Assessing social-cognitive indicators of
barriers to using condoms and testing for
HIV and STI among young people in NSW,
Australia
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Social Sciences
Centre for Social Research in Health
Dr Philippe CG Adam
Centre for Social Research in Health
UNSW Australia, Sydney
Acknowledgements
• John de Wit, Carla Treloar, Joanne Bryant, Toby Lea, Paul Byron
• Chris Bourne, Brooke Shepherd, Carolyn Murray
• Jo Holden, Tim Duck
Study funded by the Centre for Population Health, New South
Wales Ministry of Health
Background
• STI notifications continue to increase among young people in
Australia
• Reducing the prevalence of STIs through the promotion of
condom use and testing for STIs is a public health priority
Background
• Uptake of condom use and testing for STI/HIV, remains
limited among young people in Australia
• A more comprehensive understanding of barriers and
facilitators of using condoms and testing for STI/HIV is
needed to inform the development of sexual health promotion
campaigns and interventions
Review of literature
• Abundant literature on STI/HIV testing but knowledge on
barriers and facilitators of testing remains fragmented…
 De Wit & Adam, To test or not to test, HIV Medicine, 2008
 Most studies on determinants focus on a few factors
 Range of possible individual, social and structural factors not
comprehensively assessed
 Difficult to tell which factors should be addressed with priority by
sexual health programs
• Literature on barriers facilitators of condom use presents
similar gaps
Comprehensive approach to barriers to testing
• Two online surveys on indicators of potential individual, social and
structural barriers and facilitators of HIV/STI testing in NSW, Australia
 ‘Getting Down to It Study’ among young people in 2010
 ‘How much do you care? Study’ among gay men in 2012
 Adam, de Wit et al., Promoting regular testing, AIDS and Behavior,
2014
• Relative contribution of a range of social-cognitive indicators of
potential barriers and facilitators, derived from health behaviour theory:







Knowledge of HIV/STI
Perceived severity and vulnerability
Fears and worries
Attitude, perceived advantages (‘pros’) and disadvantages (‘cons’)
Perceived behavioural control
Subjective norm
Stigma and shame
Implications of previous research findings
 Multivariate analyses of data from survey of young people
 Limited influence of STI/HIV knowledge and perceived
vulnerability on testing behaviours; no association with
perceived severity or stigma and shame
 A range of other social-cognitive factors together play an
important role in explaining testing behaviours: fears and
worries, perceived advantages and disadvantages of testing,
perceived behavioural control, subjective norms of testing;
marginal association with attitude
 Findings inform sexual health promotion activities with young
people in NSW
 Online intervention ‘Play Safe’ produced by NSW STI Programs
Unit, for NSW Ministry of Health
The present study aims at…
• Extending previous research on social-cognitive indicators of
potential barriers and facilitators of testing using short
measures that can be easily used in brief (periodic) surveys
• Using the same framework and methods to also examine
social-cognitive indicators of potential barriers and facilitators
of condom use
• Appraising the extent to which sexual health promotion with
young people in NSW, Australia may contribute to reducing
barriers and promoting facilitators of STI/HIV testing and
condom use
Methods
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Recruitment and procedures
 Self-report quantitative survey conducted online between July
and November 2013 (www.project1626.csrh.org)
 Facebook advertisements used as main recruitment channel
 To be eligible, individuals had to be aged 16-26 years old, live
in NSW, Australia and provide informed consent
 Of the 900 individuals who met the eligibility criteria, 754
participants completed the survey
 Analyses are based on 502 sexually active participants
Sample characteristics
Variables
Categories
%
Age
16-20 years
51.5
21-26 years
48.6
Male
39.6
Female
60.4
Up to Year 12
62.2
Above Year 12
37.8
Anglo-Australian
74.7
Non-Anglo-Australian
25.3
Heterosexual
75.1
Bisexual, gay and other
24.9
Gender
Education
Ethnic background
Sexual identity
Survey instrument
• Sexual practices, condom use, risk
