Health Education Research Advance Access originally published online on October 5, 2005
Health Education Research 2006 21(2):230-238; doi:10.1093/her/cyh059
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The relevance of cultural factors in predicting condom-use intentions among immigrants from the Netherlands Antilles
1 TNO Quality of Life
2 Department of Health Education and Health Promotion, Maastricht University
*Correspondence to: P. L. Kocken, TNO Quality of Life, PO Box 2215, 2301 CE Leiden, The Netherlands. E-mail: pl.kocken{at}pg.tno.nl
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Abstract |
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A study into the relevance of cultural factors in predicting condom-use intentions among Antillean migrants in the Netherlands is described in this article. The association between the intention to use condoms with a new sexual partner and a perceived taboo on discussing sex, beliefs about sex education and machismo beliefs on gender and power relationships is addressed. The study was conducted among 346 Dutch Antilleans from a random sample of an Antillean population aged 15–50 years. The response rate was 37.8%. The results showed that condom-use intentions were primarily determined by perceived subjective norms, the perceived taboo on discussing sex, machismo attitudes, gender, age and educational background. Moreover, the respondent's opinion regarding machismo was an effect modificator for the association between condom-use intentions and subjective social norm. It is concluded that, in predicting condom-use intentions, factors specific to the culture of a population contribute significantly to the determinants drawn from the general social-cognition models. It is recommended that future research should use measurement instruments that are adapted to culture-specific beliefs, and should explore the influence of cultural factors on actual condom use. Moreover, interventions promoting condom use among migrant populations should target the cultural correlates of condom use.
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Introduction |
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Immigrants from the Dutch Antilles and Aruba, two island groups in the Caribbean, experience more sexual health problems in the Netherlands than the autochthonous Dutch population. Sexually transmitted diseases (STDs) are more often diagnosed among Antilleans compared with the overall patient populations of general practices and STD clinics [1, 2]. The incidence of human immunodeficiency virus (HIV) among Antilleans is relatively high [3]. Moreover, the incidence of teenage pregnancies and abortions is much higher in Antillean than in autochthonous teenagers [4]. It is frequently suggested that the prevailing sexual culture among Antilleans engenders a risk of unwanted pregnancies, STDs and HIV. A considerable number of Antillean men have multiple sexual partners, a woman's sexual and financial dependence on a man is a strong barrier to equal communication about safer sex, machismo attitudes dominate the relationship between men and women in the Antillean community and motherhood is generally perceived as important and conferring high status [5–7]. In addition, in the Antillean culture there is a strong taboo against discussing sexuality, and parents are very reluctant to educate their children about sexuality, despite the high prevalence of teenage pregnancies [6].
Today there is ample evidence on the correlates of heterosexual male condom use. Meta-analytic reviews of psychosocial correlates of condom use have revealed the following five cognition measures with medium to large correlations: attitudes towards condoms, descriptive norms in relation to condom use, i.e. perceptions that others approve of and use condoms, intentions to use condoms, pregnancy motivation, e.g. the belief that condoms should be used for contraceptive purposes and protection against sexually transmitted infections (STI), and perceived control over condom use including self-efficacy [8, 9]. Sheeran and colleagues concluded that heterosexual condom use can be better understood, and therefore more effectively promoted, through the application of psychological theory. Moreover, condom use can be best conceptualized in terms of an extended theory of reasoned action, similar in many respects to the information motivation behaviour model [10] or theory of planned behaviour [11]. A study of ethnic minority communities in Amsterdam, including Dutch Antilleans, showed that consistent condom use was primarily related to perceived social norms and perceived behavioural control, and secondarily to condom-use outcome expectations and HIV-related knowledge [12]. These findings suggest that social-cognition models can be useful for predicting and understanding condom use across populations of varying cultural or ethnic backgrounds [13, 14]. However, it has also been argued that these models do not allow for differences in sociocultural structures of societies to which the models apply [15, 16]. Problem analysis and intervention design have to account for the context of health behaviour, e.g. norms about masculinity and femininity. In this view, restriction to the social–psychological models of determinants of behaviour disregards the importance of cultural factors shaping individual behaviour.
