Condom use self-efficacy among U.S.- and foreign-born Latinos in Texas.

Latinos are the fastest growing population in the United States, and their rate of growth is having a direct impact on the HIV epidemic. The Centers for Disease Control and Prevention (CDCP, 2000) report that Hispanics represented 13% of the U.S. population (including residents of Puerto Rico), but accounted for 19% of the total number of new U.S. AIDS cases reported in 2000. CDCP data indicate that the proportion of all AIDS cases reported among adult and adolescent women in the U.S., as a group, more than tripled in the interval between 1985 and 1999 (from 7% to 25%). According to the same report, there is also a higher proportion of HIV cases among Latino men born in Mexico compared to those born in the United States, among those who have sex with other men (44% vs. 30%) and those who have sex with women (14% vs. 11%; CDCP, 2000).

The purpose of our research was to explore the influence of condom use self-efficacy on actual condom use for U.S.-born and foreign-born Latinos living in Houston, Texas. Latinos are defined in this study as individuals who were born in or trace their cultural origin to Latin America. In the United States, over 90% of Latinos come from Spanish-speaking Latin American countries, and therefore, we targeted Spanish-speaking Latinos. Given the composition of the Houston population, we expected Latinos to be primarily of Mexican, Mexican American, and Central American origin.

RISK BEHAVIORS

Studies exploring differences among U.S.-born and recently immigrated Latinos indicate that these groups differ on behaviors that put them at risk for HIV. However, place of birth (United States vs. Latin America) may also be a marker for differences that are actually due to socioeconomic status including education, income, employment, and possibly age (Sabogal, Faigeles, & Catania, 1993). Gender also has a strong influence on Latinos' risk behaviors, as men and women enter sexual relationships with different experiences and expectations based on the norms and values learned as part of their cultural heritage. One example of the interplay among these characteristics is multipartnerism. Latino men across the U.S. tend to report multiple sexual partners, particularly if they are unmarried, 18 to 29 years of age, and better educated but with lower income (Sabogal et al., 1993). Foreign-born Latinos differ from their U.S. counterparts in that they are more likely to report sex with prostitutes, and married men report less condom use in these encounters compared to single men (Organista, Balls Organista, Garcia de Alba, Castillo Moran, & Ureta Carrillo, 1997). Contact with prostitutes and having more extramarital partners has been documented more specifically among Mexican immigrant men who are married but who migrate unaccompanied by their wives (Viadro & Earp, 2000). Males have high rates of sexual activity outside of marriage or a primary relationship (Matin & Marin, 1992), perhaps because they are expected to be independent, sexually assertive, and have multiple sex partners (Martinez, Chavez, & Hubbell, 1997). The influence of traditional gender beliefs appears to be stronger among Latino immigrant men, who unfortunately decrease their use of condoms as their number of sexual partners increases (Sabogal et al., 1993).

Concurrent sexual partnerships among U.S. women have been estimated at 12% across all ethnic groups, and Latinas are the group least likely to report multiple partners (Adimora et al., 2002). However, patterns of sexual behavior are not the same for all Latinas: U.S.-born and younger Latina women tend to report more sexual partners compared to recently immigrated and older Latinas (Sabogal, Perez-Stable, & Otero-Sabogal, 1995). Differences in other sexual behaviors have also been associated with Latinas' levels of acculturation and place of birth. For example, recently immigrated Latinas report infrequent sexual activity, a preference for conventional sexual practices, and dissatisfaction with their sexual relationships (Flaskerud, Uman, Lara, Romero, & Taka, 1996). However, even when levels of sexual risk behavior vary across studies, the general trend among Latinas is for AIDS risk to increase as their preference for speaking English increases (Peragallo, 1996).

Substance abuse, and more specifically alcohol consumption, influences participation in sexual risk behaviors. Less acculturated Latino men drink more heavily and are more likely to engage in risky sexual behavior compared to men who are more acculturated. At the same time, while more acculturated Latina women drink more heavily than the less acculturated, those in the latter group engage in riskier sexual behavior (Hines & Caetano, 1998).

CONDOM USE

Spanish monolingualism and strong cultural gender norms regarding sex contribute to the risk for HIV infection, acting as barriers for consistent and effective adoption of HIV-preventive behaviors, particularly among Latina immigrant women (Gomez, Hernandez, & Faigeles, 1999). Latinos generally believe that condoms play a role in preventing HIM but they tend not to use them (Sabogal et al., 1993), although this lack of use has not been consistently reported across studies (Tanrer, Grady, Klepinger, & Billy, 1993). Condom use among Latinos tends to be low perhaps because condoms are associated with prostitution, venereal disease, and extramarital affairs (Flaskerud & Uman, 1993: Ford, King, Nerenberg, & Rojo, 2001: Marin & Marin, 1992).

