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Condom use behavioural skills mediate the relationship between condom use motivation and condom use behaviour among young adult heterosexual males: an information-motivation behavioural skills analysis.

This study examined the relationship between condom use motivation and condom use behavioural skills, and their direct and mediated influence on condom use consistency from the perspective of the Information-Motivation-Behavioural Skills (IMB) model of health behaviour. Participants were 149 currently sexually active heterosexual males aged 18-24 (M = 18.6). The motivation component of the IMB model was operationalized with measures of attitudes toward condoms and perceptions of social norms, while assessing the implementation of negotiation strategies that can be used to obtain or avoid condom use operationalized the behavioural skills component. Results indicated that condom use motivation was positively correlated with specific condom use obtaining strategies, and condom use consistency was negatively correlated with certain condom use avoiding strategies. Moreover, specific condom negotiation strategies partially mediated the relationships between motivational constructs and condom use consistency. These findings confirm the propositions of the IMB model, illustrate the utility of measurement of behavioural skills in relation to implementation of specific actions, and highlight the need for interventions to focus on dyadic negotiation and communication strategies as important influences on condom use consistency. Implications for future research and theoretical refinement are discussed.

KEY WORDS: Condom use, condom negotiation strategies, IMB model, behavioural skills

INTRODUCTION

According to the Public Health Agency of Canada, 15-24 year old youth have the highest rates of chlamydia and gonorrhoea in Canada (Public Health Agency of Canada, 2014). In view of research that indicates that 32% of sexually active 15-24 year old Canadians did not use a condom the last time they had sex (Rotermann, 2012), high rates of STIs are not surprising. To compound the problem, adolescents who report condom-use at last intercourse may well not be employing this method consistently during all sexual encounters (Fisher & Boroditzky, 2000). As it only takes a single unprotected sexual encounter to contract an STI, consistent condom use is essential for adequate STI prevention.

In the context of STI prevention among heterosexual young people, it may be prudent to focus on male's use of condoms. Female partners may purchase condoms, express positive attitudes toward condoms, request that the male partner use a condom, or apply condoms for their male partners, but it is ultimately the male who must consent to use a condom and to do so with consistency. In this connection, Edgley (2003), for example, found that while females reported initiating discussions about sexual health and STIs with their partners more often than males, and reported feeling responsible for the decision to use condoms, the couple's decision was more strongly influenced by the male's perception of whether condoms should be used than by the female partner's wishes. In light of the potentially male-controlled process of condom use and related findings, further research regarding the determinants of condom use, focusing on the influence of heterosexual males on condom use outcomes, would appear to be warranted.

The Information-Motivation-Behavioural Skills (IMB) Model (Fisher & Fisher, 1992; Fisher, Fisher, & Shuper, 2014) is an appropriate theoretical framework within which to conceptualize condom use consistency in young males, and prevention strategies based on this model have been shown to increase safer-sex behaviours among college students and multiple other target groups (Fisher, Fisher, & Shuper, 2014; Reis, Ramiro, de Matos, & Diniz, 2013; Ybarra, Korchmaros, Kiwanuka, Bangsberg, & Bull, 2013). The IMB Model proposes three fundamental determinants of condom use behaviour: (1) condom use information that is directly relevant to the practice of condom use behaviour; (2) condom use motivation involving attitudes toward condom use and social support of opposition for condom use, that incline the individual to employ condoms; and (3) condom use behavioural skills that make up the repertoire of specific skills which are necessary to enact condom use and perceptions of self-efficacy for doing so (Fisher & Fisher, 1992; Fisher, Fisher, & Shuper, 2014). The IMB model (see Figure 1) outlines a partially mediated network of relationships which emphasizes that the effects of condom use information and condom use motivation are often mediated by, and are activators of, condom use behavioural skills, identifying condom use behavioural skills as having the most direct impact on condom use consistency (Fisher & Fisher, 1992).

The IMB model asserts that condom use information is an essential prerequisite of effective condom use behaviour (Fisher & Fisher, 1992) and to strengthen such behaviour, condom use information must be direcdy relevant to the practice of condom use. For example, information concerning how and where to acquire condoms, how to use them properly, and how to negotiate condom use with a partner are more relevant to the practice of condom use behaviour than information that latex condoms can prevent HIV/AIDS or STIs. While behaviourally relevant information is an important component of the IMB model, it is clear that information by itself cannot generally sustain ongoing behaviours such as condom use (Fisher & Fisher, 1992; Fisher, Fisher, & Shuper, 2014), and that, in many situations, information concerning health behaviours may be at levels that are above threshold for the practice of such behaviours. Consequently, the current study focused on the role of condom use motivation and condom use behavioural skills, and their potential direct and mediated association with condom use behaviour.

