Abstract
Recent research
indicates that rural Australian adolescents experience a number
of barriers to their health, and in particular, their sexual health.
Consequently, the present study aimed to examine levels of sexual
health knowledge, sexual activity, condom use and attitudes towards
condoms in a rural, adolescent population. In addition, the research
tested a comprehensive model of condom use. One hundred and thirty
six 15 to 19 year old students, 51 males (M age = 16.75,
SD =.74 ) and 85 females (M age = 16.73, SD
= .85), from schools in five towns of population not more than
6000 residents completed a survey package that included demographic
information, a Sexual Health Knowledge Scale, the Condom Attitudes
Scale and the Adolescent and Young Adult contraceptive Self-efficacy
Scale. Results indicated that overall knowledge levels were low,
with males knowing significantly less than females. Sixty-five
percent of the participants had engaged in sexual intercourse,
with over half of those reporting being inconsistent users or
non-users of condoms. Within the context of the model, knowledge,
attitudes, self-efficacy and intention to use condoms, all contributed
to predicting condom use. Results suggest that rural adolescents
require education and assistance to obtain and use condoms in
a non-threatening environment.
Research suggests that as many as half of Australia's adolescents
have engaged in sexual intercourse by the time they finish secondary
school (Lindsay, Smith, & Rosenthal, 1998). The prevalence
of sexual activity among adolescents has lead to concerns over
their knowledge, attitudes and subsequent sexual behaviours. Concerns
are particularly focused on young women's susceptibility to unwanted
pregnancy and the dangers to both young men and women of sexually
transmissible diseases (STDs), including the potentially lethal
HIV/AIDS virus (Moore & Rosenthal, 1992).
In Australia, STD surveillance data indicates
that 13-19 year olds account for 20% of gonorrhoea infections,
15% of acute Hepatitis B infections, 14% of syphilis infections
and 23% of Chlamydia infections (NCHECR, 1997). Although only
limited data exists for STDs that do not have to be reported to
the government, figures recorded at an Australian sexual health
clinic suggested that 13-24 year olds represented 18% of cases
of genital herpes, 33% of incidences of genital warts and 18%
of diagnosed cases of non-specific urethritis (Stevenson &
Rodger, 1997).
A recent comprehensive study of the sexual behaviours
of Australian school students indicated that concerns over the
sexual health and welfare of adolescents in this country are well
founded. Results of the study indicated that by year 10, almost
one in four students had engaged in sexual intercourse and this
figure rose to almost one in two by year 12. Furthermore, as many
as 13% of males and 6% of females had engaged in sexual intercourse
in their first year of secondary school (Lindsay et al., 1998).
Similar results were found in a national survey of high school
students in 1992 (Dunne, Donald, Lucke, Nilsson, & Raphael,
1993).
Patterns of sexual behaviour in adolescents include multiple partners
(Lerner & Spanier, 1980; Rosenthal, Moore, & Brumen, 1990;
Turtle, 1989) and unprotected intercourse or inconsistent use
of condoms (Abrams, Abrahams, Spears, & Marks, 1999; Rosenthal
et al., 1990; Turtle, 1989). Adolescents are also at risk due
to their lack of knowledge of STDs, safe sex practices and the
skills to negotiate safe sex; poor attitudes towards condom use;
and the general misconception that adolescents are not susceptible
to HIV infection (Rosenthal & Reichler, 1994).
The potential vulnerability of adolescents to
negative consequences of unsafe sex practices initiated a number
of studies concerned with knowledge about HIV/AIDS and STDs (Morrison,
1990), attitudes towards condom use and contraception, and actual
sexual behaviour (Lindsay et al., 1998). Research indicates that
adolescents have a poor knowledge of sexual health issues (Rosenthal,
Hall, & Moore, 1992). For example, one Australian study found
some adolescents believed using the contraceptive pill constituted
safe sex (Kirkman, Smith, & Rosenthal, 1998). Furthermore,
studies indicate that adolescents consider their risk of contracting
an STD to be low, and perceive they have little control over protecting
themselves from STDs, despite STDs being entirely preventable
(Moore & Rosenthal, 1996).
Research has shown that sexual health knowledge
varies as a function of gender. Males and females are exposed
to a number of different social influences and attitudes with
the potential to mediate their sexual behaviour (Hillier &
Harrison, 1999). Furthermore, girls are more likely to gain information
about pregnancy and STDs from magazines targeted at females and
males have no real equivalent information source to the plethora
of women's magazines available (Hillier, Warr, & Haste, 1998).
