Getting your partner to use condoms: interviews with men and women at Risk of HIV/STDs.

Heterosexual transmission of HIV and other sexually transmitted diseases (STDs) is a major threat to the nation's health. Strengthening the ability of women and their heterosexual partners to protect themselves from HIV/STDs is a public health priority. The male (latex) condom is effective in protecting against HIV and a variety of STDs when used consistently and correctly (Stone, Timyan, & Thomas, 1999). Condoms are widely available, safe, easy to use, and very effective in preventing pregnancy (Feldblum & Joanis, 1994; Stone et al., 1999). Yet, studies have shown that many men and women at risk of HIV/STDs do not use condoms consistently, despite knowledge about STDs and the importance of condom use (e.g., Anderson, Brackbill, & Mosher, 1996; Baldwin, Whiteley, & Baldwin, 1990; Geringer, Marks, Allen, & Armstrong, 1993; Kost & Forrest, 1992; St. Lawrence et al., 1998). It has been argued that the inability to negotiate condom use, particularly among women, is a major impediment to practicing safer sex behaviors (e.g., Amaro, 1995; Fullilove, Fullilove, Haynes, & Gross, 1990; Gomez & Marin, 1996; Pulerwitz, Gortmaker, & DeJong, 2000; Wingood & DiClemente, 1998, 2000; Wingood, Hunter-Gamble, & DiClemente, 1993). Getting one's partner to use a condom may hot be easy for everyone. This is especially true for women because condoms are worn by men. Until other methods of HIV/STD prevention are widely available and affordable, improving the ability of heterosexual partners at risk of HIV/STDs to negotiate and consistently use male condoms is essential.

A particularly robust finding is that individuals in committed relationships are less likely to use condoms consistently than persons in casual relationships, even if they do not know their partner's or their own HIV status (Misovich, Fisher, & Fisher, 1997). For instance, when condom use at last intercourse was examined in a national survey, 36% of those aged 18-25 reported condom use when last intercourse occurred within an on-going relationship whereas 66% of this age group reported condom use when last intercourse occurred in a casual relationship (Anderson, Wilson, Doll, Jones, & Barker, 1999).

Issues surrounding trust and commitment may interfere with condom use in some heterosexual relationships. An incorrect AIDS prevention belief that trusted partners are safe partners may lead to the perception of decreased risk as trust develops in a relationship over time (Misovich et al., 1997). Individuals in diverse samples frequently mention trust as a reason for not discussing or using condoms (e.g., Hammer, Fisher, Fitzgerald, & Fisher, 1996; Kline, Kline, & Oken, 1992; Maxwell & Boyle, 1995; McQuiston & Gordon, 2000; O'Donnell, San Doval, Vornfett, & DeJong, 1994; Wingood et al., 1993). Proposing condom use to a partner may be considered a violation of trust because it suggests that one or both partners is engaging in sex outside of the relationship or has a sexual past that involves risk (Hammer et al., 1996; Maxwell & Boyle, 1995; Misovich et al., 1997; O'Donnell et al., 1994; Wingood et al., 1993). The potential for emotional, verbal, or physical abuse in response to requests to use condoms may also be a barrier to discussing and using condoms (Misovich et al., 1997; O'Donnell et al., 1994; Wingood & DiClemente, 1997). Given such expectations about the outcomes of initiating discussion of condom use, it is not surprising that negotiating condom use is perceived as difficult, especially for women.

The importance of communication about condom use is supported by a comprehensive review of correlates of condom use which reported that communication about condom use is one of the most important predictors of condom use (Sheeran, Abraham, & Orbell, 1999). Therefore, a better understanding of individuals' strategies for convincing their partners to use condoms is needed. Individuals' concerns about trust and negative reactions to requests to use condoms could potentially limit the strategies that they would use to influence condom use. Perhaps indirect rather than direct verbal strategies and nonverbal communication would be preferable in some relationships. In addition, pregnancy prevention rather than disease prevention might be emphasized in verbal influence strategies.