In this article a study is described that focuses on the contribution of culturally defined correlates of behaviour in explaining condom use among Antillean immigrants in the Netherlands. We looked at the perceived taboo on discussing sex, beliefs about sex education and machismo beliefs as culturally defined opinions which may influence condom decision making. These factors have to be distinguished from general correlates that have been proven predictive for condom use, as from the theory of planned behaviour. Culturally defined, or distal factors, affect condom use through the general or proximal determinants. Background characteristics like age and gender are also viewed as distal factors in this article [13, 17]. An evaluation of determinants of condom-use intentions in the context of sexual relationships in the Antillean culture will give insight into the role that cultural determinants play in explanatory models of behavioural change. The following research questions are addressed in this article. To what extent do Antillean immigrants in the Netherlands intend to use condoms with a new sexual partner? Do cultural factors contribute to the predictors of condom-use intention attitude, social norm, perceived behavioural control and perceived threat? It has to be mentioned that this study addresses condom-use intentions and not actual condom use. Empirical evidence confirms the theoretical assumption that the intention to use condoms is related to actual condom use [9].
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Method |
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The Municipal Health Service Rotterdam conducted a community-based intervention—called Amor i salú—in 2000 and 2001 to prevent unwanted (teenage) pregnancies, STI and HIV infection among Dutch Antillean immigrants. Baseline data from the Amor i salú evaluation study are used in this article. The study was conducted using a random sample of 1012 Dutch Antilleans, aged 15–50 years, drawn from the Rotterdam registrar's office. The respondents were visited at home and interviewed in their native language or Dutch by interviewers from the Antillean ethnic group. Contact was made with 346 persons (34.2%). The net response rate was 37.8%, when incorrect addresses were left out. All female respondents were interviewed by female interviewers. Not all male respondents could be interviewed by men, due to a shortage of male interviewers. In total 8 male and 13 female interviewers were active. The interviewers registered absence from home during a maximum of three contact attempts as the most frequent reason for non-response.
Women and the age group of 35–50 years responded more frequently compared with census data, 56.4% of respondents were female and 34.5% 35–50 years of age (Table I). The majority of respondents, 83.5%, was unmarried, as this is the rule in the Antillean community. The respondent's education level was high compared with the proportion with a higher education in an Antillean labour population, 34.9% of respondents had received at least higher vocational training or graduated from high school [18]. About 65% of respondents lived in the Netherlands for 10 years or longer.
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Questionnaire
The questionnaire included the following standard measures derived from questionnaires that had been used in earlier studies in Dutch samples. Measures on social cognitions from the theory of planned behaviour included attitude towards condom use, subjective social norms regarding condom use, perceived behavioural control regarding condom use and condom use intention. In addition, the questionnaire included measures of perceived threat and knowledge of HIV and STI because these cognitions were addressed in the Amor i salú programme and because of their potential relevance [12, 19]. The questionnaire further included measures of culturally defined determinants that had been developed specifically for this research purpose using statements drawn from qualitative interviews that were conducted in the preparation stage of the Amor i salú program. These instruments were designed with the help of Antillean peer health educators. The questionnaire was pre-tested on a group of Antillean baseball players.
The outcome measure intention to use condoms with a new sexual partner was assessed using the following question: ‘Do you think that you will use a condom in future if you have sex with a new partner?’ (1 probably not to 5 definitely). Attitude was assessed using 10 items addressing the benefits of the protective effects of condom use, reduced satisfaction with sex when using a condom and mutual trustworthiness when sexual partners propose condom use, e.g. ‘a condom protects against the AIDS virus’ and ‘making love using a condom is not genuine’ (1 agree to 3 disagree, 
= 0.68). Perceived subjective norm was assessed using three items on normative beliefs with respect to the opinions of friends and family members regarding condom use, e.g. ‘my friends think that I should use condoms with new sexual partners’ and three items on motivation to comply, e.g. ‘I consider my friends' opinion on condom use to be very important’ (1 agree to 3 disagree, = 0.69). The scores on normative beliefs were multiplied by the scores on related motivations to comply and added up as a total score on subjective norm per individual. Perceived behavioural control regarding condom use was assessed using two items, ‘I find it difficult to use condoms with a new sexual partner’ and ‘I find it difficult to say "no" when a new partner wants to have sex without a condom’ (1 agree to 3 disagree, Pearson r = 0.38).