According to the IMB model, motivation to use condoms is a function of attitudes toward the personal practice of condom use (personal motivation) and one's perception of social norms (social motivation) or social support or opposition from significant, referent others for this practice. Motivation has been shown to be a key factor in influencing health behaviours, including condom use (Albarracin, Johnson, Fishbein, & Muellerleile, 2001; Brown, 1984; Fishbein & Ajzen, 1975). With males in particular, specific negative beliefs regarding condoms, including the inconvenience of their use (Fisher, 1984; Stewart, DeForge, Hartmann, Kaminski, & Pecukonis, 1991), difficulty in putting them on and keeping them on (Grady, Klepinger, Billy, 8t Tanfer, 1993), concerns about insufficient lubrication, and the belief that loss of erection will result from putting on a condom (Bryan, Schndeldecker & Aiken, 2001), have all been shown to have a negative influence on condom use. Similarly, positive beliefs that condoms are an effective birth control method (Baffi, Schroeder, Redican, & McCluskey, 1989; Gillmore, Morrison, Lowery, & Baker 1994; Tanfer, Grady, Klepinger, & Billy, 1993) have been shown to have a positive influence on condom use among males.

There is less clarity when it comes to the influence of behavioural skills enactment on condom use behaviour. Behavioural skills have been conceptualized as involving objective skills that are necessary to perform safer-sex behaviours, such as the ability to acquire condoms discretely, the ability to properly apply condoms, or the ability to negotiate condom use assertively with a reluctant partner (Fisher & Fisher, 1992), as well as condom use self-efficacy (CUSE), or perceived ability to implement condom use (Fisher & Fisher, 1992; French & Holland, 2013). IMB model-based research has generally involved assessment of CUSE as opposed to implementation of objective condom use behavioural skills in the prediction of condom use behaviour (Fisher, Fisher, & Shuper, 2014; but see Williams et al., 1998).

From the perspective of the IMB model, objective skills that are necessary to perform a health behaviour and self-efficacy concerning their implementation are "inextricably bound," (Fisher & Fisher, 1992, p. 468), and research evidence indicates that measures of self-reported condom us self-efficacy and role-played objective skills may be correlated (Williams et al., 1998). From a conceptual perspective, however, we would assert that CUSE could be quite independent of one's ability to enact condom use. Theoretically, of course, one could have high CUSE and low objective condom use skills, or low CUSE but high objective condom use skills. Assume, for example, that a man is highly informed about the merits of condom use, is very motivated to use condoms, and believes that he can properly apply the condom. Although the IMB model would predict that such a man should use a condom, this man will still fail to use a condom at the appointed time if he objectively lacks the ability to apply one properly. Thus, CUSE and objective condom use skills may have somewhat independent influences on condom use behaviour and may explain in part why several studies have found that a high condom use self-efficacy does not always translate into actual condom use behaviour (Albarracin et al., 2001; Reinecke, Schmidt & Ajzen, 1996). As noted, however, most research applications of the IMB model employ condom use self-efficacy as the sole operationalization of behavioural skills (Fisher & Fisher, 1992; French & Holland, 2013, but see Williams et al., 1998).

In line with this reasoning, French and Holland (2013) have argued that the enactment of condom negotiation (CN) strategies are a superior operationalization of the behavioural skills construct of the IMB model, compared to sole reliance on measures of condom use self-efficacy. According to French and Holland, CN strategies are specific objective behaviours that may be used to obtain condom use (e.g. directly asking one's partner if they have a condom before intercourse). Logically, the decision to focus on the enactment of skills that are necessary to negotiate condom use makes a great deal of sense, as attempts to initiate condom use are frequently met without resistance (Edgar, Freimuth, Hammond, McDonald, & Fink, 1992), and communication about condoms is one of the strongest predictors of actual condom use among heterosexual couples (Bird, Harvey, Beckman, Johnson, 8c The PARTNERS Project, 2001; Oncale & King, 2001; Wingood & DiClemente, 2000). French and Holland (2013) have indeed reported a strong relationship between the use of CN strategies and condom use consistency among men and women. More interestingly, they also found that CN Strategies partially mediated the relationship between CUSE and condom use consistency (French & Holland, 2013).

