buying condoms and carrying them, in the
relationship between intention and condom use. The following hypotheses have been
addressed in Chapter 2: outcome expectancies will be determinants of intentions to use
condoms; intentions and maintenance self-efficacy will be determinants of the performance
of preparatory behaviours; and preparatory behaviours will be the proximal determinant of
condom use. Chapter 3 presents a longitudinal study with data collected through an online
survey, conducted with a view to analysing the role of preparatory behaviours that were
explored jointly with the volitional variables proposed by the HAPA model, to ascertain
whether in condom use, they could be important or even more important in the translation
of behavioural intentions into actual condom use. Thus, in Chapter 3, confirmation of the
following hypotheses has been sought: self-regulation, exerted through action and coping
53
CHAPTER 1: INTRODUCTION
planning, volitional self-efficacy and preparatory behaviours, will predict condom use
behaviour better than intentions alone or than the volitional variables without preparatory
behaviours. Furthermore, preparatory behaviours are considered to be the most proximal
predictors of behaviour, mediating between volitional variables proposed by the HAPA
model and condom use. In Chapter 4 data collected in an experimental/longitudinal study is
analysed with the aim of testing the utility of a brief computer-targeted intervention
(Appendix B), developed for non-intenders, namely those who have not (yet) set the goal to
act according to a previously defined criterion, and intenders who are motivated to change,
but not yet acting, to promote condom use, adapted to the stage of change. In Chapter 4
the following hypotheses have been posited:
non-intenders in the motivational
intervention condition will show higher levels in intention of using a condom two weeks and
one month later, compared to non-intenders in the control condition, and intenders in the
volitional intervention condition will show higher levels in condom use two weeks and one
month later, compared to intenders in the control condition.
The main findings of these three studies (Chapters 2, 3 and 4) as well as their principal
contributions will be discussed after the presentations of these empirical chapters, in the
general discussion section (Chapter 5).
54
2
PREPARATORY BEHAVIOR FOR CONDOM USE AMONG HETEROSEXUAL
YOUNG MEN: A LONGITUDINAL MEDIATION MODEL
This chapter is based on the paper:
Carvalho, T., Alvarez, M.-J., Barz, M., & Schwarzer, R. (2015). Preparatory behavior for
condom use among heterosexual young men: A longitudinal mediation model. Health
Education & Behavior, 42(1), 92-99. doi:10.1177/1090198114537066
CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
1. Abstract
Objective: Motivation is not sufficient to actually use condoms as self-regulatory
processes are needed to translate motivation into action. Buying condoms and carrying
them, constitute preparatory behaviors that may serve as proximal predictors of action.
Whether or not such preparatory behaviors operate as mediators between intention and
action within a broader behavior change framework has been examined.
Method: A sample of 150 heterosexual men aged between 18 and 25 years responded at
three points in time to a computer based survey that assessed behavior as well as socialcognitive antecedents. A structural equation model was specified that included preparatory
behaviors and self-efficacy as mediators at Time 2.
Results: Preparatory behaviors were the most proximal predictors of condom use, and
they were, themselves, predicted by self-efficacy and intention. The latter was partly
determined by positive emotional outcome expectancies.
Conclusion: To bridge the intention-behavior gap, preparatory behaviors play a mediating
role, and they represent a side of planning that constitutes the most proximal predictor of
condom use.
Keywords: young adults; condom use; HAPA model; self-regulation; preparatory behavior.
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
2. Introduction
To prevent infectious sexual diseases (ISDs), condom use has been identified as an
appropriate strategy. Motivation for using condoms is a prerequisite of such behavior.
However, a good intention is not always translated into action, and therefore, a mediating
role of preparatory behaviors has been suggested in previous studies. Buying condoms and
carrying them have proven to be essential steps to be taken before actual use (Bryan et al.
2002; van Empelen, & Kok, 2006, 2008). A meta-analysis has concluded that preparatory
behaviors (e.g., carrying a condom or having a condom available) were associated with
medium to large effect sizes in the prediction of condom use (Sheeran et al. 1999). In these
studies, intentions to use condoms by themselves did not appear to affect condom use,
unless the intentions were associated with preparatory behaviors, such as buying or carrying
condoms. Thus, studies that focus entirely on intentions for condom use prediction may be
missing important aspects of the process of moving from intentions to actual behavioral
change (Lewis, Kaysen, Rees, & Woods, 2010). The present study further examines the
mediating role of such behaviors within the context of a larger framework of health
behavior change.
Sexual risk behavior and condom use
Condoms are one mechanism by which to prevent the transmission of HIV (Malcolm et
al., 2013) and recent advances in knowledge involve harnessing the behavioral and social
sciences to promote improved frequency of condom use. Young men are often motivated to
use condoms, however in practice they fail to act in accordance with their intentions,
because in the heat of the moment, the motivation to prevent sexually transmitted
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
infections becomes secondary (Albarracín et al., 2005). There is a need to ensure that
accurate messages are delivered about safer sex and condom use to this vulnerable group
(East, Jackson, O'Brien, & Peters, 2007).
Changing health behaviors may be based on models that make assumptions about the
interplay of psychological constructs. One of these assumptions is related to the prominent
role of intention in health behavior change. The main determinants of health behaviors
focus primarily on motivational factors such as beliefs, attitudes and personal vulnerability
and these determinants affect behavior through the mediation of a behavioral intention.
Hence, several health behavior models converge on the idea that intention is the most
proximal cause of behavior (Armitage & Conner, 2000). However, change involves more
than an intention, and this is empirically revealed by what is acknowledged in the literature
as the intention-behavior gap, that is, successful changes in intention engender only smallto-medium change in behavior (Webb & Sheeran, 2006). Therefore, motivational models
provide only a partial account of how motivation is translated into action.
A model that attempts to explain the mechanisms that operate after individuals have
formed an intention to change their behavior is the health action process approach (HAPA;
Schwarzer, 2008) that explicitly includes post-intentional factors.
The health action process approach (HAPA)
In the HAPA, the social-cognitive factors in changing health-related behaviors are
organized as two distinct phases, one conducive to a behavioral intention, a pre-intentional
phase, and the other leading to actual behavior, a post-intentional phase (see Figure 2).
People first need to become motivated. Perceived risk, outcome expectancies and perceived
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
self-efficacy are responsible for the development of an intention to refrain from a risk
behavior or to adopt a health behavior. Secondly, in order to change, the individual needs
self-regulatory effort before taking action and maintaining such changes. Planning, action
control, perceived self-efficacy to overcome barriers and to recover from setbacks, are the
main variables proposed to explain the translation of intention into action. Risk perception
is seen as a distal antecedent of the motivation to change but is insufficient to enable a
person to form an intention if not accompanied by outcome expectancies and self-efficacy
(Schwarzer, 2008).
Outcome expectancies may be positive or negative (pros and cons), and can be divided
into the social, physical and emotional. The positive emotional outcome expectancies are
particularly supposed to facilitate intention formation (Schwarzer, 2008).
Perceived self-efficacy refers to individuals’ optimistic self-beliefs in their abilities to
control challenging demands, and is influential at all stages of the behavior change process
(Bandura, 1997). Therefore, stage-specific adaptations of the wording of self-efficacy
measures are useful. For instance, maintenance self-efficacy refers to the perceived ability
to maintain a newly adopted behavior, and cope with unexpected barriers during the
maintenance phase of behavior (Luszczynska & Schwarzer, 2003).
Planning is an important step in the creation of conditions for initiating behavior and
includes specific plans on when, where and how to perform the behavior, the anticipation of
barriers and the design of alternative actions that may help to attain one’s goals despite
barriers. As such, planning serves as an operative mediator between intentions and
behavior (Koring, et al., 2013a).
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
Self-regulatory constructs other than planning and self-efficacy might help to further
explain post-intentional processes of health behavior change. For instance, action control,
an in situ self-regulatory strategy which enables the comparison of actual behavior with
one’s own standards, has been found to improve the predictive value of the model in some
cases (Sniehotta, et al., 2005). Research on the interplay of the different underlying selfregulatory mechanisms has also improved the predictive value of the HAPA and condom use
has been found to depend on planning, mainly in self-efficacious men (Teng & Mak, 2011).
The development of self-regulatory skills plays a major role in the adoption and
maintenance of behavior. For condom use, one of the most important self-regulatory
strategies is the performance of preparatory behaviors, which implies a sequence of
actions such as purchasing and carrying condoms, thus, increasing individuals’ control
over condom use (Bryan et al., 2002).
Figure 2. Health Action Process Approach (HAPA) Model
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
Predictors of condom use: The role of preparatory behaviors
Several behavior change models have conceptualized predictors of condom use
(Albarracín, Johnson, Fishbein, & Muellerleile, 2001). One meta-analysis concluded that
three preparatory behaviors were among the strongest determinants of condom use:
purchasing condoms, having them available, and discussing condom use with a sexual
partner (Sheeran et al., 1999). However, there appears to be a lack of studies investigating
the applicability of both, the pre-intentional factors, such as positive outcome expectations,
and the post-intentional factors such as preparatory behaviors, in condom use behavior.
Sheeran et al. (1999) suggested that preparatory behaviors “emerge as medium-to-strong
predictors of condom use” (p. 118), and some studies have tested the hypothesized
mediational role of preparatory behaviors on condom use and have demonstrated that
adolescents who intended to use condoms and prepared themselves to do so (buying,
carrying and discussing condom use with a sexual partner) were more likely to actually use
condoms (Bryan et al., 2002; van Empelen & Kok, 2006, 2008; Gebhardt, et al., 2006;
Zimmerman et al., 2007).
Our study expands these results, contributing to the understanding of the role of
preparatory behaviors in the context of the HAPA model, one of the few models to
incorporate volitional influences on behavior (Conner, 2008). Preparatory behaviors are,
therefore, studied along with pre-intentional factors such as outcome expectancies as well
as post-intentional factors such as maintenance self-efficacy. Furthermore, data were
collected at three measurement points in time, more suited to a mediation model of this
type, in which preparatory behavior was assessed before condom use. This procedure was
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
chosen over the more common two measurement points in time used in many longitudinal
studies, where preparatory behavior and condom use are measured concurrently such as in
the studies of Bryan et al. (2002), Zimmerman et al. (2007) and van Empelen and Kok, (2006,
2008).
Moreover, whereas inclusion of the planning construct has received significant empirical
support (Schwarzer, 2008) and has been studied as a cognitive antecedent of action,
actually buying condoms and having them available constitutes a preparatory behavior that
might help initiate and maintain condom use which, up to now, has been seldom studied as
a salient aspect of planning. Planning, as a preparatory behavior, might facilitate the
adoption of a health behavior, as barriers are minimized and cues to action are encountered
more frequently (Koring et al., 2013).
Aims of the study
The goal of the current longitudinal study was to test the mediational role of
preparatory behaviors as a volitional factor between intention and condom use within
the HAPA framework, using three measurement points in time, among a sample of
heterosexual young men. We hypothesized that (a) outcome expectancies will be
determinants of intentions to use condoms; (b) intentions and maintenance self-efficacy will
be determinants of the performance of preparatory behaviors and (c) preparatory behaviors
will be the proximal determinant of condom use. The sample consisted of young men based
on the premise that young men are particularly vulnerable to ISD’s. Indeed, the Centers for
Disease Control (CDC) estimate that nearly half of the 20 million new ISD’s in the United
States occur among young people aged 15 to 24 years (CDC, 2013).
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
3. Method
Participants and Procedure
A total of 470 sexually active young men, recruited in Portugal from several vocational
training centers1 participated in the study at Time 1 (T1). To be eligible, they needed to be
between 18 and 25 years of age and identify themselves as being heterosexual. At Time 2
(T2), the questionnaire was answered by 218 (46%) and at Time 3 (T3) by 150 men (32%).
The present study includes only the longitudinal sample with 150 participants.
The mean age of the men was 19 years (SD = 1.71), and while 76% of them reported 10
to 12 years of schooling, 24% reported nine years or less. The participants were mostly
Portuguese (87.3%), some were African (6.7%), Brazilian (2.7%), or from other European
countries (3.3%).
After participants had been notified of the aims of the study, they gave informed
consent, and completed the first computer based questionnaire in class. The remaining two
computer based questionnaires were sent by e-mail, with two-week intervals. All students
were entitled to a raffle ticket for a gift check in return for their participation.
To increase adherence to all measurement points in time, we used a computer based
data collection procedure, based on the evidence that participants, when responding to a
web questionnaire, as opposed to a paper-and-pencil questionnaire, are less biased by
social desirability (Gosling, Vazire, & Srivastava, 2004). The study was approved by the Ethics
Committees of the institution involved.
1
Schools where vocational training is provided and, at the end of the course, the student is
awarded a joint certificate which is both an academic and professional qualification.
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
Measures
Focus groups were conducted in a previous study, prior to the construction of the
questionnaire, and items were adapted in terms of the language, cultural characteristics,
and age of the men.
Outcome expectancies, intention, maintenance self-efficacy, preparatory behaviors,
condom use and social desirability were assessed using six-point Likert scales ranging from
(1) strongly disagree to (6) strongly agree.
In the same manner as other health behaviors have been measured (Schwarzer et al.,
2007), condom use was assessed by two items at T1 and T3: (“In the last month, how often
have you always used a condom whenever you have had sexual intercourse (vaginal and /or
anal)? and “In the last month, how often was condom use part of your habitual sexual
practices”). The internal consistency was α = .86 (T1) and α = .86 (T3).
Positive outcome expectancies of condom use were measured by four items at T1 (α =
.77) (e.g. “When I use a condom, I feel safe”, “When I use a condom I feel that I'm protecting
my partner“), emphasizing the emotional aspects of this behavior (Kelly, 1995; White, Terry,
& Hogg, 1994).
Three items used to measure intention, adapted from Schwarzer (2008), were
administered at T1 (α = .93). For example: "From now on, I intend to always use a condom",
" I intend to use a condom the next time I have sex”.
Maintenance self-efficacy was measured at T2 by seven items asking men to evaluate
their confidence in maintaining condom use when faced with barriers, as mentioned in the
literature on condom use (Kelly, 1995; White, Terry, & Hogg, 1994). Example items were: "I
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
think I can always maintain the use of condoms even if I am under the influence of
substances (drugs and /or alcohol)" and "I believe I can maintain the systematic use of
condoms, even if my partner is very attractive". The internal consistency in the present study
was α = .87.
Preparatory behaviors such as buying and carrying condoms were measured at T2 using
three items adapted from Bryan et al. (2002): "I buy /acquire a condom when I expect the
possibility of sex ", "I have a condom with me when sex is a possibility" and “I keep condoms
around whenever intercourse may occur”. The internal consistency in the present study was
α = .93.
Given the sensitivity of the studied subject, social desirability was measured at T1 and
used to inspect whether data collected on the other measures were associated with social
desirability. The five-item Socially Desirable Response Set Survey (SDRS-5; Hays, Hayashi, &
Stewart, 1989) was used to assess the tendency to describe oneself in favorable terms.
Responses above 5 indicate a tendency towards socially desirable responses in answering
the questionnaire. The internal consistency in the present study was α = .69.
Data analysis
Structural Equation Modeling with AMOS 19.0 (Arbuckle & Wothke, 1999) was
performed using the Maximum Likelihood (ML) estimation. The model fit was assessed by
examining the χ2, χ2/df, comparative fit index (CFI), the root-mean-square error of
approximation (RMSEA), and the Tucker–Lewis-Index (TLI). A satisfactory model fit is
indicated by χ2/df (<2), a high CFI and TLI (>.90) and a low RMSEA (<.08) (Tabachnick &
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Fidell, 2001). The model was specified with condom use at baseline as a predictor of all
variables.
4. Results
Drop-out analysis
To examine whether the longitudinal sub-sample was representative of the initial sample,
the Time 1 answers of the participants who completed all three questionnaires (n= 150)
were compared to those who did not (n= 320). No significant differences were found
regarding age, educational level, nationality, type of relationship in which they were
involved, type of relationship at the time of the first act of intercourse and condom use at
baseline. There was only a difference in the age at the point of first intercourse, χ2 (2) =
22.47, p < .01. Participants who completed all three questionnaires had their first act of
intercourse later (> 17 years old) than those who did not complete the three questionnaires
(< 17 years old).
Preliminary Analysis
A confirmatory factor analysis of the measurement model revealed that the original
structure was maintained in the present sample (χ2 (173) = 268.13; χ2/df= 1.52, CFI = .97;
TLI = .95, RMSEA = .06). All factor loadings were higher than .50.
Main Results
All participants had already had sexual relationships, and 16% of them had had their first
intercourse at age 14 or earlier, 43% at age 15 or 16, and 41% at age 17 or later. Six was the
mean number of lifetime partners reported. Participants at Time 3 were in a steady (51%),
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casual (15%) or both types of relationships (15%), and 19% were involved in none. However,
during the period under review, they were sexually active. Twelve percent of the sample did
not report using condoms at all in the past month, at baseline.
In Table 1, the means and standard deviations are presented as well as the correlations
for the latent variables outcome expectancies, intentions, and behavior at Time 1,
maintenance self-efficacy, and preparatory behavior at Time 2, and condom use at Time 3.
All correlations among variables were significant, with the exception of social desirability.
Apart from past behavior, the highest correlation emerged for preparatory behavior and
condom use.
Table 1. Correlations of latent variables.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Mean SD
1. Outcome expectancies (T1)
-
4.88
0.82
2. Intention (T1)
.45** -
4.77
1.26
3. Condom Use (T1)
.52** .57** -
4.31
1.77
4. Preparatory Behavior (T2)
.43** .58** .51**
4.64
1.33
5. Maintenance self-efficacy (T2)
.39
4.34
1.06
6. Condom use (T3)
4.14
1.91
7. Social Desirability (T1)
3.50
0.70
**
.31
**
.26
.40
**
.52
**
.04
.05
-
**
.47
**
-
.67
**
.55
**
.24
-
.06
.10
.03
.08
**
-
Note: * p<.05; ** p<.01