Several studies have examined the use of influencing strategies in interpersonal relationships in general (e.g., Cowan, Bommersback, & Curtis, 1995; Falbo & Peplau, 1980; Frieze & McHugh, 1992; Howard, Blumstein, & Schwartz, 1986, Steil & Weltman, 1992). Few studies have examined influencing strategies specific to sexual interactions, and the majority of those have examined dating situations and the decision to have or not to have sexual intercourse (e.g., Christopher & Frandsen, 1990: Greer & Buss, 1994; La Plante, McCormick, & Brannigan, 1980; McCormick, 1979; Poppen & Segal, 1988). Because research indicates that the specific influencing strategies that women use with their sex partners depends on the desired outcome (De Bro, Campbell, & Peplau, 1994; McCormick, 1979), the strategies that men and women use to get their partners to use condoms may differ from the strategies that they use to influence other behaviors.

We found three studies in the published literature that have examined the specific strategies that heterosexual individuals use to get their partners to use condoms. In a study by Edgar, Freimuth, Hammond, McDonald, and Fink (1992), college students were asked open-ended questions regarding their interactions about the use of condoms when they last had sexual intercourse with a new partner. Over 50% of the respondents had not used a condom the last time they had sex with a new partner. Among those nonusers who had communicated to their partner that they wanted to use a condom, the most frequently used strategy was a direct request. Analyses of the responses of condom users suggested that women were more likely to refuse to have sex without a condom or to demand or directly request that a condom be used, whereas men reported that they used nonverbal strategies such as using a condom without discussing it with their partner. Participants also responded to nine scenarios in which counterresistance strategies (i.e., strategies to counter a partner's resistence to using condoms) were employed, rating the likelihood that they would use the strategy in a similar situation. Women rated the likelihood that they would use a direct request, deception, and refusal to have sex higher than other strategies. Men indicated that they would be more likely to use direct request and reward strategies. Both women and men who had used condoms with their last new sex partner reported greater likelihood that they would threaten to withhold sex than those who had not used condoms with their most recent new partner. In addition, male condom users reported higher likelihood ratings for the "you" strategy (i.e, "I care about you very much and don't want anything to happen to you") than male nonusers, and female condom users rated the likelihood of using the direct strategy more highly than female nonusers.

De Bro et al. (1994) also conducted a study with college students in which they examined perceptions of and experiences with six strategies for influencing condom use: reward, emotional coercion, risk information, deception, seduction, and withholding sex. They found that women rated withholding sex as more effective than other strategies in influencing a dating partner and had the greatest comfort with using this strategy. In comparison, men gave deception the highest ratings on effectiveness and comfort. Threatening to withhold sex was the strategy that the greatest percentage of women reported having personally used, whereas seduction was the strategy that men most frequently used.

Kline et al. (1992) conducted a focus group study with Black and Hispanic women recruited from drug treatment centers and community agencies who were (a) IV drug users, (b) HIV positive, or (c) sex partners of IV drug users (but were not currently IV drug users themselves). The participants reported using strategies such as withholding sex, seduction, and reasoning regarding the importance of using condoms in order to negotiate condom use.

Although these studies have specifically examined strategies for influencing condom use, each has limitations. The De Bro et al. (1994) and Edgar et al. (1992) studies used college samples and did not select participants based on their risk of HIV/STDs. In contrast, the sample in the focus group study by Kline et al. (1992) included women in two high-risk groups and women who were HIV positive, but did not include men. Further research is needed that investigates influencing strategies for condom use among men and women at risk for HIV/STDs.

