Determinants of condom use among intravenous drug users.

OBJECTIVE: To examine the factors associated with condom use among a cohort of sexually active intravenous drug users (IVDU). DESIGN: Data were collected via personal interview at the fourth-month assessment point of a longitudinal study monitoring HIV infection and risk behaviors among IVDU. SETTING: A community-based methadone clinic. PARTICIPANTS: A total of 158 sexually active heterosexual male and female IVDU, including both methadone patients and out-of-treatment individuals with a history of opiate abuse. MAIN OUTCOME MEASURES: We describe a new approach to identify the determinants of condom use. Previous studies have described subjects as either 'condom users' or 'condom non-users', using an individual's overall behavior as the unit of analysis. By analyzing condom use during the most recent sexual encounter, we avoided the problem of interpreting inconsistent condom use. Data were analyzed using forward stepwise logistic regression. RESULTS: Thirty-four per cent of the heterosexual subjects (n = 160) reported using a condom during their last sexual encounter. Being HIV-positive and having either a causal or commercial partner were each associated with increased probability of using a condom (odds ratio, 10.6, 4.4 and 12.1, respectively). No interactions with sex were found. CONCLUSIONS: Our results suggest that knowing that one is HIV-positive is an important determinant of condom use; HIV testing may therefore increase the use of condoms. In addition, interventions to change sexual behaviors may need to focus on the type of sexual partner.

PIP: This study was conducted to assess the factors associated with condom use among a cohort of sexually active intravenous drug users (IVDU) sampled from a community-based methadone clinic in Philadelphia, Pennsylvania. Personal interview data were taken from 158 sexually active heterosexual male and female IVDUs at the 4-month assessment point of a longitudinal study monitoring HIV infection and risk behaviors among them. The patient sample included methadone patients and out-of-treatment individuals with a history of opiate abuse. to avoid the problem of interpreting inconsistent condom use, investigators queried condom use among participants only at their most recent sexual encounter. 34% reported using a condom at last sexual encounter. Being HIV-seropositive and having either a casual or commercial partner were each associated with increased probability of using a condom. Knowing that one is HIV-seropositive is therefore an important determinant of condom use which suggests that HIV testing may increase condom use. Interventions to change sexual behavior may also need to focus upon the type of sexual partner.

Psychological distress, drug and alcohol use as correlates of condom use in HIV-serodiscordant heterosexual couples.

OBJECTIVE: To investigate the relationship between psychological distress, alcohol, drug and condom use in HIV-serodiscordant heterosexual couples. METHODS: Structured interviews were conducted to collect demographic information, detailed data on psychological distress, drug and alcohol use and sexual behavior. RESULTS: Analyses were based on 106 pairs of sexually active discordant couples. Significant differences among heterosexual condom users and non-users varied according to gender and HIV serostatus. Affect domains of interpersonal sensitivity and hostility were significant, as were the variables of regular drug or alcohol use and combining sex with drugs or alcohol. Employment was strongly associated with condom use in HIV-negative women whose regular sexual partners were HIV-positive men. CONCLUSION: The risk of vaginal sex without condoms in HIV-serodiscordant heterosexual couples may be reduced by specific psychological counseling and attention to drug and alcohol use as risk factors. Further research on the effect of employment of HIV-negative women is required.

PIP: The authors investigated the relationship of psychological distress and drug and alcohol use to reported condom use in 106 sexually active HIV-serodiscordant heterosexual couples. Significant differences were found among heterosexual condom users and non-users which varied according to gender and HIV serostatus. Affect domains of interpersonal sensitivity and hostility were significant, as were the variables of regular drug or alcohol use and combining sex with drugs or alcohol. Further, employment was strongly associated with condom use HIV-negative women whose regular sex partners were HIV-positive men. The authors therefore conclude that the risk of vaginal sex without condoms in HIV-serodiscordant heterosexual couples may be reduced by specific psychological counseling and attention to drug and alcohol use as risk factors. Further research is, however, called for on the effect of employment on HIV-negative women.

Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana.

OBJECTIVE: To assess the short- and long-term impact of a 6-month pilot intervention program on condom use among prostitutes in Accra, Ghana. DESIGN: The 4-year prospective study follows-up cohorts enrolled in the intervention in 1987 and 1988, comparing condom use in 1991 with that among a comparison group not enrolled in the intervention. SETTING: The community-based intervention was initiated in Accra, Ghana in 1987. PARTICIPANTS: Self-identified female prostitutes who volunteered participation. INTERVENTION: The educational intervention used local health workers to train and support selected prostitutes to be health educators and condom distributors to their peers. OUTCOME MEASURES: Self-reported condom use with clients. RESULTS: Reported condom use increased dramatically between 1987 and 1988 during the first 6 months of the intervention. In 1991, after 3 years of program relapse, 107 (43%) of the 248 women who had enrolled in 1987 or 1988 were still in prostitution and located for interview. Their level of condom use in 1991 was higher than pre-enrollment but similar to use among prostitutes never enrolled. Sixty-four per cent of those followed-up reported always using condoms with clients in 1991. These 'always users' were more likely to have maintained informal contact with project staff, know that HIV can be transmitted by healthy clients, and report that clients frequently initiate condom use. CONCLUSIONS: Findings support the development of long-range educational strategies that recognize the career longevity of prostitutes, available channels for informal program diffusion, individual changes in condom use over time, and the role of clients in condom negotiation.

