Applying the NIMH Multi-Site Condom Use Self-Efficacy Scale to college students.

Abstract: The purpose of this study was to better understand the psychometric properties of the National Institute of Mental Health's Multi-Site Condom Use Self-Efficacy Scale by testing it on college students. The scale was developed to measure degree of confidence in condom use and it was initially tested for use among a geographically diverse population of patients who visited sexually transmitted disease (STD) clinics. In the present study, students who visited the student health center at a Midwest university were recruited to participate. Cronbach's alpha was found to be .94 for the scale. Six factors emerged from the factor analysis. Reliability coefficients for the sub-factors ranged from .81 to .94. Results of an independent t-test showed that students with higher degree of self-efficacy were more likely to use condoms consistently. These preliminary results suggest that the instrument may be sufficiently valid and reliable for use among college students.

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Adolescents and young adults, including college students, are at higher risk of acquiring sexually transmitted diseases because many engage in high-risk behaviors (Centers for Disease Control and Prevention (CDC), 1999; Douglas, Collins, Warren, Kann, Gold, Clayton, Ross, & Kolbe, 1997). Sexual activity without protection is of particular concern to health professionals because of the serious consequences it might have, such as unintended pregnancy and STD (Beckman, Harvey, & Tiersky, 1996). It is estimated that there are 15 million new STD cases yearly in the United States. Rates of STD and pregnancy are high among college students. Twenty-five percent of all STDs occur in teenagers (Cates, 1999).

Consistent condom use has been shown to be effective in decreasing the risk of pregnancy and disease transmission (Cates, 1991; CDC, 1988). However, many young people do not use a condom or do not use a condom consistently. One indicator of the lack of condom use is that 18% of all reported AIDS cases are among those ages 20 to 29. On average, AIDS develops 10 years after initial infection (CDC, 1989). This suggests that the majority of AIDS victims were infected in their teens or early twenties.

One of the reasons for inconsistent condom use is lack of personal efficacy (Bradford & Beck, 1991). Self-efficacy, a component of Social Cognitive Theory, refers to a person's belief that he or she can perform the behavior in question. Self-efficacy is situation specific (Bandura, 1977; 1986). That is, studies indicate that people with high self-efficacy in a specific task are more likely to perform that task. The opposite is also true; people with low self-efficacy are less likely to perform the particular behavior. Condom use self-efficacy as a predictor of condom use has received sporadic attention. Recent studies have measured condom use self-efficacy using a minimum number of items (Bradford & Beck, 1991; Brien, Thombs, Mahoney, & Wallnau, 1994; Cecil & Pinkerton, 1998; Polacsek, Celentano, O'Campo, & Santelli, 1999; Sands, Archer, & Puleo, 1998; Wulfert & Wan, 1993). The National Institute of Mental Health's Multi-Site Condom Use Self-Efficacy Scale identified five factors and may represent a more comprehensive approach to condom use self-efficacy. If condom use self-efficacy can be measured reliably and validly, such an instrument could be used as a predictor of students' intention to use condoms (Mahoney, Thombs, & Ford, 1995). Having condoms accessible is obviously important. However, students need to have the confidence that they will actually be able to use the condom if safer sex programs are to be successful.

Health professionals at Indiana State University questioned whether the inconsistent condom use was due to lack of access or low condom use self-efficacy. A reasoned decision is essential when resources are limited and need for accountability is high. Should money be allocated to provide free or low cost condoms to students, or should more resources be allocated to educational efforts, including increasing students' condom use self-efficacy?

In order to measure condom use self-efficacy, valid and reliable instruments are necessary. However, instruments need to be validated for the specific population for which they are intended (Maibach & Murphy, 1995). The Condom Use Self-Efficacy Scale has been used and determined valid and reliable for use among a geographically diverse group of STD clinic patients (Dilorio, Maibach, O'Leary, Sanderson, & Celentano, 1997). The current study attempted to determine if those results could be applied to a college age population.

METHODS

During the fall 2000 semester, the Condom Use Self-Efficacy scale was administered to students, 18 years and older, who visited the student health center at Indiana State University for any reason. Answers were recorded on an optical scanning device and were deposited by the students in a sealed box at the reception area. Appropriate human subjects procedures were followed concerning voluntary participation, anonymity, and confidentiality.

ANALYSIS

Cronbach's alpha was calculated to estimate the reliability of the instrument. Internal consistency and inter-item correlation were computed for the instrument. Maximum likelihood common factor analysis was used to determine the underlying dimensions of the scale. The Statistical Package for Social Sciences was used. The same criteria used in the original study were applied to retain items and to determine factor consistency; that is, factor loading of .30 or greater; factor interpretation; and highest loading of factors (Dilorio et al., 1997). Reliability was also computed for each factor. An independent t-test was used to determine if the mean self-efficacy scores of participants who reported having used condoms consistently in the past 30 days differed from those who did not.