The present study is part of a larger project with the goal of designing, implementing, and evaluating a couple-based intervention to reduce unprotected intercourse among young women at increased risk of HIV/STDs and unintended pregnancy in their current relationships. To inform the design of the intervention, we conducted formative research to examine several aspects of couples' condom use behavior. Because prior research on influencing strategies was limited, we wanted to identify the strategies that men and women at risk of HIV/STDs would use to influence their partners to use condoms for the purpose of disease prevention. In the analyses presented here, we were interested in responses from both men and women and from those who had recently used condoms with their partner and those who had not. Secondarily, we wanted to explore whether women and men would use different strategies for disease prevention as compared to pregnancy prevention. We adopted an exploratory approach because we were interested in what men and women at risk of HIV/STDs say they would do, in their own words. Out goal was to improve understanding of the strategies for influencing condom use that would be most acceptable to out target population. Out findings would, thus, have implications for the design of interventions intended to increase condom use. More specifically, interventions could provide the information and teach the skills necessary to implement the strategies identified.

METHODS

Participants

As noted above, the data come from the formative phase of a project designed to develop, implement, and evaluate a couple-based intervention to reduce unprotected intercourse among young (aged 18-25) women and their male partners. The sample consists of 90 couples in three U.S. cities where the proposed intervention was to be implemented: Atlanta (n = 30), Los Angeles (n = 39), and Oklahoma City (n = 21). We recruited participants from family planning and STD clinics and other community locations in each city using both passive (e.g., posters and fliers) and active (e.g., recruiters approaching potential participants in the clinics) strategies. Initially, recruiters briefly described the study to potential participants, told them that they would need to be screened for eligibility and that their partner would need to agree to participate, and asked them if they were willing to be screened.

We recruited the majority of couples (n = 84) through the women. For the formative phase, women were eligible if they were 18 to 25 years old, had a male sex partner age 18 or older, had sex without a condom within the previous 3 months, and met one or more of the following criteria: (a) more than one lifetime sex partner, (b) ever had an STD, (c) ever had sex with a man who she knew or thought was having sex with other men or women, (d) ever had sex with a man who she knew or thought was using IV drugs (using a needle to inject drugs into his body), or (e) ever had sex with a man who she knew or thought had an STD or HIV/AIDS. In addition, women had to self-identify as being African American in Atlanta and as Hispanic in Los Angeles; women in Oklahoma could be of any race/ethnicity. Women also had to be willing to ask their partner to participate in the study. If women had more than one sex partner, they decided which partner to ask to participate. The male partner that they identified had to be 18 years of age or older but did not have to be of the same race/ethnicity as the woman. Women who were pregnant, who intended to become pregnant within the year, or who self-identified as being HIV positive were not eligible. Women were screened either over the telephone or in person at recruitment sites. Eligible women were asked to invite their partners to participate. Both members of a couple had to agree to participate in order for the couple to be enrolled in the study. In addition, we recruited 1 couple in Oklahoma City and 5 couples in Atlanta through the men; men had to meet similar criteria as those described above for women and, additionally, they had to report that their female partners met those criteria. In total, 507 individuals were screened. Of those, 245 (48%) were eligible. Of those who were eligible, 90 (37%) participated in the study along with their partner.

As a result of the eligibility criteria described above, the majority of women were Hispanic (43%) and African American (43%); in addition, 11% were non-Hispanic White, 1% were American Indian, and 1% were Asian/ Pacific Islander. Twenty-one percent of the women and 20% of the men reported that they were married to each other, and 59% of the women and 54% of the men said that the couple lived together. Women had a mean age of 21.6 years (SD = 2.3). Men had a mean age of 24.4 years (SD = 4.9). Forty percent of the women and 34% of the men had not graduated from high school. Over a third (36%) of women and one fifth (20%) of men were currently in school. Half (51%) of the women and 87% of the men were currently employed. Forty-nine percent of the women and 38% of the men reported that, at some point in their lives, they had been told that they had an STD. In addition, 5% of the women said that they have had sex with a man who had sex with other men and another 6% suspected that they had. Four percent of the men reported having had sex with other men. Ten percent of the women and 2% of the men reported that they have had sex with an IV-drug user, and another 4% of men suspected that they had. Sixty percent of the women and 50% of the men reported that the couple used condoms at least once in the past 3 months.