PIP: Findings of a prospective study of condom use among prostitutes in Ghana provided support for acquired immunodeficiency syndrome (AIDS) prevention educational interventions with this high risk populating and evidence of informal program diffusion. 382 self-identified prostitutes voluntarily entered the study in three waves (a pilot group of 72 recruited in June 1987, another 176 prostitutes who were admitted at their request in January 1988, and 106 who entered in September 1991). From this group, selected prostitutes were trained to educate their peers about AIDS risk factors through meetings and printed materials and to distribute free condoms. Self-reported condom use in 1991 was correlated with contact with these peer educators. During the 6-month pilot study, the proportion of prostitutes who always used condom increased from 6% at baseline to 71%. 48% of prostitutes entering the study in January 1988 were already always using condoms, suggesting a diffusion effect. In 1991, consistent condom use was reported by 56% of women from the pilot group available for follow-up and 66% of those interviewed from the 1988 wave; however, these rates were not appreciably higher than the 55% rate reported at baseline by the 1991 wave of recruits. (This convergence is assumed to reflect both suspension of the educational program in 1988-91 and increased social acceptance of condom use given the spread of AIDS.) Of the 107 women from the pilot and expanded groups available for interview in 1991, 24% identified peer outreach workers as their source of AIDS information. Women who had contact with staff were 2.63 times more likely than non-exposed women to report consistent condom use. The interaction model revealed that women who maintained contact with project staff were 3.17 times more likely to be consistent users, those who knew that healthy appearing men could transmit AIDS were 2.68 times more likely to fall into this use category, and prostitutes who had clients who initiated condom use more than half the time were 4.49 times more likely than other women to be consistent users, even when staff contact and AIDS knowledge were controlled. Given the career longevity of some prostitutes, sustained program activity is encouraged.

Predicting contraceptive behavior from attitudes: a comparison of within- versus across-subjects procedures.

Within- versus across-subjects procedures for predicting behavior from attitudes were contrasted. Each procedure requires a comparison among attitudes in order to generate a prediction; the comparison is either among the same attitudes held by different people (across subjects) or among different attitudes held by the same person (within subject). It was hypothesized that the within-subject model provides a more adequate explanation of behavior from attitudinal constructs and, hence, more accurate prediction of behavior from attitudes than does the across-subjects model. To test this view, a sample of 349 married couples was administered a questionnaire containing measures of three attitudinal components--affect, cognition, and conation--toward each of four contraceptive methods--oral contraceptives, IUD, diaphragm, and condoms. Contraceptive behavior was assessed 1 year later. In support of the hypothesis, the within-subject predictions bore a significantly stronger relation to the behavioral criteria than did the across-subjects predictions. This effect was consistent for each of the three components of attitude, for the prediction of behavior and behavioral intention, for male and female respondents, and for a variety of contraceptive behaviors. In addition, both the within- and the across-subjects analyses demonstrated a clear rank ordering in the predictive validity of the three attitudinal components: Conation was a better predictor of behavior than was affect, which, in turn, was better than cognition.

PIP: Within- vs. across-subjects procedures for predicting behavior from attitudes were contrasted. Each procedure requires a comparison among attitudes in order to generate a prediction; the comparison is either among the same attitudes held by different people (across subjects) or among different attitudes held by the same person (within subject). It was hypothesized that the within-subject model provides a more adequate explanation of behavior from attitudinal constructs and, hence, more accurate prediction of behavior from attitudes than does the across-subjects model. To test this view, a sample of 349 married couples was administered a questionnarie containing measures of 3 attitudinal components-affect, cognition, and conation--toward each of 4 contraceptive methods--oral contraceptives, IUD, diaphragm, and condom. Contraceptive behavior was assessed 1 year later. In support of the hypothesis, the within-subject predictions bore a significantly stronger relation to the behavioral criteria than did the across-subjects predictions. This effect was consistent for each of the 3 components of attitude, for the prediction of behavior, and behavioral intention, for male and female respondents, and for a variety of contraceptive behaviors. In addition, both the within- and across-subjects analyses demonstrated a clear rank ordering in the predictive validity of the 3 attitudinal components; conation was a better predictor of behavior than was affect, which, in turn, was better than cognition.

The relationship of substance use with sex to the use of condoms among young adults in two urban areas of Scotland.

The relationship of the use of alcohol or drugs in conjunction with sexual activity and the use of condoms and other contraceptives was examined among 1378 respondents in a household survey of two urban areas of Scotland. In bivariate analyses, respondents who reported having had sex under the influence of alcohol or drugs were no less likely than respondents with no such experience to report consistent use of condoms, and having had sex under the influence of substances was positively related to lifetime condom use. Multivariate analyses that included gender and urban area as predictors yielded similar findings. The results suggest that individuals who combine sex with alcohol or drugs are not necessarily more likely to engage in riskier sex.

PIP: A survey conducted among young adults in Scotland failed to provide confirmation for the assumption that sexual intercourse under the influence of drugs or alcohol is associated with a greater likelihood of failure to use condoms. Interviews were conducted in 1990 with 1378 men and women ages 16-30 years located through a random sample of households in Edinburgh's Muirhouse area and Glasgow's Easterhouse area--both economically depressed areas with a high incidence of social problems. 12% of respondents in both areas reported having had sex while using drugs, and 85% of Muirhouse residents and 81% of Easterhouse residents had sex while drinking alcohol. Although 62% of sexually active men and women were not using condoms with their current partner, 66% of men and 48% had used condoms at some point. Experience of sexual intercourse with alcohol or drugs was not significantly associated with reported condom use with current partner or condom use in the past year; however, subjects who had had sex under the influence of one of these substances reported more lifetime condom use than those who had not. Multivariate analysis, controlled for gender and area, produced the same finding.

Health belief and self-efficacy models: their utility in explaining college student condom use.