Condom use varies by level of acculturation. For example, more acculturated Latina women report a greater number of sexual partners and more condom use, while less acculturated men report sexual intercourse at younger ages and less condom use (Sabogal et al., 1995). As noted earlier, although the less acculturated Latinas are less likely to have multiple partners, they are also less likely to carry condoms (Marin, Gomez, & Tschann, 1993). Latinas' condom use is also related to demographic and relationship factors. One study showed that among Puerto Rican women, condom use was related to shorter sexual relationships, more education, current employment, less investment in the relationship, and more HIV-related communication (Saul et al., 2000). Condom use is also related to stability of the sexual relationship, and Latinos who report dating their partners also report more frequent condom use compared to those who are married (Pulewitz, Amaro, DeJong, & Gortmaker, 2002).

In general, Latinos report more condom use with their nonprimary partners. Both men and women indicate that they are more likely to use condoms in nonprimary relationships and that they perceive fewer barriers in their use compared to primary relationships (San Doval, Duran, O'Donnell, & O'Donnell, 1995). Latinas' condom use with their regular sex partners is related to procondom social norms and less negative attitudes toward condoms (Organista, Organista, Bola, Garcia de Alba, & Castillo Moran, 2000). The women who report more condom use with their primary partner are younger, discuss HIV-related issues with their primary partner, and are less likely to expect negative reactions to requests for condom use (Moore, Harrison, Kay, Deren, & Doll, 1995). Trust and social acceptability are important considerations in condom use in primary relationships (San Doval et al., 1995).

CONDOM USE SELF-EFFICACY

Self-efficacy has been defined as the individual's assessment of her or his capacity to organize and execute a course of action to achieve a particular performance (Mauer & Pierce, 1998). It is a concept that reflects confidence in the ability to exert control over oneself and one's social environment (Forsyth & Carey, 1998). Condom use self-efficacy involves the mastery of different skills for men and women. Men, as the primary users of condoms, are more directly involved in the performance of acts necessary to use them effectively. Women's involvement is less concerned with behavioral performance and more involved with negotiation skills and the ability to persuade the sexual partners to use condoms. However, as Bandura has indicated, "managing sexuality involves managing interpersonal relationships" (as cited in Bowleg, Belgrave, & Reisen, 2000, p. 617) and interpersonal management involves the power to make decisions and to control sexual activity by parties of either gender.

The gender disparity inherent in the use of condoms is probably more accentuated among Latinos, whose social norms encourage men to have control over the sexual encounter (Harvey, Beckman, Browner, & Sherman, 2002) and discourage women from being sexually assertive (Gomez & Matin, 1996; Marin, Gomez, Tschann, & Gregorich, 1997), even if they are expected to be responsible for the use of contraceptives (Harvey et al., 2002). According to these traditional norms, Latina women are not expected to be efficacious and to encourage their sex partners to use condoms, but many Latina women "subvert [their] culture" (Ortiz-Torres, Senano-Garcia, & Torres Burgos, 2000) by acting counter to their expected traditional roles and attempting to persuade their partners to use condoms. Even if Latino men are expected to take the lead in sexual activity (Harvey et al., 2002) and Latina women tend to be less efficacious in the realm of sexual negotiation (Gomez et al., 1996), when Latina women use direct power strategies with their male sex partners they report higher sexual self-efficacy: They are better able to decline sex, assert their needs, and engage in safer sex (Bowleg et al., 2000). When Latino men and women report higher condom use self-efficacy, they also tend to report more frequent condom use (Marin, Tschann, Gomez, & Gregorich, 1998). Women who report higher levels of relationship power (i.e., access to power in interpersonal decisions about sex) also report more consistent condom use (Pulewitz et al., 2002). Both condom use self-efficacy and perceived sexual decision-making power predict condom use with the steady sexual partner among Latina and non Latina White women (Gomez et al., 1996). By contrast, Latino men with more traditional gender-role beliefs report more sexual coercion, less sexual comfort, and lower condom use self-efficacy (Matin et al., 1997).

In the present study, we measured condom use self-efficacy as the ability to insist on condom use under challenging personal and interpersonal circumstances and used a scale that makes the assessment of self-efficacy relevant to both men and women (Matin et al.. 1998). Previous results with this scale indicate that less educated men and women have lower self:efficacy to discuss condoms, to manage partner resistance, to use condoms with the regular partner, and to control sexual impulses (Matin et al., 1997). In a subsequent study using the same scale, condom use self-efficacy influenced condom use with occasional sex partners among Mexican male migrants (Organista et al., 2000).

The purpose of our study was to explore the influence of condom use self-efficacy on the reported condom use of U.S.- and foreign-born Latinos. Consistent with the previous literature review, we hypothesized that demographic characteristics Cage, education, place of birth, language, and gender) would influence condom use self-efficacy. We also measured factors previously identified as influencing condom use among Latinos (language use, place of birth, relationship risk, trading sex, and using alcohol or drugs during sex) to establish the relative influence of condom use self-efficacy. We hypothesized that condom use self efficacy would have a stronger influence on condom use relative to demographic characteristics and risk behaviors.