Procedure

Interviews were conducted between July and November 1998. All interviewers were trained together at a group meeting, and procedures were standardized across sites. Individual semistructured interviews lasting approximately 60 minutes were conducted with each member of the couple in private, without the partner being present. Whenever possible, partners were interviewed concurrently. Participants and interviewers were matched according to gender at all sites, and according to race/ethnicity in Atlanta and Los Angeles. In Los Angeles, participants could choose to have the interview conducted in Spanish or English. Interviewers referred to a standard interview guide for all interview questions. The interview guide was developed specifically for this study. It included open-ended as well as structured questions. Interviews were audiotaped, and responses to close-ended questions were noted on hard copies of the guide. Participants were paid for their time and compensated for travel and/or child care costs. Institutional Review Board approval was obtained at each site, and written informed consent was obtained from each participant after the study was fully explained.

For this analysis, we examined responses to three questions. The wording of two of the questions differed slightly for male and female participants. Women were asked:

   Let's say you really wanted [PARTNER'S NAME] to use a condom to keep from
   getting a sexually transmitted disease, but you didn't know how he felt.
   What would you do or say to get him to use a condom when you have sex?

The follow-up questions were "What would you do if that didn't work?" and "Would it be any different if you asked [PARTNER'S NAME] to use a condom to prevent a pregnancy?"

Similarly, men were asked:

   Let's say you really wanted [PARTNER'S NAME] to use a condom to keep from
   getting a sexually transmitted disease, but you didn't know how she felt.
   What would you do or say to get to use a condom when you have sex?

The follow-up questions for men were "What would you do if that didn't work?" and "Would it be any different if you wanted [PARTNER'S NAME] to use a condom to prevent a pregnancy?"

Analysis

Audiotapes of the interviews were transcribed, and transcripts for interviews conducted in Spanish were translated. The data were analyzed using content analysis. The coding of text proceeded in two stages. First, the software program NUD*IST was used to construct and organize a topical indexing system of codes (topical coding) identifying sections of transcript text that contained the specific interview questions of interest and participants' responses to those questions. Second, after initial reading of the transcript, members of the research team developed a more detailed coding scheme (content coding) to capture the content, themes, or sentiment of responses. For example, themes regarding the specific strategies that participants said they would use to get their partners to use condoms (e.g., threatening to withhold sex) were identified. Next, trained coders read all the transcript text pertaining to the relevant interview questions, individually coding the text according to the themes. They then compared their coding of the text to assess agreement. Although few discrepancies in coding were found, differences were discussed and consensus was reached. The predominant strategies used by different groups (e.g., men and women, condom users and nonusers) were also identified. Quotations from the transcript were then selected to illustrate t he themes. In presenting our results, for every quotation we report the site where the interview occurred (AT = Atlanta; LA = Los Angeles; and OK = Oklahoma City) and whether the participant was male or female. We did not use the couple as the unit of analysis because out research questions concerned the hypothetical behavior of individuals.

RESULTS

Overview

Participants identified several strategies that they would use to get their partner to use a condom for disease prevention. The first overarching theme that emerged from the analysis was that some influencing strategies were verbal, while others were nonverbal. The vast majority of the influencing strategies reported by participants were verbal, and included (a) persuading their partner to use condoms or suggesting condom use, (b) commanding or asserting their desire for condom use, and (c) threatening to withhold sex if condoms are not used. Activities involving condoms themselves (e.g., putting a condom on themselves or their partner, buying or getting condoms, or presenting a condom to their partner) emerged as the primary nonverbal technique that participants said they would use. Verbal and nonverbal strategies were reported by both individuals who had recently used condoms with their partner and those who had not. Many participants, however, said that the strategy that they would use to get their partner to use condoms would differ for pregnancy prevention. These themes are described in more detail in the following sections.