While French and Holland's (2013) work contributes a potentially important operational refinement of the IMB model, several shortcomings in their study remain. For example, CUSE was used as the sole predictor of CN strategies and condom use consistency in this study, leaving other important components of the IMB model, namely, information and motivation, unexplored. As certain attitudes held among males are known to be associated with condom use and nonuse (Baffi et al., 1989; Gillmore et al., 1994; Tanfer et al., 1993), it seems possible that positive or negative attitudes toward condoms may influence the use of CN strategies, which in turn, may influence condom use consistency. Furthermore, French and Holland's (2013) exploration of CN strategies paints only half the picture. In their study, it was assumed that participants were either using strategies to obtain condom use or not using these strategies; they did not consider the possibility that some participants may actually be employing strategies to specifically avoid condom use. In this regard, research by Tschann, Flores, de Groat, Deardorffi and Wibbelsman (2010) is particularly enlightening. In Tschann et al's (2010) research, motivations to use condoms, as well as both condom-obtaining strategies and condom-avoiding strategies were assessed among men and women. Results showed that 95% of participants who were motivated to use condoms employed a strategy to obtain condom use, while 91% of those who were low in motivation employed a strategy to avoid condom use (Tschann et al., 2010).

The aim of the present study was to examine the associations between condom use motivation, condom use behavioural skills, and condom use consistency and to explore the possibility that condom use behavioural skills--operationalized with a measure of CN approach and avoidance strategies--would mediate the relationship between condom use motivation and condom use consistency. The following predictions were made:

PI: Condom-Obtaining Strategies would be associated with higher condom use consistency and Condom-Avoiding Strategies will be associated with lower condom use consistency among a sample of young adult heterosexual males.

P2a: Positive attitudes toward condoms (personal motivation) would be associated with higher condom use consistency.

P2b: Positive attitudes toward condoms (personal motivation) would be positively associated with condom-obtaining strategies and negatively associated with condom-avoiding strategies. P2c: The relationship between attitudes toward condoms (personal motivation) and condom use consistency would be partially mediated by condom-obtaining and condom-avoiding strategies.

P3a: Positive perceptions of social norms (social motivation) would be associated with higher condom use consistency.

P3b: Positive perceptions of social norms (social motivation) would be positively associated with condom-obtaining strategies and negatively associated with condom-avoiding strategies.

P3c: The relationship between perceptions of social norms (social motivation) and condom use consistency would be partially mediated by condom-obtaining and condom-avoiding strategies.

METHOD

Participants

One hundred 53 heterosexually-active males (having engaged in vaginal intercourse within the last six months) between the ages of 18 and 24 (M = 18.6) were recruited for this study. All participants were enrolled in an introductory psychology participant pool at a large university in Ontario, Canada and were compensated with partial course credit. The university's research ethics board approved this study.

Procedure

Interested participants met individually with a researcher who provided them with a Letter of Information, explained the nature of the study, and answered any questions. Participants were then screened to ensure their eligibility to participate in the study. Ineligible participants (those who were not male, heterosexually active, or between ages of 18-24) were thanked for their interest and dismissed.

Following informed consent, participants were instructed to respond to a survey, in private, on a computer terminal.

Once participants completed the survey, they were debriefed and any questions that they had were answered. References were provided with further information about related research and sexual health, and free condoms were distributed to interested participants.

Materials

The study survey was administered with Qualtrics software. Participants were directed to the survey through a URL, where their responses were anonymously recorded.

The survey began with demographic items assessing age, ethnicity, and relationship status, followed by an item measuring frequency with which condoms were used during vaginal intercourse over the past 6 months ("How often do you and your partner use condoms when you engage in vaginal intercourse?") on a Likert scale ranging from 1 (never) to 6 (every time).

The survey then assessed attitudes toward condoms (personal motivation) using 25 items from the UCLA Multidimensional Condom Attitudes Scale (MCAS) (Helweg-Larsen & Collins, 1994). Participants were asked to respond to each item with a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The MCAS, includes five dimensions along which attitudes toward condoms are measured: Reliability and Effectiveness (5 items; [alpha] = .82; e.g. "Condoms are an effective method of birth control"), Pleasure (5 items; [alpha] = .77; e.g. "The use of condoms can make sex more stimulating"), Identity Stigma (5 items; [alpha] = .65; e.g. "Men who suggest using a condom are really boring"), Embarrassment About Negotiation or Use (5 items; [alpha] = .86; e.g. "It is easy to suggest to my partner that we use a condom"), and Embarrassment About Purchase (5 items; [alpha] = .90; e.g. "I don't think that buying condoms is awkward"). Scores for each dimension are arithmetic means of the relevant items. Higher scores on the Reliability and Effectiveness, and Pleasure dimensions reflect more positive attitudes toward condoms, while higher scores on the Identity Stigma, Embarrassment About Negotiation, and Embarrassment About Purchase reflect more negative attitudes toward condoms. Helweg-Larsen and Collins (1994) have reported findings that are supportive of the validity of this measure in three separate studies for male participants and meta-analysis of psychosocial factors of heterosexual condom use also found that the UCLA-MCAS was a valid measure of attitudes (Sheeran, Abraham, & Orbell, 1999; see also Wang, 2013).