METHOD

Data presented in this report were collected as part of a behavioral rapid needs assessment (BRNA) survey designed to collect HIV-related information from foreign-born and U.S.-born Latinos living in Houston, Texas. The Houston Department of Health and Human Services (HDHHS) Bureau of HIV/STD Prevention decided to conduct these surveys among 11 different ethnic and gender subpopulations identified to he at higher risk for H|V in the city of Houston (HDHHS, 2003). The Latino population makes up a significant proportion of the overall population in Houston, and current trends show a slight increase in the overall incidence of HIV infection in this group (HDHHS, 2000). Three of the 11 prioritized subpopulations included (a) U.S.-born Latina women, (b) Latino immigrant men, and (c) Latino immigrant women. U.S.-born Latino men were not included in this sampling frame because rankings based on local epidemiological data (HDHHS, 2000) did not assign them the highest priority for the current needs assessment cycle. The Bureau of HIV/STD Prevention adopted the rapid assessment response and evaluation (RARE) method (Trotter, Needle, Goosby, Bates, & Singer, 2001) to simultaneously interview 11 populations using the same methodology. Rapid needs assessment (RNA) is an epidemiological and participatory research method adapted from rural needs assessment and disaster research to address a variety of global and catastrophic problems including war, hunger, and earthquakes (Daley, Karpati, & Sheik, 2001; Dondero, 1985). The general methodological guidelines followed in our rapid needs assessment are based on recommendations provided for populations at risk for HIV (Trotter et al., 2001).

Recruitment

The study sample was stratified by place of birth (U.S. or Latin America) and gender (male or female). We included three gender-place of origin groups (n = 50 per group): (a) foreign-born Latina women, (b) foreign-born Latino men, and (c) U.S.-born Eatina women. Completion of this survey took place between November 2002 and January 2003.

The short time to complete the study and the parameters of the sampling flame only allowed for the recruitment of a small nonprobabilistic sample based on the selection of residentially based groups assumed to be highly homogeneous. Since foreign-born Latinos who are recent immigrants (i.e., living in the U.S. < 10 years) tend to concentrate in clusters of apartment complexes located throughout Houston, apartments in neighborhoods with over 80% Latino population were targeted for inclusion. We balanced the need to select homogeneous groups in terms of place of birth (United States vs. Latin America) by increasing group variability in terms of country of origin. To achieve this goal, we selected apartment complexes located on opposite sides of the city and known to be populated by Mexican and Central American immigrants (primarily from El Salvador and Honduras). Selection of the U.S.-born Latinas group followed a similar geographical dispersion strategy, but it was based on the selection of residential units because this group lives dispersed in ethnically mixed neighborhoods of similar (lower-to-middle) socioeconomic status. A total of four apartment complexes and two separate residential areas were included in the study. Our sampling approach was successful in achieving geographical dispersion but fell short of reaching the Central American sampling quota that we expected (n = 19 vs. n = 50).

Procedures

Each interviewer was assigned to complete interviews in a specific location within an apartment complex or residential area, following a strategy that systematically distributed the assigned interview quota across all units of a complex or houses in a residential area. Interviewers were instructed to start from a randomly selected address and to use their assigned numerical code (2-3, 1-4, etc.) to select the next residential or apartment unit as they walked around an apartment building or a residential area. Prior to conducting the interview, interviewers introduced then>elves and explained the nature of the survey, including its confidentiality and voluntary participation. All interviews were matched by gender. If a person was available for an interview at the designated location, the interviewer read an oral consent statement prior to the interview. If the targeted person agreed, the interviewer proceeded to conduct the interview on-site as long as there were no other adults or children over 5 years of age present. Otherwise, interviewers were instructed to conduct the interview in a public area. Only one person from each apartment or residential unit could be interviewed, and in cases where two or more individuals from the same unit were available, the person whose birthday had been celebrated most recently was selected. After the interview was completed, each participant received a $10.00 coupon to be redeemed at a local supermarket. The interview took 25 to 30 minutes to complete on average. Procedures for this study received approval from the Committee for the Protection of Human Subjects at the University of Texas Health Science Center.

Interviewer Training

We hired a total of 10 Latino interviewers to complete the survey. Of this total, 3 were U.S.-born Latino men, 3 were U.S.-born Latina women, and 4 were foreign-born Latina women. Interviewers participated in a l-day training workshop where they received information about study objectives, participant screening and enrollment procedures, questionnaire administration and skip patterns, and sexual behavior and drug use data collection procedures. As part of the training, they also practiced and role-played the administration of the interview. Additional quality control measures implemented during data collection included regular debriefing sessions with the interview supervisor to clarify and reinforce proper interview procedures. A second quality control supervisor verified the completion of a randomly selected portion of the interviews and assessed the study participants" satisfaction with the inter viewing process.