Research suggests that the availability of information via magazines
translates into perceptible gender differences in knowledge levels
when tested (Carrera, Kaye, Philliber, & West, 2000; Langille,
Andreou, Beazely, & Delaney, 1998). In particular, girls have
been shown to be more knowledgeable about contraception (Langana,
1999) and sexually transmissible diseases (Hillier et al., 1998).
It should be noted however, that while females appear to have
more knowledge than males, in both the aforementioned studies,
overall knowledge levels were still deemed to be unacceptably
low.
It is evident, therefore, that Australian adolescents
are having sex, with little knowledge about potential risks and
consequences. The focus of research on increasing the use of condoms
among adolescents is important, given that condoms are the only
method of contraception that protects from STDs and HIV/AIDS (Geis
& Garrard, 1983). Research suggests, however, that condom
use in Australian adolescents is disconcertingly irregular or
non-existent. For example, a nationwide study of Australian adolescents
in Years 10 to 12 indicated that, for males, condom use decreased
with age (Rosenthal & Reichler, 1994). Specifically, 52.5%
of males in Year 10 reported using condoms all of the time, as
compared with 45.6% in Year 11 and 44.8% in Year 12. Females reported
utilising condoms significantly less often than males. In Year
10, 32% of girls used condoms each time they had sex, as compared
with 36.5% of Year 11 girls and 24.3% of Year 12 girls. This level
of condom use has remained consistent over time (Mitchell &
Smith, 2000).
The links between condom use and the knowledge
and attitudes of adolescents have been widely researched (Hardeman,
Pierro, & Manneti, 1997; Johnson, Rozmus, & Edmison, 1999).
Research consistently demonstrates that even when adolescents
are knowledgeable about safe sex practices, they are not deterred
from unsafe sexual behaviour and many still fail to protect themselves
from unwanted pregnancy and STDs (Margislow & Mott, 1986;
Orr, 1992; Zelnick & Kanter, 1980). There appears to be little
or no direct relationship between sexual and contraceptive knowledge
and actual behaviour and contraceptive use (Kelly, 1996; Levison,
1995). Hence, research needs to move beyond studies that simply
record knowledge and attitudes regarding pregnancy, STDs and condom
use and explore a theoretical model that attempts to clarify adolescent
sexual behaviour.
There have been attempts to explain adolescent
sexual behaviour in terms of the health belief model (Becker,
1988; Rosenthal et al., 1992), which proposes that when making
a decision about health behaviours, an individual makes a rational
cost benefit analysis, weighing up the benefits of taking action
against the barriers to taking action. In the context of AIDS
preventive behaviours, the health belief model failed to explain
sexual risk taking in adolescents (Becker, 1988; Eisen, 1985;
Rosenthal et al., 1992). These findings may be largely attributable
to the fact that the health belief model requires adolescent sexual
risk taking to be viewed as a rationally governed behaviour. The
Health Belief Model does not account substantially for the emotions,
peer pressures, physical or communication barriers involved in
safe sex behaviours (Rosenthal et al., 1992). A further problem
arises in attempting to apply rational decision-making models
to sexual behaviour because the negative outcomes of 'bad' behaviour
are not immediately apparent, especially in the case of some STDs
and HIV/AIDS. Consequences such as infertility that may result
from contracting an STD are too far in the future for adolescents
to consider and the threat of diseases such as AIDS seems irrelevant
because of the delayed onset of the disease. Positive outcomes
of 'good' behaviour are not clearly apparent either, because health
is not noticeably improved by practising safe sexual behaviours
(DeVisser & Smith, 2001; Rosenthal et al., 1992).
Similar criticisms have been made of attempts
to explain condom use via the Theory of Planned Behaviour (DeVisser
& Smith, 2001). Again, the inherent problem of applying such
a model to condom use is the assumption that the decision to use
a condom is a rational and informed process (DeVisser & Smith,
2001). Like the Health Belief Model, the Theory of Planned Behaviour
fails to consider that sexual behaviour involves emotions and
judgements of self worth. Furthermore, both of these models neglect
to regard the interactive nature of a sexual encounter; an individual's
ability to effectively cope within a sexual situation may be influenced
by their partner (DeVisser & Smith, 2001). Determinants of
adolescent sexual behaviour and sexual decisions are multifactorial.
Social, developmental, cultural and psychological factors are
all implicated in an adolescent's willingness to tolerate, accept
or seek risks. Decisions to engage in risky sexual behaviour are
not rational; they are influenced by all these factors (St Lawrence,
1994). Consequently, there is a clear need to consider self-efficacy
in sexual situations.