INSTRUMENT

The instrument used was the National Institute of Mental Health Multi-Site Condom Use Self-Efficacy Scale (Dilorio et al., 1997) (see Table 1). This instrument is designed to measure one's degree of confidence in the following areas of condom use: multifaceted risk avoidance, condom placement, persuasion, eroticizing condoms, and persuasion under the influence of alcohol or another substance.

The instrument consists of 26 items. Each item is rated on a 5-point scale from "not at all sure" (1) to "completely sure I can do" (5). The instrument has been shown to be valid and reliable among STD clinic patients.

RESULTS

SAMPLE DEMOGRAPHICS 

Table 2 summarizes the demographic characteristics of the 109 participants who completed the survey. The majority (72.5%) of the respondents were female. About ninety-three percent (92.9%) of the participants were undergraduate students. Most participants (78.8%) were Caucasian, and about two-thirds (61.9%) had never been married, 7.1% were currently married, 3.5% were widowed, and another 27.4% were separated.

RELIABILITY

Cronbach's alpha was calculated to estimate the reliability of the instrument. An alpha of .94 resulted, suggesting a high degree of internal consistency. Means of individual items ranged from 3.88 to 4.65 and standard deviations ranged from 0.80 to 1.41. Interitem correlations ranged from .008 to .865. Questions 25 and 26 were highly correlated (r = .865), indicating that one is redundant (Nunnally & Bernstein, 1994). Cronbach's alpha was also calculated on the six subscales. Internal consistency was again very high, ranging from .81 to .93 (see Table 3).

FACTOR ANALYSIS

Maximum likelihood common factor analysis was used to determine the underlying dimensions of the scale; varimax rotation was applied; convergence required 10 iterations. A six factor, 26 items solution resulted. The first factor consists of 9 items. This factor had initially been labeled by Dilorio et al. (1997) "multifaceted risk avoidance," and includes items 1 through 5, 7, and items 9 through 11. The second factor, originally labeled "condom placement," includes items 15 through 17, and item 24. Items 6, 14, and items 18 through 20 loaded on the third factor, "persuasion." The fourth factor, "eroticizing condoms," consists of three items (21, 22, and 23). The fifth factor, "persuasion under the influence," includes two items, 25 and 26. The sixth factor also includes two items, items 8 (I can always take a condom with me when I go out) and 12 (I can always keep a supply of condoms at home). Both items refer to students having condoms available and the factor has been labeled "condom availability." One item (I can pull out while still erect after ejaculating when having sex with a condom) did not meet the criterion of a factor loading of .30 or higher and was not retained for further analysis.

CONSTRUCT VALIDITY 

The results of the independent sample t-test indicated a statistically significant difference between the mean self-efficacy scores of the students who reported using condoms consistently during the past 30 days and those who did not (t = -2.701, df = 62, p = 0.009). Participants who had a higher condom use self-efficacy level were more likely to have used condoms consistently during the last 30 days.

DISCUSSION

The purpose of the study was to determine the applicability of the National Institute Mental Health Multi-Site Condom Use Self-Efficacy Scale among a college age sample. Previous research (Dilorio et al., 1997) tested the instrument against a sample of a geographically diverse group of STD clinic patients, and was found to have satisfactory reliability and construct validity. If, through subsequent research, this instrument can be shown to be valid and reliable among other populations, it might be possible to use it as a predictor of condom use.

In this study, six factors emerged from the factor analysis, as opposed to five in the Dilorio's (1997) study. All six factors appear to represent different dimensions of condom use self-efficacy: multifaceted risk avoidance (risk reduction through a variety of behaviors), condom placement (proper condom use), persuasion or negotiation skills, persuasion under the influence, and condom availability. However, only two items loaded on the fifth and sixth factors. It is important to develop more items to measure these domains adequately. The information gathered from the subscales can be used by health professionals as an important assessment tool to further address the specific areas of condom use self-efficacy through specified behavior change programs, such as negotiation skills or proper condom use.

Students who reported using condoms consistently during the last 30 days scored statistically significantly higher on the self-efficacy scale, supporting Bandura's self-efficacy theory. This suggests that the self-efficacy scale could be used as a predictor of consistent condom use among the college population. In addition, specific areas of condom use self-efficacy can be addressed to increase consistent condom use. However, other factors, such as outcome expectation and social norms, might also play a significant role in condom use and need to be further explored.

One limitation of the study was the use of a convenience sample at the student health center. Another limitation is the use of self-report measures of consistent condom use. Nonetheless, the results of the research indicate that the scale is both reliable and valid and can be valuable in determining the condom use self-efficacy level among college students, and that the results can be used cautiously as a predictor for condom use and for the development of appropriate interventions.

REFERENCES

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Yasenka Peterson, Ph.D., CHES, is an Assistant Professor and Steve G. Gabany, Ph.D. is a Professor in the Department of Health and Safety at Indiana State University. Address all correspondence to Dr. Perterson at the Department of Health and Safety; Indiana State University; Terre Haute, IN 47809; (PH) 812.237.3075; (FAX) 812.237.4338; Email: [e-mail].