In the model, preparatory behavior was specified as a predictor of condom use. It was
hypothesized that intentions and maintenance self-efficacy would predict preparatory
behavior, and maintenance self-efficacy would have an indirect effect on behavior through
preparatory behavior (Figure 3). The fit indices confirmed that the model represented the
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CHAPTER 2: PREPARATORY BEHAVIOR FOR CONDOM USE
data appropriately χ2 (180) = 280.44, χ2/df = 1.55, CFI = .95; TLI = .94, RMSEA = .06.
Figure 3. Structural equation model with standardized parameter estimates
(Note: *p < .05; **p < .01)
Outcome expectancies, ß = 0.24, p < .05, were a predictor of intentions and accounted
for 44% of the variance in intentions. The direct path from intentions to condom use proved
not to be significant, ß = 0.14, p = .10, which indicates a full mediation by preparatory
behavior.
As shown in Figure 3, intentions predicted preparatory behaviors, ß = 0.33, p < .01,
whereas preparatory behaviors predicted condom use, ß = 0.24, p < .01. The indirect effect
of intention on behavior through preparatory behavior was ß = 0.08 (ZSobel =2.32, p = .01).
Maintenance self-efficacy, in turn, was a predictor of preparatory behavior, ß = 0.29, p<.01
but was not a predictor of condom use (ß = - 0.14, p =.31). The indirect effect of
maintenance self-efficacy on behavior through preparatory behavior was ß = 0.06 (ZSobel =
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2.32, p =.01). With baseline behavior included, the model explained 64% of the condom use
variance, while without the baseline it explained 40% of condom use variance.
5. Discussion
The present study has examined the mediational role of preparatory behaviors as a
volitional factor between intention and condom use within the HAPA framework, among
a sample of heterosexual young men. The model provides a good fit to the longitudinal data.
It was shown that (a), positive outcome expectancies were determinants of intentions to
use condoms (b) intentions and maintenance self-efficacy were determinants of the
performance of preparatory behaviors and (c) post-intentional volitional factor, namely
preparatory behaviors predicted condom use.
Intention and maintenance self-efficacy were shown to predict condom use through
preparatory behaviors. Consistent with previous research (Sheeran et al., 1999), these
findings suggest that these variables are proximal predictors of condom use in heterosexual
young men. Given that outcome expectancies were a powerful predictor of intention,
results also suggest that in order to successfully persuade individuals to use condoms,
presenting and emphasizing the positive emotional outcomes of safer sex may be effective
in increasing condom use.
Maintenance self-efficacy seems to play an important role in the performance of
preparatory behaviors for condom use also. Within the context of this model, maintenance
self-efficacy functioned as an indirect factor through which preparatory behaviors exerted
their influence on condom use. This construct emphasizes the confidence in dealing with
difficulties when preparing or executing an action. High confidence in the ability of condom
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use encourages people to try harder to come up with more strategies when one strategy
fails (Teng & Mak, 2011). In order to change habitual behavior and condom use, active selfregulation is necessary since the habits to be overcome are strongly elicited by situational
cues (Sutton, 1994). From this stance, the perceived ability to maintain one’s behavior
mirrors an optimistic belief in competent self-regulation. The effect of maintenance selfefficacy on preparatory behavior is, therefore, in line with these considerations.
The proposed model provides a possible explanation of pathways to condom use among
heterosexual young men, underscoring the findings by Teng and Mak (2011) that the HAPA
could be applied successfully to condom use in homosexual men. Nevertheless, it would be
useful to replicate the present findings in other samples beyond heterosexual young men,
for example in men who have sex with men. The relevance of preparatory acts may also be
generalized to other health behaviors, as Koring et al. (2013) found that the acquisition of a
pedometer represents a preparatory behavior that also facilitates physical activity.
There are a number of approaches to promote condom use among people at high risk of
sexual transmission of HIV, namely individual-level interventions (ILIs) and group-level
interventions (GLIs). These interventions directly address knowledge, attitudes, skills, and
behaviors related to condom use (e.g., Noar, 2008), and some emphasize preparatory
behaviors. Objective measures of condom availability have proven to be associated with
increased condom use (CDC, 1999). Our findings, in turn, confirm that it is important to
assess preparatory behaviors, and examine the mechanisms involved in the self-regulatory
sequence leading from goal setting to goal pursuit. The findings also suggest some general
guidelines for the design of educational interventions to promote condom use among
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sexually active young men. Such interventions should increase positive emotional
expectancies associated with condom use and target volitional self-efficacy beliefs, since
they have proven to facilitate intention formation and preparatory behaviors.
These
interventions should also ensure that young men are motivated not only to use condoms,
but also to plan to do so, through buying and carrying them, given the mediational role of
preparatory behaviors found in the study.
Some limitations need to be addressed. First, condom use was measured by self-reports
only, which may have been biased by social desirability. However, the average rate of social
desirability in our study was not very high, and it is consistent with the idea that high
desirability is not associated with condom use (Teng & Mak, 2011). Secondly, the results
should be generalized with caution, due to the specific socio-cultural characteristics of the
participants (e.g., low level of education). Future studies should include more representative
samples of young men to test the universality of the mechanisms found in this study. A third
limitation stems from the high dropout rate, which was perhaps due to the lack of financial
compensation. Although the high attrition rate was high, it is close to the average 40%
response rate that was identified in a meta-analysis on internet-based studies (Cook, Heath,
& Thompson, 2000). Furthermore, participants in the longitudinal sample did not differ from
those who had only filled out the first questionnaire, with the exception of the age at first
intercourse. However, there may always be differences in relevant unmeasured variables.
For example, analyzing the role played by substance abuse and relationship status might
have revealed relevant associations among the present model variables.
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Nevertheless, the innovative aspect of the current study lies in the evaluation of the
HAPA model for condom use in young heterosexual men. Findings contribute to the
understanding of the role of preparatory behaviors in the context of this process model that
incorporates motivational and volitional influences on behavior.
The act of buying condoms and having them to hand at the time of intercourse are
preparatory behaviors that one must carry out for condom use to occur. Thus, enacting
preparatory behaviors may be considered necessary in order to facilitate the desired
behavior. The findings point to the convenience of assessing preparatory behaviors and of
examining the mechanisms that are involved in the self-regulatory sequence leading from
goal setting to goal pursuit. Preparatory action, reflecting initiative, has been neglected in
most health behavior theories although it constitutes an obvious proximal predictor of
action. Interventions may well have succeeded in motivating individuals to prepare for
action, however this positive effect has remained invisible, as only target behaviors have
been assessed, failing to include such antecedents as useful indicators of treatment success.
For practitioners this study may also facilitate HIV prevention strategies to equip young men
with the necessary skills (e.g., to increase confidence in dealing with difficulties in condom
use, and to plan how and when to purchase and carry condoms) to effectively mitigate
many of the condom use barriers. Further research and practice, therefore, should consider
preparatory action as one of the aims and outcomes of interventions.
74
3
PREPARING FOR MALE CONDOM USE: THE IMPORTANCE OF
VOLITIONAL PREDICTORS
This chapter is based on the paper:
Carvalho, T., & Alvarez, M-J. (in press). Preparing for male condom use: The
importance of volitional predictors. International Journal of Sexual Health.
doi:10.1080/19317611.2014.982264
CHAPTER 3: PREPARING FOR MALE CONDOM USE
1. Abstract
Objective: Intention is not sufficient to actually use condoms, as self-regulatory
processes are needed to translate motivation into action. This study has focused on the role
of preparatory behaviors as a proximal predictor of condom use and examined how they
contribute to the self-regulatory processes proposed by the HAPA model (Health Action
Process Approach).
Method: An on-screen longitudinal study was conducted with three measurement
points, each of which two weeks apart. The participants were young men aged 18 to 25
years (N =203) recruited from vocational training centers. Outcome expectancies, perceived
self efficacy, intention, action planning, coping planning, volitional self-efficacy, preparatory
behaviors and condom use were assessed by self-report. A structural equation analysis was
used to test a series of three nested models, with all parameters estimated by
bootstrapping.
Results: The model proposed that the included preparatory behaviors provided the best
fit to the data. Preparatory behaviors were the most proximal predictors of condom use,
and mediation occurred in a sequential manner with preparatory behaviors preceding the
volitional variables, action and coping planning and volitional self-efficacy.
Conclusion: In order to bridge the intention-behavior gap, preparatory behaviors play a
mediating role, demonstrating how they work in conjunction with other volitional variables
such as planning and self-efficacy in the translation of behavioral intentions into actual
condom use.
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2. Introduction
For sexually active individuals, the condom is still the single, most efficient available
method to reduce the sexual transmission of HIV and other sexually transmitted infections
(STIs), however, its use has remained inconsistent (Alvarez & Garcia-Marques, 2008; Reis,
Ramiro, Matos, & Dinis, 2013). Globally, an estimated 2.3 million people became newly
infected with HIV in 2013 (UNAIDS, 2013). In Europe, around 11% of the new cases in 2011
corresponded to young people aged between 15 to 24 years (European Centre for Disease
Prevention and Control, 2013). In Portugal, according to the Department of Infectious
Diseases (DID, 2013), the total cases of HIV/AIDS amounted to approximately 42.995, of
which 5.507 included cases of HIV/AIDS (12.8%), corresponding to the group of individuals
aged between 15 and 24 years. Such data demonstrate that young people constitute an atrisk population. Individuals exert control over their behavior, but often fail, despite being
motivated to successfully manage their risk behaviors, and when habitual behaviors are at
stake, they can be even more challenging for the continued effort that such changes
require. However, successful behavior change can be attained through self-regulatory
efforts (Sniehotta, Scholz, & Schwarzer, 2005) and the gap between motivation and action
may be due, at least partially, to a lack of preparedness, namely for sexual encounters (van
Empelen & Kok, 2006, 2008).
This study aims to identify the predictors of condom use in order to shed light upon the
psychological processes underlying this protective behavior, thus contributing to helping
individuals to protect themselves. With a view to explaining condom use the Health Action
Process Approach model (HAPA) (Schwarzer, 2008) was employed. This model considers
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that the efforts after deciding to behave protectively constitute essential processes in health
behavior change. Hence, clarification of the predictors of prerequisite preparatory actions
could provide important guidance on the effective design of safer sex interventions for
young adults (Jellema, Abraham, Schaalma, Gebhardt, & van Empelen, 2013).
The Health Action Process Approach (HAPA)
Several health behavior models have been developed to further understand why and
how people engage in healthy behaviors and refrain from those considered healthcompromising. In traditional health behavior theories, intentions are seen as a key
ingredient in the change process (for an overview, see Abraham & Sheeran, 2000; Armitage
& Conner, 2000). However, forming strong intentions to act does not necessarily lead to
behavior change (Armitage, 2005), and this is often referred to as the ‘intention-behavior
gap’ (Webb & Sheeran, 2006).
The HAPA model was developed to address this gap by including post-intentional
mediators of behavior and is divided into two stages, the motivational stage which leads to
behavioral intention, and the volitional stage leading to actual health behavior (Schwarzer,
2008).
According to this model, the individual first needs to become motivated to change and
the perception of risk, positive outcome expectancies and perceived self-efficacy are
responsible for the formulation of an intention to refrain from risk behavior or to adopt
healthy behavior. Risk perception is seen as a distal antecedent of the motivation to change,
but is insufficient to enable a person to form an intention if not accompanied by outcome
expectancies and self-efficacy (Schwarzer, 2008). It is assumed that individuals balance the
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pros and cons of a certain behavior when thinking about whether they should change their
own or not, and positive emotional outcome expectancies are the most important
facilitators of intention formation (Schwarzer, 2008). Intentions are also increased by selfefficacy, defined as an individual's perceived ability to master emerging demands and tasks
successfully (Bandura, 1997). However, according to the HAPA model, self-efficacy, is
hypothesized to be crucial in both phases of behavior change. Therefore, it may be
differentiated as motivational self-efficacy, which acts as one of the predictors of intention
formation in the motivational phase, and as volitional self-efficacy, a predictor of behavior
in the volitional phase (Schwarzer & Luszczynska, 2008). After having formed an intention,
self-efficacious individuals, believing in their ability to overcome potential obstacles, may
find it easier to initiate and maintain behavior changes than someone with low self-efficacy.
This concept of phase-specific self-efficacy has been used in the domain of addictive
behaviors (Marlatt, Baer, & Quigley, 1995).
Once a behavioral intention is formed, individuals may enter the volitional phase. In
order to exert volition, the intended behavior must be planned, initiated, maintained and
restarted when setbacks occur. During the volitional phase, investment in self-regulatory
efforts is required until the new behavior becomes habitual. It is this second stage that sets
the HAPA apart from other theories, since it is one of the few models to incorporate
volitional influences on behavior (Conner, 2008). It assumes the mediation of the intention–
behavior gap by a number of volitional factors, such as planning (action and coping) and
volition self-efficacy.
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Action and Coping Planning
Planning is one of the efforts involved in self-regulation and precedes the initiation of
behavior change. By planning action, individuals develop a mental representation of a
desirable future situation (‘when’ and ‘where’) and a behavioral action (‘how’), which is
equivalent to the concept of implementation intentions proposed by Gollwitzer (1999).
Many studies investigating the effects of action planning on different behaviors have shed
light upon its usefulness for behavior change (see Gollwitzer & Sheeran, 2006). Action
planning has proven to be of great importance in boosting several target behaviors such as
physical activity (e.g. Koring et al., 2013b; Luszczynska, 2006), nutrition (e.g. Renner,
Hankonen, Ghisletta, & Absetz, 2012; Wiedemann et al., 2011a) and dental flossing (e.g.
Schuz, Wiedemann, Mallach, & Scholz, 2009a) and, furthermore, condom use has been
found to depend on planning, mainly in self-efficacious men (Teng & Mak, 2011).
Coping planning refers to the anticipation of difficulties or barriers that might hinder the
implementation of one’s behavioral intentions and includes detailed planning on how to
overcome such difficulties (Sniehotta, et al., 2005). By forming coping plans, individuals
anticipate how they might control barriers and how to cope with difficulties that interfere
with the execution of the target behavior. Empirical evidence emphasizes the usefulness of
coping planning for changing complex behaviors (see Kwasnicka, Presseau, White, &
Sniehotta, 2013) such as regular physical exercise (e.g. Sniehotta et al., 2006; Ziegelmann et
al., 2006), fruit and vegetable intake (e.g. Godinho et al., 2014) and smoking cessation (e.g.
van Osch, Lechner, Reubsaet, Wigger, & de Vries, 2008).
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Both types of planning are generally regarded as a means for simulating behavior
mentally, so that individuals may be prepared for situations in which such behavior might be
performed in the future. Indeed, planning has been found to serve as an operative mediator
between intentions and behavior.
Volitional self-efficacy
Volitional self-efficacy refers to the perceived ability to cope with unexpected barriers
and maintain difficult behaviors, many of which may turn out to be far more challenging to
adopt than initially anticipated. However, a self-efficacious person is better equipped to
confidently overcome such hindrances with more effective strategies.
Phase-specific self-efficacy has been found to exert an important influence on several
health behaviors, such as healthy eating (Renner et al., 2008) and physical activity
(Luszczynska et al., 2010). It has also proven to play an important role in the performance of
preparatory behaviors for condom use (Carvalho, Alvarez, Barz, & Schwarzer, 2015). In the
latter study, volitional self-efficacy acted as an indirect factor through which preparatory
behaviors exerted their influence on condom use. High confidence in the ability to use
condoms encourages people to try harder to seek alternative strategies when one of them
fails (Teng & Mak, 2011).
Preparatory behaviors
While inclusion of the planning construct has received significant empirical support and
has been studied as a cognitive antecedent of action, preparatory behaviors, which may
help initiate and maintain complex health behaviors, have seldom been studied as a salient
aspect of planning or of the preparation for behavior change (Koring et al., 2013). In fact,
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forming implementation intentions for the preparatory actions preceding actual condom
use has been found to involve the planning of separate concrete actions (i.e. buying,
carrying and discussing condoms) (de Vet et al., 2011).
In a meta-analysis, Sheeran and colleagues (1999) showed that preparatory behaviors
‘emerge as medium-to-strong predictors of condom use’ (p. 118) and Bryan et al. (2002),
found that one of the most important self-regulatory strategies for condom use
encompasses the buying and carrying of condoms, thus increasing individuals’ control over
the use of such protection.
Preparatory action has been neglected in most health behavior theories, although it
constitutes an obvious proximal predictor of action (Koring et al., 2013). Some studies have
tested the hypothesized mediating role of preparatory behaviors between intentions and
condom use and have demonstrated that adolescents who intended to use condoms and
prepared themselves to do so (buying, carrying and discussing condom use with a sexual
partner) were more likely to actually use them (Bryan et al., 2002; Gebhardt et al., 2006; van
Empelen & Kok, 2006, 2008; Zimmerman et al., 2007). In line with such research, a study
with heterosexual young men highlighted preparatory behaviors as the most important
proximal predictors of condom use (Carvalho et al., 2015).
Aims of the present study
There is limited evidence attesting the importance of volitional variables on condom use
in heterosexual young adults, and few studies have specifically addressed them. Moreover,
whenever volitional variables were studied, preparatory behaviors were not taken into
consideration in the explanation of condom use. Within the framework of the HAPA model,
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we aim to investigate the further contribution of preparatory behaviors, added to a set of
volitional variables (volitional self-efficacy, action planning and coping planning) in condom
use, and to test whether these variables sequentially mediate the relationship between
intention and condom use.
A longitudinal study with three assessment points in time was conducted to examine the
new outlined model for condom use in heterosexual young adults. There are different
dynamics in heterosexual and homosexual relationships that may justify separate studies