Risk appraisal for STI and HIV infection was assessed using two five-point scaled items (1 I did not run risk to 5 I ran great risk, Pearson r = 0.89) and two items related to perceived severity of attracting AIDS and STDs (1 very severe to 5 not severe, Pearson r = 0.89). A score for perceived threat was derived by multiplying the score totals on the risk appraisal and perceived severity items. Knowledge was assessed using a seven-item scale addressing HIV and STD transmission, e.g. ‘Do you think that the AIDS virus can be transmitted by kissing?’ (1 yes, 2 no, = 0.61).
The questionnaire included four ‘cultural’ factors. Perceived taboo on discussing sexuality was assessed using a single item ‘discussing sex is taboo among Antilleans’ (1 agree to 3 disagree). Attitudes towards sex education were assessed using three items derived from qualitative interviews held at the start of the project, e.g. ‘sex education encourages young children to have sex’ (1 agree to 3 disagree, = 0.51). Machismo beliefs on gender and power relations included four items addressing the female role in sexual relationships, e.g. ‘a woman needs a man to take care for her’ (1 agree to 3 disagree, = 0.68), and two items addressing machismo beliefs concerning the role of males, ‘a man proves his manliness when he has many children’ and ‘a man proves his manliness when he has many girl friends’ (1 agree to 3 disagree; Pearson r = 0.73) [5]. Finally, the questionnaire included background characteristics: gender, age, duration of stay in the Netherlands, educational level and multiple sexual partners or not.
Analysis
All measures were dichotomized because of skewed scale scores. Cut off points were calculated using the 50th percentile of the scale scores. After dichotomization, a high, desirable score, e.g. favouring condom use, was coded 1 and a low, undesirable score 0. Firstly, the association between intention to use condoms and its correlates was analysed univariately. Secondly, a multivariate logistic regression analysis procedure was used to account for the effects of the other determinants. The proximal determinants from the extended theory of planned behaviour were included in the regression model first. Subsequently, the cultural variables and background characteristics were included in the regression model. We used a hierarchical backward elimination procedure excluding variables that did not reach significance (P < 0.05). Two-way interactions between significant determinants in the ultimate regression model were tested to assess the strength of the relationship between the intention and its correlates within subgroups, adding one interaction term to the model at a time (P < 0.10). Odds ratios (ORs) were tested using 95% confidence intervals (95% CIs). The intention to use condoms is higher in the population scoring high on the determinant measure, compared with the group scoring low, if the OR exceeds value 1. A reverse relationship is found if the OR is <1. A relationship is lacking if the OR = 1. The statistical package SPSS 11.5 was used.
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Results |
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Condom-use intention
The distributions of sexual contacts and condom-use intention in the study group are described in Table I. A rather large proportion of respondents (27.1%) reported having had no sexual intercourse in the 6 months prior to the interview. This can be explained by the relatively young age of the response group. The 8.9% who reported sexual contacts with multiple partners was lower than expected. The intention to use condoms with a new sexual partner in the future was positive among 66.2% of the respondents, 33.9% was not yet convinced of their intention to have safe sex.
Determinants of condom-use intention
At the univariate level condom-use intention was statistically significant related to perceived subjective norms regarding condom use. The other determinants from the theory of planned behaviour—attitude and perceived behavioural control—were not significantly related at 0.05 significance level, although the direction of the association was as expected. In addition to perceived subjective norm, knowledge of HIV and STD transmission, a perceived taboo on discussing sexuality, educational level, gender and machismo beliefs concerning the role of women were significantly related to condom-use intention. The ORs are given in Table II. The result that young Antilleans and people who do not observe a taboo with regard to discussing sex were less inclined to use condoms was unexpected.
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A hierarchical logistic regression was conducted to explore the correlates of condom-use intention. First, the proximal determinants attitude, perceived subjective norm, behavioural control and perceived threat and knowledge were included in the regression model using a stepwise backward procedure. Whereas the attitude towards condoms was not significantly related to condom-use intention at the univariate level, the association between attitude and intention appeared to be significant when controlling for the other determinants (Table III). Antilleans with a positive attitude towards condoms were more likely to use condoms in future, than those with a negative attitude (OR 1.86, 95% CI 1.12–3.08). Antillean respondents who perceived a strong norm favouring condom use were more likely to use condoms in the future, than those who perceived a weak subjective norm (OR 3.38, 95% CI 1.97–5.79). Perceived behavioural control, perceived threat and knowledge of HIV and STD transmission were not significantly related to condom-use intention when included in the multivariate logistic regression analysis.