To measure perceptions of social norms (social motivation), the survey included 8 items taken from Grady et al.'s (1993) research, assessing participants' rating of the extent to which various social others think that they should or should not use condoms with a current or future sexual partner. For example, items included "With respect to using a condom during sexual intercourse, my parents think that ..." were rated on a Likert scale that ranged from 1 ("I should use condoms") to 7 ("I should not use condoms") with points 2-6 indicating intermediate judgments between these answers Grady et al., 1993). Summary scores were computed for each participant by calculating the mean response to all the items, so that higher scores indicated more positive perceptions of social norms (a = .77). Studies that have examined measures of perceptions of social norms have previously found them to be predictors of condom use (Kasprzyk, Montano & Fishbein, 1998).

The survey also included 27 items from the Condom Negotiation (CN) Scale (Tschann et al., 2010), which assesses the use of condom-obtaining strategies and condom-avoiding strategies. Participants were asked about the types of negotiation strategies they had used in response to partners' previous attempts to use or to avoid using a condom during sex (e.g. "If my partner suggested using a condom before vaginal intercourse I ..."). Some of the options they were given indicated responses that are used to obtain condom use (e.g. "Told my partner to use a condom because they could get pregnant"), while others options indicated responses that are used to avoid condom use (e.g. "Used sweet talk to avoid condom use"). All items were rated on Likert scales that ranged from 1 ("never") to 4 ("more than a few times"). The CN Scale is organized into groups of items measuring qualitatively different types of condom-obtaining strategies: Risk Information/ Request (7 items; [alpha] = .85; e.g. "Told my partner they needed a condom to be safe"), Direct Verbal/Nonverbal Communication (6 items; [alpha] = .85; e.g. "Offered to put a condom on myself/my partner"), Insist on Condom Use (2 items; [alpha] = .71; e.g. "Insisted to my partner on using a condom"). This scale further organizes condom-avoiding strategies into four groups of items: Emotional Coercion (3 items; [alpha] = .75; e.g. "Got upset with my partner for suggesting condom use"), Ignore Condom Use (2 items; [alpha] = .50; e.g. "Just kept having sex"), Dislike Condoms (5 items; [alpha] = .61; e.g. "Told my partner that sex feels better without a condom"), and Seduction (2 items; [alpha] = .67; e.g. "Tried to get my partner too turned on to think about using a condom") (Tschann et al., 2010). The CN Scale has face-validity and is one of the only published measures that include items for condom-avoiding strategies alongside items for condom-obtaining strategies.

Data Analysis

It was expected that the relationship between condom use motivation and condom use consistency would be mediated by condom use behavioural skills, operationalized with the measure of CN strategies. Rather than view CN strategies as a single mediator, it was expected that specific types of CN strategies could have separate effects on condom use. For this reason, each of the seven CN obtaining and avoidance strategy types, as defined by Tschann et al.'s CN Scale (2010), was treated as a potentially independent mediator. As parameter biases can occur when conducting separate simple mediation analyses for multiple mediators due to omitted variables (Preacher & Hayes, 2008), a multiple mediator analyses was conducted for each condom use Motivational construct assessed with the CN measure employed in this study.

To this end, data were analyzed using Preacher and Hayes's (2008) SPSS macro, INDIRECT, which tests mediation models that include multiple mediators. As the parameters estimated in this procedure are unlikely to be distributed normally, this method uses bootstrapping, a nonparametric resampling procedure, which does not assume normality of the sampling distribution. For each mediator, a sample was drawn with replacement from the observed sample in the present study and the mediating effect was computed. This procedure was repeated 1000 times and the resulting 1000 estimates for each mediating effect were averaged to yield an overall point estimate, and percentile 95% CIs for the indirect effect were constructed. This analysis allows for an examination of the total indirect effect of a particular Motivational construct on condom use consistency through CN strategies as a set of predictors, as well as the indirect effects of this construct through specific types of CN strategies, in the presence of the other CN strategies. The interpretation of the resulting unique effects produced by this method is somewhat analogous to the interpretation of significant coefficients in multiple regression models.