(Kelly, 1995) and the benefits of such protection are equally necessary for heterosexual
men, who have a higher rate of infection than women.
It is hypothesized that self-regulation, exerted through action and coping planning,
volitional self-efficacy and preparatory behaviors, will predict condom use behavior better
than intentions alone or than the volitional variables without preparatory behaviors.
Furthermore, preparatory behaviors are considered to be the most proximal predictors of
behavior, mediating between volitional variables proposed by the HAPA model and condom
use.
Positive outcome expectancies and perceived self-efficacy are also assumed to predict
the intention to use condoms. Finally, the role of previous condom use has also been
addressed and while, typically, prior behavior is the best predictor of future behavior, this
may no longer be the case if more proximal (e.g., post-intentional) constructs are included
in a behavior change model.
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3. Method
Participants and Procedure
A total of 534 men, young, heterosexual adults, aged between 18 and 25 years (M= 19.0;
SD=1.70), studying in vocational training centers, completed the first questionnaire at the
first time point (T1). At time 2 (T2), the questionnaire was answered by 275 (51%)
participants, and at time 3 (T3) by 203 men (38%). For the purpose of this study, only the
longitudinal sample with the 203 participants who completed all 3 measurement points in
time has been included.
The majority of participants (68%) had 10 to 12 years of schooling, 30% had nine years
and around 2 % had less than nine years of schooling. Participants were mainly Portuguese
(88%), some African (6%), Brazilian (3%) or from other EU countries (3. 5%). All participants
had had sex at some stage in their lives and 19% had sexual intercourse for the first time at
the age of 14 or younger, 43% at 15 or 16 years and 38% at the age of 17 or later. Sixty one
percent of participants had sexual intercourse for the first time while in a long-term
relationship (61%), 78% used contraception during this encounter, and one of the most
frequently used contraceptive methods by the sample was condom use (93%). The mean
number of reported sexual partners was six. At T3 participants were in a long-term
relationship (45%), casual (17%) or both types of relationships (3%), while 35% were not in a
relationship at this collection point. However, during the period under review, all
participants were sexually active. The participants were fully informed about the subject of
the study before enrolling in the study and answered to the first questionnaire, giving their
informed consent, in accordance with the ethical standards of the institution involved. The
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first onscreen questionnaire was completed in class and the two remaining questionnaires
for T2 and T3 were sent by email at two week intervals, thus forming a one-month
longitudinal study. Participants were entitled to a check in exchange for their participation
in the three data collection stages.
Measures
Prior to construction of the questionnaires for data collection, a group of young adults
were consulted to verify the suitability of the questionnaires in terms of language, cultural
characteristics and age of young adults, with a view to adapting them accordingly.
In order to maximize the specificity of the collected information, participants were asked
to answer
the questionnaire on the basis of their current relationship (long-term
relationship, casual) and whenever they were in both types, they were requested to focus
on the casual.
The majority of measures used in this study were adapted from Schwarzer (2008) and it is
stated whenever they have been adopted from other research studies. All the variables,
with the exception of condom use, were assessed through a Likert-type scale of 6 points
from (1) strongly disagree to (6) strongly agree.
Positive outcome expectancies for condom use were measured (T1) through four items
(e.g. ‘When I use a condom, I feel safe’, ‘When I use a condom I feel that I'm protecting my
partner’), which stressed the emotional aspects of this behavior (Kelly, 1995; White, Terry, &
Hogg, 1994). The internal consistency of this measure was α = .78.
Perceived self-efficacy (T1) was measured by four items adopted from the CUSES scale ‘The Condom Use Self-Efficacy Scale’ by Brien and colleagues (Brien, Thombs, Mahoney, &
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Wallnau, 1994). These items were related to the mechanical aspects of putting on the
condoms (‘I believe I can always use a condom correctly’), disapproval of the partner(‘I think
I can always use a condom even though I am afraid that my partner thinks I have a sexually
transmitted infection’), assertiveness (‘I believe in my ability to discuss the use of condoms
with my partner’) and intoxication (‘I think I'll remember to always use a condom even after I
have been drinking or consuming drugs’), α = .73.
Intention was assessed (T1) by three items, for example: ‘From now on, I intend to always
use a condom’, ‘I intend to use a condom the next time I have sex’, α = .93.
Action planning was measured by three items (T2), after the stem ‘I have made concrete
plans on: ‘when to always use a condom (when I have sex, vaginal and / or anal
intercourse)’; ‘where I always use a condom (at home, at parties, in the car)’ and ‘how I
always use a condom (know where to buy them, carry them around with me)’, α = .92.
Coping planning was measured by seven possible obstacles to condom use (T2),
mentioned in the literature (Kelly, 1995; White et al., 1994), namely the fact that the
partner does not want to use condoms; when under the influence of substances (drugs and
/ or alcohol); being in the ‘heat of the moment’; not having condoms available; having a very
attractive partner; the partner being a girlfriend and; when in an occasional encounter.
Participants were asked to assess which of these seven situations constituted a barrier for
them (yes / no) and to what extent had they planned alternatives to such barrier(s). Some
examples of these items are: ‘I've made concrete plans about what to do when my partner
does not want to always use a condom’ and ‘I have made concrete plans about what to do
when I do not have condoms available’, α = .99. Volitional self-efficacy was measured by
four items (T2) that assessed confidence in maintaining condom use and recovery of its use
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after a relapse when faced with barriers presented in the coping planning measure. Some
examples of items are: ‘I believe I can maintain the systematic use of condoms, even if my
partner is very attractive’, ‘I think I can / could return go back to always using a condom,
even if I had unprotected sexual intercourse once’, α = .83.
Preparatory behaviors were measured using three items (T2) adopted from Bryan et al.,
(2002): ‘I buy /acquire a condom when I expect the possibility of sex’; ‘I have a condom with
me when sex is a possibility’ and ‘I keep condoms around whenever intercourse may occur’.
The internal consistency of this measure was α = .93.
Condom use behavior was measured using a similar approach to assess other health
behaviors (Schwarzer et al., 2007) through two items assessed at T1 and T3: (‘In the last
month, how often have you always used a condom whenever you have had sexual
intercourse (vaginal and /or anal)? ’ and ‘In the last month, how often has condom use been
a part of your habitual sexual practices’), with a Likert-type scale of 6 points from (1) never
and (6) always, α = .86 at T1 and α = .84 at T3.
We also analyzed the social desirability towards condom use, given the sensitivity of the
object of study, which was measured using a scale of 5 items SDRS-5 (Socially Desirable
Response Set Measure, Hays, Hayashi, & Stewart, 1989), e.g. ‘ I am always courteous even to
people who are disagreeable’, ‘There have been occasions when I have taken advantage of
someone’ , α = .63. Responses above a mean of 5 indicate a tendency towards socially
desirable responses in answering the questionnaire.
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
Data Analysis
The measurement model was tested using Confirmatory Factor Analysis with AMOS v. 20.
The proposed models were tested through structural equation modelling (SEM) with AMOS
v. 20 by means of a variance-covariance matrix of the indicators. All parameters were
estimated by bootstrap generated from 1.000 samples.
Bootstrapping is a nonparametric resampling procedure that does not require a normal
distribution of the sample and is recommended for mediation analysis (Hayes, 2009). A
structural equation analysis was chosen, since it enables testing of the model fit and the
complex estimation of its parameters, while also controlling measurement errors.
In order to test the volitional mechanisms capable of mediating between behavioral
intentions and condom use, three nested models were estimated. The models included
motivational variables (outcome expectancies and perceived self-efficacy) measured at T1
as predictors of intention, which were also measured at T1. Intention (T1) and volitional selfefficacy, action planning, coping planning and preparatory behaviors, measured at T2, were
specified as predictors of condom use at T3. Past behavior (condom use at baseline, T1) was
included in all models as a direct predictor of condom use at T3. All the predictors were
specified as latent variables and motivational variables and past behavior (i.e., variables
measured at T1) were allowed to correlate.
The sequence of estimated models ranged from an unconstrained model, where
preparatory behaviors were considered the closest variable to condom use and the other
volitional predictors (volitional self-efficacy, action planning and coping planning) were
specified as mediators between intention and preparatory behaviors (Model 1), to a less
restricted model, where volitional predictors (without preparatory behaviors) were tested
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
as parallel mediators between intention and behavior (alternative Model 1), to a more
constrained model, where only intention predicted behavior (alternative Model 2). Paths
not used in the alternative models were constrained to 0. In Model 1, all parameters were
freely estimated.
To evaluate the overall fit of the different models, several goodness-of-fit indices were
used, such as the chi-square test (χ2), the comparative index (CFI), the Tucker-Lewis index
(TLI), the Root Mean Square Error of Approximation (RMSEA) and p(RMSEA≤0.05). A χ2 / df
under 2 is indicative of good overall fit (Arbuckle, 2008). For CFI and TLI, values over .90
indicate an acceptable model fit and values over .95 a very good fit (Bentler, 1990; Bentler &
Bonnet, 1980). For the RMSEA, values under .08 indicate an adequate model fit (Hu &
Bentler, 1999). To compare the fit among the three models estimated with the same data,
the Akaike Information Criterion (AIC) was additionally used, with lower values being
indicative of a better and more parsimonious fit (Kline, 2011) and a chi-square difference
test (Bollen, 1989).
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
4. Results
Dropout Analysis
To examine whether the longitudinal sample proved to be representative of the initial
sample, a comparative analysis was performed at Time 1 between the answers of
participants who completed the three questionnaires (n = 203) with those who completed
only the first (n= 331). No significant differences were found regarding age, nationality,
education, type of relationship in which they were involved, type of relationship at the time
of the first act of intercourse or in the use and type of contraceptive method used in the
first act of intercourse. Neither were differences found in the use of condoms at baseline. A
difference was found in the age at the time of the first act of sexual intercourse χ2 (3) =
17.44, p < 0.01.
Confirmatory Factor Analysis
A confirmatory factor analysis was conducted to evaluate the quality of fit of the
proposed measurement model in the correlational structure of the observed variables. Eight
factors were specified (outcome expectancies, perceived self-efficacy, intention, action
planning, coping planning, volitional self-efficacy, preparatory behaviors and condom use,
the latter measured at Time 1 and Time 3) and freely inter-correlated. All factors were
standardized by fixing their variances to 1. The final measurement model showed a good fit
- χ2 (264) = 471.57; χ2/ df = 1.78; CFI = .94; TLI = .94; RMSEA = .006, p(RMSEA)=.000,
revealing that the proposed measurement is a good fit for what was theoretically expected.
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
Descriptive statistics
Table 2 presents the means, standard deviations and inter-correlations among all latent
variables at the corresponding measurement time.
All variables were significantly associated with each other and all showed moderate
correlations, indicating that they were measuring different constructs. All variables, except
perceived self-efficacy, had positive significant associations with condom use at Time 3.
Condom use at Time 1 showed the highest correlation with condom use at Time 3, which
reflects some stability in the measure used to assess condom use over a period of one
month. In addition to this, the highest correlation was found between condom use and
preparatory behaviors.
Table 2. Means, standard deviations and correlations of the latent variables
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
1. Outcome expectancies (T1)
-
2. Perceived self-efficacy (T1)
.47**
3. Intention (T1)
.49** .27**
4. Volitional self-efficacy (T2)
.36** .30** .34**
5. Action Planning (T2)
.33** .27** .47** .55**
6. Coping Planning (T2)
.38** .29** .38** .54** .66**
7. Preparatory Behaviors (T2)
.41** .24** .56** .59** .63** .60**
-
8. Condom use (T1)
.41** .19** .56** .37** .38** .38**
.53**
9. Condom use (T3)
.27** .12 .39** .30** .34** .31** .48**
.61**
-
10. Social Desirability (T1)
.006 -.04
.21**
.14*
.09
(10)
-
.07
-
.16*
-
.19** .15*
-
-
M
SD
4.85
0.87
4.82
0.83
4.76
1.29
4.78
0.96
4.52
1.25
4.13
1.35
4.66
1.29
4.30
1.78
4.32
1.82
3.51
0.78
Note. *p < 0.05; **p < 0.01
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
Mediational Analyses
Model 1: Preparatory behaviors as mediators of the relationship between volitional
variables and condom use.
In Model 1 (Figure 4), the path from preparatory behaviors and volitional variables to
behavior was freely estimated. This model presented a good fit to the data (Table 3).
Table 3. Overall fit of the three models tested and comparisons between models
Model 1
Alternative
Model 1
Alternative
Model 2
Alt1 vs. Alt 2
Χ2
df
Χ2/df
CFI
TLI
RMSEA
AIC
Δχ2
Δdf
640.38
280
2.28
90
.88
.08
782.38
---
---
647.37
281
2.30
.90
.88
.08
787.37
6.991**
1
650.41
284
2.29
.90
.88
.08
836.41
10.032*
4
---
---
---
---
---
---
---
3.043
3
1
comparison Model 1 vs. Alternative Model 1; 2comparison Model 1 vs. Alternative Model 2; 3comparison
Model 1 vs. Alternative Model 2
*p < .05; ** p< .01
Outcome expectations were the only predictor of intention and responsible for 38% of
the variation in intention. Perceived self-efficacy was a predictor of volitional self-efficacy
and with the intentions explained 19% of its variance. Intention proved to be a strong
predictor of action planning, coping planning and volitional self-efficacy. These volitional
variables proved to be predictors of preparatory behaviors and together explained 58% of
their variability. Only preparatory behaviors proved to be a direct predictor of condom use
at Time 3, suggesting that these behaviors are effective mediators in the relationship among
intention and volitional variables and condom use.
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
Figure 4. Model 1 with standardized coefficient estimates
Note. **p < .01; ***p <.001
Intentions predicted preparatory behaviors, and this effect was mediated by volitional
self-efficacy (indirect effect β = 0.11, C.I [0.04;0.22]), action planning (indirect effect β =
0.12, C.I [0.03;0.25]) ,and coping planning (indirect effect β = 0.10, C.I [0.05;0.17]), thus
finding threefold partial mediation by volitional variables between intention and
preparatory behaviors.
None of the studied volitional variables had a direct effect on condom use, however, the
indirect effect of these variables on condom use through preparatory behaviors showed
that the latter fully mediated the relations: volitional self-efficacy (indirect effect β = 0.09, CI
[0.0 4 -0. 22]), action planning (indirect effect β = 0.10, C.I [0.04-0.22]) and coping planning
(indirect effect β = 0. 07, CI [0.03 - 0.15]). Three double mediations were then tested by
examining whether the effect of intentions on condom use was sequentially mediated by
volitional self-efficacy/action planning /coping planning and by preparatory behaviors (Table
4).
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
Table 4. Decomposition of the effect of intention on condom use at Time 3, controlling condom use at Time 1
Condom use
Total effect
Estimated
.05
Indirect effect
Volitional Self-efficacy - Preparatory Behavior
Action Planning– Preparatory Behavior
Coping Planning - Preparatory Behavior
.16
.17
.12
Direct Effect
-.11
95% CI
-.12;.23
.06 ; .29
.05 ; .31
.05 ; .22
-.30;. 05
As may be observed in Table 4, the relationship between intention and condom use was
significantly mediated by the three chains of proposed mediation. Without past behavior,
the model explained 32% of condom use at Time 3.
Alternative Model 1: The HAPA volitional variables as mediators of the relationship
between intention and condom use
In the alternative Model 1, suppressing the path between preparatory behaviors and
condom use, none of the studied volitional variables proved to be a mediator between
intention and condom use [volitional self-efficacy β = 0.07, p = 0.30, action planning β =
0.06, p = 0.44 and coping planning β = 0.03, p = 0.68]. However, the suitability of the model
still proved to be acceptable (Table 3). Without past behavior, the model explained 26% of
condom use at Time3.
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
Alternative Model 2: Intention as a predictor of condom use
In the alternative Model 2, suppressing all the paths from volitional variables and
preparatory behaviors to condom use, intention did not predict condom use directly, β =
0.02, p = .84, and was responsible for only 23% of its total variance, when condom use at
baseline was not taken into consideration. However, the fit was equally acceptable (Table
3).
Comparing Model 1 and the alternative Model 2, Δχ2 (4) = 10.03 p <.05, Model 1 and the
alternative Model 1, Δχ2 (1) = 6.99, p <.001, and the alternative models among themselves,
Δχ2 (3) = 3.04, p n.s (Table 3), the proposed Model 1 was significantly better, with a lower
AIC value compared with the other two alternative models, which was indicative of a better
fit.
5. Discussion
This three-wave longitudinal study provides evidence of the usefulness of preparatory
behaviors as proximal predictors of condom use and has examined the psychological
mechanisms that might operate in its use. More specifically, the role of preparatory
behaviors as a mediator of the relations among intention and volitional self-efficacy, action
planning and coping planning and condom use was ascertained, in order to improve the
predictive power of the model.
As hypothesized, preparatory behaviors sequentially contributed to the translation of
intentions into actual behavior. This is a new finding, although in line with Sniehotta et al.,
(2005) who found in their study of action control that a volitional variable mediated the
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
relationship between action planning and physical activity, suggesting that planning must be
converted into closer monitoring of behavior.
Complementing what is proposed in the HAPA model, our findings show that the
relationship between intention and behavior was not mediated by volitional variables
(action and coping planning and volitional self-efficacy) alone but by a sequential mediation
through preparatory behaviors. However, the volitional variables proposed by the HAPA
model reiterate their effectiveness in predicting condom use more accurately than
behavioral intention alone, showing the importance of self-regulation for behavior change.
Nevertheless, the current study is innovative since it reveals that preparatory behaviors
are a more proximal volitional predictor of condom use in heterosexual young men.
Preparatory behaviors prove to be both a direct predictor of condom use, and as our
findings suggest, are also effective mediators in the relations among intention, volitional
variables and condom use.
Three double mediations occurred in a sequential manner with self-efficacy, action
planning and coping planning predicting engagement in preparatory behaviors, which, in
turn, are precisely those to have a direct influence on condom use. Our findings point to
self-regulatory efforts requiring concrete measures associated with the availability of
condoms which involve their purchase in order to become operative. Without them these
efforts rarely translate into effective behavioral change. Future studies should examine
whether the outlined mediational chain varies according to the individual’s stage of
readiness to adopt this particular behavior and make use of experimental designs to attest
for robust evidence of causality.
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CHAPTER 3: PREPARING FOR MALE CONDOM USE
A similar mediation process has recently been found for other behaviors, such as coping
planning and action control, simultaneously mediating the relationship between intention