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Subsequently, distal cultural and demographic variables were added to the logistic regression model including attitude and subjective norm. The results showed that in addition to the perceived subjective norm, machismo beliefs on the role of women and the descriptive norm regarding a taboo on discussing sex were significantly related to condom-use intentions (Table III). The attitude towards condom use was removed form the regression model. Respondents who were less likely to have beliefs favouring machismo were more inclined to use condoms, than respondents who had the opinion that women had a secondary role in intimate relationships (OR 1.86, 95% CI 1.08–3.21). Respondents who perceived a taboo on talking about sexuality were more likely to use condoms than people who did not perceive such a taboo (OR 0.50, 95% CI 0.29–0.87). Gender, age and educational level also added significantly to the model. Women were more likely to have intentions to use condoms than men (OR 2.45, 95% CI 1.42–4.21). Respondents of 31–50 years of age were more inclined to use condoms than the young (OR 0.56, 95% CI 0.32–0.97). The higher educated more often expressed intentions to use condoms than the lower educated (OR 2.13, 95% CI 1.17–3.91). Beliefs about sex education, length of time in the Netherlands, having had sex with multiple partners and machismo beliefs on the male role were not included in the logistic regression model. The explained variance of the model amounted to 25.8%, whereas the first regression model restricted to the proximal determinants explained 10.8%.
Examination of effect modification yielded only a statistically significant interaction effect of machismo beliefs and the subjective social norm on condom-use intention. It appeared that the relationship between subjective social norm and condom-use intention was significant within respondents who adhered to machismo beliefs (OR 6.00, 95% CI 2.66–13.51). The relationship among respondents who had less strong machismo beliefs was much weaker and not statistically significant (OR 1.74, 95% CI 0.81–3.71).
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Discussion |
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The influence of culturally defined determinants on condom-use intention among Antillean immigrants 15–50 years of age in the Netherlands is addressed in this article, and the contribution of distal correlates of condom use in addition to the social-cognition correlates that were identified in meta-analyses on condom use was examined. The results revealed that two-thirds of the respondents had positive intentions towards condom use with a new sexual partner, whereas one-third was more or less hesitating. The results also showed that the intention to use condoms was primarily related to perceived norms towards condom use, a perceived taboo on discussing sex, machismo beliefs concerning the role of females, gender, age and educational level. It can be concluded that the factors specific for the culture of a minority population contributed to the determinants of condom-use intention from the general social-cognition models. Taboo and machismo were important in the multivariate model, whereas general attitudes towards condoms were eliminated. This result underlines the importance of culturally defined determinants in explanatory models for behaviour.
This study has some limitations related to the research setting of a hard-to-reach minority population and the study design used as a consequence. Research in the Dutch Antillean community is generally hindered by low participation rates—in our study the response rate was 37.8%. Antillean men especially are hard to reach for both research and prevention, and consequently women in the age group of 35–50 years were over-represented in our study. This may have biased the results of our study. Moreover, the results may be biased because participants in surveys into sexual behaviour generally have more sexual experience, a higher self-esteem and a more liberal attitude towards sexuality than those who are unwilling to participate [20].
We limited the number of scale items and answer categories based on advise from key figures of the Antillean community, to meet the inexperience of the Antillean population with surveys. We hoped that a concise questionnaire would enhance the response. As a consequence, the determinants used in this study do not cover the full range of factors that may affect condom use. For instance, we did not include the partner's attitude towards condoms and past behaviour [9]. Moreover, some dimensions of determinants are lacking due to the use of data that were collected for evaluation purposes. For instance, perceived behavioural control was confined to a direct measure of perceived barriers and difficulties and did not include other power items or factors that inhibit or facilitate the target behaviour [21]. This measurement limitation implies that the explanatory model presented in this article is not all-inclusive. The rather low proportion of variance accounted for by the initial regression model, including the proximal determinants, may be explained by our choice for concise measurements. On the other hand, the proportion of variance accounted for increased by 15%, when the distal factors were added to the regression model. This result suggests that the ‘traditional’ social-cognitive determinants do not fully account for variance in the intention to use condoms with new sexual partners in the population of Antillean immigrants, and that it is worthwhile to consider culturally specific factors.