RESULTS

Of the 153 currently sexually active heterosexual males that were recruited for this study, four were excluded due to missing data (N = 149). Seventy-two percent (71.8%; n = 107) of the 149 retained participants were Caucasian, 16.8% (n = 25) were Asian, and 11.4% {n = 17) specified another ethnicity (primarily African, Middle Eastern, and Hispanic decent). Participants' mean age was M = 18.6. Approximately 40 percent (40.3%; n = 60) of participants reported that they always used condoms, 24.8% (n = 37) reported often using condoms, 17.4% (n = 26) reported sometimes using condoms, 9.4% (n = 14) reported infrequently using condoms, and 8.1% (n = 12) reported never using condoms.

Condom Negotiation (CN) Strategies and Condom Use Consistency

The extent to which participants used each CN strategy can be found in Table 1. To test whether CN Strategies predicted condom use consistency (PI), the correlation between each of the seven CN Strategies and condom use consistency was examined (Table 2). Two items from the survey were not included in analysis for reliability (Dislike of Condom Use item 6, Emotional Coercion item 3). Partially consistent with our expectation, the condom-obtaining strategies Risk Information/Request, r = .165, p < .05, and Direct Verbal/Nonverbal Communication, r = .237, p < .01, were positively and significantly correlated with condom use consistency. However, the correlation between Insist on Condom Use and condom use consistency was not significant. Similarly, findings for condom-avoiding strategies were partially consistent with our prediction (see Table 1). Dislike of Condoms, r = -.303, p < .001, and Seduction, r = -.256, p < .01, strategies were negatively and significantly correlated with condom use. However, the associations between Ignore Condom Use and condom use consistency, and between Emotional Coercion and condom use consistency were not significant.

To meet the requirements of a multiple mediator model, only those CN strategies that significantly predicted condom use consistency were included in tests of possible mediation. Specifically, the condom-obtaining strategies: (1) Risk Information/Request, and (2) Direct Verbal/Nonverbal Communication; and the Condom-Avoiding Strategies: (1) Dislike, and (2) Seduction were retained for further analyses below.

Attitudes Towards Condoms and Condom Use Consistency

To test whether attitudes (personal motivation) predict condom use consistency (P2a) the correlations between each dimension of the MCAS and condom use consistency were examined (Table 2). Of the five attitude dimensions, Pleasure was positively correlated with condom use consistency, r = .418, p < .001, in accordance with the prediction that more positive attitudes toward condoms are associated with higher condom use consistency. Further, and contrary to this prediction, Embarrassment about Purchase was also positively correlated with condom use consistency, r = .284, p < .001, such that a more negative attitude toward condoms as reflected in embarrassment to purchase was associated with higher condom use consistency in this sample. No other significant correlations were found.

As only those variables that significantly predict condom use consistency should be included in the tests of multiple mediation, the Pleasure and Embarrassment about

Purchase dimensions of attitudes toward condoms were next correlated with the CN strategies that were found to be associated with condom use consistency (P2b; see Table 3). A significant, positive correlation was found between the Pleasure dimension of the attitudes toward condoms and the Risk Information/Request CN Strategy, r = .294, p < .001, however, no correlation was found between the Pleasure dimension and the Direct Verbal/Nonverbal Communication strategy. Further, significant negative correlations were found between the Pleasure dimension and both the Dislike, r = -.236, p < .01, and Seduction, r = -.187, p < .05, CN strategies. These findings suggested that the CN strategies Risk Information/ Request, Dislike, and Seduction could act as mediators of the relationship between the Pleasure dimension of attitudes toward condoms and condom use consistency, and were therefore used in the multiple mediator analysis discussed below.

As no significant correlations were found between Embarrassment about Purchase and any of the 4 CN strategies, there was no reason to suggest that these strategies could be possible mediators of the unanticipated positive relationship between Embarrassment about Purchase and condom use consistency, and therefore no multiple mediator analyses were performed on these variables.

Testing the Mediators. Preacher and Hayes's (2008) SPSS macro, INDIRECT, was used to test whether Risk Information/Request, Dislike, and Seduction CN strategies mediated the relationship between the Pleasure dimension of attitudes toward condoms and condom use consistency (P2c). This analysis revealed a significant total indirect effect of the Pleasure dimension of attitudes toward condoms on condom use consistency through these three CN strategies, [SIGMA]ab = .1540, 95% CI = 0.0289-0.2822, indicating that, as a set of three mediating variables, the CN strategies Risk Information/ Request, Dislike, and Seduction mediated the relationship between Pleasure and condom use consistency. However, as can be seen in Figure 2, no single CN Strategy had a significant unique indirect effect on the association between the Pleasure dimension of attitudes toward condoms and condom use consistency. Further, this analysis found that a significant direct effect of the Pleasure dimension on condom use consistency (c' = .3615, p < .01) remains after controlling for these three mediators, which in the context of a significant total indirect effect, indicates that the relationship was partially rather than fully mediated by these CN strategies overall.