Verbal Strategies

Most of the men and women reported that they would use bilateral verbal techniques to influence their partner to use a condom for disease prevention. These strategies are bilateral (Falbo & Peplau, 1980) because they involve interaction between partners. These techniques were, by far, the most frequently mentioned approach for influencing condom use. More specifically, participants said they would persuade their partner to use condoms by engaging him or her in conversations about disease prevention, pregnancy prevention, or condom use. They also said they would suggest condom use to their partner or talk to their partner about using condoms. The following quotations illustrate this strategy:

   I would simply say to her, there is something that's bothering me and it
   has to do with your health, and this is the situation. It might make you
   feel uncomfortable, but I think the way to do it is us having a discussion.
   Then having the discussion.... I would feel better about having a
   discussion, because I would have availed myself to being honest with her.
   (AT, male)

   Talk to him. Tell him that it is the best for both of us. Having safe sex.
   I would acknowledge that I don't know what his point of view is. I don't
   know how to explain it well. I have no idea. I would just bring it up. (LA,
   female)

   I guess, I would try and talk to him more about it. Ask him why he doesn't
   want to [use condoms], you know try to understand where he's coming from
   you know, he might have some big aversion that I don't know about, about
   condoms or something you know. (OK, female)

The majority of participants who mentioned bilateral techniques said that they would reason with and provide information about the risk of HIV/STDs and unintended pregnancy to persuade and/or negotiate with their partner to use condoms. As one woman in Atlanta said, "I would tell him that a friend of mine caught a disease and I'm scared that it will happen to me." Similarly, a male participant in Atlanta reported, "I guess I could tell her that I got a disease ... or that I could have one, you know."

A direct, unilateral approach emerged as the second most common verbal strategy that participants reported that they would use. Over one fourth of men and women indicated that they would assert their needs or wants directly by requesting, telling, or commanding their partner to use condoms or by expressing desire to use condoms without giving reasons why. This strategy reflects sentiments such as "This is what I want," "This is what I need," or "This is who I am." It is unilateral (Falbo & Peplau, 1980) because it does not involve negotiating or reasoning with their partner. The following comments illustrate this strategy:

   I would just tell him.... And I would be very firm. (OK, female)

   I would just come out with it, "Which color do you want?" (OK, male)

   Basically I would say, "Go get a condom." If he keeps going and not
   listening to me I would say, "GO GET A CONDOM." I would basically be more
   forceful. (LA, female)

   I'd first bring it out and then I would just say, "We're going to use
   condoms." (LA, male)

The third most common verbal influencing tactic mentioned by participants involved threatening to withhold sex if their partner refused to use condoms. Nearly a third of the women but few men mentioned that they would use this strategy. These participants explained that they would give their partner a choice between using a condom or not having sex. As one woman in Los Angeles remarked, "I would probably say, if you're not going to wear a condom, then we're not going to do it." Similarly, a male participant in Atlanta explained, "I would say, `[PARTNER'S NAME], I'm going to wear this condom, and if you don't like it, we ain't having sex.'"

Nonverbal Strategies

In addition to verbal strategies, participants reported that they would use nonverbal techniques to get their partner to use condoms. About one fourth of the men and one fifth of the women described nonverbal strategies involving condoms themselves. These tactics included putting a condom on themselves or their partner, buying or getting condoms, or presenting a condom to their partner. The following comments illustrate this strategy.

   Give her a condom.... [I would] just use it, just do it. (AT, male)

   I would simply put it on. (LA, male)

   I would, I don't know, maybe try to put it on myself and make it into a
   foreplay type of scene. (LA, female)

   I could put it on him myself, and he ain't gonna fight it. (OK, female)

Other nonverbal strategies were mentioned by only a few participants. Six women and three men indicated that they would use seductive techniques--getting their partner in the mood, relaxing him and making him feel good, taking her out to dinner. The following descriptions from three women are illustrative of this strategy:

   Just be sweet and everything, you know....Be kissing on him and everything.
   (AT, female)

   I probably relax him, get him in the mood and then go for the kill when it
   is time for it. When he [has] a hard on he really wants it then I will let
   him know. (AT, female)

   I would have to entice him, you know, like put on my high heel shoes, and
   dance and stuff like that. "Oh [PARTNER'S NAME], if you want this, you got
   to use this." (LA, female)

A small number of men and women reported that they would use passive techniques such as leaving, pouting, or going to bed. As one woman in Oklahoma described, "I would probably ... just go lay down and start pouting or go to bed or something." Finally, four women indicated that they would use physical resistance if their partner would not wear a condom or get mad if he refused. For example, one woman in Los Angeles remarked: "Yeah, I would probably resist. Try to push him off. Close my legs."

