Perceptions About HIV and Condoms and Consistent Condom Use Among Male Clients of Commercial Sex Workers in the Philippines.

Abstract

Because consistent condom use is an effective strategy in the prevention of sexually transmitted infections and HIV transmission, it is important to examine social cognitive influences of consistent condom use not only among female sex workers (FSWs) but also among their male clients, for whom less is known. Because little is known about how HIV knowledge and condom attitudes affect condom use among male clients of FSWs in the Philippines, the main objective was to determine what characteristics (age, education, HIV knowledge, marital status) as well as attributes taken from protection motivation theory (perceived vulnerability, perceived severity, response efficacy) are significantly associated with consistent condom use among male clients of FSWs. Logistic regression analyses showed that the odds of using condoms consistently with an FSW are 13% higher for those with more years of education (adjusted odds ratio [AOR] = 1.13; 95% confidence interval [CI] = 1.03, 1.23), higher versus lower perception of severity of HIV/AIDS (AOR = 1.97; 95% CI = 1.04, 3.73), and had a higher score for response efficacy of condoms (AOR = 1.14; 95% CI = 1.03, 1.27). Future HIV/AIDS prevention interventions that address condom use among male clients should promote educational attainment and focus on awareness of the enduring negative health consequences of acquiring HIV/AIDS, as well as cultivate positive attitudes toward the efficacy of condom use, using creative social marketing strategies.

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Health Education & Behavior
XX(X) 1 –7
© 2012 Society for Public
Health Education
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DOI: 10.1177/1090198112446809
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According to UNAIDS, there were 8,700 adults and children
living with HIV/AIDS in the Philippines at the end of 2009
(UNAIDS, 2010). Rates of increase can be described as “low
and slow,” with a stable estimate of HIV prevalence at <0.1%
(UNAIDS, 2010). Among groups the Philippines govern-
ment considers most at risk for HIV (injection drug users,
female sex workers [FSWs], overseas contract workers, and
men who have sex with men), the HIV prevalence is approxi-
mately 1% (Philippine Health Department, 2003; Philippines
National AIDS Council, 2010). However, in some regions of
the country, the prevalence among high-risk groups is
slightly higher at 1% to 2% (Ghys, Jenkins, & Pisani, 2001;
Mateo, Sarol, & Poblete, 2004). Although the prevalence of
HIV/AIDS is currently low in the Philippines, the prevalence
of sexually transmitted infections (STIs) is high. Prevalence
of Chlamydia has been reported to be between 21% and 36%
(World Health Organization—Western Pacific Region
[WHO-WPR], 2002) and as high as 40% (UNAIDS, 2004)
among FSWs. Additionally, prevalence ranges between 15%
and 31% for gonorrhea and between 1% and 7% for syphilis
(WHO-WPR, 2002). Prevalence of STIs is also reported as
high among the general population, with a prevalence of
Chlamydia of 5.6% among women attending antenatal
clinics (UNAIDS, 2004) and between 4% and 9% among the
general population. Rates of gonorrhea and syphilis in the
general population are low (0.7% to 1.7% and 0.2%, respec-
tively) but still causes alarm (WHO-WPR, 2002). The high
rates of STIs are of concern since the presence of STIs
increases the efficiency of HIV transmission. Because of
high STI rates, and unsafe sex practices, public health offi-
cials are concerned that the current low HIV/AIDS preva-
lence rates will continue to rise if prevention efforts are not
tailored for those at highest risk (Wi et al., 2006). It is clear
that the potential for an increase in HIV/AIDS prevalence
exists, and therefore the promotion of condom use by FSWs
and their male partners has been one strategy of the
government to prevent a burgeoning epidemic from occur-
ring in the Philippines as it has in other parts of the region.