Perceptions of Social Norms

To test whether perceptions of social norms (social motivation) predicted condom use consistency (P3a), the correlation between these two variables was examined (Table 2). As, expected, perceptions of social norms had a significant positive correlation with condom use consistency, r = .547, p < .001.

To test whether perceptions of social norms predicted CN strategies (P3b), the respective correlations between perceptions of social norms and the four CN strategies that predicted condom use consistency were determined (Table 4). Significant positive correlations were found between perceptions of social norms and Direct Verbal/Nonverbal Communication, r = .217, p < .01, but not between perceptions of social norms and Risk Information/Request. Similarly, significant negative correlations were found between perceptions of social norms and both the Dislike, r = -.319, p < .001, and Seduction, r = -.228, p < .01, CN strategies. These findings suggest that the CN Strategies Direct Verbal/Nonverbal Communication, Dislike, and Seduction could act as possible mediators of the relationship between Perceptions of Social Norms and condom use consistency, and were therefore used in a multiple mediator analysis that follows.

Testing the Mediators. Once again, Preacher and Hayes's (2008) SPSS macro, INDIRECT, was used to test whether the three CN Strategies Risk Information/Request,

Dislike, and Seduction mediated the relationship between Perceptions of Social Norms and condom use consistency (P3c). This analysis indicated a significant total indirect effect through these CN Strategies, [SIGMA]ab = .2193, 95% CI = 0.37760.0979, suggesting that, as a set of three mediating variables, the CN Strategies Direct Verbal/Nonverbal Communication, Dislike, and Seduction mediated the relationship between Perceptions of

Social Norms and condom use consistency. As can be seen in Figure 3, there was also a significant unique indirect effect of perceptions of social norms on condom use consistency through Direct Verbal/Nonverbal Communication, ab = .0782, 95% CI = 0.1996-0.0005. Finally, there was a significant direct effect of perceptions of social norms on condom use consistency, c' = .7715, p < .001, after controlling for the mediating variables, which indicates that the relationship was partially mediated by these CN Strategies.

DISCUSSION

The present study investigated the relationship between the IMB model constructs of condom use Motivation (attitudes toward condoms, perceptions of social norms) condom use behavioural skill implementation (CN strategies), and their direct and mediated influence on condom use consistency in a sample of young adult, heterosexually-active males. Findings generally supported the hypotheses and predictions, in that attitudes, social norms, and CN strategies were directly associated with condom use consistency, and CN strategy implementation partially mediated the relationships between motivation to use condoms and condom use consistency. This research both replicates previously established relationships between CN strategies and self-reported condom use (French & Holland, 2013; Tschann et al., 2010), as well as extends the argument that CN strategies are an appropriate operationalization of behavioural skills construct of the IMB model (French & Holland, 2013). These findings also support the utility of sharpening the operationalization of condom use behavioural skills to include the assessment of the enactment of skills that are used to facilitate or avoid the behavioural outcome at focus.

As predicted, young adult heterosexually active males in the current sample who used strategies such as verbally suggesting the importance of using a condom to protect against STIs or directly communicating their desire to use a condom reported higher condom use consistency than those who did not employ these strategies as often. It was also predicted and confirmed that those who reported using strategies to avoid condom usage would report lower condom use consistency. These findings are consistent with French and Holland's (2013) and Tschann et al.'s (2010) previous results, and reinforce research that shows that communication about condoms is an important predictor of actual condom use among heterosexual couples (Bird et al., 2001; Oncale & King, 2001; Wingood & DiClemente, 2000; Sheeran et al., 1999).

The results of this study also show that CN strategies can be a conceptually and methodologically appropriate operationalization of the Behavioural Skills construct in the IMB Model (French & Holland, 2013), as they assess the conceptualized bridge between motivation to use condoms and condom use consistency in the manner that is described by the IMB Model. Of the five dimensions of attitudes toward condoms, Pleasure was positively associated with higher condom use consistency, as predicted. Pleasure was also positively associated with the condom-obtaining strategy Risk Information/ Request, and negatively associated with the condom-avoiding strategies Dislike of Condom Use and Seduction. Furthermore, these CN strategies, as a set of three variables, were partial mediators of the relationship between Pleasure and condom use consistency. Attitudes toward the pleasure of condom use not only had a direct effect on actual condom use, but also an indirect effect on condom use through these 3 CN strategies. Conversely, this also suggests that having a negative attitude toward the pleasure of condom use is associated with greater use of condom-avoiding strategies, and lower use of condom-obtaining strategies, which in turn, may deter the use of condoms.