This investigation tested the ability of the Health Belief Model (HBM), dimensions of self-efficacy, various behavioral variables (i.e., number of sex partners in the past 12 months, frequency of drunkenness during sexual intercourse, and number of diagnosed sexually transmitted diseases), and demographic measures to distinguish between three condom user groups (i.e., nonusers, sporadic users, and consistent users). The usable sample consisted of 366 college students, ages 18 to 24. The study operationalized the following HBM components: perceived susceptibility, perceived benefits, and perceived barriers. The multidimensional Condom Use Self-Efficacy Scale (CUSES) was also used in this investigation. Results from a discriminant analysis indicated that sporadic users were best distinguished from both consistent and nonusers by number of sex partners in the past year, frequency of drunkenness during sexual intercourse, perceived susceptibility to HIV/AIDS and other STDs, and a self-efficacy factor labeled Assertive. The sporadic users had significantly more sex partners, were drunk more often when engaging in sexual intercourse, perceived themselves as more susceptible to HIV/AIDS and other STDs, and were less confident in their ability to discuss and insist on condom use with a partner. It was also discovered that each condom user group was best defined by different subsets of discriminating variables. Implications of these findings for campus-based prevention programs and future research are discussed.

PIP: The ability of the health belief model and self-efficacy concept to discriminate among three condom use groups--nonusers, sporadic users, and consistent users--was assessed in a sample of 366 sexually active college students 18-24 years of age. The mean number of sex partners in the 12 months preceding the survey was 2.2. The students could be classified as follows: nonusers, 70 (19%); sporadic users (defined as having more total sex partners in the preceding year than partners with whom a condom was always used), 157 (43%); and consistent users, 107 (29%), Principal components factor analyses of the health belief model constructs indicated that perceived benefits, perceived barriers, and perceived susceptibility are multidimensional. In univariate analyses, statistically significant differences across condom use groups were found for the following measures: perceived susceptibility of partner, perceived susceptibility of self, assertiveness, partner disapproval of condoms, intoxicants, number of sex partners, and inebriation during sexual intercourse. When a multiple discriminant function analysis was conducted with these variables, they failed to differentiate significantly between nonusers and consistent users but did distinguish sporadic users. Sporadic condom users perceived themselves and their partners as at highest risk of acquired immunodeficiency syndrome and other sexually transmitted diseases, had the largest number of sex partners in the past year, reported more inebriation during sexual intercourse, and were less confident in their ability to negotiate condom use with a partner than their counterparts in the other two use groups. Out of the variable subsets, the health belief model was best at identifying sporadic users, behavioral variables were most pertinent for nonusers, and the self-efficacy measure was most relevant in the case of consistent use.

Factors related to condom use among four groups of female sex workers in Bali, Indonesia.

This article tests a behavioral model of condom use for four groups of female commercial sex workers. Data were drawn from a study of 614 female sex workers conducted in Bali, Indonesia. AIDS knowledge, risk behaviors, and factors related to condom use varied substantially among the four groups of women and reflect the social context of their work. Interventions for each group need to reflect these differences. Important factors to consider include the level of AIDS and STD knowledge in their environment, the characteristics of the clients served, and the degree of supervision that they receive.

PIP: The efficacy of a behavioral model of condom use was evaluated in 4 groups of commercial sex workers in Bali, Indonesia, in 1992-93: 1) women working in low-price complexes supervised by a pimp in the Denpasar area (n = 407); 2) mid-price women who rent rooms within family complexes or bungalows (n = 77); 3) women working at high-price houses in and around Denpasar (n = 50); and 4) independent workers at the Kuta tourist resort (n = 80). Mean knowledge scores among the 614 prostitutes ranged from 8.3 to 11.6 out of a possible 19. Common misconceptions were that an HIV-infected person could appear healthy and that AIDS can be cured with medicine or injections. The mean number of clients in the week preceding the interview was 15.8 at low-price brothels, 10.5 in the bungalow group, 4.7 at high-price houses, and 3.2 at the resort. Condom use with clients was 19%, 68%, 71%, and 90%, respectively. The effects of independent variables on condom use were evaluated through multiple regression analysis. Among women in the low-price and bungalow groups, condom use was significantly associated with beliefs about condoms' ability to prevent sexually transmitted disease (STD) and pregnancy, the belief condoms enhance sexual pleasure, perceived susceptibility to STDs (but not HIV), self-efficacy, number of clients in the past week, and pregnancy history. For women in the resort area, condom use was related to beliefs about the ability of condoms to protect against STDs and AIDS, perceived susceptibility to HIV infection, and experience with an STD. Finally, among high-price prostitutes, condom use was associated with the belief condoms prevent AIDS and increase pleasure, self-efficacy, and pregnancy experience. These findings indicate that levels of AIDS knowledge and the extent of risky behaviors are related to the particular social context in which sex work is practiced.

Prevalence and determinants of current contraceptive method use in a palm oil company in Cameroon.

The principal reasons given by African women for not using contraception include their lack of economic power and control over their choice of partner. An epidemiologic descriptive survey of a cross-section of the female personnel of a Cameroonian palm oil company (SOCAPALM) was carried out in August 1995, to evaluate the various determinants and level of use of various family planning methods in a well defined population of women in employment. An exhaustive list of all the households in the five villages of SOCAPALM was compiled and all women between 15 and 49 years of age who had lived on the palm oil plantation for at least a year were interviewed. The adjusted odds ratios showed that use of modern contraceptive methods was significantly associated with the woman having received secondary education, having more than three children, being the head of the household and, in cases where there was a man regularly present in the household, his approval of family planning. Recently receiving information (during the last month) about family planning was not identified by multivariate analysis as a significant factor affecting the decision to use modern or traditional contraception. The same factors were found to be associated with the use of traditional methods of contraception, but having had an illegal abortion was also associated with the use of such methods. Thus, the level of knowledge about family planning and the prevalence of contraceptive use was significantly higher for women living in industrial environments (such as SOCAPALM), than in the overall population of women in Cameroon. The economic power of the woman, the presence of a strong social reproductive health network, and the positive attitude of men and community leaders were the most important factors affecting the family planning decision of the women.