and fruit and vegetable consumption (Godinho et al., 2014). Barrier anticipation needs to be
accompanied by the monitoring of behavior in order to have an effect on the change of a
habitual and regular behavior. Future research should examine the circumstances under
which other mediators operate in condom use (e.g., action control, social norms) and
whether moderating effects can be identified.
Our other hypotheses, in line with previous studies on condom use (see Teng & Mak,
2011), were also confirmed, where positive outcome expectancies were the only predictor
of intention however, confirmation that intention predicted condom use one month later
was not attained. The results suggest that although our sample intended to have condoms
available (intentions predict preparatory behaviors), intention alone does not predict
behavior.
Some limitations of this study need to be addressed. The fact that volitional predictors
and preparatory behaviors were assessed at the same data collection point calls for some
prudence in the interpretation of the present findings, since measuring predictors and
mediators at the same point in time raises doubts as to the mediating mechanism. Another
limitation is that all the data was collected by means of self-reported measures, which may
generate bias due to social desirability. However, the average rate of social desirability in
our study was not high, and it is consistent with other studies where social desirability
proved not to be associated with condom use (Teng & Mak, 2011), and there was stability in
the reported condom use mean over the one-month period, attesting that, at least
throughout the study, mere measurement effects did not occur.
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Moreover, care should be taken in generalizing the findings, given the specific sociocultural characteristics of the participants under study (e.g., low level of schooling) and
future studies should include more diverse samples of young and older men, including gay
and bisexual men, to test the universality of the mechanisms found in this study.
Notwithstanding its limitations, the present study contributes to accumulating evidence
of the usefulness of self-regulatory processes in condom use. Furthermore, it highlights the
relevance of preparatory behaviors, showing how they work in conjunction with other
volitional variables such as planning and self-efficacy in the translation of behavioral
intentions into actual condom use. This is important, as by revealing the mechanisms
involved in condom use, a valuable backdrop for future intervention studies is provided.
Technicians should, therefore, be encouraged to pay particular attention to preparatory
behaviors and facilitate their occurrence among young adults. Understanding the
mechanisms that lead to safer sexual behavior could contribute to the development and
evaluation of preventive interventions aimed at increasing condom use among young
adults.
Such interventions should ensure that young men are not only motivated to use condoms
but also to plan to do so, through buying and carrying them around, given the mediational
role of preparatory behaviors found in the study. For practitioners, this study may also
facilitate HIV prevention strategies to equip young men with the necessary skills, such as
increasing their confidence in dealing with difficulties in condom use and planning how and
when to purchase and have condoms with them, to effectively mitigate many of the
condom-use barriers.
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4
STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS TO INCREASE
CONDOM USE IN YOUNG MEN
This chapter is based on the paper:
Carvalho, T., Alvarez, M.-J., Cícero, P., & Schwarzer, R. (submitted). Stage-based
computer-delivered Interventions to increase condom use in young men.
CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
1. Abstract
Objectives: The aim is to examine whether adopting or increasing condom use can be
influenced by psychological treatment targeting both motivational and volitional aspects, if
such components are matched to the characteristics of the recipients.
Method: In a randomized controlled trial, 159 heterosexual young men (intervention
groups, n = 113; control condition, n = 46) were exposed to two computer-delivered
intervention arms, one targeting non-intenders (n = 36; motivational intervention arm) and
the other targeting intenders (n = 77; volitional intervention arm). Intention and condom
use were assessed at three points in time, each two weeks apart.
Results: Experimental non-intenders obtained higher levels of intention and condom use
than control non-intenders. Experimental intenders reported an increase in condom use
whereas control intenders did not.
Conclusions:
A
stage-based
computer-delivered
intervention
design
including
motivational and volitional treatment appears to be suitable for improving condom use
motivation as well as behavior.
Keywords: young adults; condom use; stages of change; health behavior interventions;
computerized intervention.
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
2. Introduction
In 2013, an estimated 2.3 million people became newly infected with HIV in the world
(UNAIDS, 2013), and in Europe, around 11% of the new cases in 2011 corresponded to
young people aged between 15 to 24 years (European Centre for Disease Prevention and
Control, 2013). According to the Department of Infectious Diseases (CVEDT, 2013), in
Portugal there were 42.995 cases of HIV/AIDS, of which 5.507 were aged between 15 and 24
years (12.8%), demonstrating that young people constitute an at-risk population. Although
condom use is the most efficient method for reducing the sexual transmission of HIV and
other sexually transmitted infections (STIs), its use has remained inconsistent (Alvarez &
Garcia-Marques, 2008; Reis et al., 2013).
The development of effective health behavior interventions to increase condom use
continues to top the agenda to prevent disease and death among at risk-populations (ScottSheldon, Huedo-Medina, Warren, Johnson, & Carey, 2011) and young people in particular
(Ramiro, Reis, Gaspar de Matos, & Diniz, 2013).
In a study developed among tertiary and heterosexual young students (Newton, Newton,
Windisch, & Ewing, 2012), condom use remains a source of embarrassment, and previous
research suggests that men and women hold different beliefs (and consequently behaviors)
in relation to their health (Courtenay, 2000). Many men, for instance, appear reluctant to
engage in preventative health behaviors (Springer & Mouzon, 2011). Indeed, within the
context of sexual intimacy, men are often reluctant to use condoms (Davis, et al., 2014)
leaving themselves (and their sexual partner) vulnerable to STIs. Therefore, it has been
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
suggested that safe sex interventions should equip young men with the necessary skills to
effectively mitigate many of the condom use barriers.
Interventions
Health behavior interventions have proven to have different effects when targeting
individuals at different stages of change (e.g. Weinstein et al., 1998). Stage models of health
behavior assume that individuals progress through an ordered set of stages while
contemplating, initiating and maintaining health behavior change (Prochaska, DiClemente,
& Norcross, 1992). Despite differences in numbers of stages and processes relevant for
stage progressions, stage theories such as the Transtheoretical Model (Prochaska et al.,
1992), and the Health Action Process Approach (HAPA; Schwarzer, 2008) distinguish
between individuals who have not yet decided to change their behavior (pre-decisional or
motivational stages) and those who have decided to change or who have already
implemented the changes and perform the target behavior (post-decisional or volitional
stages).
Most behavior change interventions for HIV/AIDS prevention have attempted to increase
condom use by boosting intentions towards its use (Bauman et al., 2007; Mevissen et al.,
2011). Few have focused upon helping those who have already formed strong intentions to
use condoms to actually carry out these intentions (Althoff, et. al, 2014; von Haeften et al.,
2000). In order to fill this gap, our intervention to increase condom use among young men is
based on the HAPA model (Schwarzer, 2008) which distinguishes between a pre-intentional
stage, that includes individuals who have not (yet) set the goal to act according to a
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
previously defined criterion (non-intenders), an intentional stage, comprising individuals
motivated to change, but not yet acting (intenders), and an action stage, including those
who have already attained the behavioral criterion (actors) (see Schüz, et al., 2009). It is the
second stage that sets the HAPA apart from other theories, since it is one of the few models
to incorporate volitional influences on behavior (Conner, 2008).
Computer-delivered stage-based interventions
Over the past decade, an increasing number of interventions designed to promote
health behavior change have been delivered via the Internet, and meta-analyses have
shown that Internet-based interventions have positive effects on behaviors such as physical
activity, healthy eating, and smoking cessation (e.g. Lustria et al., 2013; Webb et al., 2010).
A variety of Internet-based safer sex interventions exist with varying rates of costeffectiveness (Pinkerton et al., 2002), however hardly any of the studies have specifically
addressed a computer intervention for condom use, targeted to the stages of change.
Targeting is a way of improving the efficacy of interventions through a combination of
strategies and information based on the identification of similarities in a group or sub-group
of individuals, and further adapting the communication to meet those characteristics (Noar
et al., 2009). Content matching is one of such strategies and consists of adapting constructs
theoretically associated with the outcome of interest (e.g. attitudes, self-efficacy,
behavioural intentions) to group scores (Hawkins et al., 2008). Thus, stage models offer a
useful template for adapting interventions to individuals´ needs, as they provide guidance
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
for the selection of a parsimonious set of relevant determinants upon which they may be
tailored (Godinho, et al., 2013).
Indeed, interventions may be most efficient when targeted to stages of change.
Studies with the HAPA model have demonstrated that interventions targeting determinants
of intention were only effective among pre-decisional individuals (Luszczynska et al., 2011;
Reuter et al., 2008) and that interventions targeting predictors that are important at the
intentional phase were only effective when applied to individuals at that stage (e.g., Lippke
et al., 2010; Reuter et al., 2008; Wiedemann et al., 2011a). These studies, were applied, for
instance, to physical exercise, dental flossing, dietary and fruit and vegetable intake,
however to our knowledge, no prior study has used a stage-based computer-delivered
intervention drawing on the HAPA model as a theoretical backdrop for condom use.
According to the HAPA, outcome expectancies (i.e. anticipating positive outcomes
resulting from changing one´s behavior) encompass social, physical and emotional
consequences, the latter particularly assumed to facilitate intention formation (Schwarzer,
2008). Self-efficacy (i.e., holding the belief that one will be able to change) has been put
forward as the factor that operates in the transition from the non-intentional to the
intentional stage (Wiedemann et al., 2009). For transitions from the intentional to the action
stage, planning has been proposed as a key strategy, serving as a mediator between
intentions and behavior. This transition has been thought to be facilitated by action planning
(i.e., the establishment of when, where and how one will implement the intended changes)
and coping planning (i.e., the anticipation of barriers for the implementation of action plans
and strategies to overcome them). Therefore, in order to propel stage transitions, non108
CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
intenders would mostly benefit from some sort of presentation of the positive consequences
of adopting such behavior and from overcoming their self-doubts to take action by being
encouraged to attribute success to their ability, thus increasing their behavioral intentions.
On their part, intenders, already motivated to change, who do not act, possibly due to a lack
of the right skills to translate their intention into action, would benefit from interventions
that would help them to do so via careful action planning and coping planning (Schwarzer,
2008a).
Aims and hypotheses
Two stage-based interventions for non-intenders and intenders were tested. We
posited that non-intenders would mainly benefit from a motivational intervention, through
outcome expectancies and self-efficacy, which increases intention for condom use, whereas
intenders would mainly benefit from a volitional intervention through action and coping
planning for the promotion of condom use. More specifically, we hypothesized that:
H1. Non-intenders in the motivational intervention condition would show higher levels
in intention of using a condom two weeks and one month later, compared to non-intenders
in the control condition. No changes in condom use one month later are expected.
H2. Intenders in the volitional intervention condition would show higher levels in
condom use two weeks and one month later, compared to intenders in the control
condition
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
3. Method
Participants
The first questionnaire was answered by 551 young men, between 18 and 25 years of
age, recruited from several vocational training centers. Eligible participants, 347 nonintenders and intenders, identifying themselves as heterosexual, were included in the
analyses as long as they completed the questionnaire at the three points in time. Thus, the
final longitudinal sample consisted of 159 participants (M = 19.75 years; SD = 1.79).
Measures
Socio-demographic information such as age and schooling was collected in addition to
the contraceptive method used, type of partner and age at first intercourse, number of
lifetime sexual partners, and type of current relationship.
The intention measure was adapted from Schwarzer (2008) and assessed by three items
at Time 1 (T1), Time 2 (T2) and Time 3 (T3), e.g. ‘From now on, I intend to always use a
condom’, ‘I intend to use a condom the next time I have sex’, with a six-point response
format ranging from (1) strongly disagree to (6) strongly agree, Cronbach’s α = .95 (T1).
Condom use behavior was assessed with two items at T1, T2 and T3 in the same way as
other health behaviors are typically assessed (Schwarzer et al., 2007), ‘In the last month,
how often have you always used a condom whenever you have had sexual intercourse
(vaginal and /or anal)? ’ and ‘In the last month, how often has condom use been part of your
habitual sexual practices), using a response format from 1 (never) to 6 (always), Cronbach’s
α = .89 (T1).
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
Procedure
Before participating in the study, individuals were fully informed about its subject, giving
their informed consent in accordance with the ethical standards of the institutions involved
and proceeded to answer the first onscreen questionnaire (T1) in a classroom setting. The
two remaining questionnaires (T2 and T3) were sent by email at two week intervals, forming
a month-long longitudinal study. Participants were entitled to a voucher in exchange for
their participation at all three data collection waves.
An algorithm, similar to those used in previous studies (e.g., Lippke, Ziegelmann,
Schwarzer, & Velicer, 2009) was applied, using the first of the two items, requesting
information on condom use. Participants were classified as actors (n = 204; 36% of 551)
whenever their answer was “always used a condom” and were excluded from the study
since they seemed not to require an intervention to help them increase condom use. Those
who answered “not always” and in addition (a) “intended to use a condom” (scoring above
3.01; n = 225; 65% of 347) were classified as intenders, whereas those who responded (b)”
did not intend to use a condom” (scoring below or equal to 3; n = 122; 35% of 347), were
classified as non-intenders (Lippke et al., 2009)
Eligible participants, non-intenders and intenders, were then randomly assigned to either
a control (n = 46) or intervention (n = 113) condition. The intervention condition consisted
of two arms, one for non-intenders (n = 36) and one for intenders (n =77). The majority of
participants in our sample were intenders (Figure 5).
111
CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
Figure 5. Flow diagram of participants
Intervention
Two different types of intervention – motivational and volitional treatment - were
developed, based on previous interventions for physical activity such as those reported by
Schwarzer, Cao and Lippke (2010), and Ziegelmann et al. (2006). Following the behavioral
change techniques (BCTs) (Michie at al., 2013), the motivational intervention used two BCTs,
namely decisional balance (generating pros and cons), focus on past success (to trigger self-
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
efficacy). This intervention consisted of screen content from which participants read some
positive outcome expectancies for condom use. They were taught that adopting condom
use may have positive outcomes (e.g. “Condoms can be transformed into something highly
entertaining in sexual intercourse”) then, they were asked to generate four other benefits
for using a condom. A written testimony by a role model of the same age range was
presented to encourage participants to engage in more regular condom use, in which a
young man who had had many heterosexual encounters presented reason for advising
everyone to always use a condom. Participants were then asked to write about a situation in
which they had thought they would not have been able to achieve something and had
eventually succeeded (self-efficacy beliefs).
In the volitional intervention, two BCTs were used, action planning and coping planning
(Michie at al., 2013). A page was presented on which participants were encouraged to form
action plans such as “I will always use a condom…” by specifying and writing exactly when,
where, and how they planned to use condoms. Moreover, to stimulate coping planning
(Sniehotta, Scholz, & Schwarzer, 2006), barriers to condom use were presented, such as
being under the influence of substances (drugs and / or alcohol) and not having a condom
available (Kelly, 1995; White et al., 1994), and participants were asked to form plans to
overcome these difficulties. This intervention required elaborated mental simulation and
reflection on the part of the participant. All questions were open ended.
The control group did not receive treatment but links were provided to sites where
participants could find more information on condom use.
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Analytical Procedures
Statistical analyses were conducted with SPSS v. 21. Dropout analyses were analyzed by
χ2 tests and t-tests comparing the longitudinal sample to dropouts after T1.For each
dependent variable, data were analyzed using planned single-degree-of-freedom contrasts
(Judd, McClelland, & Culhane, 1995) in order to test the hypotheses that intentions and
behavior increase across the three measurement points in time within intervention groups.
A t-test for independent samples was used to confirm the results for the planned contrast in
volitional intervention for intenders.
4. Results
Dropout analyses comparing the longitudinal sample to dropouts after T1 showed
differences in four out of 9 of the tested variables (demographics, intention and condom use
behavior). The longitudinal sample differed somewhat from the initial sample in terms of
the type of relationship in which participants were involved at the time (less casual
relationships), age at first intercourse (first sexual intercourse later), education (higher
education) and condom use at T1 (had used condoms less frequently). The dropout analysis
suggested, however, that the longitudinal sample was roughly representative for the initial
baseline sample. The dropout analysis suggested that the longitudinal sample has
similarities and some differences when compared to the initial baseline sample.
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
Motivational intervention for non-intenders
Means and standard deviations for intention and behavior across the three measurement
points in time are presented in Table 5.
Table 5. Means and (standard deviations) for intention and behavior in non-intenders
Intention
control
intervention
Behavior
T1
T2
T3
T1
T2
T3
2.53 (.80)
3.02 (1.34)
2.95 (1.22)
2.28 (1.29)
2.00 (1.09)
2.03 (1.71)
2.19c (.73)
2.60b (1.30)
3.41a (1.84)
2.17b (1.32)
2.11b (1.38)
3.22a (2.10)
Note. For each dependent variable, means with different subscript represent significant differences in the
planned contrasts.
Planned contrasts showed that in the intervention condition a significant increase
emerged in intention from T1 to T2, F(1, 54) = 3.30, p = .07, χ2= .06, from T1 to T3, F(1, 54) =
15.82, p < .001, χ2= .23, and from T2 to T3, F(1, 54) = 9.13, p < .01, χ2= .15. Moreover,
there was a significant increase in behavior between T1 and T3, F(1, 54) = 14.67, p < .001,
χ2= .21, and between T2 and T3, F(1, 54) = 15.86 , p < .001, χ2= .23, but not between T1 and
T2, F(1, 54) = .13, ns. This pattern of results indicated that the manipulation was successful
in changing intention and behavior across time. Importantly, within the control group, there
was no change in intention and behavior (Figure 6).
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