With respect to perceptions of social norms, findings were quite consistent with the hypotheses that positive perceptions of social norms would be associated both with higher condom use consistency and with condom-obtaining strategies, while negative perceptions of social norms would be associated with lower condom use consistency and condom-avoiding strategies. Perceptions of social norms were associated with 3 CN strategies that in turn predicted condom use consistency. Specifically, perceiving others to believe that one should use condoms was related with using more of Direct Verbal/Nonverbal Communication strategy and using less of the strategies Dislike of Condom Use and Seduction. These CN strategies (i.e., Direct Verbal/Nonverbal Communication, Dislike of Condom Use, and Seduction) as a set of 3 mediating variables were partial mediators of the relationship between perceptions of social norms and condom use consistency. This suggests that having the belief that important people in one's life have favourable attitudes toward condom use is associated with less use of strategies to convince partners to not use condoms and greater use of strategies such as directly asking your partner to use a condom, and this pattern of behaviour was associated with higher condom use.

It is important to note that, while the relationship between the Pleasure dimension of attitudes and condom use consistency, and the relationship between perceptions of social norms and condom use consistency were both partially mediated by the same condom-avoiding strategies (Dislike of Condom Use and Seduction), they were mediated by different condom-approach strategies (Risk Information/Request and Direct Verbal/Nonverbal Communication). The implication of this finding is not readily apparent, though the common paths through Dislike of Condom Use and Seduction underline the importance of condom-avoiding strategies, an aspect of condom negotiation previously overlooked by French and Holland (2013).

In light of the current findings as well as the theoretical conceptualizations of behavioural skills as an enactment of specific skills that are necessary to perform the target behaviour at focus, future applications of the IMB model in the domain of safer-sex behaviours may benefit from the application of similar operationalizations of behavioural skills rather than relying solely on measures of self-efficacy. Behavioural skills operationalizations also need not be limited to the use of condom negotiation strategies. The knowledge and enactment of other skills may also contribute to condom use consistency (e.g. simple unilateral use of a condom without discussion; correct application of condom to avoid breakage, adequate use of artificial lubricant to promote pleasurable condom use, etc.), and alternative behavioural operationalizations should be considered in future research.

The results of this study also emphasize the importance of encouraging researchers to examine both approach and avoidance motivation, rather than simply high/low motivation alone. Our results suggest that, while high approach Motivation may lead to the enactment of facilitating behavioural skills, and subsequently, the performance of the specific behaviour, high avoidance motivation can lead to the enactment of behavioural skills aimed at avoidance of condom use. The use of such distinctions in future research would better reflect the complex and, at times, ambivalent attitudes that people have toward safer-sexual practices. It could also be useful in identifying maladaptive behavioural skills that may be amenable to change through safer-sex interventions and increase the predictive utility of the IMB model.

Limitations

Several limitations apply to this study. Clearly, the results cannot be generalized to all males as only heterosexual males from one university were examined. Although understanding the CN strategies used by men in same-sex encounters is also important, such strategies could differ substantially from those used in heterosexual encounters, and the present study focused solely on condom use in heterosexual intercourse. The present study was also unable to recruit a sufficient sample size to explore the role of neither sexual encounters that occur in casual vs. committed relationships nor partner's use of birth control on the associations under investigation. It seems likely that Motivations to use condoms as well as the use of specific condom negotiation strategies may differ between exclusive and casual partners, and between couples who use and do not use other methods of birth control. Moreover, the current study examined what is fundamentally a dyadic outcome (condom use) at the individual level of analysis and, ultimately, a study of this phenomenon at the dyadic level is needed.

It is notable that this study included several measures of the key constructs of interest that did not perform as predicted by the hypotheses. Only one of five dimensions of MCAS measure of attitudes toward condoms correlated with condom use consistency in the hypothesized direction, and some dimensions of CN strategies also failed to correlate with condom use consistency. Further work would need to be conducted to determine if the failure of these measures reflects idiosyncratic characteristics of the current sample, instrument shortcomings, or recent changes in the predictive utility of these measures. Such findings may also indicate that other relevant variables, such as individual personality traits, may be contributing to the associations that were examined. The unexpected relationship between condom use consistency and the attitude Embarrassment about Purchase, for example, may have been partially driven by individual-differences in neuroticism, which may be positively related to both an individual's wariness of STIs as well as wariness of social evaluation that can occur when condoms are purchased. It may also be beneficial to explore other possible relevant variables and their interactions with the IMB model. Finally, while mediational analysis assumes causal direction between the variables studied, evidence of mediation cannot be taken as evidence of causality. It may be the case, for example, that those participants who rarely use condom-obtaining strategies, and frequently use condom-avoiding strategies infer from these experiences that they do not like condoms because they are not pleasurable. Causal evidence must be derived through experimental manipulation of the presumed causal variables.