What if the Strategy Fails?

When asked what they would do if the influencing strategy that they proposed did not work, several participants mentioned that they would try the same tactic again or use another approach to influence their partners' behavior. In addition, nearly half of the women and several men stated that they would avoid sex or refuse to have sex if their partner did not agree to use condoms, as portrayed in the following dialog between an interviewer and a woman in Oklahoma:

   Interviewer: Would there be anything you would do?

   Participant: Just give him a condom to wear.

   Interviewer: What would you do if that didn't work?

   Participant: We wouldn't have sex. No sex.

Influencing Strategies and Condom-use Experience

Because of their experience using condoms, men and women who had recently used condoms with their partner may have different ideas about how they would go about getting their partners to use condoms in the future than those who had not. In order to explore such differences, we examined the themes regarding influencing strategies for condom users and nonusers separately. Participants were considered condom users if they reported that they had used condoms with their partner (i.e., the partner who was also participating in the study) at least one time in the last 3 months. Among male and female participants, all of the major verbal influencing strategies were reported by both condom users and nonusers. More specifically, among both men and women, condom users and nonusers reported that they would persuade their partner or suggest using condoms, command that condoms be used or assert their desires, and threaten to withhold sex. One possible difference emerged: whereas several male and female condom users said that they would use nonverbal strategies involving condoms, few of the men and women who were nonusers said that they would use such tactics.

Different Strategy for Pregnancy Prevention?

Because influencing tactics will likely vary depending on the desired outcome, we explored whether participants would employ different strategies to get their partner to use condoms for pregnancy prevention. When asked if the influencing strategy would be different if they asked their partner to use a condom to prevent pregnancy, about hall of the women and one third of the men responded affirmatively. More specifically, these participants believed that the strategy would differ because it would be easier to convince a partner to use condoms for pregnancy prevention than it would be for disease prevention. When asked why it would be easier, both men and women mentioned the following reasons: the risk of contracting a disease would be perceived as low, the risk of unintended pregnancy would be perceived as real, and introducing condom use for pregnancy prevention as compared to disease prevention would not provoke issues involving trust. Several women mentioned that they would be more persistent about condom use for pregnancy prevention than for disease prevention. Others said that because they were using another form of birth control or because other methods were available, their request for condom use could potentially be met with resistance by their partner. The following quotes illustrate some of these views:

   Yeah, because I know for sure he ain't ready to have no baby, I'm not ready
   to have no baby, so I would talk him into it better, but you know as far as
   a sexually transmitted disease goes, I don't think that's a concern for
   both of us, so I wouldn't push it as hard. (AT, female)

   I think it would definitely be different. I don't think it would be a
   question as much.... But I think it would be more acceptable than if I said
   I don't want to get any disease from you. Even though in the beginning
   that's what I said, "It is not that I don't trust you. I just don't trust
   the last person you were with." (LA, female)

   The difference would be that I would not make her feel bad. I mean, by
   talking ... simply telling her that we have to use a condom to prevent
   disease transmission, she would be suspicious that maybe I am sick and
   don't want to tell her. Or that I might be thinking that she is sick and
   that would be shameful. She would tell me "You think I am sick or that you
   are sick, and that is why you want to use a condom, so we better not." But
   to avoid pregnancy I think it is logical. Even, like I said, that several
   women tell you in the Latino community, "No, I count my monthly days, I
   know the dates when I will get pregnant or not." Like I told you, I don't
   trust that. So, I think that if she would tell me, it would be in that way.
   (LA, male)