Figure 6. Intention and behavior level for non-intenders in experimental and control group
Volitional intervention for intenders
Means and standard deviations for behavior across the three time points are presented
in Table 6.
Table 6. Means and (standard deviations) for behavior in intenders
Behavior
T1
T2
T3
control
4.23 (1.37)
4.15 (1.24)
3.83 (1.74)
intervention
3.54c (1.52)
3.60b (1.80)
3.97a (1.75)
Note. Means with different subscript represent significant differences in the planned contrasts.
Planned contrasts revealed that in the intervention condition there was a significant
increase in behavior between T1 and T3, F(1, 101) = 5.01, p < .05, χ2= .05, and between T2
and T3, F(1, 101) = 4.5, p < .05, χ2= .04, but not between T1 and T2, F(1, 101) = 0.12, ns. In
the control group, there was no significant behavior change. Due to very similar means at
T3 in the intervention and control conditions, we double checked this result comparing
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
differences between T3 and T1 in both groups. To such effect, we computed a difference
score by subtracting behaviors at T1 from behaviors at T3 (i.e., T3 minus T1). Results
indicated that improvement in condom use was greater in the intervention group (M = .429)
than in the control group (M = -.477), and the difference proved to be significant, t(97) =
2.21, p = .03. As in the motivational intervention, this pattern of results also indicated that
the intervention was successful in changing the behavior of intenders (Figure 7).
Figure 7: Behavior level for intenders in experimental and control group
5. Discussion
This randomized trial to promote condom use among young men compared two
intervention arms, a motivational condition designed for non-intenders and a volitional arm
designed for intenders. Both treatment arms were superior to the passive control group.
We hypothesized that non-intenders would mainly benefit from a motivational
intervention (outcome expectancies and self-efficacy) that increases intention for condom
use, whereas a volitional intervention (action and coping planning) would be beneficial in
promoting condom use for intenders. All these hypotheses were confirmed, as found in
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
previous studies for different behaviors (e.g., Lippke et al., 2010; Godinho, Alvarez, Lima, &
Schwarzer , 2nd revision).
In line with the hypotheses, non-intenders in the intervention condition showed
higher intention levels of using a condom two and four weeks after the intervention,
compared to non-intenders in the control condition. . Findings show not only non-intenders'
increased level of intention but also their increased level of condom use, which had not
been anticipated. In non-intenders, intention was rapidly increased, and the change
occurred two weeks later, but this was also the case with behavior four weeks later. Despite
taking longer, in this case a month, behavior changed as if some self-regulatory processes
had been put into action following intention changes. This was also found in other studies
where a stage-specific multiple mediator model showed that non-intenders, without
planning manipulation, had better results than intenders with planning manipulation, in
behavior change (Godinho et al., 2nd revision).
Furthermore, intenders in the intervention condition showed higher levels in
condom use four weeks but not after two weeks. It has been argued that it is easier to
change intentions than actual behavior and, therefore, it seems easier to let non-intenders
progress to the intentional stage than moving intenders to action (Webb & Sheeran, 2006).
In other words, moderate to large effects on intention correspond to only a small to
moderate effect on behavior.
The present findings show not only non-intenders' increasing level of intention but
also non-intenders and intenders’ increasing level of condom use. Thus, the overall pattern
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
of results suggests that a very brief stage-based computer-delivered intervention can be
effective in promoting changes in the intention towards and in condom use.
Our pattern of results indicated that the manipulation was successful in changing
intention and behavior over a short time period. This may be explained by the fact that
these changes require certain prior conditions to be met, such as thinking about the positive
outcome expectancies or planning when to buy a condom, facilitated by an active
participant’s involvement through elaborated mental simulation and reflection. Although
for non-intenders intention was rapidly increased, and the change occurred two weeks
later, for behavior it took longer, a month, as participants may not have afforded enough
time for self-regulatory processes to be put into action.
Computer-delivered interventions according to the audience's characteristics have
become easier and less expensive to implement, due to the Internet which constitutes a
“hybrid” channel to allow for mass communication, and due to the persuasive properties of
interpersonal communication (Noar et al., 2009). The positive results of these interventions
add to the literature on the efficacy of computer-delivered interventions in the context of
sexual health promotion.
Some limitations should be addressed, such as the sample being only composed of
young men, thus constraining generalizability of the findings for more heterogeneous
populations Due to the characteristic of the sample under study, we do not know whether
the intervention is most effective for individuals in regular relationships, with higher
education and less condom use. Furthermore, the fact that the amount of time the
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CHAPTER 4: STAGE-BASED COMPUTER-DELIVERED INTERVENTIONS
intervention took for each participant was not measured does not permit a reliable
appreciation of the impact of the length of the intervention on its effects. Additionally,
changes in relevant social-cognitive determinants were not analyzed (outcome
expectancies, self-efficacy, action and coping planning) and the explanatory mechanisms of
the changes were, therefore, unable to be further examined. In keeping with the context of
condom use studies, all variables were self-reported. Finally, more sophisticated
experimental designs of matched-mismatched interventions may offer the most powerful
evidence for the validity of stage-matched interventions and may be a better option for
future studies.
Findings stress the use of ICT-based interventions as a strategy for promoting
changes in health behaviors. A stage-based computer-delivered intervention design,
including motivational and volitional treatment, appears to be suitable for improving
condom use intention as well as behavior. Therefore, it can be used for health education
initiatives, as it suggests that one single intervention, over a short period of time, aimed at
those who do not intend to use condoms , can, in fact, successfully change intention, setting
in motion self-regulation processes. This also occurs with those who have the intention,
which is translated into actual behavior change. Nevertheless, this study provides evidence
for the relevance of considering stage-specific computer-delivered interventions in condom
use change and may also contribute to the literature on health behavior change in general.
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5
GENERAL DISCUSSION
CHAPTER 5: GENERAL DISCUSSION
General Discussion
This research emerged from the interest in studying the non use and inconsistent use
of condoms in young adults, described in Chapter 1, which contribute to the increased rates
of sexually transmitted infections, including HIV, among young Portuguese adults. Condom
use is influenced by an array of different factors, such as socio-economic, cultural and
educational. Social cognitive theories and models assume that all these factors exert their
influence, to a large extent, through specific beliefs (e.g. outcome expectancies, perceived
self-efficacy) that individuals hold with regard to the target behaviour (Conner & Armitage,
2000). Studies evaluating the effects of several types of external factors (e.g., socialdemographic, social) on different health-related outcomes, including condom use, have
generally supported this claim, whereby these effects are mediated through social cognitive
factors (e.g., Sniehotta et al., 2013). However, most of the studies conducted have been
correlational, while longitudinal studies attesting a causal relationship between predictors
and behaviour are still necessary.
Motivational processes culminating in goal-setting must be accompanied by volitional
processes involved in the development and enaction of strategies for goal pursuit. The study
of the volitional processes that help individuals translate their intentions into action is
especially important for complex behaviours that demand a considerable self-regulatory
effort, and where multiple barriers are anticipated (Conner & Norman, 2005). Volitional
determinants of condom use are still largely unaddressed, and there is scarce evidence on
the effectiveness of stage interventions for its promotion, as well as on the factors that may
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CHAPTER 5: GENERAL DISCUSSION
limit its effectiveness. The HAPA model, a clearly specified model, was used as the
theoretical backdrop of the studies developed within the scope of this thesis.
The present dissertation set out to identify relevant variables and mechanisms by
which key psychological antecedents affect condom use, and to use this knowledge, as well
as the pertinent theory, to design health education interventions, and to evaluate their
effectiveness in promoting this behaviour. First, preparatory behaviours, a less studied
variable in behaviour planning, were tested to identify their role as a proximal predictor of
condom use (Chapter 2). Secondly, the theoretically predicted relations among key
psychological determinants were modelled to investigate the further contribution of
preparatory behaviours added to a set of volitional variables (volitional self-efficacy, action
planning and coping planning) and post intentional mechanisms were tested (Chapter 3).
Finally, a specific psychological treatment was run, targeting both motivational and
volitional conditions, for the adoption or the increase of condom use through a stage-based
computer-delivered intervention (Chapter 4).
In the following sections, the major findings obtained in each study will be briefly
reviewed, by revisiting the initial issues that were raised in the introductory chapter. Major
findings will be subsequently discussed, stressing their implications at both theoretical and
applied levels. The main limitations of the studies presented will then be summarized, and
some directions for future research will be highlighted. Finally, some concluding comments
on the contribution of the present work will be presented.
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CHAPTER 5: GENERAL DISCUSSION
1. Summary of Findings
The longitudinal study presented in Chapter 2 aimed to investigate, within the HAPA
framework, whether a psychological predictor in the context of condom use, namely
preparatory behaviours, is a volitional predictor of condom use behaviour in conjunction
with motivational factors, by exploring its role in the translation of intentions into action in
heterosexual young adults. Our findings reveal that preparatory behaviours directly mediate
the relationship between intentions and condom use. Moreover, positive outcome
expectancies are determinants of intentions to use condoms and account for 44% of its
variance, and intentions and maintenance self-efficacy are determinants of the performance
of preparatory behaviours. Without past behaviour, the considered social cognitive
constructs enable the explanation of 40% of variability in condom use.
The longitudinal study presented in Chapter 3 serves to attest the importance of
volitional variables in condom use among heterosexual young adults, strengthening the
further contribution of preparatory behaviours, added to a set of volitional variables, such
as volitional self-efficacy, action planning and coping planning, in condom use. Results show
that these variables sequentially mediate the relationship between intention and condom
use and further reveal that preparatory behaviours are the more proximal volitional
predictors of condom use. These volitional variables proved to be predictors of preparatory
behaviours and together, without past behaviour, explained 32% of condom use.
Chapter 4 describes an experimental and longitudinal study whose main goal was to
test whether two stage-based interventions adapted for non-intenders and intenders led to
higher changes in condom use than a passive control intervention. In this study, a series of
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CHAPTER 5: GENERAL DISCUSSION
hypotheses drawn from the HAPA model were tested. It was posited that non-intenders
would mainly benefit from a motivational intervention, through outcome expectancies and
self-efficacy as BCTs, which increase intention for condom use, whereas intenders would
mainly benefit from a volitional intervention through action and coping planning as BCTs for
the promotion of condom use. In line with the hypotheses, non-intenders in the
intervention condition showed higher intention levels of using a condom two weeks after
the intervention and in actual condom use one month later, compared to non-intenders in
the control condition, and intenders in the intervention condition showed higher levels in
condom use four weeks later, compared to the control condition. Therefore, not only did
non-intenders increase the level of intention but also both non-intenders and intenders
increased the level of condom use.
2. Discussion of the Findings and Main Implications
The HAPA contends that positive outcome expectancies are one of the most important
predictors of intention (Schwarzer, 2008). Our results, in the studies presented in Chapters 2
and 3, provide support for such a claim, with positive outcome expectancies regarding
condom use predicting intention for its use, and explaining 44% and 38% of the total
variance of intention, respectively. These results suggest that in order to successfully
persuade individuals to use condoms, presenting and emphasizing the positive emotional
outcomes of safer sex may be effective in increasing condom use intention and are in line
with other studies on condom use, namely among homosexual young men (e.g., Teng &
Mak, 2011).
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CHAPTER 5: GENERAL DISCUSSION
Intention and maintenance self-efficacy predict condom use through preparatory
behaviours, suggesting that the latter variable is a proximal predictor of condom use among
heterosexual young men. Maintenance self-efficacy emphasizes the confidence in dealing
with difficulties when preparing or executing an action. High confidence in the ability of
condom use encourages people to try harder to come up with more strategies when one
strategy fails. The results obtained in the study described in Chapter 2 support this notion
that maintenance self-efficacy functions as an indirect factor through which preparatory
behaviours exert their influence on condom use. Thus, individuals who understand that they
can intentionally regulate themselves to employ specific strategies and skills to prepare
themselves to use condoms (buying and having condoms readily available) effectively
become better users. In short, the effect of maintenance self-efficacy on preparatory
behaviours emphasizes that active self-regulation is necessary in order to change habitual
behaviour towards condom use, since habits to be overcome are strongly elicited by
situational cues (Sutton, 1994). In line with previous studies on condom use (see Bauman,
et. al., 2007), intention does not predict condom use one month later (Chapters 2 and 3).
The results suggest that although our samples intend to have condoms available (intentions
predict preparatory behaviours), intention alone does not predict behaviour, thus
reiterating the importance of preparatory behaviours.
In some HAPA studies (e.g. Sniehotta et al., 2005), past behaviour frequency adds
significant amounts of explained variance into the prediction of future behaviour, and in our
studies past behaviour (i.e., behaviour measured at Time 1) was also considered a direct
predictor of condom use, accounting for an additional 24% (Chapter 2) and 18% (Chapter 3)
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CHAPTER 5: GENERAL DISCUSSION
of variance of condom use at Time 3. Thus, by having included behaviour measured at Time
1 as a predictor of behaviour at Time 3, we believe the specified models enable one to
envisage behaviour from a dynamic perspective (see Renner et al., 2012), leading us to look
at the change in behaviour over time.
In Chapter 2, the most important focus in modelling the psychological mechanisms
contributing to condom use is, however, on preparatory behaviours that have been studied
before, but not in the context of simultaneous motivational and volitional processes.
According to the HAPA, planning is a self-regulatory process that is vital to goal-striving, and
condom use has been found to depend on planning, mainly in self-efficacious men (Teng &
Mak, 2011). Thereby, buying condoms and having them available constitute preparatory
behaviours that might help initiate and maintain condom use which, up to now, have been
seldom studied as a salient aspect of planning. The overall model reveals a good fit to the
data, in accordance with the premise that for condom use one of the most important selfregulatory strategies is the performance of preparatory behaviours (Bryan et al., 2002). In
other words, there is convergent evidence that preparatory behaviours are a proximal
determinant of condom use.
The findings obtained in the study presented in Chapter 3 clearly demonstrate that in
order to bridge the intention-behavior gap, the role of preparatory behaviours as a mediator
in the relationships among intention, and volitional self-efficacy, action planning and coping
planning, and condom use was ascertained. These findings help to clarify the role of
preparatory behaviours in self-regulatory processes, namely that preparatory behaviours
are the most proximal volitional predictors of condom use in heterosexual young adults.
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CHAPTER 5: GENERAL DISCUSSION
These results also suggest that they are an effective mediator in the relations among
intention, volitional variables and condom use. This is a new finding, although in line with
Sniehotta et al. (2005), who found in their study of action control (i.e., the self-monitoring of
behaviour and the adjustment of subsequent behaviour in order to attain the intended
goals) that this volitional variable mediated the relationship between action planning and
physical activity, suggesting that planning must be converted into closer monitoring of
behaviour.
The volitional variables proposed by the HAPA model reiterate their effectiveness in
predicting condom use more accurately than behavioural intention alone, showing the
importance of self-regulation for behaviour change. Volitional self-efficacy, as shown in
Chapter 2, proves to play an important role in the performance of preparatory behaviours
for condom use, as well as acting as an indirect factor through which preparatory
behaviours exert their influence on condom use, as presented in Chapter 3. Planning is
generally regarded as a means for simulating behaviour mentally, so that individuals may be
prepared for situations in which such behaviour might be performed in the future and for
anticipating barriers and generating alternative behaviours to overcome them. Indeed,
planning has been found to serve as an operative mediator between intentions and
behaviour with several empirical backups (e.g. Godinho et al., 2014; Sniehotta, et al., 2006;
Ziegelmann et al., 2006). Notwithstanding, our findings show that the relationship between
intention and behaviour was not mediated by traditional planning alone, but by a sequential
mediation through preparatory behaviours, suggesting that self-regulatory efforts require
concrete measures associated with condoms, involving their purchase and availability in
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CHAPTER 5: GENERAL DISCUSSION
order to become operative. Without them these efforts rarely translate into effective
behavioural change. Thus, although planning is commonly regarded as a mediator between
intention and action across a wide range of behaviours, this effect may vanish if other
volitional constructs are included in the model such as recovery self-efficacy or action
control (Schwarzer & Luszczynska, in press). Our findings are in keeping with others, such as
a recent study where a similar mediation process was found for fruit and vegetable intake
(Godinho et al., 2014), when action control was included in the structural equation model,
showing that although planning was closely associated with intentions, its effect on
behaviour was not direct, revealing serial mediation via action control.
In Chapter 4, a stage-based computer-delivered intervention designed for nonintenders and intenders is presented. The HAPA model is very explicit with regard to the
specific factors that predict stage transitions and which should, therefore, be targeted at
each stage. On this basis, it was hypothesized that non-intenders would mainly benefit from
a motivational intervention focused on outcome expectancies and self-efficacy that increase
intention for condom use, whereas a volitional intervention, exploring action and coping
planning, would be beneficial in promoting condom use for intenders. Hence, the