The dependent variable of this study is intention to use condoms with a new sexual partner, and not the behaviour itself. Although the meta-analysis of Sheeran and Orbell showed rather strong correlations of an average of 0.43 between condom-use intentions and actual condom use, a considerable proportion of variance in condom-use behaviour remains unaccounted for [9]. It might be that the cultural factors that proved relevant for the intention to use a condom in our study also have an additional influence on the relation between intention and actual behaviour, at least as far as condom use with new sex partners is concerned. The respondents' low report of multiple partners may be explained by the tendency in the Antillean community to consider near partners with whom people have frequent sexual contacts as steady partners and not as casual partners. This means that the study results cannot be transferred directly to the intention to use condoms with these steady partners, yet having such partners is also a risk for contracting HIV and STDs. As such, the model of correlates of intended condom use as presented in our study only applies to persons who may engage in having sex with a new partner, e.g. to young people without sexual experience, persons for whom the new sexual partner may turn out to be a so-called steady partner in future and persons in the precontemplation or contemplation stage, who do not consistently use condoms.
The results of our study suggest that cultural factors—defined as distal factors—may play an important role in explaining intentions to use condoms. Although we did not expect a positive association between a perceived taboo on discussing sex and condom-use intention, it might be that people who perceive that discussing sex is a taboo among Antilleans may themselves have more liberal thoughts about condom use. The traditional machismo beliefs on the role of females in partner relationships only influence intention to use condoms in combination with strong perceived norms towards condom use. Machismo is depicted both positively and negatively in the literature. On the one hand, a macho man is an individualistic, power-seeking and sexual promiscuous person. On the other hand, a macho man is viewed as a caring and protective individual towards wife and children, strong, proud and respectable [22–25]. Prevention programs to promote safer sex among migrant populations such as the Antillean population in the Netherlands will benefit from targeting these and alike cultural beliefs. For instance, the caring and protective aspects of machismo can be used to make clear to Antillean men that using condoms means caring for your family [26, 27].
In this study a distinction has been made between proximal and distal determinants. The variables taboo on discussing sex and machismo beliefs, however, may not be that distinct from the proximal determinants of condom-use intention. Although the distal, cultural determinants did not specifically focus on condom use, they do address issues that are related to sexual behaviour. We suggest that proximal determinants from general social-cognition models include culturally specific translations of the behaviours aimed at. Our questionnaire items on e.g. attitudes towards condoms may have been too general and may have lacked aspects of machismo and the taboo on discussing sex. It is advisable to formulate instruments for health education research that are as situation and time specific as possible, and that therefore incorporate cultural aspects of importance for the behaviour in the minority group under study [13, 28]. It therefore seems useful to base questionnaire design on thorough qualitative research on culturally specific values and beliefs [15].
An implication of this study for future research is to examine the influence of cultural factors on the actual behaviour of condom use and its association with intention: and since our study is limited to condom use with new sexual partners, future research should focus on the use of condoms in steady relationships. The definition of type of sexual relationships is a point of attention for future research in minority groups. In the case of Antilleans, a distinction has to be made between one steady partner, multiple steady partners and new partners, which may turn out to be casual partners.
This study supports the idea that research on the correlates of health behaviour should take the cultural background of target populations into consideration. Future research on other health behaviours and among various target populations may improve our insight into the role of the cultural factor in explaining behaviour. Longitudinal study designs may be needed to unravel causal mechanisms of condom use. Evaluation research into safer sex activities aimed at minority groups, among which is the Amor i salú project in the Netherlands, will teach us how to motivate communities to take action to pursue effective prevention programs.
Insight into the contribution of cultural factors to determinants of condom-use intention will help in the continued effort to prevent sexual health problems in minority groups. The development of interventions for behavioural change in these groups, in general, should be based on a thorough needs assessment, and on theory-based methods and strategies [29]. This study demonstrates once again that the younger age group and males are important target groups for STD and AIDS prevention programs, and that the development of sexual health promoting programs will benefit from a careful consideration of culturally directed beliefs.
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Received on December 13, 2004; accepted on August 23, 2005
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