PIP: The prevalence and determinants of contraceptive usage were investigated in a cross-sectional study of female workers at a palm oil company in Kienke, Cameroon. All 385 women 15-49 years of age (mean age, 29.8 years) who had lived on the palm oil plantation for at least a year and were at risk of pregnancy were interviewed. 28% of respondents reported ever-use of modern contraception and 21% had used traditional methods; use rates at the time of interview were 10% and 16%, respectively. Multivariate analysis indicated use of modern contraceptive methods was significantly associated with a secondary education or higher, having more than three children, being the head of the household, and (if a man was present in the household) partner approval of family planning. These same factors, with the addition of a history of illegal abortion, were significant determinants of use of traditional methods. Receipt of family planning information in the previous month was not a significant determinant of use of either modern or traditional contraception. The higher prevalence of contraceptive use among women living in this industrial environment relative to women in other parts of Cameroon or in west and central Africa suggests the salience of economic power to women's contraceptive use patterns.

A hierarchical model of contraceptive use in urban and rural Bangladesh.

In this paper, a model is developed for examining the hierarchical effects of contraceptive use and its determinants in urban-rural Bangladesh by employing data from the 1989 Bangladesh Fertility Survey (BFS). In the survey, a total of 11,905 ever-married women of reproductive age were interviewed in urban and rural situations. An investigation has been carried out in this study using a set of demographic, socio-economic, cultural, and decision-making variables. A number of new findings emerge from this study. It has been found that contraceptive use has no significant variation between regions; however, a statistically significant variation exists between the blocks (census tracts) of Bangladesh. Findings also indicate that mother's parity, her education, family planning decisions, and female independence score are found to have a significant positive effect on the use of contraception in urban and rural Bangladesh, whereas child death has a significant negative influence. Religion and work experience of women are found to have little effect on contraceptive use. The findings of the study indicate priority points for policy purposes.

PIP: In this paper, a model is developed for examining the hierarchical effects of contraceptive use and its determinants in urban-rural Bangladesh by employing data from the 1989 Bangladesh Fertility Survey (BFS). In the survey, a total of 11,905 ever-married women of reproductive age were interviewed in urban and rural situations. An investigation has been carried out in this study using a set of demographic, socioeconomic, cultural, and decision-making variables. A number of new findings emerge from this study. It has been found that contraceptive use has no significant variation between regions; however, a statistically significant variation exists between the blocks (census tracts) of Bangladesh. Findings also indicate that maternal parity, maternal education, family planning decisions, and female independence score are found to have a significant positive effect on the use of contraception in urban and rural Bangladesh, whereas child death has a significant negative influence. Religion and work experience of women are found to have little effect on contraceptive use. The findings of the study indicate priority points for policy purposes.

Factors affecting continuation rates of DMPA.

A prospective study was conducted with 430 new depot medroxyprogesterone acetate (DMPA) acceptors to estimate continuation rates and investigate factors associated with length of use. Data were collected on services received and sociodemographic characteristics of participants. Women were enrolled over the course of 1 year and were followed for up to 13 months. Failure to return to the same clinic within 104 days of the last injection was the outcome of interest. The 3-, 6-, 9-, and 12-month continuation rates were 68%, 67%, 55%, and 51%, respectively. In the bivariate analysis, women who were told to return to the clinic for side effects were more likely to continue using DMPA than those who were not given such advice (p <0.05). Likewise, women who received information on DMPA efficacy, side effects, and amenorrhea were more likely to continue using DMPA compared to those who did not receive such information (p <0.05). A proportional hazards regression model was constructed to estimate the simultaneous effect of various factors on length of use. In results consistent with the bivariate analysis, women who were told to return to the clinic were 2.7 times more likely to continue using DMPA compared to women who did not receive that advice. Likewise, women who were told about the possibility of amenorrhea were 2.5 times more likely to continue using DMPA compared to those who did not receive that information. The regression model also identified new factors such as number of children, attitude toward menstruation, lactating at admission, and spousal input on method choice. The findings suggest that providers play an important role in ensuring the highest possible continuation rates for DMPA.

Determinants of oral contraceptive use in northern Italy.

Socio-demographic characteristics, general lifestyle habits, reproductive and medical histories were compared of 328 women who had ever used oral contraceptives and 2306 never users from a case-control surveillance conducted in Northern Italy. Oral contraceptive use was positively and strongly related with the level of education and indicators of social class. The rate ratio of ever use (adjusted for age and diagnostic category) was 3.3 for women with 12 years of education or more compared with less than 7 years, and 3.0 for women of highest compared with lowest social class. The frequency of pill use was lower among never married women, and significantly elevated among smokers (rate ratio = 2.4 for heavy smokers). In contrast, no relation was evident between alcohol or coffee consumption and pill use. Likewise, ever users of oral contraceptives were not significantly different from women who had never used the pill with regard to major reproductive factors (parity and age at first pregnancy) or several medical variables of potential interest (e.g., diabetes, hypertension, hyperlipidemia), with the only possible exclusion of obesity which was less frequent among pill users. Thus, this study indicates that the major determinants of the persistently low frequency of oral contraceptive use in this Northern Italian population are social rather than reproductive or medical factors. These findings have important implications for epidemiological research on oral contraceptive and disease in this population, and underline the importance of selection and screening of oral contraceptive users on the basis of knowledge of medical factors and lifestyle habits.