Bandura (1990) has proposed a self-efficacy
model of safer sex based in social cognitive theory. Within the
context of sexual behaviour, contraceptive self-efficacy has been
defined as an individual's belief in their ability to carry out
all aspects of obtaining and using contraception (condoms), including
discussion with a sexual partner about condom use or insisting
on the use of condoms (Brein & Thombs, 1994). Bandura (1990)
has suggested that increasing the use of condoms among adolescents
will not occur through the provision of knowledge per se, but
in attempting to equip adolescents with skills that enable them
to apply their knowledge consistently, even when confronted with
conflicting social influences. Bandura (1990) further suggested
that adolescents may experience difficulties in carrying out contraceptive
behaviours consistent with their knowledge because interpersonal
pressures and sentiments often diverge from well-founded knowledge
and intentions. He proposed that the interpersonal predicaments
that adolescents frequently experience during sexual encounters
are often heightened by sexual arousal, the desire for social
acceptance, coercive pressures, situational constraints, fear
of rejection and/or personal embarrassment. According to social
cognitive theory, as applied to sexual situations, the weaker
the perceived self-efficacy to exercise control over the sexual
situation, the more these social and affective factors can increase
abandonment of existing knowledge and induce risky sexual behaviour.
A similar relationship between self-efficacy and attitudes towards
contraceptive behaviour has been demonstrated. For example, research
comparing condom users with non-users indicated that condom users
possess significantly stronger self-efficacy for the task than
non-users (Bradford & Beck, 1991).
Low contraceptive self-efficacy may in itself be a barrier to
safe sex practices. Research indicates that low contraceptive
self-efficacy leads to greater levels of embarrassment surrounding
contraceptive use (Kelly, 1996). In addition to this, adolescents
with low self-efficacy for refusing sex have been shown to be
twice as likely to have had sex as their more confident counterparts.
Moreover, low self-efficacy for correct and consistent condom
use leads adolescents to be five times less likely to be consistent
condom users (Kasen, Vaughen, & Walter, 1992). It has been
proposed that before sexual health knowledge can be put into practice,
contraceptive self-efficacy needs to be achieved (Kelly, 1996).
Wulfert and Wan (1993) appear to be the only
researchers to date to include knowledge, attitudes, self-efficacy
and condom use in one comprehensive model. The relationship of
sexual attitudes to condom use has often been explored, and findings
indicate that poor attitudes are linked to low intention and failure
to use contraceptives (Fisher, 1984) and difficulty discussing
condom use with a partner (Fisher, Fisher, & Byrne, 1971).
They proposed that self-efficacy mediates the relationship between
attitudes towards contraceptives and condoms and actual condom
use. Wulfert and Wan's study, however, only investigated AIDS
knowledge and found no relationship between AIDS knowledge and
self-efficacy. This is in contrast with the findings of an earlier
study (Levison, 1995) which found a positive relationship between
general sexual health knowledge and self-efficacy and between
self-efficacy and sexual health behaviours. These findings were
not, however, in the context of a model.
A number of other studies have noted a link
between contraceptive self-efficacy and condom use (Ford, Redd,
Wirawan, Muliawan, & Sutarga, 2000; Levison, 1995; Yeh, 1998).
What remains to be investigated is a model of condom use, which
considers the role of contraceptive self-efficacy, sexual health
knowledge (inclusive of pregnancy, STDs), attitudes towards condom
use and intention to use condoms.
When investigating sexual health issues in adolescents,
researchers have focused almost exclusively on those residing
in urban areas. In fact rural adolescents have been described
as the 'forgotten group' in the area of sexuality research (Rosenthal
& Reichler, 1994). Research consistently indicates that living
in rural Australia increases an individual's risk of poor health
(Australian Institute of Health and Welfare, 1998) and there are
a number of barriers that have a seriously detrimental effect
on rural adolescents' knowledge of STD transmission and symptomology
(Hillier et al., 1998).
Living in rural areas is associated with reduced access to and
utilisation of health care services (Australian Institute of Health
& Welfare, 1998; Humphreys, Matthews-Cowey, & Weinand,
1997). Under utilisation of local health centres has been attributed
to their relative lack of privacy, along with the failure of generic
health services to provide a comfortable environment for adolescents
(Hillier & Harrison, 1999).