XXX10.1177/1090198112446809Regan and MoriskyHealth Education & Behavior
2012
1University of California, Los Angeles, Los Angeles, CA, USA
2University of California, San Francisco, San Francisco, CA, USA
Corresponding Author:
Donald Morisky, UCLA School of Public Health, Department of
Community Health Sciences, 650 Charles E. Young Drive South, 46-071
CHS, Los Angeles, CA 90095-1772, USA
Email: dmorisky@ucla.edu
Perceptions About HIV and Condoms and
Consistent Condom Use Among Male Clients
of Commercial Sex Workers in the Philippines
Rotrease Regan, PhD, MS, MPH1,2, and Donald Morisky, ScD, MSPH1[AQ: 1]
Abstract
Because consistent condom use is an effective strategy in the prevention of sexually transmitted infections and HIV
transmission, it is important to examine social cognitive influences of consistent condom use not only among female
sex workers (FSWs) but also among their male clients, for whom less is known. Because little is known about how HIV
knowledge and condom attitudes affect condom use among male clients of FSWs in the Philippines, the main objective
was to determine what characteristics (age, education, HIV knowledge, marital status) as well as attributes taken from
protection motivation theory (perceived vulnerability, perceived severity, response efficacy) are significantly associated
with consistent condom use among male clients of FSWs. Logistic regression analyses showed that the odds of using
condoms consistently with an FSW are 13% higher for those with more years of education (adjusted odds ratio [AOR] =
1.13; 95% confidence interval [CI] = 1.03, 1.23), higher versus lower perception of severity of HIV/AIDS (AOR = 1.97;
95% CI = 1.04, 3.73), and had a higher score for response efficacy of condoms (AOR = 1.14; 95% CI = 1.03, 1.27). Future
HIV/AIDS prevention interventions that address condom use among male clients should promote educational attainment
and focus on awareness of the enduring negative health consequences of acquiring HIV/AIDS, as well as cultivate positive
attitudes toward the efficacy of condom use, using creative social marketing strategies.
Keywords
Asian/Pacific Islander, health promotion, HIV/AIDS, sex behavior, women’s health

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Health Education & Behavior XX(X)
In the Philippines, HIV is predominantly acquired via het-
erosexual intercourse and among men who have sex with men
(UNAIDS, 2010). The commercial sex work industry is con-
sidered to contribute significantly to the rates of heterosexual
transmission of HIV with FSWs and their male clients serving
as “bridges” to the spread of HIV/AIDS to the general popula-
tion (Potterat, Rothenberg, & Bross, 1979; Remple, Patrick,
Johnston, Tyndall, & Jolly, 2007). In the Philippines, although
prostitution is illegal, some female employees of entertain-
ment establishments such as bars, beer gardens, nightclubs,
karaoke halls, and massage parlors often engage in clandestine
sexual relations with clients who frequent these establish-
ments. A network of Sexual Health Clinics provide STI
screening and prescriptions for registered female “entertain-
ment workers” in more than 140 cities (Wi et al., 2006).
Structural interventions such as policies mandating condom
use within entertainment establishments have also been a
strategy aimed to increase condom use and decrease new HIV/
STI infections (Rojanapithayakorn, 2006). Research has sug-
gested that mandatory STI screening as well as the presence of
management support for establishment-based condom policy
is significantly associated with higher rates of condom use by
FSWs (Amadora-Nolasco, Alburo, Aguilar, & Trevathan,
2001; Morisky, Peña, Tiglao, & Liu, 2002). However, not all
establishments have a mandatory condom use policy, and
enforcement of existing policies is often challenging.
Therefore, despite the presence of these policies barriers to
consistent condom use exist (Amadora-Nolasco et al., 2001).
Since consistent condom use is an effective strategy of
STI prevention, it is important to examine social cognitive
influences of consistent condom use not only among FSWs
but also among their male clients, for whom less is known.
Because little is known about the factors associated with
condom use among male clients of FSWs in the Philippines,
our main objective is to determine what attributes are signifi-
cantly associated with consistent condom use among male
clients of FSWs.