DISCUSSION

Although out findings are not directly comparable to those of other studies due to differences in methodology, in general the strategies identified by out sample are similar to those reported in earlier research (De Bro et al., 1994; Edgar et al., 1992; Kline et al., 1992). Two exceptions were round: Very few participants in our study indicated that they would use seductive techniques, and almost none reported that they would use deception. Furthermore, although men in the study by Edgar et al. (1992) reported that they used nonverbal strategies involving condoms (i.e., many said they had used condoms without discussing it with their partners), in out study both men and women described such nonverbal techniques. In addition to putting a condom on, participants talked about buying or getting condoms and presenting condoms to their partners. Participants in this study may have been more likely to propose strategies such as these because they had more experience using condoms or because the interview focused heavily on condoms. Nonverbal influencing strategies are often ignored in the literature. Out findings suggest that future research should consider nonverbal as well as verbal influencing strategies for condom use.

Not surprisingly, several participants who had recently used condoms with their partner reported that they would use nonverbal strategies involving condoms, but few nonusers said they would use such techniques. Participants who had recently used condoms with their partner are probably more likely to have condoms in their possession and to feel comfortable buying condoms or initiating their use than those who had not. Recent condom users may also have a broader range of strategies because they have experienced more situations in which they have had to try to get their partners to use condoms. It is noteworthy that few major differences between condom users and nonusers with respect to verbal influencing strategies were apparent. The similarities between condom users and nonusers may be due to our definition of current condom use (i.e, they had used condoms with the partner who was also participating in the study at least one time in the last 3 months). Perhaps a more stringent definition would have revealed greater differences between condom users and nonusers. On the other hand, the similarities may reflect our sample's general comfort with talking about sexual activity and condom use.

Some studies investigating influencing strategies in intimate relationships have round differences in the reports of strategies used by men and women (e.g., Cowan et al., 1995; De Bro et al., 1994; Falbo & Peplau, 1980; Steil & Weltman, 1992). Yet, other studies have failed to find gender differences (e.g., Aida & Falbo, 1991; Buss, Gomes, Higgins, & Lauterbach, 1987). Such contradictory results may be partly attributable to differences in measurement and sample characteristics (i.e., college students in dating relationships vs. married couples). Despite the inconsistencies in samples and methods, some studies suggest that an imbalance of power (Aida & Falbo, 1991) and unequal access to structural resources (Howard et al., 1986) underlie gender differences in influencing strategy use. That research suggests that individuals who hold less power and have fewer resources are more likely to use indirect or weak influencing strategies.

In this study, however, we found few major differences in what male and female participants said they would do to get their partners to use condoms, and the strategies most frequently reported were neither weak nor indirect. There are several possible explanations for these findings. First, the men and women in this study were couples, and members of couples may be more similar to each other than a sample of unrelated men and women. Second, because couples in this study were willing to be interviewed about their sexual behavior, HIV/STDs, and condom use, they may have been more comfortable talking directly and candidly about condom use with their partners than other men and women. Third, couples in this study may have had more egalitarian relationships than the participants in other studies. For example, because in most cases the man agreed to participate after his partner asked him to do so, women in this study may have more relationship power than other women. Fourth, participants may be willing to use direct strategies when considering a situation in which they felt at risk of an STD. In addition, participants may have reported strategies that they felt were socially desirable (i.e., they reported strategies that they felt they should use).

Several women, but only a few men, said that they would threaten to withhold sex in order to get their partner to use a condom. Perhaps the female participants perceived greater risk of HIV/STD infection or worse consequences for unprotected sex than the men did. Alternatively, men may not need to resort to the threat of withholding sex because condom use is in their domain. If a man really wants to wear a condom, he can put one on. A woman must rely on her partner's cooperation. Women's potential use of withholding sex may, thus, reflect the fact that condoms are not female controlled.

Given its exploratory nature, we believe that a strength of our study was the use of qualitative methodology. Because participants responded to open-ended questions, they could describe influencing strategies that we may not have identified a priori. In particular, the finding that both men and women said that they would undertake a variety of nonverbal activities involving condoms may hot have emerged. Interestingly, in the Edgar et al. (1992) study, men reported nonverbal strategies in response to open-ended questions as well.