Research indicates that even accessing health
services or buying condoms in rural areas has the potential to
sully a girl's reputation, irrespective of whether or not sex
takes place (Hillier et al., 1998). Thus, concern over a damaged
reputation is likely to inhibit safe sex behaviours, especially
if buying a condom or insisting on condom use is construed as
preparedness to engage in sex or promiscuity (Hillier & Harrison,
1999).
It has been demonstrated that rural adolescents
may be particularly susceptible to the myth that having sex with
a regular partner is safe (Hillier et al., 1998). This increased
susceptibility is a consequence of adolescents believing they
can obtain accurate information about a partner's sexual history
and faithfulness based on town gossip and conjecture (Hillier
et al., 1998). Hence, there is a tendency for rural adolescents
to confuse avoiding certain partners with practicing safe sex
(Grunseit, Lupton, Crawford, Klippax, & Noble, 1995).
The conditions under which sexual activity takes
place for rural adolescents must also be considered. The influence
of underage alcohol consumption and binge drinking are vital considerations
and research indicates they occur more frequently in rural adolescents
(Dixon & Welch, 2000).
Thus, there are a number of significant barriers to participating
in safe sex practices for rural Australian adolescents. It is
proposed that the sexual and contraceptive knowledge, attitudes
and behaviours of rural adolescents is likely to be affected by
their available health resources and the ability to access these
resources calmly and confidently (Hillier et al., 1998).
Aims
and Hypotheses.
Research of rural Australian adolescents'
sexual health behaviours is negligible. This is of particular
concern considering the likelihood that rural adolescents experience
a number of barriers to sexual health. Consequently, this study
aimed to investigate the level of sexual health knowledge of adolescents
who reside in rural communities of populations not more than 6000
residents. This study further aimed to investigate the level of
sexual activity and condom use in this population, as well as
their attitudes towards condoms. It was further hypothesised that
knowledge will vary according to gender, with females being more
knowledgeable than males.
In addition to describing the sexual behaviours of rural adolescents,
this study aimed to test a comprehensive model of condom use that
includes gender, sexual health knowledge, attitudes towards condoms,
self-efficacy and intention to use condoms. The proposed model
is shown in Figure 1.
Figure 1. Proposed model
of condom use.
It was hypothesised that both knowledge and
attitudes will contribute to contraceptive self-efficacy and that
contraceptive self-efficacy will be a predictor of intention to
use condoms and actual condom use. It was also proposed that there
would be a direct link between attitudes and intention to use
condoms and a direct link between intention to use condoms and
actual condom use.
Method
Participants
The participants were 136 Year 10 to12 students who returned consent
forms on the day the researcher visited the school for data collection.
The sample consisted of 51 male (M age = 16.75, SD
=.74 ) and 85 female (M age = 16.73, SD = .85) students,
from secondary schools in towns of less than 6000 residents. Towns
were situated at least 40 kilometres from a major regional centre.
The completion of the questionnaires was voluntary. For the participants
under the age of 18, parental consent was sought in writing. Participants
were also required to give informed written consent.
Measures
A cover page was constructed with two sections.
Section one consisted of demographic information on the respondent's
age, gender, and region of residence and section two included
items regarding sexual experience, recent condom use (last 6 months)
and intention to use condoms in the future (next six months).
The self-administered Sexual Health Knowledge
questionnaire (Langille et al., 1998) consisted of 29 items and
addressed knowledge of general sexual health issues, HIV/AIDS,
contraception and condom use by asking for a "true",
"false" or "don't know" response for each
item. The number of correct answers were summed, so that higher
scores indicated greater knowledge. The scale is internally consistent
(µ = .77).
The Condom Attitude scale comprises 23
items that measure adolescents' attitudes towards condoms (Johnson
et al., 1999). The participants responded to each item on a six
point Likert scale (1 = strongly agree, 5 = strongly disagree
and 6 = don't know). Scores on the condom attitude scale lie between
23 (positive attitude) and 115 (negative attitude). The condom
attitudes scale exhibits excellent psychometric properties (µ
= .92, test re-test reliability = .84).
The Adolescent and Young Adult Condom
Self-efficacy scale (Hanna, 1999) is a 14-item scale that encompasses
three subscales, to give a total score for condom use self-efficacy.
Communication self-efficacy consists of five items that involve
negotiating condom use with a sexual partner in various situations.
Correct use self-efficacy consists of six items that involve specific
behaviours related to putting on and taking off condoms. Consistent
use self-efficacy consists of three items that involve using a
condom with each sexual intercourse experience, using a new condom
each time and being prepared by carrying a condom. All questions
required the participants to respond on a five point Likert scale
(1 = very unsure, 5 = very sure). Scores range from 14 to 70,
with higher scores indicating higher self-efficacy. The scale
has been shown to internally consistent (µ = .85).