PIP: Socio-demographic characteristics, general lifestyle habits, and reproductive and medical histories were compared of 328 women who had ever used oral contraceptives (OCs) and 2306 never users from a case-control surveillance conducted in Northern Italy. OC use was positively and strongly related with the level of education and indicators of social class. The rate ratio of ever use (adjusted for age and diagnostic category) was 3.3 for women with 12 years of education or more compared with less than 7 years, and 3.0 for women of highest compared with lowest social class. The frequency of pill use was lower among never married women, and significantly elevated among smokers. In contrast, no relation was evident between alcohol or coffee consumption and pill use. Likewise, ever users of OCs were not significantly different from women who had never used the pill with regard to major reproductive factors (parity and age at 1st pregnancy) or several medical variables of potential interest (e.g., diabetes, hypertension, hyperlipidemia), with the only possible exclusion of obesity which was less frequent among pill users. Thus, this study indicates that the major determinants of the persistently low frequency of OC use in the Northern Italian population are social rather than reproductive or medical factors. These findings have important implications for epidemiological research on OCs and disease in this population, and underline the importance of selection and screening of OC users on the basis of knowledge of medical factors and lifestyle habits.

Adolescent contraceptive use and its determinants in Bangladesh: evidence from Bangladesh Fertility Survey 1989.

This study is concerned with contraceptive use among the currently married adolescents in Bangladesh utilizing the 1989 Bangladesh Fertility Survey (BFS) data. The study analyzes the factors affecting the current use of contraception among the adolescents through bivariate and multivariate logistic regression analysis. The results indicate that although adolescents have almost universal knowledge about contraceptive methods, only 15 percent are currently using any method of contraception. The corresponding figures for the adults and for the nation as a whole are 34.4 percent and 31.4 percent, respectively. Among the individual methods currently used by the adolescents, the pill appears as the most popular method, followed by safe period. A substantial proportion of the adolescents were found to rely on the traditional methods of contraception. Among the socio-economic variables (as revealed by the logistic regression analysis), respondents' education, participation in the family planning decision, visit by family planning workers, region of residence, husband's occupation and possession of electricity in the household appear as the most significant factors determining the current use of contraception among the adolescents.

PIP: The 1989 Bangladesh Fertility Survey recorded a contraceptive prevalence rate of only 15.3% for married women under 20 years of age compared to 34.4% for respondents 20 years of age and older. 10.7% of married adolescents were using a modern method, primarily the pill, compared to 25.7% of adult women. A lack of knowledge does not appear to play a role in this pattern, since awareness of contraceptive methods is only slightly lower among adolescents. Rather, the low contraceptive prevalence rate for married adolescent women seems to reflect socioeconomic factors. The contraceptive use rate was 29% among adolescents with a higher secondary and above level of education compared to 10.3% among those with less education. This rate ranged from a low of 9.4% in the conservative Chittagong administrative division to a high of 17.2% in the more developed Khulna division. Logistic regression analysis identified education, participation in family planning decisions, visits from family planning workers, administrative division, husband's occupation, and electricity in the household as significant predictors of adolescent contraceptive usage. Place of residence, husband's education, and religion were not significant. These results suggest that use of modern contraceptive methods by young married women in Bangladesh will be increased through measures to improve women's status and bring them into contact with family planning outreach workers.

Correlates of oral contraceptive use in Italian women, 1991-93.

In order to understand the determinants of oral contraceptive (OC) use in Italy, we analyzed data on 1577 women aged under age 60 (median age 50 years) admitted as controls in a case-control study of breast cancer. Included in this group were women with acute, non-neoplastic, non-gynecologic, non-hormone-related diseases, admitted between 1991 and 1994 to a network of hospitals in six Italian centres. A total of 275 (17.4%) women reported ever OC use. Oral contraceptive use was strongly related to the level of education: in comparison with women reporting < 7 years of schooling, the multivariate odds ratios (OR) of ever OC use were 2.2 and 3.5, respectively, in women reporting 7-11 and > or = 12 years of schooling (chi 1(2) trend 40.87 p < 0.001). OC use was inversely related to body mass index (BMI): in comparison with leaner women (BMI, Kg/m2, < 25), the OR of being an ever OC user was 0.8 and 0.7, respectively, in women with BMI 25-< 30 and > or = 30 (chi 1(2) trend 3.36, p = 0.07). Parous women more frequently tended to be OC users than nulliparous ones, the estimated OR being 2.4 and 2.3, respectively, in women reporting 1 or 2 and 3 or more births in comparison with nulliparae. Likewise, women with history of induced abortions were more frequently ever OC users (OR for > or = 1 induced abortions vs no induced abortion, 1.8, 95% Cl 1.2-2.6). However, no relationship emerged between OC use and history of spontaneous abortions. Finally, there was no relation between pill use and history of hypertension, cholelithiasis, thyroid diseases, hyperlipidemia, family history of breast cancer, uterine fibroids and benign breast disease. Women with a history of diabetes were less likely to be OC users (OR 0.6), but the finding was not significant. The results of this analysis are comparable with those of a study conducted in the same population in the early 1980's, and suggest that sociodemographic and reproductive factors, rather than medical history, are major determinants of OC use in this population.