Measures

We developed a survey questionnaire in collaboration with the HDHHS Bureau of HIV/STD Prevention to identify a common set of sexual behavior and drug use items to be administered among 11 subpopulations at risk for HIV (HDHHS, 2003). The survey for this study's Latino subpopulation included these items and additional psychosocial items measuring condom use norms and attitudes, sexual comfort, and condom use self-efficacy, based on the Survey of Latino Adults (Marin et al., 1997; Marin et al., 1998) Most of the psychosocial items were already available in Spanish and English, had undergone the process of translation and back-translation (Marin & Marin, 1991), and had been tested with Latino respondents similar to our target population. The sexual behavior and drug use items were translated to Spanish and adapted to the specific language use needs and face-to-face mode of administration used with our local Latino population. Rating scales depicting response choices for norm and attitude statements were printed on plastic cards and handed to respondents during the interviews to cue appropriate answers and facilitate responding. Interviewers administered the questionnaire in English or Spanish according to the respondent's language preferences. While there were minor differences between the regional Spanish dialects of the Mexican and Central American participants, postinterview debriefing of both interviewers and participants revealed that these differences posed no problem for either group in understanding the content of the questionnaire. There were no comprehension problems reported among respondents who completed the English version of the questionnaire.

Demographic measures. Demographic measures included in the survey are listed in Table 1 and included age, years of education, spoken language, length of residence in the United States (immigrants only), and current employment.

Risk behaviors and condom use. The sexual and drug use questions are listed in Table 2. Items included total sex partners in the last 12 months, trading sex (giving or receiving drugs or money in exchange for sex), using a condom in the last sexual encounter, using a condom with the primary or secondary sexual partner(s) in the last 12 months, and being under the influence of alcohol or other drugs the last time the respondent had sex with the primary or secondary partner(s). All variables, except for number of sexual partners, were coded dichotomously as 1 = yes, 0 = no. We also created a measure of "relationship risk" to measure risk for HIV associated with the sexual relationship. This categorical variable was coded to indicate increasing levels of HIV risk associated with the type and number of sexual partners as follows: 0 = no sexual partner, 1 = one primary sex partner, 2 = one nonprimary sex partner. 3 = multiple sex partners. We used this variable to predict the odds of condom use in the last sexual encounter, but we could not use it when respondents with a primary partner were selected for analysis. In that case, we measured relationship risk as having additional secondary partners and dichotomized it (1 = yes, 0 = no) and eliminated other response options.

Condom use self-efficacy. The condom use self-efficacy scale adapted for this study was developed by Marin et al. (1998). The scale was developed and pilot-tested in Spanish and translated to English. The original 20-item scale measured self-efficacy according to different personal and interpersonal circumstances and different gradations of challenge relevant to Latinos, in accordance with procedures recommended by Bandura (1997) and other HIV prevention experts (Forsyth & Carey, 1998: Murphy, Stein, Schlenger, & Maibach, 2001). Factor analytic results obtained from the original 20-item scale revealed the existence of five underlying factors: condom use with the regular partner, impulse control, partner resistance, STD thoughts, and partner discussion. Consistent with recommendations by the senior author (B. Marin, personal communication, October 21, 2002), we administered an abbreviated scale consisting only of 10 items to participants in the present study. The items in the reduced scale corresponded to the following types of items included in the original scale: impulse control (n = 4), partner resistance (n = 2), and STD thoughts (n = 2). Two additional items measured the refusal of sex if the partner doesn't use condoms and insisting on condom use with a partner who has multiple partners (see Table 3). We conducted a factor analysis of the reduced 10-item scale and our results confirmed the existence of a single underlying condom use self-efficacy factor (Marin et al., 1998). The reduced scale explained 52% of the variance, and each item was scored according to a 5-point Likert scale (I = definitely yes, 2 = probably yes, 3 = more yes than no, 4 = probably no, 5 = definitely no). To facilitate interpretation, we reversed the scoring to indicate higher self-efficacy with a higher score. Additional analyses indicated that the 10-item reduced scale had high internal consistency ([alpha] = .89). We summed the ten items and used the resulting score as the measure of condom use self-efficacy in all regression analyses.

Data Analysis

Demographic characteristics, risk behaviors, and the responses to the condom use self-efficacy scale were cross-tabulated by group. We used the chi-square statistic or a one-way ANOVA to estimate group differences with categorical or continuous variables, respectively. We used a logistic regression analysis to estimate the odds that a participant used a condom in the last sexual encounter or with the primary sexual partner in the last 12 months. Finally, a multiple regression analysis identified the demographic characteristics that influenced condom use self-efficacy in this sample of Latinos.

RESULTS

A total of 152 face-to-face interviews were completed between November 2002 and January 2003 according to the pre-established place of origin-gender quotas as follows: 51 recently immigrated Latina women, 50 recently immigrated Latino men, and 51 U.S.-born Latina women. Geographic distribution of interviewed cases within the city of Houston was as follows: southeast (n = 73), northwest (n = 29), and southwest (n = 36).

Demographic Characteristics

The majority of Latinos interviewed were of Mexican origin (51.7 %), 34% were U.S.-born, and 13% were born in Central America (9 in El Salvador, 6 in Honduras, 1 in Nicaragua, and 3 in Guatemala). Ninety-two percent of the U.S.-born Latinas indicated that the cultural origin of their parents was Mexican. Demographic characteristics presented in Table 1 indicate that this sample was relatively young (mean age = 30 years) with no statistically significant differences by group interviewed. The average time Latino immigrants had been in the U.S. was 8.27 years, and there were no significant differences by gender. Language differed by group as expected. The great majority of foreign-born Latino men and women were Spanish monolingual, while a relatively large proportion of the U.S.-born Latinas considered themselves bilingual. In addition, U.S.-born Latinas had more years of education than the foreign-born participants. Employment patterns were significantly different across the three groups: most of the foreign-born Latino men had a current job, while two thirds of U.S.-born and about one third of the foreign-born Latinas had a current job.