interventions focused on these targeted factors that have also been identified in prior
research as associated with stage transitions (Schuz et al., 2009). In Chapter 4, the majority
of the hypotheses raised were confirmed, such as those found in previous studies for
different behaviours (e.g., Godinho, et al., 2nd revision; Lippke et al., 2010). Thus, despite
some issues requiring further refinement, such as the mechanisms responsible for intention
and behaviour change that were not analysed, our findings reveal the existence of two
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CHAPTER 5: GENERAL DISCUSSION
intervention arms, a motivational condition designed for non-intenders and a volitional arm
designed for intenders that were superior to the passive control group. Findings show not
only non-intenders' increasing level of intention but also their increasing level of condom
use, which had not been anticipated. This result was unexpected due to the fact that there
is abundant research showing that moderate to large effects on intention have only a small
to moderate effect on behaviour (Webb & Sheeran, 2006), and only the determinants of
intention in the motivational intervention were manipulated. In non-intenders, intention
was rapidly increased, and the change occurred two weeks later, but this was also the case
with behaviour. Despite taking longer, a month this time, behaviour changed as if some selfregulatory processes had been put into action following intention changes. This was also
found in other studies where a stage-specific multiple mediator model showed that nonintenders, without planning manipulation, had better results than intenders with planning
manipulation, in behaviour change (Godinho et al., 2nd revision). As for intenders in the
intervention condition, our findings showed higher levels in condom use four weeks later, as
the gold standard of any intervention, especially when targeting intenders, should be
behavioural change.
Our pattern of results indicated that the manipulation was successful in changing
intention and behaviour over a short time period. This success may be explained by the fact
that the changes require that certain prior conditions are met, such as thinking about the
positive outcome expectancies in non-intenders or planning when to buy a condom,
facilitated by an active participant’s involvement through elaborated mental simulation and
reflection in intenders. Albeit significant, the effects of the stage-based computer131
CHAPTER 5: GENERAL DISCUSSION
intervention are small. This should not be surprising, taking into consideration that we were
trying to change a very complex behaviour, which is influenced by a myriad of different
factors, through a minimal and very brief intervention, consisting of a single exposure to a
computer intervention.
The major implications of our findings underscore the need for preparatory
behaviours and an understanding of how they work in conjunction with other volitional
variables, such as planning and self-efficacy in the translation of behavioural intentions into
actual condom use. By revealing the mechanisms involved in condom use, a valuable
backdrop for future intervention studies has been provided. Educational interventions for
HIV prevention should, therefore, be encouraged to pay particular attention to preparatory
behaviours and facilitate their occurrence among young adults. Furthermore, interventions
should ensure that young men are not only motivated to use condoms but also to plan to do
so, through buying and carrying them around, given the mediating role of preparatory
behaviours found in the studies presented in Chapters 2 and 3. For practitioners, these
studies may also facilitate equipping young men with the necessary skills, such as increasing
their confidence in dealing with difficulties in condom use and planning how and when to
purchase and have condoms on them, to effectively mitigate many of the condom-use
barriers. Findings also stress the use of ICT-based interventions as a strategy for promoting
changes in health behaviours. A stage-based computer-delivered intervention design
including motivational and volitional treatment appears to be suitable for improving
condom use motivation as well as behaviour, which can be used for health education
initiatives.
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CHAPTER 5: GENERAL DISCUSSION
In short, results have attested the relevance of the HAPA model for the prediction of
condom use by adding the role of preparatory behaviours for the translation of intentions
into action. They have also confirmed the usefulness of a stage-based computer delivered
intervention to increase condom use through variables provided by the HAPA, and of how
crucial it is for the passage of non-intender to intender stage and of intender to actor stage.
These findings may be considered important from a health education perspective, since
interventions should contemplate preparatory behaviours as obvious proximal predictors of
action and that interventions should include behaviour antecedents to ensure the success of
treatment. On the other hand, our findings have confirmed that it is useful to distinguish
the pre-intentional stage from the intentional stage, showing that there are theory-specified
constructs that constitute relevant targets for interventions addressing people at different
stages of change, which should lead to increased success in health behaviour change.
Nevertheless, other variables that have not been addressed in the current study might also
be operationalized in future interventions. These findings indicate that pre-intenders profit
from interventions targeting outcome expectancies and self-efficacy and intenders benefit
from planning (when, where, how, and what to do in the face of when confronted with
obstacles) the behaviour they intend to adopt. As already mentioned, pre-intenders were
not expected to adopt a new behaviour after an intention formation, since a volitional
intervention is expected to help to translate this intention into actual behaviour change.
This finding may be useful in health education , as it suggests that one single intervention,
over a short period of time, aimed at those who do not intend to use condoms, can, in fact,
successfully change intention, setting in motion self-regulation processes. This also occurs
with those who have the intention, which is translated into actual behavior change.
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CHAPTER 5: GENERAL DISCUSSION
3. Limitations and Future Directions
Some limitations to the presented studies should be addressed. In order to suitably
interpret the data on condom use, the aspect of voluntary response should be taken into
consideration, given that a convenience and not a probabilistic sample was used.
Furthermore, all the studies used samples composed of participants with little schooling,
and they were all young men. These last two characteristics are, however, important given
that the most disadvantaged individuals tend to be more exposed to health risks, have less
access to information and are more likely not to use condoms (Bull & Shlay, 2005; Marshall
et al., 2009), and young men, especially young people aged 15 to 24 years, are particularly
vulnerable to STIs (Tanner et al., 2009). Future studies should seek to replicate the findings
using more heterogeneous samples, for instance young and older men, including gay and
bisexual men, to test the universality of the mechanisms found in the studies conducted.
Research has shown that another limitation related to the selection of specific
audiences for intervention is the fact that volunteers for sex research differ from nonvolunteers, namely in their attitudes towards sex, reported sexual behaviour and sexual
experience, which could hamper the generalization of our findings, such as the importance
of preparatory behaviours. Non-volunteers have proven to be less willing to disclose sexual
information, less sexually experienced in terms of number of lifetime sexual partners and
amount of exposure to written material about sexuality (Bogaert, 1996; Strassberg 1995;
Wiederman, Wels, & Allgeier, 1994). These dimensions may be relevant for the
generalization of the results, due to the fact that the participants in this study may have had
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more positive attitudes and broader sexual experience, which could have led them to give
greater importance to becoming more involved in preparatory behaviours.
Measures of condom use were obtained through self-report which can lead to
problems of recall bias and social desirability (Michie & Abraham, 2004). However, the
average rate of social desirability in our studies (Chapters 2 and 3) was not high, and is
consistent with other studies where social desirability proved not to be associated with
condom use reports (Teng & Mak, 2011). Moreover, stability was found in the reported
condom use mean over a one-month period, attesting that, at least throughout the studies,
mere measurement effects did not occur.
Despite research on condom use being difficult, owing to the fact that objective
measures are not normally available (e.g. biomarker data such as detection of ejaculation or
sexually transmitted infection in vaginal samples), future studies could complement
subjective measures with the use of, for example, a prospective daily diary that allows for an
objective record of an “at the moment nature” (Hope et al., 2008).
Another limitation to the present studies stems from the high drop-out rate, which
was perhaps due to the fact that the questionnaire was too long and the lack of financial
compensation. Although the attrition rate was high, the average 40% response rate was
close to what was identified in a meta-analysis on online-based studies (Cook et al., 2000).
In Chapter 4, due to the characteristic of the sample under study, we do not know
whether the intervention was most effective for individuals in regular relationships, with
higher education and less condom use. Furthermore, the fact that the amount of time that
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the intervention took for each participant was not measured does not allow for a full
appreciation of the impact of the length of the intervention on its effects.
In the studies of the relevant mechanisms by which key psychological antecedents
affect condom use, volitional predictors and preparatory behaviours were assessed at the
same data collection point. Ideally, the mediators should not be measured at the same time
as the predictors, which may raise doubts in the mediating mechanism. In future stagebased computer-intervention studies it would be helpful to include booster sessions and a
follow-up assessment a few months after the intervention, to insure that possible effects of
changes in volitional processes have been captured and to ascertain whether longer-term
effects of the intervention have also been detected. As targeting individuals according to the
stage of change seems to be effective, future studies should develop interventions,
introducing, for instance, different forms of tailoring, including graphs and other visual
material where others could be performing the target behaviours as a way to promote selfefficacy in participants, showing people buying condoms, giving practical advice on how to
carry condoms around, and showing the best way of preserving them. Future studies may
also be complemented by other more qualitative methodologies, for instance, focus groups
that contribute to furthering young men’s understanding of condom use (Davis et al., 2014).
Another suggestion for future studies includes the examination of whether the
outlined mediating chain presented in Chapter 3 varies according to the individual’s stage of
readiness to adopt this particular behaviour (condom use), the preparatory behaviours
assessed at a different data collection point from the other volitional predictors, and making
use of experimental designs to attest for robust evidence of causality.
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Another important line for future studies is to investigate whether health education
interventions may contribute to sustained changes in condom use. Although the focus of
our studies was on initiation rather than on maintenance of behaviour in order to have an
impact on health, adequate condom use must be maintained over a prolonged period of
time (Conner & Norman, 2005). As highlighted by stage theories, the factors predicting and
determining behavioural maintenance may differ from those which promote initiation
(Armitage & Conner, 2000). The HAPA model proposes that actors rather need relapse
prevention that helps them to recover from setbacks, and, in the case of a relapse, they
need strategies for coping with them effectively, thus contributing to the maintenance of
health behaviours (Schwarzer et al., 2011). Considering that promoting the maintenance of
correct and consistent condom use is a very important goal, future research should also
include actors, and examine whether interventions targeting factors related to behavioural
maintenance, such as those proposed by the HAPA model, are successful.
Moreover, for future research it would be useful to explore the change mechanisms in
a stage-based computer-delivered intervention and a more sophisticated experimental
design of matched-mismatched interventions would offer the most powerful evidence for
the validity of stage-matched interventions.
Nowadays, it is widely acknowledged that condom use is a complex decision-making
process involving two individuals. Based on this awareness, researchers have drawn
attention to the relational nature of this behaviour has densifies their comprehension,
leading them to explore other processes, besides the cognitive (Widman et al., 2014).
Therefore, it is apparently essential to analyse the individual variability in the explanatory
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CHAPTER 5: GENERAL DISCUSSION
intention – behaviour gap, as well as to explore the mutual influence between partners to
explain the use of condoms. Another aspect that future studies should examine is emotion
regulation, which has been considered an important process in the self-regulatory efforts
underlying health behaviour change (Schwarzer, 2008a). Future research should also
examine the circumstances under which other mediators operate in condom use (e.g.,
action control, social norms) and whether moderating effects can be identified, such as, for
example, the type of relationship (casual or regular). Although this predictor was evaluated,
it was not taken into consideration, because the sample was not large enough to compare
the two types of relationship, given that there were disproportionately more young men in
regular rather than casual relationships.
4. Concluding Comments
The research presented in this dissertation contributes to furthering the theoretical
knowledge on the psychological processes involved in condom use. The innovative aspect of
the research conducted lies, mainly, in the study of preparatory behaviours for condom use
in young heterosexual men. It is the planning-behaviour gap that comes into focus, and
findings contribute to the understanding of the role of preparatory behaviours in this gap.
The relevance of preparatory behaviours is highlighted, showing how they work in
conjunction with other volitional variables such as action and coping planning and selfefficacy in the translation of behavioural intentions into actual condom use, drawing
attention to the open architecture of the HAPA model (Schwarzer & Luszczynska, in press).
Understanding the mechanisms that lead to safer sexual behaviour is an important
138
CHAPTER 5: GENERAL DISCUSSION
contribution to the development and evaluation of preventive interventions aimed at
increasing condom use among young adults. Educational interventions should, therefore, be
encouraged to pay particular attention to preparatory behaviours and facilitate their
occurrence among young adults.
A second innovative aspect is that on an applied level, the design of a brief stagebased computer-delivered intervention, adapted to the stage of change of individuals,
which was effective in promoting changes in the intention to use and actual practice of
using condoms, contributes to making new options available to boost effective health
behaviour change.
A third innovative aspect of the current studies is the fact that this is the first ever
evaluation of the HAPA model for condom use among a sample of young heterosexual men.
The thesis contributes to the current debate on volitional factors that help to predict health
behaviours. It not only stresses the explanatory value of the model in condom use in a new
sample, but also points to its suitability as a theoretical framework for interventions.
Our studies also contribute to raising several important issues for health education on
condom use. First, contrary to the commonly held tenet of health education that a one-time
intervention is not generally sufficient to change behaviour, the results of this study suggest
that a one-time, relatively brief intervention can, indeed, result in behaviour change.
Moreover, although significant changes tended to be short-lived, there was a trend for
better outcomes at that time point. This is crucial since a brief intervention can be
implemented in the “real world” in a school or another setting, without unduly constraining
the major activities. Therefore, practitioners should consider developing and testing brief
139
CHAPTER 5: GENERAL DISCUSSION
interventions that can be carried out in the settings where the target population is found, so
that these interventions can benefit a much larger population (Roye, Silverman, & Krauss,
2007). Second, the results of these studies have shown that some strategies must be
contemplated to equip young men with the significant skills, i.e., preparatory behaviours to
effectively promote condom use, in other words, interventions may well be successful if
individuals are motivated to prepare themselves for action. Third, these findings have
important implications for public health initiatives seeking to use individual adapted
computer-delivered interventions as a strategy for promoting changes in condom use
behaviour. Hopefully, this work will stimulate effective interventions that help to reduce the
number of young people infected with STIs and lead to future research, as well as to a
better articulation between theory and health education, through the development of
theory-guided and evidence-based delivered interventions.
140
6
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7
APPENDICES
APPENDICES
Appendix A. Questionnaire on Condom Use Among Young Portuguese Adults (Chapters 2
and 3)
Note: The questionnaire was set up online using Qualtrics Software
Informed Consent
Please read this text before agreeing to participate in the study. This research is integrated
within Inter-University PhD Program in Psychology of Lisbon and Coimbra Universities (FPUL
and FPCEUC) in Educational Psychology.
We are currently conducting a study to learn about the psychological mechanisms that lead
individuals to engage in protective sexual behaviors such as condom use. It is also our
intention to find ways to support young people in increasing control over their actions and
implementing a series of strategies so as to act according to their intentions.
IMPORTANT: In order to participate in the study you must be at least 18 years of age and
have heterosexual relationship.
Should you agree to participate, you will be prompted to answer a questionnaire that will
not take longer than around 20 minutes. Once you have started, we urge you to answer to
the end. If you give up halfway through, or do not complete the questionnaire, we will be
unable to use your data.
In an attempt to test the stability of beliefs related to condom use, we would like to ask you
to fill in another two questionnaires that will be sent to your e-mail, with an interval of two
weeks between them. Thus, by participating in our study you will be asked to answer three
questionnaires: the first now, the second in two weeks and the third in a month.
Any information you provide will be treated in a strictly confidential and anonymous
manner, and your answers will only be used within the scope of our research project, thus,
retaining one’s privacy. There are no "right" or "wrong" answers, so try to answer honestly.
This site does not control the IP (internet address) of its users, so it is very important that
you provide us with a correct email address that is used on a regular basis.
In the questionnaire you must click on the option you consider applicable to yourself and at
the end of each page you should click "Continue" to proceed to the next page.
179
APPENDICES
At the end of the questionnaire you will find the contact to be used should more
information be required or for doubt clarification in relation to sexual issues that may have
arisen in the questionnaire.
Your participation is very valuable for our research and we would appreciate your
contribution immensely.
Many thanks.
By pressing the "Start" button I declare to be over the age of 18 and agree to participate
in this study about which I have been provided sufficient information.
Welcome to the study on condom use among young Portuguese adults.
Answers to the following are related to the LAST TWO MONTHS
Have you been or are you involved in a steady relationship: yes / no
Number of girlfriends over the past two months: 0,1,2, ≥ 3
Have you been or are you involved in a casual relationship (date): Yes / No
Number of sexual partners over the past two months: 0,1,2, ≥ 3
In your current relationship(s), have you had sexual intercourse (vaginal and / or
anal): Yes / No
In your opinion, when should a condom be used:

Pregnancy prevention;

Sexually transmitted disease prevention;

Protection against HIV/ AIDS;

Other
180
APPENDICES
Some young people find disadvantages in using condoms, while others consider its use
advantageous. What is your opinion?
Strongly
Disagree
Disagree
somewhat
Disagree
Agree
Agree Strongly
somewhat agree
When I use a condom I feel safe.
When I use a condom I feel I am
protecting my partner.
When I use a condom I feel I am
transmitting confidence.
Some young people feel that it is difficult to always use condoms. How do you feel?
Strongly
Disagree
Disagree
somewhat
Disagree Agree
Agree
Strongly
somewhat agree
I believe I can always use a condom
properly.
I think I can always use a condom even
though if I am afraid that my partner thinks I
have a sexually transmitted disease.
I believe in my abilities to discuss the
systematic use of condoms with my partner.
I think I will always remember to always use
a condom even after have been drinking or
consuming drugs.
Over the next two weeks, what are your intentions about using condoms systematically?
Strongly
Disagree
Disagree
somewhat
Disagree Agree
Agree
Strongly
somewhat agree
From now on, I intend to always use
condoms.
From now on, I intend to always use a
condom the next time I have sex.
I intend to use a condom every time I
have sex.
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APPENDICES
Some young people intend to protect themselves sexually, using condoms and, therefore,
establish an active plan for this purpose. What do you do?
Strongly
Disagree
Disagree
somewhat
Disagree Agree Agree
somewhat
Strongly
agree
I have already made specific plans about when
to always use a condom (when I have sex
vaginal and / or anal sex).
I have already made concrete plans about
where I always use a condom (at home, at
parties, in the car)
I have already made concrete plans about how
I always use condoms (know where to buy
them, bring them with me)
Which of these 7 situations are, in your opinion, a barrier to the systematic use of
condoms:
Yes
Not
The partner does not want to use condoms
☐
☐
Being under the influence of substances (drugs and / or alcohol)
☐
☐
Experiencing the "heat of the moment"
☐
☐
Not having a condom available
☐
☐
The partner is very attractive
☐
☐
The partner is a casual one
☐
☐
The partner is a girlfriend
☐
☐
Some young people make plans to anticipate these barriers. What do you do?
Strongly
Disagree
Disagree
somewhat
Disagree Agree Agree
somewhat
Strongly
agree
I have already made concrete plans about what
to do when my partner does not want to always
use condoms.
I have already made concrete plans to always
use a condom when I am under the influence of
substances (drugs and / or alcohol.).
I have already made concrete plans of what to
do - to always use condoms in the "heat of the
moment."
I have already made concrete plans of what to
do when I do not have condoms available.
I have already made concrete plans to always
use a condom if my partner is very attractive.
I have already made concrete plans to always
182
APPENDICES
use a condom if my partner is casual.
I have already made concrete plans to always
use a condom if my partner is my girlfriend
Once you start using condoms in a relationship, it is important to maintain their systematic
use. Do you feel confident about continuing this behavior?
Strongly
Disagree
Disagree
somewhat
Disagree Agree Agree
Strongly
somewhat agree
I think I can maintain the use of condoms even if
my partner does not want to use them.
I think I can maintain the use of condoms even if I
am under the influence of substances (drugs and /
or alcohol.)
I think in my ability to maintain the systematic
use of condoms, even in the "heat of the
moment."
I think I can maintain my decision to always use
condoms, even if I do not have them readily
available (delaying sexual intercourse or getting
involved in safe sexual practices).
I think I can maintain the systematic use of
condoms, even if my partner is very attractive.
I think I can maintain the systematic use of
condoms, even if my partner is casual.
I think I can maintain the systematic use of
condoms, even if my partner is my girlfriend.
Imagine that tomorrow, you will have the opportunity to have sex with your partner, what
would you normally do in this situation?
Strongly
Disagree
Disagree
somewhat
Disagree Agree
Agree
Strongly
somewhat agree
I buy / acquire a condom when I expect
the possibility of sex.
I have a condom with me when sex is a
possibility.
I keep condoms around whenever
intercourse may occur
183
APPENDICES
In the last month, how often have you always used a condom, whenever you had sexual
intercourse (vaginal and / or anal)?
Never
Rarely
A few Someti Almost Always
times mes
always
In the last two months I have used a condom
Condom was part of my habitual sexual practices
If you answered "never" check, please, why you did not use a condom?
Yes
Not
☐
☐
☐
☐
☐
☐
I did not have sexual intercourse
☐
☐
Despite the intention to use condoms, I failed
☐
☐
Trusted my partner so did not feel the need to use condoms
Had no partner
You and your partner have completed the screening test for HIV and have agreed
not to use condoms.
How do you consider yourself socially?
Strongly
Disagree
Disagree Disagree Agree Agree
Strongly
somewhat
somewhat agree
I'm always courteous even to people who
are disagreeable.
There have been occasions when I took
advantage of someone.
I sometimes try to get even rather than
forgive or forget.
I sometimes feel resentful when I do not
get things my way.
No matter who I'm talking about, I'm
always a good listener.
What vocational training are you attending?
Have you had any internship experience in a company?
AGE:
LEVEL OF EDUCATION:
NATIONALITY:
RESIDENCE AREA:
184
APPENDICES
BIRTHDAY:
TOTAL NUMBER OF SEXUAL PARTNERS:
BEGAN HAVING SEXUAL RELATIONS WITH:
Casual PARTNER (date) / Stable PARTNER (relationship)
Used a Contraceptive Method in the 1st SEXUAL ENCOUNTER? yes / no
IF YES, which? Condom / contraceptive pill / withdrawal / other_____
AGE OF FIRST SEXUAL ENCOUNTER
≤ 14 years old / 15-16 years old / ≥ 17 years old
Thank you for your participation. All answers are appreciated.
Within two weeks, you will receive an email asking you to fill in another short questionnaire.
We are very grateful for your participation.
If
you
have
any
comments
or
suggestions,
please
send
an
email
to
[email protected]
If you have any questions, we suggest you consult the following links:
http://www.sida.pt/
http://www.aidsportugal.com/
http://www.apf.pt/
http://juventude.gov.pt/Portal/SaudeSexualidadeJuvenil/TemassSexualidade/SexualidadePr
evencao/O+preservativo.htm
185
APPENDICES
186
APPENDICES
Appendix B. Intervention ON- SCREEN (Chapters 4)
Note: The intervention ON- SCREEN was set up online using Qualtrics Software
Motivational intervention for non-intenders
People like to have sex!
However, it is important to remember that, when you have sex, is important to protect
yourself.