In the current study, constructs from Protection Motivation
Theory (PMT; Rogers, 1975, 1983) guide our examination of
male attributes. PMT expands on other models of behavior
change, including the Health Belief Model (Rosenstock,
1974); Information, Motivation, and Behavior Model (Fisher
& Fisher, 1992); and Bandura’s (1977) Social Cognitive
Theory. According to PMT, an individual’s motivation to pro-
tect oneself from a threat depends on several factors: (a) the
perceived severity of the event (in the current study, the
“event” is the possible acquisition of an STI or infection with
HIV during an episode of unprotected sex), (b) the perceived
vulnerability (probability) of the occurrence of the event,
and (c) the perceived efficacy of the recommended preven-
tive behavior (e.g., condom use). Perception of HIV/AIDS
severity and vulnerability are purported to be associated with
more consistent condom use by increasing perceptions of the
benefits of condom use (Wang et al., 2009). Additionally,
although it has long been acknowledged that knowledge
alone is necessary but not sufficient for behavior change to
occur, HIV/AIDS knowledge as well as positive attitudes
and beliefs about condoms and their utility in preventing
infections have been associated with condom use (Thomsen,
Stalker, & Toroitich-Ruto, 2004; Wang et al., 2009).
Understanding which attributes of male clients are related to
consistent condom use may inform intervention strategies that
address the prevention of sexually transmitted infections,
including HIV in the Philippines. The current study attempted
to answer the primary research question: Which characteristics
(age, education, HIV knowledge, and marital status) and attri-
butes taken from PMT (perceived severity, perceived vulnera-
bility, and/or perceived efficacy of condom use) are related to
consistent condom use among male clients in the Philippines?
Method
Source of Data
This study is a secondary analysis of data gathered for a
larger study. Data for this study are from a longitudinal study
designed to improve knowledge, attitudes, and practices con-
cerning STI/HIV among FSWs, potential male clients (mili-
tary, police and firemen, factory workers, drivers associations,
and community residents), and establishment in six different
geographic regions of the southern Philippines, namely,
Lapu-Lapu and Mandaue City in Metropolitan Cebu, Legaspi
and Daraga in the Bicol Region, and Cagayan de Oro City in
Mindanao and Cavite City in the southern Tagalog Region
(Morisky, Ang, Coly, & Tiglao, 2004; Morisky, Nguyen,
Ang, & Tiglao, 2005; Morisky & Tiglao, 2010). A cross-
lagged panel study design was implemented in four sites in
southern Philippines. Formative research indicated that these
groups were a large source of clients for FSWs (Morisky et al.,
2005). In all, 18 organizations participated in the study in
which all men were surveyed at baseline. Through the assis-
tance of the City Health Officer and physician from the
Social Hygiene Clinic, as well as the mayors, city officials,
and participating nongovernmental organizations, men from
these organizations were approached and asked to participate
in the study. A total of 3,118 males participated in the longi-
tudinal intervention parent study. Details of this parent study
have been described (Morisky et al., 2004). This study uses
data from the baseline interview of 405 men who reported
ever paying for vaginal sex with an FSW. Data were excluded
for 19 (4.7%) of these participants because of incomplete
information on study variables, leaving a sample of 386 men.
Data Collection
Participants completed the questionnaire in their language of
choice (Tagalog, Cebuano, Bicol, or English). The question-
naire collected data on individual’s demographic character-
istics including age, marital status, and education. The
instrument also contained items that captured HIV/AIDS
knowledge, as well as condom use behaviors and attitudes
toward condom use. The measures presented in this study

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Regan and Morisky
3
were derived from male survey items from the larger parent
study (Morisky et al., 2004; Tiglao, Morisky, Tempongko,
Baltazar, & Detels, 1996). The study received approval from
the institutional review boards of the University of the
Philippines and the University of California, Los Angeles.
Measures
Consistency of condom use with sex worker. Participants
who acknowledged ever having vaginal sex with an FSW
from an entertainment establishment were asked how often
they used a condom when they had vaginal sex. Overall fre-
quency of condom use was coded as 1 = every time, reflect-
ing consistent condom use, and 0 = not every time.