• Testing for STI and HIV
• STI/HIV knowledge was measured with 16 questions
(extracted from a 32 item-scale used in previous research)
• Multi-item scales used to measure social-cognitive indicators
of potential barriers and facilitators of testing in previous
research were replaced by single items; answers were
provided on 5 point scale (Totally disagree – Totally agree)
• Mirrored questions were used to measure social-cognitive
indicators of potential barriers and facilitators of condom use
Short measures of social-cognitive barriers and facilitators
to condom use or testing for STIs
Perceived vulnerability ‘I feel I’m unlikely to get an STI’
Perceived severity
‘Contracting an STI could seriously affect my health’
Attitudes
‘Using condoms/Testing for STIs is a good thing’
Perceived ‘pros’
‘Using condoms/Testing for STIs has many advantages’
Perceived ‘cons’
‘Using condoms/Testing for STIs has many disadvantages’
Worries
‘I’m worried about testing for STIs’
Perceived control
‘I’m confident I can use condoms/test for STIs when I want to’
Subjective norms
‘My best friends believe I should use condoms/test for STIs’
Reputation threat
‘Using condoms/Testing for STIs is bad for my reputation’
Embarrassment
‘Using condoms/Testing for STIs can be embarrassing’
Note: *Answers to each question were provided on a 5 point scale (Totally disagree – Totally agree)
Results
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STI/HIV knowledge
Mean
SD
Overall knowledge of STIs/HIV
6.18
2.13
Specific areas of
Symptoms
5.72
2.94
knowledge
Transmission
7.64
2.38
Consequences
5.10
2.73
Treatment
6.27
3.04
Sexual risk and STI/HIV testing
%
Unprotected intercourse with any partners (12 months)
62.2
Tested for either STIs or HIV (ever)
44.4
Testing for STIs
Extent and contribution of social-cognitive
correlates
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Extent of potential barriers/facilitators of STI/HIV testing
Factors
Measures*
Agree†
%
Perceived vulnerability
‘I feel I’m unlikely to get an STI’
63.6
Perceived severity
‘Contracting an STI could seriously affect my health’
92.8
Worries
‘I’m worried about testing for STIs’
29.3
Attitude
‘Testing for STIs is a good thing’
95.8
Perceived ‘pros’
‘Testing for STIs has many advantages’
95.0
Perceived ‘cons’
‘Testing for STIs has many disadvantages’
8.8
Perceived control
‘I’m confident I can use condoms when I want to’
79.5
Subjective norms
‘My best friends believe I should use condoms’
39.4
Reputation threat
‘Testing for STIs is bad for my reputation’
10.2
Embarrassment
‘Testing for STIs can be embarrassing’
65.3
Note: *Answers to each question were provided on a 5 point scale (Totally disagree – Totally agree)
† Somewhat agree and totally agree combined.
Extent of potential barriers/facilitators of STI/HIV testing
Factors
Measures*
Agree
%
Perceived vulnerability
Low
‘I feel I’m unlikely to get an STI’
63.6
Perceived severity
Very high
‘Contracting an STI could seriously affect my health’
92.8
Worries
Low
‘I’m worried about testing for STIs’
29.3
Attitudes
Very positive ‘Testing for STIs is a good thing’
Perceived ‘pros’
Very high
‘Testing for STIs has many advantages’
95.0
Perceived ‘cons’
Very low
‘Testing for STIs has many disadvantages’
8.8
Perceived control
High
‘I’m confident I can use condoms when I want to’
79.5
Subjective norms
Low
‘My best friends believe I should use condoms’
39.4
Reputation threat
Very low
‘Testing for STIs is bad for my reputation’
10.2
Embarrassment
High
‘Testing for STIs can be embarrassing’
65.3
Note: *Answers to each question were provided on a 5 point scale (Totally disagree – Totally agree)
† Somewhat agree and totally agree combined.
95.8
Contribution of social-cognitive correlates to STI/HIV testing
Univariate analyses
OR
p-value
Multivariate analyses*
Adj. OR
p-value
STI/HIV knowledge
1.22
< .001
1.13
<.05
Low perceived vulnerability
.82
< .01
.85
<.1
Perceived severity
1.12
ns
Worries
.81
<.01
.85
<.1
Positive attitudes
1.79
<.001
1.82
ns
Perceived ‘pros’
1.53
<.01
.86
ns
Perceived ‘cons’
.94
ns
Perceived behavioural control
1.80
<.001
1.55
<.001
Subjective norms
1.54
<.001
1.42
<.001
Reputation threat
.77
<.01
1.09
ns
Embarrassment
.85
<.05
.99
ns
Note: * Controlling for socio-behavioural factors associated with STI testing (age, gender, sexual identity,
unprotected intercourse with casual partners); ns = non-significant.