PIP: In order to understand the determinants of oral contraceptive (OC) use in Italy, data were analyzed on 1577 women under age 60 (median age 50 years) admitted as controls in a case-control study of breast cancer. Women were included with acute, non-neoplastic, non-gynecologic, non-hormone-related diseases, admitted between 1991 and 1994 to a network of hospitals in 6 Italian centers. A total of 275 (17.4%) women reported ever use of OCs. OC use was strongly related to the level of education: the multivariate odds ratios (OR) of ever use were 2.2 and 3.5, respectively, in women reporting 7-11 and or= 12 years of schooling (p 0.001) compared to women reporting 7 years of schooling. OC use was inversely related to body mass index (BMI): the OR of ever use was 0.8 and 0.7, respectively, in women with BMI 25 - 30 and or= 30 (p = 0.07) compared to leaner women (BMI, Kg/m2, 25). Parous women more frequently tended to be OC users than nulliparous ones, the estimated OR being 2.4 and 2.3, respectively, in women reporting 1 or 2-3 or more births in comparison with nulliparae. Likewise, women with a history of induced abortions were more frequently ever users (OR for or= 1 induced abortions vs. no induced abortion, 1.8, (95% CI 1.2-2.6). However, no relationship emerged between OC use and history of spontaneous abortions. Finally, there was no relation between pill use and history of hypertension, cholelithiasis, thyroid diseases, hyperlipidemia, family history of breast cancer, uterine fibroids and benign breast disease. Women with a history of diabetes were less likely to be OC users (OR 0.6), but the finding was not significant. The results of this analysis are comparable with those of a study conducted in the same population in the early 1980's, and suggest that sociodemographic and reproductive factors, rather than medical history, are major determinants of OC use in this population.

Sexual and reproductive life events in relation to duration of oral contraceptive use.

In order to disclose differences between users and non-users of oral contraceptives (OC), 620 women aged 15-54 were invited to participate in an in depth interview about sexual, contraceptive, and reproductive life events. Of the 585 women who participated, 459 were consecutive gynecological in- or outpatients, and 126 were selected from visitors in general practice. Data was analysed by multivariate test statistics. After correction for present age and social class, the duration of use of OC (DOC) among women 15-34 years of age correlated negatively to age at menarche and coital debut and positively to number of sexual partners, oral-genital sexual practice, and number of pelvic inflammatory diseases. Among women over 35, DOC was positively associated only to cigarette smoking. No correlation was found to coital frequency (whether earlier, present or during pregnancy or menstruation), number of births and abortions, or to social classification. In epidemiological research on benefits and risks of oral contraceptives, confounding influence of one or more variables is of crucial importance. The present findings point at sexual and life-style habits as potential confounders in the study of OC and associated diseases.

PIP: The purpose of this study was to determine whether or not oral contraceptive users differ from nonusers in ways which might influence any apparent causal relationship between duration of oral contraceptive use and thromboembolism, cervical dysplasia, or breast cancer. 585 women participated in the study--459 gynecological patients and 126 patients in general practice. The average age of the women was 30.8 years, and the average duration of use of oral contraceptives was 4.3 years. Duration of oral contraceptive use was used as the operative variable because it could be quantified. The major confounding factors identified were present age, age at menarche, and number of sexual partners. After correction of age, duration of oral contraceptive use among women aged 15-34 was correlated to low age at menarche, early coital debut, many sexual partners, and frequency of oral-genital sexual practice. Among women over 35 duration of oral contraceptive use was correlated only with cigarette smoking. These correlations may influence the associations between oral contraceptives and breast cancer, cervical dysplasia, cervical cancer, and thromboembolism.

Correlates of intention to use the female condom among women taking methadone.

PIP: The correlates of high-risk women's intentions to use the female condom were investigated in a descriptive study involving 148 sexually active women from 3 US methadone clinics. 51% of women were Latina and 38% were African-American; the mean age was 39 years. Male condoms, douching, sterilization, and withdrawal were the most frequently used contraceptive methods in the 90 days preceding the study. 56% had heard of the female condom, but only 6% had used it. Of the 139 women who had never used the female condom, 32% indicated they intended to use it in the future. Such intention was significantly, positively correlated with age under 39 years, African-American ethnicity, and the belief the female condom offers users a sense of personal control over their sexuality. Those who intended to use the female condom were more likely to have previously used male condoms, believe their partners would be supportive of the device, think female condom use could be erotic and fun, feel confident in their ability to negotiate safer sex, and to welcome an additional option for practicing safer sex. They were also less likely than their counterparts, who did not intend to use a female condom, to believe use of this method would imply they had a sexually transmitted disease or were too eager to have sex. Compared with women who did not intend to use the female condom, those who did were more likely to discuss the device with at least 1 member of their social network. These findings confirm the necessity of considering gender relations and social networks in the design of female condom promotion strategies.^ieng

Psychosocial conventionality, health orientation, and contraceptive use in adolescence.

PURPOSE: The purpose of this paper is to determine psychosocial and behavioral factors that are associated with variation in contraceptive use among adolescents. Because regular use of contraception may be seen both as a conventional behavior and as a health-protective behavior, analyses assess the association between psychosocial conventionality and health orientation, on the one hand, and variation in contraceptive use, on the other. METHODS: Analyses are based on an urban sample of 971 white, African-American, and Hispanic male and female sexually active high school students. Study participants filled out a 38-page questionnaire that included a wide range of measures derived from Problem-Behavior Theory. RESULTS: Correlational analysis and hierarchical regression analysis indicate that more regular contraceptive use is associated with greater psychosocial conventionality and also with greater orientation toward health for both male and female adolescents. These relationships hold when the sociodemographic characteristics of race/ethnicity, socioeconomic status, grade in school, family composition, and pregnancy experience are controlled. The linkages of psychosocial conventionality and health orientation to contraceptive behavior are stronger for African-American than for white and Hispanic adolescents. CONCLUSIONS: The present findings establish a more comprehensive and more distal set of influences on regularity of contraceptive use. In its negative relationship to problem behavior and its positive linkage with health behavior, contraceptive behavior may be seen as part of a larger, organized system of behavior in this stage of development (i.e., a more conventional adolescent lifestyle).