Perceived severity. As perceived severity of HIV/AIDS was
measured by a single item that asked participants if they believed
that “a person with HIV/AIDS can be cured?” Responses were
coded “1” = no, reflecting a higher perception of severity, and
“0” = yes, reflecting a lower perception of severity.
Perceived vulnerability. Perceived vulnerability was mea-
sured by a single item that asked, “How worried are you
about getting AIDS?” Responses ranged from “0” = not wor-
ried at all to “4” = extremely worried.
Response efficacy. Response efficacy was measured with a
scale derived from four questionnaire items similar to those
developed in previous research (Li et al., 2004). Respon-
dents were asked to report the degree to which they agreed or
disagreed to four statements: “Condoms are good at prevent-
ing pregnancy,” “Condoms can prevent sexually transmitted
diseases if used properly,” “ If my partner asked me to I
would use a condom,” and “Condoms are appropriate for use
with casual partners.” Responses were on a Likert-type
scale: 1 = strongly disagree, 2 = disagree, 3 = neutral/no
opinion/don’t know, 4 = agree, and 5 = strongly agree. A con-
tinuous score was created by summing responses to the four
items. The internal consistency reliability was α = .55.
HIV/AIDS knowledge. HIV/AIDS knowledge was measured
by eight “yes/no” items developed and piloted in the parent
study and used in previous research (Morisky et al., 1998).
These items assess knowledge and understanding of possible
transmission routes. Respondents were asked whether they
thought a person could get infected with HIV via (a) blood
transfusion, (b) sexual intercourse, (c) drug use/sharing nee-
dles, (d) kissing, (e) breathing air infected with HIV, (f) mos-
quitoes, (g) toilet seats, or (h) from mother to baby (α = .70).
Participants received a code of “1” for each correct response
and “0” for incorrect responses. Responses of don’t know were
coded as “0.” Correct responses were summed to create an
index where higher items were indicative of higher HIV/AIDS
knowledge. HIV/AIDS knowledge ranged from 0 to 8.
Demographic Characteristics
Participant background characteristics were assessed during
the interview, and data on age, educational attainment, and
marital status were collected.
Analytic Methods
First, descriptive statistics were used to examine the mean
standard deviation, ranges, or percentages for all variables in
the analysis. Bivariate logistic regression was then conducted
to evaluate the relationships between the independent variables
and the outcome variable. Subsequently, an adjusted multi-
variate logistic regression analysis was conducted. Variables
that were significant at p < .10 were selected for inclusion in
the final adjusted multivariate model (Hosmer & Lemeshow,
1989). Statistical significance of variables in the final model
was determined by significance level of p < .05. Analyses were
conducted in STATA version 11.1 (StataCorp, 2009).
Results
Demographic Characteristics, HIV Knowledge,
and Condom Use Behaviors
The description of the study population and variables included
in the analysis is shown in Table 1. Consistency of condom
use was reported as either “every time” (n = 86; 22.3%) or
“not every time” (n = 300; 77.7%). Overall, the mean age was
about 35 years, with a mean of 11 years of education. HIV/
AIDS knowledge was not very high among these men, with
the mean score on the HIV knowledge items being just more
than 5 (SD = 1.74; range = 0-8). The majority (63.5%) of men
were married. The responses of the participants reflected
somewhat higher rather than lower perceptions of vulnerabil-
ity (M = 2.76; SD = 1.36; range = 0-4). However, more than
25% of the men reported that HIV/AIDS was a curable ill-
ness, reflecting lowered perception of severity of this disease.
The men’s response efficacy toward condom use were posi-
tive overall (M = 15; SD = 2.56; range = 5-20), reflecting their
attitudes that condoms are efficacious in preventing infec-
tions. A descriptive comparison between consistent condom
users and inconsistent condom users revealed that consistent
condom users were slightly younger and more educated than
inconsistent condom users. Although some differences were
small, consistent condom users reflected a group with a lower
proportion of married men, higher HIV/AIDS knowledge,
higher perception of HIV/AIDS severity, and slightly lower
perception of vulnerability and higher response efficacy of
condom use than their counterparts.