Testing for STIs
Impact of campaigns on practices, intentions
and social-cognitive correlates
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Exposure to STI testing campaigns
Exposure to sexual health campaigns
advising young people to test for STI
%
Never
6.0
33.9%
Rarely
27.9
Occasionally
35.4
Often
22.1
Very often
9.6
67.1%
Association of frequency of exposure to STI testing
campaigns with prior STI/HIV testing and intention to test
Never/rarely
Occasionally/often/very often
p-value
Ever tested for
STI/HIV
%
Intention to test in the
next months
Mean (SD)
37.6
47.9
2.85 (1.24)
3.21 (1.24)
< .05
<.01
Association of frequency of exposure to STI/HIV testing
campaigns with social-cognitive correlates of testing
Beta
t
p-value
STI/HIV knowledge
.176
2.824
.005
Low perceived vulnerability
-.042
-.934
ns
Worries
-.029
-.640
ns
Positive attitudes
.013
.282
ns
Perceived ‘pros’
.027
.601
ns
Perceived control
.087
1.947
.052
Subjective norms
.118
2.663
.008
Reputation threat
-.044
-.990
ns
Embarrassment
.024
.537
ns
Campaigns impact on all 3 social-cognitive barriers/facilitators associated
with STI/HIV testing in previous multivariate analyses
Condom use
Extent and contribution of social-cognitive
correlates
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Extent of potential barriers/facilitators of condom use
Factors
Measures*
Agree†
%
Perceived vulnerability
Low
‘I feel I’m unlikely to get an STI’
63.6
Perceived severity
Very high
‘Contracting an STI could seriously affect my health’
92.8
Attitudes
Positive
‘Using condoms is a good thing’
87.9
Perceived ‘pros’
High
‘Using condoms has many advantages’
86.1
Perceived ‘cons’
Low
‘Using condoms has many disadvantages’
27.7
Perceived control
High
‘I’m confident I can use condoms when I want to’
86.5
Subjective norms
Moderate
‘My best friends believe I should use condoms’
58.1
Reputation threat
Very low
‘Using condoms is bad for my reputation’
0.6
Embarrassment
Low
‘Using condoms can be embarrassing’
17.5
Note: *Answers to each question were provided on a 5 point scale (Totally disagree – Totally agree)
† Somewhat agree and totally agree combined
Contribution of social-cognitive correlates to condomless sex
Univariate analyses
OR
p-value
Multivariate analyses*
Adj. OR
p-value
STI/HIV knowledge
1.02
ns
Low perceived vulnerability
.89
ns
Perceived severity
.83
ns
Positive attitudes
.52
< .001
.57
< .05
Perceived ‘pros’
.75
< .05
1.21
ns
Perceived ‘cons’
1.35
< .001
1.21
<.06
Perceived behavioural control
.77
< .001
.92
ns
Subjective norms
.67
< .001
.65
<.001
Reputation threat
1.13
ns
Embarrassment
1.16
< .1
Note: * Controlling for socio-behavioural factors associated with engaging in unprotected sex (reporting regular
partner(s), casual partners, and being ever tested for STIs); ns = non-significant.
Condom use
Impact of campaigns on practices, intentions
and social-cognitive correlates
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Exposure to condom use campaigns
Frequency of exposure to sexual health
campaigns advising young people to use
condoms
%
Never
6.8
34.7%
Rarely
27.9
Occasionally
29.1
Often
24.7
Very often
11.6
65.3%
Association of frequency of exposure to STI testing campaigns
with prior condomless sex and intention to use condoms
Unprotected
intercourse with
any partner in the
past 12 months
Never/rarely
Occasionally/often/very often
p-value
Note: * ns = non-significant.
%
58.6
64.0
ns
Intention to
use condoms with…
Regular
Casual
partners
partners
Mean (SD)
3.63 (1.41)
3.57 (1.39)
ns
Mean (SD)
3.72 (1.39)
3.80 (1.47)
ns
Association of frequency of exposure to condom use campaigns
with social-cognitive correlates
Beta
t
p-value
Positive attitudes
.026
.581
ns
Perceived ‘cons’
-.066
-1.469
ns
Perceived ‘pros’
Perceived control
.046
.091
1.019
2.034
ns
.043
Subjective norms
.105
2.358
.019
Note: * ns = non-significant.
Campaigns impact on 1 of the 3 social-cognitive barriers/facilitators (subjective
norms) associated with condomless sex in previous multivariate +analyses
Conclusion
• The present study confirms and expands previous research
• Social-cognitive factors individually are moderately associated
but together significantly explain STI/HIV testing and condom
use behaviours among young people
• Sexual health promotion programs face the challenge of having
to address a range of small hurdles rather than a single major
barrier
 More than increasing knowledge and raising risk awareness
 Promoting positive attitudes and perceived advantages of sexual
health behaviours and addressing perceived disadvantages
 Increasing young people’s sense of control over sexual health
behaviours and stimulating positive social norms
Conclusion
• Recent campaigns to promote STI/HIV testing among young
people in NSW by directly addressing relevant social-cognitive
barriers/facilitators, are showing promising effects
 Association with behaviour and intention
 Through influence on social-cognitive correlates
• A similar sexual health promotion framework could be used to
promote condom use
• Collaboration between research and practice has the potential
to considerably increase the effectiveness of sexual health
promotion programs
Thank you!
philippe.adam@unsw.edu.au
Never Stand Still
Arts
Social Sciences
Centre for Social Research in Health