Using a condom is the only way to protect yourself from HIV / AIDS when you want
to have sex with someone.

The condom is the most effective mean to prevent sexually transmitted diseases
such as hepatitis or syphilis and an unwanted pregnancy.

Using a condom is the best way to show someone that you like her, sex without a
condom is not natural since 1990.

Condoms can be transformed into something highly entertaining in sexual
intercourse - with different kind of thickness, with lubricant or not, with different
colors, textures, or even playing music.
187
APPENDICES
In your opinion, what other advantages there are in using condoms?
1. ______________________________________________
______________________________________________
2. ______________________________________________
______________________________________________
3. ______________________________________________
______________________________________________
4. ______________________________________________
______________________________________________
James, a 18 year old, has many encounters with girls. That's why he suggests you should
never forget to use the condom:
"When I know I'll have an encounter with a girl who I know can evolve a little more than a
coffee, I'm cautious, so I always carry with me a condom ... for me there is no reason not to
use, not even the excuse that one can lose sensitivity because nowadays we can buy thinner
condoms. We are all aware that the only way to protect against sexually transmitted
diseases, especially HIV / AIDS, so I never lose an opportunity. I feel more calm and relaxed
because I know I'm protected."
Describe briefly a situation that you had the feeling that you would not to do it and then you
did it (the situation may be sexual or not):
188
APPENDICES
Volitional intervention for intenders
Use a condom every time you have sex in the next 15 days it is easier if you have planned
carefully what to do.
I can always use a condom:

When: (example: every time you have sex, vaginal and / or anal)

With whom: (e.g. girlfriend likes)

Where: (example: at a party, in the car, at home)
To be able to use a condom, you must first buy it and bring it with you.

Where to buy / get? (For example, the pharmacy, the supermarket, the health
center, the machines found in clubs, bars and shopping centers)

What type of condom I want to use (for example: normal, with flavors and different
textures ...)?

When? (e.g. after school, on weekends, before going on holiday).

Where do I will bring them? (e.g: pocket, wallet, car...)
189
APPENDICES
What is the barrier that I can prevent to always use a condom? (Please choose)
Barrier 1:
The partner does not want to use condoms
Being under the influence of substances (drugs and / or alcohol)
Experiencing the "heat of the moment"
Not having a condom available
The partner is very attractive
The partner is a casual one
The partner is a girlfriend
What strategy can be adopted to overcome this barrier?
STRATEGY to deal with BARRIER 1:
What is the barrier that can prevent so always use a condom? (Please choose)
Barrier 2:
The partner does not want to use condoms
Being under the influence of substances (drugs and / or alcohol)
Experiencing the "heat of the moment"
Not having a condom available
The partner is very attractive
The partner is a casual one
The partner is a girlfriend
What strategy can be adopted to overcome this barrier?
STRATEGY to deal with BARRIER 2:
What is the barrier that can prevent so always use a condom? (Please choose)
Barrier 3:
190
APPENDICES
The partner does not want to use condoms
Being under the influence of substances (drugs and / or alcohol)
Experiencing the "heat of the moment"
Not having a condom available
The partner is very attractive
The partner is a casual one
The partner is a girlfriend
What strategy can be adopted to overcome this barrier?
STRATEGY to deal with BARRIER 3:
I can always use a condom.
191