Procedure
Students who returned a consent form signed
by both themselves and a parent/guardian were given a questionnaire
in a health or physical education class, or a class time allocated
to sessions with the school nurse. All participants were informed
before beginning the survey that they were free to stop answering
any questions at any stage they wished, or leave any questions
they did not wish to answer. Examination conditions were imposed
to protect the privacy of participants. The order of scales was
counter balanced and randomly distributed.
Results
Preliminary Analyses.
Reliability coefficients were calculated for each scale and results
indicated satisfactory reliability: Condom Attitudes Scale ¥
= .79, Sexual Health Knowledge Scale ¥ = .70 and Contraceptive
Self-efficacy Scale ¥ = .93.
A multivariate analysis of variance was used to test for any order
effects. Results indicated that there were no significant order
effects, F (3, 132) = 0.43, p > .05.
Sexual Activity and Condom Use.
Sixty five percent of the participants
had engaged in sexual intercourse: 25% of 15 year olds, 69% of
16 year olds, 60% of 17 year olds, and 87% of 18 year olds. Of
those who had engaged in sex, 36% had more than one partner and
20% had three or more partners.
Less than half (47.5%) of the sexually active adolescents reported
that they had always used a condom in the last six months. Further,
20% said they sometimes used a condom, 16% said they rarely used
a condom and an additional 16% said they never used a condom.
The pattern of use of condoms among males and females, Pearson
c2 (4, N = 136) = 2.76, Cramérs V = .14,
and across the age groups, Pearson c2 (12, N = 136) = 13.41,
Cramérs V = .18, was similar.
Attitudes Toward Condoms.
One way analysis of variance indicated that males (M =
46.57, SD = 11.25) and females (M = 44.28, SD
= 11.18), reported similar attitudes towards condoms, F(1,
128) = 0.03, p > .05. There were no differences evident
in attitudes towards condoms across the age groups, F(3,
128) = 0.84, p > .05.
Sexual Health Knowledge.
No participant answered every question on the knowledge scale
correctly, and 36% of the sample answered less than half the questions
correctly. As indicated by an independent samples t test, females
(M = 18.35, SD = 4.23) scored significantly higher
than males (M = 15.29, SD = 3.73) on the Sexual
Health Knowledge Questionnaire, t (134) = 4.26, p
< .05. Total percentages correct for males and females for
each question are shown in Table 1.
Table 1
Responses of Male and Female Students to the Sexual Health
Knowledge Questions
| Question |
%
correct males
|
% correct females
|
Total
% correct
|
| 1. Babies born to girls aged 15 to 19 are more
likely to have health problems than babies born to mothers
who are older and married. True |
23.5
|
24.7
|
24.3
|
| 2. Unwed mothers aged 15 to 19 are more likely
to have financial problems than mothers who are older and
married. True. |
78.4
|
75.3
|
76.5
|
| 3. More than half the adolescents in Australia
have sexual intercourse before age 14. False |
49.0
|
40.0
|
44.5
|
| 4. A girl aged 15 to 19 who has sexual intercourse,
can become pregnant if she forgets to take her birth control
pills for three days in a row. True |
60.8
|
77.6
|
69.2
|
| 5. Birth control pills can help prevent sexually
transmitted disease. False |
84.3
|
94.1
|
90.4
|
| 6. Using birth control pills will very likely
harm the health of girl's aged 15 to 19. False |
33.3
|
68.2
|
55.1
|
| 7. Doctors need parents permission in order
to prescribe birth control pills to girls younger than 18.
False |
27.5
|
43.5
|
37.5
|
| 8. Used properly, condoms can prevent pregnancy.
True |
92.2
|
95.3
|
94.1
|
| 9. Vaseline is a good lubricant to use with
condoms. False |
52.9
|
40.0
|
44.9
|
| 10. You only need to use condoms during "one
night stands" False |
92.2
|
100
|
97.1
|
| 11. Used properly, condoms can prevent sexually
transmitted diseases (STDs) True |
80.4
|
89.4
|
86
|
| 12. Condoms should fit snugly at the top of
the penis False |
23.5
|
35.3
|
30.9
|
| 14. Condoms can be safely stored in a wallet
for up to two months. False |
37.3
|
40.0
|
39.0
|
| 15. Guys with Chlamydia always have symptoms.
False |
15.7
|
41.2
|
31.6
|
| 16. Girls with Chlamydia always have symptoms.