Future Directions

While this study furthers the understanding of Condom Negotiation Strategies by examining the use of such strategies within the context of an important theoretical tradition, the dynamics that are involved when negotiations take place within intimate relationships are difficult to capture using quantitative methods alone. For this reason, we suggest that qualitative research may still provide useful information for the development of interventions that are designed to foster direct communicating one's desire to use condoms with a partner. Moreover, including both members of heterosexual dyads in such research could be extremely beneficial for developing interventions that teach men and women effective ways of countering the condom-avoiding strategies of their partners. Building on such research, role-play techniques involving men and women simulating negotiation with an unwilling partner may be a particularly effective exercise to incorporate in future safer-sex interventions.

Inconsistent condom use remains an issue that needs to be addressed. In this study alone, only 40% of males reported that they always used condoms. Overall, the results of this study stress the importance of promoting consistent condom use in young heterosexual males through interventions that mitigate behaviours that specifically put themselves, and others, at a high sexual risk. Further theoretical and methodological refinements, along with an improved understanding of the complexities involved with safer-sex negotiations are important next steps for improving condom use consistency, and the researchers in this study encourage others to continue exploring these issues.

doi: 10.3138/cjhs.242-A1

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Michelle Camilleri, (1) Taylor Kohut, (1) and William Fisher (1,2)

(1) Department of Psychology, Western University, London, ON

(2) Department of Obstetrics and Gynaecology, Western University, London, ON

Correspondence concerning this article should be addressed to Michelle Camilleri, Department of Psychology, Social Science Center, Rm. 7430, Western University, London, Ontario, Canada, N6A 5C2, Email: mcamillel024@gmail.com

Table 1. Condom Negotiation Strategy Implementation by
Participants *

                                          M **    SD

Condom Obtaining Strategies
  Direct Verbal/Nonverbal Communication   2.89   0.656
  (6 items)
  Insist on Condom Use (2 items)          2.54   0.913
  Risk Information/Request (7 items)      2.34   0.612
Condom Avoiding Strategies
  Seduction (2 items)                     1.4    0.727
  Dislike Condom Use (5 items)            1.85   0.789
  Ignore Condom Use (2 items)             1.27   0.611
  Emotional Coercion (2 items)            1.15   0.45

* n = 149

** mean rating of items on a scale from 1 (never used) to 4
(always used)

Table 2. Correlations Between Constructs and Condom Use

Constructs                                    r        P

Condom-Obtaining Strategies
  Risk Information/Request *                 0.165   <.05
  Direct Verbal/Nonverbal Communication *    0.237   <.01
  Insist on Condom Use                       0.056   n.s.
Condom-Avoiding Strategies
  Emotional Coercion                         0.037   n.s.
  Ignore Condom Use                         -0.056   n.s.
  Dislike Condom Use *                      -0.313   <.001
  Seduction *                               -0.256   <.01
Attitudes Towards Condoms
  Reliability and Effectiveness              0.099   n.s.
  Pleasure *                                 0.418   <.001
  Identity Stigma                           -0.11    n.s.
  Embarrassment about Negotiation and Use   -0.017    n.s
  Embarrassment about Purchase *             0.284   <.001
  Perceptions of Social Norms *              0.547   <.001

* employed in tests of mediation

Table 3. Correlations between CN Strategies and Attitudes
Towards Condoms

                                    Pleasure       Embarrassment
                                                  About Purchase

                                 r        p        r        p

Condom Obtaining Strategies
  Risk Information Request *   0.294    <.001    0.049     n.s.
  Direct Verbal/Nonverbal
    Communication               0.15     n.s.    0.063     n.s.
Condom Avoiding Strategies
  Dislike Condom Use *         -0.466   <.001    -0.052    n.s.
  Seduction *                   -0.3    <.001    0.078     n.s.

* used in tests of mediation

Table 4. Correlations between CN Strategies and Perceptions
of Social Norms

                                              r        P

Condom Obtaining Strategies
  Risk Information/Request                  0.134    n.s.
  Direct Verbal/Nonverbal Communication *   0.217    <.01
Condom Avoiding Strategies
  Dislike of Condoms *                      -0.319   <.001
  Seduction *                               -0.228   <.01

* used in tests of mediation
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Title Annotation:Research Presented at the 41st Annual Meeting of the Canadian Sex Research Forum, Kingston, Ontario, October 23-25, 2014
Author:Camilleri, Michelle; Kohut, Taylor; Fisher, William
Publication:The Canadian Journal of Human Sexuality
Article Type:Report
Date:Aug 1, 2015
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