Sexual and Drug-Use Behaviors

Results in Table 2 indicate that there were significant differences among the three groups in sexual and drug-use behaviors and that most of those differences appeared to be related to gender. Foreign-born Latino men were more likely to report having more sexual partners in the last year, trading sex for money or drugs, and being under the influence of alcohol or drugs the last time they had sex with their primary partners. However. Latino men were less likely to have a primary partner and more likely to have one nonprimary partner (6 of 12 reported nonprimary partners were sex-trade partners) or multiple sex partners. Foreign-born Latina women were less likely to report condom use in the last sexual encounter and more likely to report condom rise with the primary sexual partner, but these group differences were not statistically significant.

Condom Use Self-Efficacy

Items in the condom use self-efficacy scale were recoded dichotomously (1 = yes, 0 = no) to determine the extent to which groups interviewed differed in their endorsement of each item. Results presented in Table 3 indicate that the majority of respondents in each of the three groups believed that they could insist on condom use under a variety of challenging circumstances. Given the number of group comparisons made with all items in the scale, we restricted the alpha level (p [less than or equal to] .01) to estimate statistical significance. Chi-square results indicated that women reported higher condom use self-efficacy compared to men (Table 3). Foreign-born Latinas were more likely to report higher efficacy in impulse control items, while U.S.-born Latinas reported higher efficacy in items measuring condom use with a partner who claims he is not infected with a disease or who has sex with several other partners. When items in the condom use self-efficacy scale were summed as a single score, foreign-born Latinas had slightly higher scores compared to U.S.-born Latinas or foreign-born Latino men (41.9 vs. 40.94 and 38.04, respectively). This gender-birthplace comparison was not significant (p = .09). When we compared scores by place of birth or by gender, there were no significant differences by birthplace (F = 0.34, df = 1, p = .56) but there were differences by gender (F = 4.56, df = 1, p =.03). Scale scores confirmed patterns inferred from items presented in Table 3: that is, women tended to report higher condom use self-efficacy scores compared to men.

Logistic Regressions

We conducted separate logistic regressions to estimate the likelihood that a participant used condoms in the last sexual encounter or with the primary sexual partner. The odds of condom use with the secondary partner(s) could not be estimated because very few participants reported secondary sexual partners (n = 28). We used SPSS for Windows binary logistic regression procedures to enter the hypothesized predictors in two blocks. The first block entered tender, birthplace, and relationship risk, while the second block entered sex trade, having sex while under the influence of drugs or alcohol, and condom use self-efficacy.

The first logistic regression predicted the odds of condom use in the last sexual encounter (Table 4). Results obtained alter entering the first block of variables indicated that respondents were 2.91 times more likely to report condom use in the last sexual encounter per each unit increase in relationship risk, while gender and place of birth were not significant predictors. The second block of variables added to the model included trading sex lot money, having sex under the influence of alcohol or drugs, and condom use self-efficacy. This Rill model indicated that individuals who reported condom use in the last sexual encounter were 90% less likely to participate in sex trade, 6% more likely to use condoms per each unit increase in the condom use self-efficacy scale, and 4.39 times more likely to use condoms per unit increase in relationship risk. In sum, logistic regression results indicated that being in a risky sexual relationship, trading sex for money, and having a higher condom use self-efficacy score predicted condom use in the last sexual encounter (Nagelkerke [R.sup.2] = .20, [chi square] = 21.79, df = 6, n = 137). The model correctly classified 26.7% of those who used and 94.6% of those who did not use condoms in the last sexual encounter, with an overall success rate of 72.3%.

The second logistic regression entered predictors following procedures similar to those in the first regression. There was only one difference in the use of variables: Relationship risk was measured as the risk that the respondent would also have secondary partners. We used demographic characteristics, risk behaviors, and condom use self-efficacy to predict condom use with the primary sexual partner (Table 5). Results obtained after entering the first block of variables indicated that female gender increased the odds of using condoms with the primary partner 3.45 times, foreign birth increased the odds 2.37 times, and having secondary partners increased the odds by 17.96 times. The second block of variables added sex trade, having sex under the influence of alcohol or drugs, and condom use self-efficacy to the model. Results of the frill model indicated that female gender increased the odds of using condoms with the primary partner 3.28 times, while relationship risk (i.e., having secondary partners) increased the odds 23.65 times. There was also a 5% increase in the odds of reporting condom use per unit increase in the condom use self-efficacy scale. Overall, logistic regression results indicated that being a woman, having secondary partners, and having a higher condom use self-efficacy score were associated with the use of condoms with the primary sexual partner (Nagelkerke [R.sup.2] = .22, [chi square] = 22.04, df = 6, n = 122). The model correctly classified 68.9% of those individuals who did not use and 59% of those who did use condoms with the primary sexual partner, with tin overall success rate of 63.9%.