False |
11.8
|
30.6
|
23.5
|
| 17. Chlamydia infection in women can result
in being unable to have children (Infertility) True |
13.7
|
42.4
|
31.6
|
| 18. If a guy or girl gets Chlamydia, and is
treated properly, he or she can never get it again. False |
23.5
|
47.1
|
38.2
|
| 19. Chlamydia is common in people aged 15-19.
True |
7.8
|
28.2
|
20.6
|
| 20. A family doctor must tell parents if a guy
or girl less than 18 years of age has an STD. False |
35.5
|
42.4
|
39.7
|
| 21. Anyone who has unsafe sex with someone with
the AIDS (HIV) virus can get infected. True |
96.1
|
91.8
|
93.4
|
| 22. If you know a person's sexual history and
lifestyle before you have sex with them, you don't need to
use a condom. False |
92.2
|
95.3
|
94.1
|
| 23. Used properly, latex condoms prevent the
spread of the AIDS virus (HIV). True |
66.7
|
60.0
|
62.5
|
| 24. Making sure that a sexual partner looks
healthy will decrease the transmission of the AIDS virus (HIV).
False |
80.4
|
82.4
|
81.6
|
| 25. A person can have the AIDS virus (HIV) for
ten or more years without having symptoms of illness. True |
64.7
|
60.0
|
62.3
|
| 26. A girl aged 15-19 can't get pregnant the
first time she has sex. False |
52.9
|
76.5
|
64.7
|
| 27. The time in the monthly menstrual cycle
when a girl is most likely to get pregnant is about two weeks
before her period begins. True |
37.3
|
67.1
|
52.2
|
| 28. There is some chance that a girl aged 15
to 19 who has sexual intercourse at any time of the month
can get pregnant if she does not use birth control. True |
58.8
|
83.5
|
71.2
|
| 29. Withdrawal 'pulling out' before coming is
an effective way to prevent pregnancy. False |
74.5
|
81.2
|
77.9
|
Condom Use Model
Correlations between the variables from the
predicted model (Figure 1) are shown in Table 2.
Table 2
Pearson's Product Moment Correlations Between Variables in the
Proposed Model
| |
Gender
|
Knowledge
|
Attitudes
|
Self-Efficacy
|
Condom Intentions
|
Condom Use
|
| Gender |
1.00
|
.35**
|
-0.1**
|
.12
|
-.04
|
-0.12
|
| Knowledge |
|
1.00
|
-.11
|
-2.8**
|
-.01
|
0.05
|
| Attitudes |
|
|
1.00
|
-.20*
|
-.41**
|
-0.47**
|
| Self-efficacy |
|
|
|
1.00
|
.11
|
0.30**
|
| Condom Intentions |
|
|
|
|
1.00
|
0.77**
|
| Condom Use |
|
|
|
|
|
1.00
|
*p < .05 **p < .01
There was a significant relationship between knowledge and gender,
indicating that females had greater knowledge than males. It was
evident that more knowledge was associated with greater contraceptive
self-efficacy.
Positive attitudes towards condoms were associated with greater
condom self-efficacy, a greater intention to use condoms and actual
condom use. Results further indicated that as self-efficacy increased,
so did the likelihood of actual condom use. Self-efficacy was
not, however, correlated with intention to use condoms. Intention
to use a condom was associated with actual condom use
In order to test the hypothesised model, a path analysis was conducted
using AMOS graphics version 4.0. Figure 2 presents the path diagram
of the hypothesised model with standardized coefficients and squared
multiple correlations.
Figure 2. Path model of knowledge and attitudes, self - efficacy,
intention to use condoms and actual condom use.
Amos indicates the fit of a path model in a number of ways: by
the size of the Chi square and degrees of freedom, such that if
p is greater than .05 then the model is accepted; and using the
normative fit index, which gives a value between 0 and 1, where
1 indicates a perfect fit (Arbuckle & Wothke, 1999). The fit
of the proposed model to the data is extremely good (c2
= 6.02, df = 8, p > .05; Normative Fit Index
.99).
The squared multiple correlations in the path diagram indicate
the proportion of a variable's variance accounted for by its predictors
(Arbuckle & Wothke, 1999). Figure 2 indicates that attitudes
account for 17% of the variance in intention to use condoms and
the model accounts for 55% of the variance in condom use.