Predictors of Consistent
Condom Use With FSWs
Table 2 shows the results of the bivariate and multivariate
logistic regression analyses of associations with consistent
condom use among male clients of FSWs. The results of the
bivariate models showed that male clients were significantly
more likely to report consistent condom use with an FSW if
they were better educated (odds ratio [OR] = 1.15; 95% con-
fidence interval [CI] = 1.05, 1.25), had a high rather than low
perception of severity of HIV/AIDS (OR = 0.74; 95% CI =

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Health Education & Behavior XX(X)
1.12, 3.92), and if their response efficacy of condoms was
higher (OR = 1.16; 95% CI = 1.05, 1.29). Although only
significant at the p < .10 level, males who had a higher per-
ceived vulnerability to HIV/AIDS were less likely to use
condoms consistently (OR = −0.15; 95% CI = 0.72, 1.02).
However, in accordance with the data analysis plan, this vari-
able was maintained and entered into the multivariate model.
Overall, the multivariate logistic regression model remained
consistent with the bivariate associations. Educational attain-
ment, perceived vulnerability, and response efficacy of con-
doms were each significant predictors of consistent condom
use among the male clients of FSWs in this study. For each
additional year of education, the odds of using condoms con-
sistently increases by 13% (adjusted odds ratio [AOR] = 1.13;
95% CI = 1.03, 1.23). For those with a high versus low
perception of severity of HIV/AIDS, the odds of consistent
condom use is almost twice as great (AOR = 1.97; 95% CI =
1.04, 3.73). Finally, for each unit increase in score for
response efficacy of condoms, the odds of consistent condom
use increased by 14% (AOR = 1.14; 95% CI = 1.03, 1.27).
Discussion
This study is one of few that have examined condom use
among male clients of FSWs in the Philippines. Consistent
condom use was found to be quite low in the current study.
Although data on consistent condom use among male clients
of FSWs in the Philippines is scant, one survey reported that
among high-risk groups (FSWs, MSM, and IDUs), consis-
tent condom use reported for the prior week was less than
Table 1. Baseline Characteristics of Male Clients of Female Sex Workers by Consistency of Condom Use (N = 386)
Consistency of Condom Use
Every Time, n = 86 (22.28%)
Not Every Time,
n = 300 (77.72%)
Total, N = 386
(100%)
Age (range = 16-77 years)
Years of education (range = 2-18 years)
Marital status
Married
Not married
HIV/AIDS knowledge (range = 0-8)
Perceived severity of HIV/AIDS
High
Low
Perceived vulnerability of HIV/AIDS (range = 0-4)
Response efficacy (range = 5-20)
33.50 ± 9.36
12.20 ± 3.06
35.28 ± 9.48
11.10 ± 2.87
34.88 ± 9.47
11.34 ± 2.95
49 (56.98)
37 (43.02)
5.27 ± 1.77
196 (65.33)
104 (4.67)
5.14 ± 1.74
245 (63.47)
141 (6.53)
5.17 ± 1.74
72 (83.72)
14 (16.28)
2.53 ± 1.52
15.70 ± 1.95
213 (71.00)
87 (29.00)
2.82 ± 1.30
14.79 ± 2.68
285 (73.83)
101 (26.17)
2.76 ± 1.36
14.99 ± 2.56
Note. Continuous variables are expressed as a mean ± standard deviation; categorical variables are expressed as frequency (percentage).