Multiple Regression

To further understand the factors that influence condom use self-efficacy, we entered the following demographic variables as a single block in a multiple regression: gender, place of birth, age, spoken language, years of education, and current employment. Only gender and years of education predicted condom use self-efficacy (Table 6). Being a woman and having more years of education were associated with higher scores on the condom use self-efficacy scale ([R.sup.2] = .10, F = 2.66, p < .05).

DISCUSSION

This study explored the influence of condom use self-efficacy on the reported condom use of U.S.--and foreign-born Latino men and women. Results indicated that condom use self-efficacy influenced condom use, but the odds of using condoms in the last sexual encounter or with the primary sexual partner increased with relationship risk and gender more than with condom use self-efficacy. As most respondents reported high levels of self-efficacy, its influence on reported condom use may have been attenuated by a restricted range ill self-efficacy scores. Alternatively, the few cases of reported nonprimary or multiple sexual partners may have inflated the importance of being in a "risky" relationship. Regression results also indicated that gender and education predicted condom use self-efficacy. Overall, the results indicate that relationship risk influenced condom use, and education influenced condom use self-efficacy. Gender had a direct influence on condom use as well as an indirect influence through condom use self-efficacy. Given the centrality of gender suggested by the results, we will elaborate on the implications of these findings.

Women had higher condom use self-efficacy scores compared to men, and being a woman increased the odds of using a condom with the primary sexual partner. Although there is previous evidence indicating that Latinas report high condom use self-efficacy (Marin et al., 1998) and frequent condom use with their primary partners (Organista et al., 2000), the preponderance of the evidence indicates that Latinas do not use condoms consistently and that they are not highly self-efficacious. Similar to the studies conducted by Martin Organista, and their colleagues cited above, our results appear to contradict the common trend.

Although we do not have evidence to confirm or disconfirm any pattern, there are two plausible explanations for the results we obtained: The first one follows from Latino cultural gender norms and the second one is counter-cultural. The cultural explanation would suggest that the condom use self-efficacy scores we obtained among Latina women are artificially high. because Latinas (particularly the more traditional) are generally discouraged from being sexually assertive and would not be expected to have the skills to insist on condom use. If so, then women may have overreported their use of condoms with their primary partners and may have overestimated their own efficacy to use them. A possible justification for these results may be that socially desirable responses may have been more prevalent among women than among men. Latina women may have felt uncomfortable discussing their private sexual behavior but would have preferred to provide (rather than to refuse) an answer to an interviewer out of politeness.

The counter-cultural explanation would indicate that Latina women's experience with condom use can be understood in juxtaposition to the sexual risk behaviors reported by men. Although men and women in this study were interviewed separately, the behaviors reported by each group represent gender-based patterns. Therefore, women who reported more condom use and higher self-efficacy may have been providing accurate inform-nation reflecting their experience with their partners' sexual risk. Women who suspect or become aware of the extramarital and sex-trading practices of their male sex partners may decide not to acquiesce and ignore their own HIV/STD risk. Instead, they may insist that their partners use condoms, particularly if condoms are the couple's primary form of contraception. According to this explanation, Latina women may become more "culturally subversive" (Ortiz-Torres et al., 2000) out of a need for self-protection.

A cultural explanation also appears to support the results among Latino men. Traditional cultural norms encourage Latino men to use protection against STDs and pregnancy in casual encounters more than in stable primary relationships. The men in our sample reported condom use patterns consistent with this cultural norm. In addition, Latino men's lower condom use self-efficacy may reflect their gender role: Men as the users of condoms are expected to have the skills to use them more than they are expected to have the skills to persuade their partners about their use. Thus, Latinos" lower ability to persuade their partners may reflect traditional cultural norms and their expected gender role. If Latino men are less able to talk about condoms with their sexual partners, their self-efficacy needs deserve more attention.

There is another pattern of results among Latina women that merits closer attention in future work. Information presented in Table 3 indicates that foreign-born Latinas consistently reported higher self-efficacy in items indicative of greater impulse control, while U.S.-born Latinas reported higher self-efficacy in items related to difficult partner situations. There are no previous studies reporting these findings, and we can only speculate on the reason for this difference. Consistent with the cultural explanation described earlier, the more traditional foreign-born Latinas may be overestimating their self-efficacy, but their level of confidence (or overconfidence) should be subjected to more careful scrutiny. If these results are replicated, they could indicate a need for developing different condom use interventions to address the unique self-efficacy needs of foreign-born and U.S.-born Latinas. We would like to encourage other researchers to explore the self-efficacy needs of the two groups of Latinas.

Given their public health implications, the results obtained in this study for Latino men and women deserve more careful exploration in future surveys of sexual behavior. In addition, HIV and other STD prevention programs need to create spaces and opportunities that allow Latina women the privacy to engage in frank discussions of their sexual behaviors. Programs also need to create realistic partner-related scenarios that empower Latinas to negotiate condom use effectively. Latinas with low levels of education face greater challenges in learning negotiation skills that involve persuasion and assertiveness, and their communication needs have to be considered carefully. Foreign-born Latino men need to be targeted by programs that motivate them to increase condoms use in primary and secondary sexual relationships. More importantly, Latino men need to be targeted by programs that help them gain greater self-efficacy in the use and negotiation of condoms, particularly if they have previously tried (but failed) to use them.