PIP: This study examines the influence of psychosocial conventionality and health value orientation on regularity of condom use among adolescents in the US. Data were obtained from 971 ethnically and racially mixed students from a large urban school district in the Rocky Mountain Region who were followed up in the final wave of a 4-wave longitudinal study of adolescent health and development in 1992. The sample included only non-virgins and unmarried, sexually active persons, who had scores ranging from 151-217 on a regularity of contraceptive use measure. The most commonly used contraceptive method was the condom. Explanatory factors included a three-item scale of contraceptive use, three indexes of conventionality (the Independence-Achievement Value Discrepancy index and the Parent-Friends Compatibility and the Deviant Behavior scales), and 11 health measures on personality characteristics, perceived environmental factors, and behavior (Value on Health, Maternal Model for Health Behavior, and Exercise scales). Findings are given for a bivariate analysis, multivariate analyses, and a comparative analysis of bivariate and multivariate results. The general finding is that greater psychosocial and behavioral conventionality and greater health orientation were associated with more regular contraceptive use among sexually active male and female adolescents. Patterns were comparable for males and females. The relationships remained stable, after controls were introduced for sociodemographic characteristics. Conventionality was expressed as a higher value being placed on academic achievement and greater involvement in school achievement than on independence and having fewer friends with problem behaviors, such as drinking and smoking marijuana. More regular contraceptive use was related to greater health orientation, such as exercise, healthy diets, and seat belt use. The relationship between health orientation and conventionality and contraceptive use was stronger for African-Americans.

Predicting contraceptive vigilance in adolescent females: a projective method for assessing ego development.

PURPOSE: To test the hypothesis that ego development would predict contraceptive use. Problems in ego development were defined in terms of three factors: (1) realism, (2) complexity, and (3) discontinuity. METHODS: Forty-one respondents aged 14-17 years were selected from a group of 233 adolescents who were administered a projective pregnancy scenario and participated in a 12-month follow-up. Twenty of these adolescents were randomly selected from the group determined to be effective contraceptive users, while 21 were randomly selected from the group of poor contraceptors. RESULTS: Chi-square test revealed a significant association (p < .0005) between the composite ego maturity (EM) measure and contraceptive outcome (chi 2 = 13.82, with df-1). Low scores on the ego maturity measure predicted poor contraceptive use. EM was unrelated to age but was associated with race (chi 2 = 7.535, .025 < p < .05). However, EM predicted contraceptive use when controlling for the effects of race. CONCLUSIONS: A simple, time-efficient projective pregnancy scenario is an effective way of determining adolescent females at risk for poor contraceptive effectiveness and, therefore, untimely pregnancy. These stories are analyzed using factors related to the ego development of the adolescent. Subjects who scored lower on this measure have poor contraceptive effectiveness while subjects with higher levels demonstrated effective contraception use, at 1-year follow-up.

PIP: The hypothesis that ego development predicts adolescent contraceptive use was investigated in 41 females 14-17 years of age. These 41 subjects were recruited from a broader group of 233 adolescents attending teen clinics in San Francisco, California, who completed a projective pregnancy scenario and were followed for up to 12 months; 20 subjects were randomly selected from the subgroup determined to be effective contraceptive users, while 21 were drawn from the subgroup of poor contraceptors. An ego maturity index was developed for each teen based on an assessment of three dimensions of the adolescents' projective stories: 1) realism, idealism, or cynicism; 2) complexity, concreteness, or overelaboration; and 3) continuity, mild discontinuity, or abrupt discontinuity. The 25 adolescents whose stories were realistic, continuous, and articulately told were rated high in ego maturity, and 18 of these young women were effective contraceptors (defined as always or almost always using at least 1 moderately or very effective method) at the 1-year follow-up. In contrast, only 2 of the 16 participants with low ego maturity were effective contraceptors. Chi-square test revealed a significant association (p 0.0005) between the composite ego maturity measure and contraceptive outcome. This association remained significant (p 0.01) even after controlling for race. These findings suggest the feasibility of targeting sexually active adolescents with signs of lower ego development for early intervention.

Predictors of condom use in sexually active adolescents.

Unprotected sexual intercourse places a substantial number of adolescents at risk for sexually transmitted disease (STD) and human immunodeficiency virus (HIV) infection. While the most effective means of preventing STD/HIV infection among sexually active adolescents is consistent condom use, little is known about the factors that influence their consistent use among adolescents. This study of adolescents (n = 1049, mean age = 16.2 years) found that of the 266 teens who recently became sexually active, only 29% reported using condoms consistently. Consistent condom use was more frequent in males, those with little history of risk behavior and those with stronger intentions to use condoms in the future. Fear and anxiety of HIV, attitudes about risks other than HIV, and other safe behavior intentions were not significantly related to consistent condom use. Although intentions and recent behavior were significantly related, a different group of factors was found to predict intention to use condoms (e.g., perception of condom use by friends, general impulsive attitudes). Identifying and understanding the factors that influence adolescent sexual behavior and intentions is important for developing maximally effective HIV education/prevention programs.