Table 2. Results of Bivariate and Multivariate Logistic Regression Analyses Demonstrating Associations Between Individual
Characteristics and Consistent Condom Use With Female Sex Workers (N = 386)
Bivariate Analysis
Multivariate Analysis
VariableEstimate (b) Unadjusted OR95% CIEstimate (b)
Adjusted
OR95% CI
Age
Years of education
Marital status (Married = 1; Not
married = 0)
HIV/AIDS knowledge
Perceived severity of HIV/AIDS
(High = 1; Low = 0)
Perceived vulnerability of HIV/AIDS
Response efficacy
−0.02
0.14
−0.35
0.98
1.15
0.70
[0.95, 1.00]
[1.05, 1.25]**
[0.43, 1.15]
—
0.12
—
—
1.13
—
—
[1.03, 1.23]**
—
0.05
0.74
1.05
2.10
[0.91, 1.20]
[1.12, 3.92]*
—
0.68
—
1.97
—
[1.04, 3.73]*
−0.15
0.15
0.86
1.16
[0.72, 1.02]†
[1.05, 1.29]**
−0.09
0.13
0.92
1.14
[0.77, 1.09]
[1.03, 1.27]**
Note. OR = odds ratio; CI = confidence interval. Odds ratios reflect the odds of using condoms “every time” versus “not every time.” For continuous
variables, the OR should be interpreted as an increase in odds for a one-unit increase in the continuous independent variable.
**p ≤ .01. *p ≤ .05. †p ≤ .10.

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Regan and Morisky
5
35% overall. Therefore, the results of the current study are
in line with the overall low trend in condom use reported
among other high-risk groups in the Philippines (WHO-
WPR, 2002). The current analysis revealed that significant
factors of consistent condom use among male clients of
FSWs included educational attainment, perception of HIV/
AIDS severity, and response efficacy toward condoms.
These findings are consistent with previous studies and with
the tenants of PMT and may inform intervention efforts to
increase condom use among male clients of FSWs in the
Philippines.
The significant association between education and con-
dom use is consistent with findings from previous studies
(Bankole, Ahmed, Neema, Ouedraogo, & Konyani, 2007;
Zellner, 2003). It may be that education provides individuals
with tools to understand the complexities of HIV/AIDS as
well as understand the benefits of preventive behaviors. A
higher versus lower perception of HIV/AIDS severity was
associated with an increase in almost twice the odds of con-
sistent condom use. This implies that perception of severity
plays a large role in consistent condom use among this sam-
ple of male clients. This would lead us to suggest that
attempts to increase awareness of the severity of an HIV/
AIDS diagnosis may translate into increased condom use
among male clients of FSWs.
This study showed that men with higher perceptions that
condoms can be beneficial and effective in STI/HIV preven-
tion (response efficacy) were more likely to use condoms
consistently. This provides support for interventions aimed
at promoting condom use by emphasizing the benefits of
condom use. Future studies should determine whether and
how the framing of condom use messages affects condom
use among Filipino men.
Several factors in our study were not found to be signifi-
cantly associated with consistent condom use. Age, HIV/
AIDS knowledge, marital status, or perceived vulnerability
were not significantly associated with condom use in the cur-
rent study. Although not significant in the current study,
older age has been reported as a significant predictor of con-
dom use in previous studies (Belza et al., 2008; Yang, Latkin,
Luan, & Nelson, 2010; Zellner, 2003).
The finding that HIV knowledge was not associated with
condom use in the current study was expected and is consistent
with previous literature, as well as with the conclusions of a
study conducted with FSWs in the Philippines (Amadora-
Nolasco et al., 2001). It has been reported that HIV knowledge
alone is not sufficient to change behavior (Rosenstock,
Strecher, & Becker, 1994). Evidence that supports the role of
HIV knowledge in encouraging preventive behaviors may be
best within a comprehensive view of HIV/AIDS education and
prevention that addresses multiple factors simultaneously.
Marital status has also been shown to be a predictor of
condom use in some studies (Zellner, 2003) but not in others
(Belza et al., 2008; Yang et al., 2010). The fact that marital
status was not significantly associated with condom use in
the bivariate analysis conducted in the current study is trou-
bling. This is because condom use is low overall, and the
percentage of men who are married is high, suggesting that
some wives may be exposed to infections that might be
acquired when their husbands have unprotected intercourse
with FSWs.