This rapid needs assessment study suffered methodological limitations similar to those encountered by other rapid needs assessments and small sample studies. The brief interview period allowed us to only take a behavioral "snapshot" of the targeted groups, and the small sample size makes it difficult to judge the strength and stability of the results. The manner in which the interview was administered may have been an additional limitation. Given the low literacy level of the target population, we decided to administer a face-to-face interview rather than an anonymous survey. However, as discussed earlier, the trade-off may have been to increase the probability of getting socially desirable responses. Although we probed interviewers about participants' reactions to the sexual behavior questions and although interviewers did not report unusual or particularly uncomfortable responses by either men or women, we cannot rule out the effect of social desirability. Thus, we suspect the presence of social desirability effects similar to those encountered in other surveys of Latino sexual behavior. We would like to encourage other sex researchers conducting surveys with Latinos to consider adopting computer-assisted interviewing methods (in English and Spanish) that address the need for privacy and the low literacy levels of this population.

The results of this study are consistent with those previously obtained in studies of condom use self-efficacy with Latino migrants (Organista et al., 2000) and those living in urban areas (Marin et al., 1998). However, since we made efforts to obtain a systematic sample that would resemble the U.S.--and foreign-born population of Latinos living in Houston, our results are more likely to be generally applicable to Latinos living in urban areas.

Table 1. Demographic Characteristics of the Latino Sample

                                                     Immigrant
                                                       women
                                        Mean   SD    (n = 51)

Mean age                                30.0   9.3     29.8
Mean years in U.S. (immigrants only)     8.2   7.5      7.5
Mean years of education                  9.5   3.4      8.2
Language spoken
  Spanish                                              92.2%
  Both                                                  7.8%
  English                                               0
Currently employed                                     29.4%

                                        Immigrant    U.S.-born
                                           men        Latinas
                                         (n = 50)    (n = 51)      p

Mean age                                  31.5         29.5       .52
Mean years in U.S. (immigrants only)       8.5                    .45
Mean years of education                    8.8         11.4      <.001
Language spoken                                                  <.001
  Spanish                                 82.0%         7.8%
  Both                                    16.0%        47.1%
  English                                  2.0%        45.1%
Currently employed                        82.0%        64.7%     <.001

Table 2. Prevalence of HIV Risk Behaviors

                                                  Immigrant   Immigrant
                                                    women        men
                                                  (n = 51)    (n = 50)
                                                      %           %

Sex partners in past 12 months
  0                                                  5.9         8.0
  1                                                 90.2        52.0
  2                                                  2.0        12.0
  3+                                                 2.0        28.0
Gave/received drugs or money for sex in
    past 12 months
  Yes                                                0          22.0
  No                                               100          78.0
Relationship risk
  No sexual partner                                  7.8         6.0
  One primary partner                               90.2        50.0
  One nonprimary partner                             2.0        30.0
  Multiple sex partners                              0          14.0
Used condom last time had sex                       27.5        36.7
Used condom with primary partner in last            62.2        46.7
  12 months (n = 122)                              (28/45)     (14/30)
Under the influence of alcohol/ drugs last time      2.2        12.5
  had sex with primary partner
Used a condom with nonprimary partner in           100          82.4
  last 12 months (n = 28)                           (1/1)      (14/17)
Under the influence of alcohol/drugs last time        0         31.8
  had sex with nonprimary partner

                                                  U.S.-born
                                                   Latinas
                                                  (n = 51)      p
                                                      %

Sex partners in past 12 months                                <.01
  0                                                  7.8
  1                                                 72.5
  2                                                  5.9
  3+                                                13.7
Gave/received drugs or money for sex in                       .000
    past 12 months
  Yes                                                2.0
  No                                                98.0
Relationship risk                                             .000
  No sexual partner                                  9.8
  One primary partner                               80.4
  One nonprimary partner                             3.9
  Multiple sex partners                              5.9
Used condom last time had sex                       33.3      .57
Used condom with primary partner in last            44.2      .19
  12 months (n = 122)                              (19/43)
Under the influence of alcohol/ drugs last time      9.5      .00
  had sex with primary partner
Used a condom with nonprimary partner in             100      .54
  last 12 months (n = 28)                           (5/5)
Under the influence of alcohol/drugs last time      40.0      .63
  had sex with nonprimary partner

Table 3. Condom Use Self-Efficacy Scale (% answering "yes")

                                                  Immigrant   Immigrant
                                                    women        men
                                                  (n = 51)    (n = 50)

                                       Impulse control

Can you insist on condom use regularly when
  you're under the influence of alcohol or
    drugs?                                          78.4        63.2
Can you stop to look for a condom if you and
  your partner are already sexually aroused?        78.4        59.1
Can you stop and put a condom on a partner
  (put on a condom) without spoiling the mood?      82.3        55.1
Can you insist on condom use regularly when your
  partner is under the influence of alcohol or
    drugs?                                          84.3        70.0

