A better understanding of the predictors of condom acquisition among individuals at high risk of acquiring and transmitting sexually transmitted diseases (STDs) is needed to plan interventions in the sexual and reproductive health care settings they use. Inner-city public STD clinics treat large numbers of individuals with multiple risk factors for STDs, including frequent unprotected sex, multiple sexual partners, history of an STD and residence in communities with exceptionally high rates of infection with the human immunodeficiency virus (HIV) and other STDs, as well as high rates of unintended pregnancies.(1) Such clinics serve primarily low-income residents, many of whom are recent immigrants to the United States. Specially targeted and culturally appropriate prevention programs are needed to educate different groups within this clinic population and promote consistent condom use, for protection from both disease and pregnancy.
A number of studies have examined patterns and predictors of condom use.(2) Differences by race and education exist in knowledge of and attitudes toward HIV and other STDs, and in self-reported condom use.(3) The extent of acculturation also has been shown to be related to one's perceived HIV risk and high-risk behavior. For example, less acculturated Hispanic men have more positive attitudes toward condoms and carry them more frequently than do more acculturated Hispanic men;(4) however, Hispanics in general may be less likely than non-Hispanic whites or blacks to use condoms.(5) For immigrants from English-speaking countries, to whom the standard language measure of acculturation does not apply, their length of residence in the United States may also influence condom acceptability.
Individuals who are at the greatest risk for HIV and STD infection--such as STD clinic clients--are unlikely to report consistent condom use.(6) Furthermore, the use of contraceptive methods other than the condom has been negatively associated with condom use.(7)
Several studies have documented the relationship between psychosocial factors and self-reported condom use. While these factors may all play some role in predicting condom use, the findings across studies have been inconsistent.(8) Although some studies have shown that gender and cultural background influence psychosocial predictors of condom use,(9) few have been based on samples that were sufficiently large and diverse to fully explore the relationship. Further, most of these studies have been limited by reliance on self-reports of condom use, instead of on behavioral measures.
In this article we use an innovative proxy measure--a strategy of dispensing coupons for condoms that was first employed by Solomon and DeJong(10)--to identify factors that predict condom acquisition following patient visits to a large STD clinic in New York City. Women and recent immigrants to the United States constitute significant proportions of this clinic population. Thus, the gender and cultural diversity of the patient population make it an ideal sample with which to examine the characteristics of individuals who are sufficiently motivated to redeem the coupon at a local pharmacy. Specifically, we were interested in learning whether there were differences in condom acquisition that would suggest targeting interventions to special population groups. We were also interested in learning the risk profiles of clients who redeemed their coupons--that is, whether motivated clients were at a relatively high or low risk for acquiring an STD.
Methods
From December 1991 through December 1992 all men and women who attended one of the largest STD clinics in New York City were enrolled in a study designed to evaluate a video-based educational intervention to promote condom use. We report on a proportionate random sample of 691 black and Hispanic recipients of regular clinic services who served as the control group for a planned test of the intervention at the clinic.
The proportionate random sampling strategy was based on the gender and ethnic distributions of the patient population as determined from a review of clinic records. Typically, patients arrive before or during the first hour of clinic operation on any given day, and each patient is registered and assigned a number in the order of their arrival. For this study, on random days of clinic operation throughout the study period, all patients over age 18 were approached in consecutive order to fill predetermined gender and ethnic cells. Participants could enroll in the study only once. Of those who were eligible, 96.5% agreed to participate. All participants provided informed consent. Study procedures were approved by the New York City Department of Health.
While participants waited to be examined, they were interviewed in their choice of English or Spanish by one of three trained interviewers, two men and one woman. The interview questionnaire solicited social and demographic information on individuals' sexual practices, risk behaviors and STD history. In addition, participants responded to a brief survey on psychosocial factors, including knowledge and attitudes about HIV, STDs and condoms, intentions to use condoms, and perceptions of risk of acquiring an STD, including HIV.
While giving clients several condoms at the end of a visit is standard procedure for STD clinics run by the Health Department in New York City, preliminary research found that this was not always done because of time pressures, heavy patient loads, inadequate supplies or uninformed staff. To assure consistency in condom distribution at the clinic site, the interviewers offered each participant a selection of three free condoms at the completion of the interview. All participants accepted these condoms. Clients were then given a coded coupon that could be redeemed for an additional three condoms of their choice at a private pharmacy several blocks from the clinic (within a 10-minute walk) at any time within the next two months. Coupon redemption at the pharmacy was used as a measure of condom acquisition.
We employed a stepwise regression to determine factors associated with whether a client would redeem the coupon. Using multiple logistic regression, we first identified predictors of condom acquisition from three separate sets of variables; we then entered the significant predictors into a full logistic regression model to assess the overall influence of these factors on condom acquisition.
Dichotomous background factors included gender, ethnicity, age (above the mean age versus below the mean age), education (high school graduate versus nongraduate), and acculturation score (above the mean value versus below the mean value). Acculturation was assessed using a summated scale of length of residence in he United States and language spoken at home.
The second set of dichotomous variables assessed participants' risk of contracting HIV and other STDs. These were whether a respondent currently had a primary sexual partner, the number of sexual partners in the previous month (>=2 versus one or none), consistency of condom use (sometimes or frequently versus rarely or never), whether they had ever been to an STD clinic before, and whether they had ever had an STD.
The third set of variables included a number of scales to measure knowledge and attitudes that may predict condom acquisition. The knowledge scale consisted of 17 items related to STD and HIV transmission and symptoms, and to correct condom use.(1*) Scores were computed by tallying the responses as 1 if correct, -1 if incorrect, and 0 for no answer.
The attitudes scale consisted of 11 agree or disagree statements about problems with using condoms, with a high score indicating a positive attitude toward condoms(2*) (Chronbach's reliability coefficient = 0.71). The risk perception scale was based on responses to three questions regarding how much risk the respondent thought they had for getting an STD; how much risk they thought they had for HIV infection; and how much risk they thought their sex partner(s) had for HIV infection. Each item was scored from 1 (low risk) to 3 (high risk) (Chronbach's repliability coefficient = 0.83).
We measured intentions to use condoms by responses to the following two questions: "The next time you have sex will you use a condom?" (yes or maybe versus no); and "as a result of your visit to the clinic today, which best describes how you will use condoms--I will never use condoms; I won't use condoms any more or less often; I will use condoms more often; or I will always use condoms."