In addition to the aforementioned study limitations, our sample consisted of young couples at risk of HIV/STDs who were recruited from family planning and STD clinics and other community locations in Atlanta, Los Angeles, and Oklahoma City and, therefore, our findings may have limited generalizability. In addition, we asked participants to describe hypothetical behavior. In other words, they reported the strategies that they would use to get their partner to use a condom if they wanted to protect themselves from STDs. We do not know whether participants would actually use the reported strategies in such a situation or whether the strategies are effective when implemented. Further research should address these limitations. However, because participants were inconsistent condoms users who were at increased risk of HIV, other STDs, and unintended pregnancy, knowing their perceptions about what influencing strategies they would use is useful. More specifically, the findings suggest what sorts of strategies would be most acceptable to the target population. Interventions can provide the information and teach the skills necessary to implement those (and other) strategies. A final limitation is that because we took an exploratory, qualitative approach, our sample size and instrumentation are not well-suited to quantitative analyses. Studies with larger samples should examine the themes that we identified here using quantitative methodologies.

Despite these limitations, out findings have implications for the design of interventions directed at reducing unprotected intercourse among young women at increased risk of HIV/STDs and their male partners. First, the finding that the majority of participants indicated that they would use verbal, bilateral, influencing strategies such as persuading and reasoning with their partner suggests that interventions need to emphasize communication and negotiations skills for couples. Programs need to teach effective communication techniques that individuals can use to initiate and maintain a discussion with their partner regarding the reasons to use condoms. In addition, interventions need to provide accurate information about HIV/STDs and risk factors so that individuals are equipped to reason with their partners and to convey essential and accurate information in order to persuade them to use condoms. Consistent with other literature (e.g., Becker, 1996; Misovich et al., 1997) and because condom use is a dyadic behavior, prevention programs may benefit from targeting both men and women, even if they are not couples. In addition, because almost a third of the women but few men mentioned that they would use the strategy of threatening to withhold sex, programs might consider addressing gender differences in safer sex behaviors, while also teaching a variety of influencing strategies that both men and women could utilize to influence condom use behavior.

Some of the participants, particularly those who had recently used condoms with their partners, also described the use of nonverbal strategies involving condoms such as putting a condom on themselves or their partner and presenting a condom to their partner. This finding indicates that prevention programs need to address correct condom use and teach the behavioral skills related to using condoms such as buying condoms and putting them on correctly. Interventions could also address and promote comfort with using condoms.

Finally, the finding that both male and female participants thought it would be easier to convince their partner to use a condom for pregnancy prevention than for disease prevention further illustrates the importance of incorporating effective communication skills into prevention programs that teach individuals how to talk about difficult sexual issues, including issues related to trust in a relationship. Furthermore, this finding suggests that interventions and programs that address the prevention of both unintended pregnancy and HIV/STDs may be more effective in promoting condom use among populations at increased risk.

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Sheryl Thorburn Bird University of Oregon

S. Marie Harvey University of Oregon and Public Health Institute, Berkeley, California

Linda J. Beckman Alliant University, Los Angeles

Christa H. Johnson Children's Hospital of Oklahoma

The PARTNERS Project

This research was conducted as part of the PARTNERS Project, supported by cooperative agreements #U30/CCU 915062-1-0 and #U30/CCU 615166-1-0 with the Centers for Disease Control and Prevention (CDC). Members of the PARTNERS Project include S. Marie Harvey, Principal Investigator for the Los Angeles and Portland, Oregon sites; Heather C. Huszti, Principal Investigator for the Oklahoma City and Atlanta sites; and Christine Galavotti, Katina A. Pappas-DeLuca, and Joan Marie Kraft, CDC Project Officers.

We give special thanks to Sarah J. Satre, MS, and Meredith Roberts Branch, MPH, for their assistance with data analysis.

Address correspondence to Sheryl Thorburn Bird, Center for the Study of Women in Society, 1201 University of Oregon, Eugene, OR 97403-1201; e-mail: [e-mail].