                                    Partner resistance

Can you insist on condom use if your partner
  does not want to use one?                         78.4        72.0
Can you continue to insist on condom use with a
  person who gets angry when you suggest it?        80.3        56.0

                                          STD thoughts

Can you suggest using condoms with a partner
  even if he [she] will think that you have a
    sexually transmitted disease?                   78.0        69.3
Can you insist on condom use whenever you are
  with someone who says he/she is not infected
    with any disease?                               82.4        78.0

                                           Other items

Could you tell your partner that you are not
  going to have sex if condoms are not used?        78.4        63.2
Can you insist on condom use whenever you are
  with someone you know has sex with several
    other partners?                                 82.0        78.0

                                                  U.S.-born
                                                   Latinas
                                                  (n = 51)     p

                                       Impulse control

Can you insist on condom use regularly when
  you're under the influence of alcohol or
    drugs?                                          56.8      .02
Can you stop to look for a condom if you and
  your partner are already sexually aroused?         6.8      .01
Can you stop and put a condom on a partner
  (put on a condom) without spoiling the mood?      54.9      .01
Can you insist on condom use regularly when your
  partner is under the influence of alcohol or
    drugs?                                          66.6      .01

                                    Partner resistance

Can you insist on condom use if your partner
  does not want to use one?                         88.2      .10
Can you continue to insist on condom use with a
  person who gets angry when you suggest it?        66.6      .01

                                          STD thoughts

Can you suggest using condoms with a partner
  even if he [she] will think that you have a
    sexually transmitted disease?                   88.2      .05
Can you insist on condom use whenever you are
  with someone who says he/she is not infected
    with any disease?                               90.1      .01


                                           Other items

Could you tell your partner that you are not
  going to have sex if condoms are not used?        56.8      .02
Can you insist on condom use whenever you are
  with someone you know has sex with several
    other partners?                                 90.0      .01

Table 4. Condom Use in Last Sexual Encounter, Logistic Regression
Results (N = 137)

                                                 Model 1

                                                    Odds
Variables                              B      SE    ratio    Wald

Gender                                0.16   0.52   1.12    0.10
Place of birth                       -0.26   0.46   0.77    0.34
Relationship risk                     1.07   0.38   2.91    8.04 **
Sex trade
Using drugs or alcohol during sex
Condom use self-efficacy

                                                 Model 2

                                                    Odds
Variables                              B      SE    ratio    Wald

Gender                               -0.25   0.56   0.78    0.20
Place of birth                       -0.34   0.47   0.71    0.51
Relationship risk                     1.48   0.47   4.39    9.84 **
Sex trade                            -2.32   1.12   0.10    4.32 *
Using drugs or alcohol during sex    -0.16   0.83   0.85    1.04
Condom use self-efficacy              0.06   0.03   1.06    4.62 *

* p [less than or equal to] .05. ** p [less than or equal to] .01.

Table 5. Condom Use With Primary Sexual Partner, Logistic Regression
Results (N = 122)

                                                Model 1

                                                   Odds
Variables                             B      SE    ratio    Wald

Gender                               1.24   0.52    3.45    5.63 *
Place of birth                       0.86   0.44    2.37    3.90 *
Relationship risk                    2.89   1.11   17.96    6.83 **
Sex trade                                                   0.87
Using drugs or alcohol during sex                          -0.98
Condom use self-efficacy                                    0.05

                                                Model 2

Model 1                                            Odds
Variables                            B      SE     ratio     Wald

Gender                               1.19   0.56    3.28     4.54 *
Place of birth                       0.84   0.45    2.32     3.46
Relationship risk                    3.16   1.26   23.66     6.34 *
Sex trade                            1.32   2.39    0.44
Using drugs or alcohol during sex    0.92   0.37    1.51
Condom use self-efficacy             0.02   1.05    4.71 *

* p [less than or equal to] .05. ** P [less than or equal to] .01.

Table 6. Predictors of Condom Use Self-Efficacy Among
U.S.-and Foreign-Born Latinos

Variables            [beta]     p

Gender                .27      .009
Place of birth        .23      .118
Age                  -.018     .82
Spoken language       .05      .74
Years of education    .24      .009
Current employment    .11      .018
[R.sup.2]             .10      .018

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Manuscript accepted May 26, 2004

Maria Eugenia Fernandez-Esquer, John Atkinson, Pamela Diamond, and Bernardo Useche

University of Texas Health Science Center at Houston

Ricardo Mendiola

Georgia Department of Human Resources

This study was funded by the Houston Department of Health and Human Services, Bureau of HIV/STD. We would like to thank Glenda Gardner, former Bureau Chief, for her vision and her support. We would also like to thank Esperanza Fajardo and Shelley Gentry for their involvement in data management, quality, and analysis, along with all of the interviewers who participated in this study, particularly Mike Dominguez for his help in mapping the location of apartment complexes in Houston's Latino neighbor:hoods.

Address correspondence to Maria Eugenia Fernandez-Esquer, Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, 7000 Fannin, Suite 2518, Houston, TX 77030; e-mail: [e-mail].