It has been posited that a perception of vulnerability to
illness/infection is essential to health behavior change (Janz
& Becker, 1984). However, research has returned mixed
results regarding the significance of this construct to HIV
prevention (Montgomery, Joseph, Becker, & Ostrow, 1989).
The current study did not find a significant association
between perceived vulnerability of HIV/AIDS and condom
use, which is consistent with a study by Volk and Koopman
(2001), who found no association between perceived vulner-
ability and condom use among male and female participants.
However, our findings are inconsistent with a study by Yang
et al. (2010), who reported that a high perception of HIV/
AIDS vulnerability was associated with consistent condom
use among male clients of FSWs. This difference in study
findings could be because of measurement or cultural differ-
ences between populations studied. However, it has been
suggested that perception of severity and vulnerability to STI
or HIV infection may decrease as relationships progress
(Fortenberry, Tu, Harezlak, Katz, & Orr, 2002). Therefore, if
male clients frequent the same sex establishments and/or
engage in sexual relations with familiar sex workers, their
perceptions of risk may decrease over time, resulting in less
condom use (Cooper, Shapiro, & Powers, 1998). Further
study is needed to further elucidate the relationship between
perceptions of vulnerability and condom use among male
clients of FSWs.
Limitations and Strengths
Several limitations should be taken into account when inter-
preting this study. First, data collected for this study were
assessed at one point in time and thus limiting the ability to
make conclusions regarding causality. Although the data
were collected from different geographic regions of the
Philippines, this study was limited to a subsample of men
who reported being clients of FSWs. It is possible that other
men were reluctant to disclose their sexual relationships
with FSWs for a variety of reasons and were therefore not
included, and the findings of this study are not generalizable
to all Filipino men. It is also not possible to rule out potential
bias because of inaccurate or intentionally misleading
responses. Data were not collected on rates of anal sex;
therefore, our interpretation of the findings applies only to
instances of vaginal intercourse. The PMT scale of response
efficacy used in this study was found to have internal consis-
tency reliability. The reliability of .55 found in the current
study compares with the reliability of a similar scale devel-
oped in a study by Li et al. (2004). However, it is acknowl-
edged that future research is warranted so that this construct

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Health Education & Behavior XX(X)
can be better assessed. Finally, there are other factors not
included in this study that contribute to consistent condom
use among male clients of FSWs. Some of these factors may
preclude focus at the individual level. For instance, although
this study did not address the impact of religion, the large
presence of Catholics in the Philippines makes it relevant to
explore the role of Catholicism and the Catholic Church in
future studies (Human Rights Watch, 2004).
Conclusion
Despite its limitations, this study has important implications
for the design of interventions aimed at increasing condom
use in the context of commercial sex work. This study dem-
onstrated that education, perceived severity of HIV/AIDS,
and positive response efficacy toward condoms are signifi-
cant predictors of condom use among male clients of FSWs.
Future HIV/AIDS prevention interventions that address
condom use among male clients should promote educational
attainment and focus on awareness of the enduring negative
health consequences of acquiring HIV/AIDS, as well as
cultivate positive attitudes toward the efficacy of condom
use, using creative social marketing strategies. Combining
these approaches along with environmental–structural
approaches, which have been implemented in some coun-
tries (Kerrigan et al., 2006; Morisky et al., 2002; Morisky &
Tiglao, 2010), may increase the percentage of male clients
who use condoms consistently in the Philippines.
Acknowledgment
We extend appreciation to our coinvestigator Dr. Teodora Tiglao
(deceased); research manager, Charlie Mendoza; site coordinators,
Dorcas Romen, Grace Carungay, Angelica Mallari, Mildred
Publico, and Grace Ong.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.[AQ: 2]
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article:
This research was supported by Grant R01-AI33845 from the
National Institute of Allergy and Infectious Diseases to Donald E.
Morisky, and written with support from the UCLA Graduate
Division Doctoral Training Program in the Social and Behavioral
Determinants of HIV/AIDS Prevention; and Grant T32 MH19105
from the National Institutes of Mental Health.[AQ: 3]
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