Path analysis allows examination of both direct and indirect effects
(Dooley, 1995). As shown in Figure 2, knowledge directly predicts
self-efficacy. Figure 2 also shows attitudes to be a significant
predictor of self-efficacy and furthermore, demonstrates a direct
effect between attitudes and intention to use condoms. Intention
to use condoms directly predicts actual condom use.
Figure 2 indicates that there is an indirect effect of attitudes
toward condoms on actual condom use via intention to use condoms.
In summary:
· Levels of knowledge for both males and females are low,
however females had significantly more knowledge than males.
· More than 60% of the sample had engaged in sexual intercourse.
· More than half of sexual active participants were inconsistent
users or non users of condoms.
· Path analysis of the proposed model indicated that the
data showed a good fit to the model.
· The model predicted 55% of the variance in condom use.
Discussion
Adolescent sexual behaviour is complex
and living in a rural community has the ability to exacerbate
these complexities (Warr & Hillier, 1997). The present study
aimed to investigate the levels of sexual health knowledge, sexual
activity, condom use and attitudes towards condoms in a sample
of rural adolescents. It further aimed to integrate these elements
as well as self-efficacy into a comprehensive model of condom
use.
Overall knowledge scores of these rural adolescents were poor
and indicate a desperate need for sexual health education. Knowledge
for questions pertaining to HIV/AIDS was of a reasonable standard,
which is a consistent with research into the AIDS knowledge of
young people (Boldero, Moore, & Rosenthal, 1992). The poor
knowledge for correct use and storage of condoms may partially
explain the lack of knowledge and confidence regarding the ability
of condoms to protect from STDs. Furthermore, the knowledge of
STDs in this sample was extremely low, especially for Chlamydia.
The deficiencies in the general sexual health knowledge of this
sample suggests a lack of information from credible and reliable
resources. Whereas larger towns have community health centres
that can offer information to adolescents, the only available
community medical resource in the towns surveyed was the local
general practitioner. It may, therefore, be necessary to instigate
programs that give readily available and confidential access to
sexual health information from doctors. Due to the limited resources
available in rural areas, parents may need to take responsibility
for the education of their children. Moreover, parents are an
accessible and generally trusted source of information for young
people (Hillier & Harrison, 1999). It is therefore important
to ensure that information given to children by parents is accurate.
A community or school run education program for parents that coincided
with the adolescent education program would help ensure the quality
of knowledge young people were receiving, as well as possibly
alleviating parental anxieties about teenage sex.
An additional aim of this study was to investigate the levels
of sexual activity and condom use of rural adolescents. Two-thirds
of the participants had engaged in sexual intercourse. The number
of fifteen year olds who had engaged in sexual activity was consistent
with previous research (approximately one in four) (Lindsay et
al., 1998). The rate of sexual activity in the older adolescents
was however higher than previous research has suggested for the
same age group (Lindsay et al., 1998). In the current sample,
87% of the senior students had engaged in sexual intercourse,
compared with almost 50% in earlier studies (Lindsay et al., 1998).
The social life of rural adolescents is very limited and sexual
activity may be a result of experimentation to overcome boredom
(Marmot & Wilkinson, 1999).
Less than half of the adolescents in this study reported using
condoms for every sexual encounter. This is consistent with previous
research (Mitchell & Smith, 2000; Rosenthal & Reichler,
1994). In contrast to a previous study (Rosenthal & Reichler,
1994) that demonstrated that males used condoms significantly
more often than females, the current sample showed no such difference.
In the current study, 16% of the sample reported never using a
condom during sex. This figure is slightly higher than that reported
in previous research. For example, an Australian study indicated
that approx 11% of boys and 12% of girls never used a condom when
engaging in sexual intercourse (Rosenthal & Reichler, 1994).
Intentions to use condoms have been related to attitudes towards
condoms. Research indicates that negative attitudes towards condoms
are related to fewer intentions to use condoms (Hardeman et al,
1997). The results of current study supported this relationship.
Results clearly indicated that negative attitudes towards condoms
were related to decreased intentions to use condoms and less actual
condom use. Negative attitudes were also related to lower contraceptive
self-efficacy.
The final aim of the study was to investigate the efficacy of
a comprehensive model of condom use in a sample of rural adolescents.
Support was demonstrated for the proposed model, as the overall
fit of the data to the model was good. As hypothesised, sexual
health knowledge and attitudes towards condoms both made significant
contributions towards explaining an individual's self-efficacy.
Higher levels of knowledge and more positive attitudes towards
condoms were both associated with higher self-efficacy. High self-efficacy
was in turn associated with greater condom use. The correlation
between self-efficacy and intention to use condoms was not significant.