PIP: Unprotected sexual intercourse places a substantial number of adolescents at risk for sexually transmitted diseases (STD) and human immunodeficiency virus (HIV) infection. While the most effective means of preventing STD/HIV infection among sexually active adolescents is consistent condom use, little is known about the factors that influence their consistent use among adolescents. This study of adolescents (n = 1049, mean age = 16.2 years) found that of the 266 teens who recently became sexually active, only 29% reported using condoms consistently. Consistent condom use was more frequent in males, those with little history of risk behavior, and those with stronger intentions to use condoms in the future. Fear and anxiety of HIV, attitudes about risks other than HIV, and other safe behavior intentions were not significantly related to consistent condom use. Although intentions and recent behavior were significantly related, a different group of factors was found to predict intention to use condoms (e.g., perception of condom use by friends, general impulsive attitudes). Identifying and understanding the factors that influence adolescent sexual behavior and intentions is important for developing maximally effective HIV education/prevention programs.

Predictors of reported condom use in central Harlem youth as conceptualized by the health belief model.

PURPOSE: To examine the relationship of reported condom use to specific sociodemographics, psychosocial variables, and perceptions of and motivations for condom use as conceptualized by the Health Belief Model. METHODS: This study performed a cross-sectional survey of 557 adolescents enrolled in a hospital-based pregnancy prevention program in an urban community hospital (Harlem Hospital). Multiple logistic regression analysis examined the combined relationship of the significant psychosocial variables to consistent condom use. RESULTS: Males were less likely than females to report teen-parent conflict and depression and more likely to report support for birth control, participation in community activities, and favorable attitudes toward delaying parenthood. Consistent with the Health Belief Model adjusting for age, the strongest predictors of consistent condom use were partner preference for condoms, perceived benefit of avoidance of pregnancy, male gender, and support for birth control (usually by a parent). CONCLUSIONS: The data on this urban, predominantly African-American sample of adolescents suggest the importance of the influences on specific motivations to use protection--that is, the wish to avoid pregnancy, human immunodeficiency virus/acquired immunodeficiency syndrome, and sexually transmitted diseases, although the mechanisms are still unclear. In addition, gender and the modifying effects of parental and partner support of the use of protection strongly influence the reported use of condoms by adolescents. These factors (in addition to psychosocial factors such as depression) may be important in planning interventions to increase condom use by sexually active teens.

PIP: The relationship of condom use to the sociodemographic, psychosocial, and cognitive factors included in the Health Belief Model was investigated in a cross-sectional study of 557 primarily low-income, African-American youth 12-19 years of age (mean age, 15.9 years) enrolled in a pregnancy prevention program at Harlem Hospital, New York City, during 1991-93. 74% reported ever having sex, 51% in the preceding 3 months. At last intercourse, 47% used no protection, 43% reported condom use, and 10% used another method. Males were more than 4 times as likely to report condom use than females. Males had more assets, more positive attitudes toward delaying parenthood, less teen-parent conflict, less depression, and more social support for birth control than females. Consistent with the Health Belief Model, the strongest predictors of consistent condom use (after adjustment for age) were partner preference for condoms, perceived benefit of avoidance of pregnancy, male gender, and social (mostly parental) support for birth control. These factors should be considered in the planning of interventions to increase condom use among sexually active teenagers.

Sexual intercourse, contraception, and risk-taking behavior among unselected French adolescents aged 11-20 years.

An epidemiological study was carried out among 4,255 adolescents, aged 11-19 years, randomly selected from secondary schools in a northern urban area of France. The questionnaire concerned sexual activity, contraception, health status, licit and illicit drug consumption, and other risk-taking behavior. A total of 31% of the adolescents had had sexual relations (43% of the boys, 20% of the girls). Sexual activity increased with age. A large majority (70%) of the sexually active adolescents used some form of contraception. The study confirms the relationship between smoking, drinking, illicit drug consumption, and sexual activity, but shows that contraceptive behavior is not related to problem behavior.

PIP: Questionnaires from 4255 randomly selected adolescents from 42 schools in the northern district of Arras in France in the winter of 1988/89 were obtained in order to examine 1) the relationship between risk-taking behavior and sexual behavior, and 2) the negative relationship between contraception and risk-taking behavior by age and sex. Questions were based on a tool developed by Choquet and Menke and included measures of sociodemographics, academic standing and difficulties, life style, quality of family and peer relationships, self-perception, sexual activity, contraceptive habits, licit and illicit drug use, and recent health visits. Stepwise logistic regression was used in the analysis of the sexually experienced (SI), who were further grouped into contraceptive users (CTC) or not (NCTC). Relative odds ratio (OR) and logistic regression were used to assess the relative effect of risk-taking behavior on contraceptive use or sexual intercourse. Descriptive results showed 52.3% boys and 47.7 girls. 86.8% of fathers and 51.3% of mothers were employed. Fathers were in a variety of professions: executives (13%), shopkeepers (8%), middle managers (13%), office employees (19%), blue-collar workers (32%), and farmers (6%). 81% of parents were married. 43% of boys and 20% of girls were SIs, of whom 50% were active regularly. 71% of boys and 76% of girls used contraception (p.05) and 50% of boys and 69% of girls used it systematically. SIs increased with age. For boys, each risk behavior at any age was related to sexual activity; proportions of sexually active varied with risk behavior. For girls, similar trends were found, i.e., heavy smoking and regular illicit drug use were correlated the most significantly with sexual activity. There were differences also. CTC and NCTC groups had similar risk-taking behavior. Frequency of contraceptive use was 2.5 times greater in the older boys' age group (OR = 2.45). Smoking (the strongest predictor), drinking (more prevalent among boys), and illicit drug use are all related to sexual activity, but not necessarily contraception. The implications are that contraceptive use would have been lower and sexual activity higher if other populations had been included. For health care providers, it is important that treatment of adolescent sexuality involve the whole person and context, and not as an isolated problem. A weakness was in not including confounding factors such as social class and the lack of detailed questions on topics.