Factors associated with condom use differ depending on whether a woman has a history of sexually transmitted disease (STD), according to a study of women attending public STD clinics in Alabama.1 Women reporting a history of any STD had an increased likelihood of using condoms with their main partner if they viewed condom use as important in a long-term relationship, considered condom use common among their peers or perceived themselves to be at risk for STDs. On the other hand, women with no STD history had an increased likelihood of using condoms if they thought condom use was important in a trusting relationship, and a reduced likelihood of doing so if they were in a long-term relationship or had experienced violence in their relationship.
The data for this analysis were collected as part of a prospective study of the effectiveness of male and female condoms. Investigators recruited women between July 1995 and August 1997 at county STD clinics in Jefferson and Madison Counties, Alabama. Women were eligible to participate if they were 18-34 years old, were not pregnant or planning to become pregnant in the next six months, had not undergone a hysterectomy and were not receiving a long-term course of antibiotics. A female interviewer asked each participant about her socioeconomic characteristics; relationships with her main partner (i.e., husband or boyfriend) and other partners; condom use in the past 30 days with her main and other partners; sexual, reproductive and medical history; attitudes and beliefs regarding condom use; and perceived risk for HIV or other STDs.
Applying factor analysis to the interview responses, the investigators defined 18 predictive factors for condom use. They measured condom use in terms of the proportion of coital acts in the past 30 days in which a male condom was used; this proportion was calculated separately for main and other partners. In initial bivariate analyses, the investigators assessed the correlation between the predictive factors and condom use. They then used the predictors that were significant at p<.01 to construct binomial regression models assessing the factors associated with condom use for women overall and separately for those with and without a history of STD.
In all, 1,159 women participated in interviews. The majority of participants were black (84%) and had a high school education or less (63%); their average age was 24 years. Among the 45% of participants who were employed, median income was between $300 and $600 per month. Women had been in a relationship for 27 months, on average; 104 women reported having engaged in sex with someone other than their main partner during the past 30 days. Almost half (49%) of the women were currently using condoms for birth control.
In the bivariate analysis, use of condoms with one's main partner was significantly correlated with 13 predictive factors. Twelve of these remained significant in the overall regression analysis: Condom use with one's main partner was positively associated with how accepting the woman's partner was of her request to use condoms; the number of times the woman had put the condom on the man in the past 30 days; and the woman's perceptions of the convenience of condom use, the need for use in long-term and in trusting relationships, her risk of contracting HIV or other STDs from her main partner, and her peers' use of condoms (adjusted relative risks, 1.1-1.6). Use also increased as a woman's self-efficacy in using condoms increased (relative risk, 0.6 on a scale on which a low score indicates high self-efficacy). A woman's likelihood of using condoms with her main partner declined as her age, the duration of her relationship, her reported number of risk factors related to drug use and her experience of violence in her relationship increased (adjusted relative risks, 0.7-0.99).
Only three factors were associated with condom use with a main partner both for women who reported a history of STD and for those who did not: the partner's acceptance of condom use requests (adjusted relative risks, 1.5 and 1.3, respectively), condom use self-efficacy (0.6 and 0.4, descending scale) and perceived convenience of condom use (1.3 and 2.9). In addition to these, a distinct set of factors were significantly associated with condom use for each group of women. Among participants who reported a previous STD, the likelihood of condom use with one's main partner was elevated for those who perceived condom use to be important in long-term relationships (1.5), viewed condom use as normative behavior among their peers (1.6), or felt at risk for acquiring HIV or other STDs (1.3); it also increased with the number of times a woman reported putting condoms on her partner (1.1). Women who reported no previous STDs had an increased risk of using condoms with their main partner if they considered condom use important in a trusting relationship (adjusted relative risk of 1.8); their likelihood of using condoms fell as the duration of their relationship and their experience of violence in the relationship increased (0.98 and 0.6, respectively).
Condom use with partners other than husbands or boyfriends was positively correlated in the bivariate analysis with women's lifetime number of sex partners; educational attainment; perception of the need for condom use in long-term relationships, of the convenience of using condoms and of peers' condom use; the number of times the woman put the condom on the man in the past 30 days; and condom use self-efficacy. One factor, more frequent condom application by the man, was inversely associated with condom use. None of these factors were significantly associated with condom use in the binomial regression analyses.
According to the investigators, their results "support previous findings on determinants of condom use and the need for theoretically based interventions addressing these important predictors." They note that their study is the first to investigate STD history as a modifying factor in condom use, and suggest that a woman's STD history "may be an important factor in targeting public health interventions to increase condom use." --A. Hirozawa
1. Posner SF et al., Psychosocial factors associated with self-reported male condom use among women attending public health clinics, Sexually Transmitted Diseases, 2001, 28(7):387-393.