One indirect effect was evident, with attitudes towards condoms
predicting actual condom use via intention to use condoms.
The lack of knowledge, combined with the prevalence of unprotected
sexual activity in this group of rural adolescents, indicates
the need for broad based educational efforts. Such efforts should
include education in schools, increased availability of health
resources, increased ease of access to condoms, and individual
counselling. As the model suggests, there are more factors involved
in condom use than knowledge. These results suggest possible routes
for improving condom use in non-users or inconsistent users. As
self-efficacy and attitudes are both related to condom use within
the context of the model, an educational approach that provides
more than information is needed.
With the objective of increasing condom use, the findings of the
present study suggest that self-efficacy should be one essential
element of education programs. According to Bandura's (1982) Social
Learning theory, self-efficacy can be influenced in a number of
ways. One way is through mastery experiences, or successful completion
of a task. Although this may not be applicable to actual condom
use, it could apply to obtaining and discussing condoms. A second
method of improving self-efficacy is through role modelling, or
watching others perform or talk about the task. For condom use
this may include having the educator demonstrate putting a condom
on a model, or a role-play of two people discussing condom use.
In order to increase self-efficacy, adolescents need experience
of buying condoms, of taking them on a date, discussing their
use and putting them on. The role of the educator then is to make
it as easy as possible for adolescents to complete these tasks.
In designing education programs, it appears necessary to afford
special attention to individuals with more than one partner who
are not using condoms or are using them inconsistently. Results
from this study indicated that 36% of the sample had more than
partner and 20% had 3 or more partners. These results are consistent
with research that suggests that a higher incidence of such activity
occurs in rural areas (Kasenda, Calzavara, Johnson, & Le Blanc,
1997). Thus the situation may be improved by implementing an educational
campaign targeted at young, rural people specifically.
Clearly one of the biggest considerations in encouraging and ensuring
the use of condoms is condom availability. Although the most obvious
way to reach the majority of the adolescent population in a rural
area is through schools, the concept of making condoms available
in schools is controversial. Proponents of placing condoms in
schools claim that these programs give adolescents greater access
to condoms, decrease the number of unprotected sexual acts and
create a more positive social environment where suggesting using
a condom is easier (Schuster & Bell, 1998). Opponents believe
that increasing the availability of condoms creates the idea that
the school condones sexual activity and encourages adolescents
to engage in sex (Schuster & Bell, 1998). Research favours
the view of the proponents, indicating that when schools make
condoms available, the rate of sexual activity does not increase,
but the frequency of condom use does (Raab, 1998; Schuster &
Bell, 1998). Despite positive findings, there are still problems
inherent in making condoms available in schools. If condoms are
free, the system is likely to be abused and condoms used for other
than the intended purpose. Conversely, if a cost is administered,
some students will not be able to afford condoms. Further, the
majority of sexual activity takes place outside of school hours,
thus obtaining condoms requires prior planning and condoms are
still unlikely to be used in high-risk, opportunistic or drunken
circumstances.
Providing condoms in public spaces is also difficult in rural
areas. Placing condom vending machines in bars is problematic
because they will still be inaccessible to individuals under 18,
while placing them in the street creates privacy issues. Future
research could consider the views of adolescents of when, where,
and how they would be most likely to access condoms.
Living in the country appears to present difficult circumstances
for young people in terms of their sexual health (Warr & Hillier,
1997). The low incidence of condom use in this sample suggests
that it is important for young people to have some privacy in
which to instigate and maintain their sexual health. Young people
in rural areas acutely feel the private, sensitive and potentially
embarrassing nature of sexuality. As adolescents begin to explore
their sexual identities and mature into sexually active beings,
their vulnerability needs to be recognised by community and school
health services and confidentiality maintained. It is vital that
in designing and offering education programs, educators recognise
the potential anxieties of young rural adolescents. Furthermore,
the high incidence of sexual activity and inconsistent or non-use
of condoms in this sample underlies the importance of encouraging
and facilitating the circumstances in which young, rural people
can be proactive and effective in protecting their health.
In summary, the results of this study indicate that rural adolescents
display poor levels of sexual health knowledge and are engaging
in unsafe sexual behaviours. Furthermore, this study offers a
model of condom use that indicates that sexual health knowledge,
attitudes towards condoms, self efficacy and attention to use
condoms are together useful in predicting condom use. The findings
of this study suggest that a combined initiative that increases
availability of condoms and implements a comprehensive education
program inclusive of information, role-plays and modelling would
be of significant value to rural adolescents.
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