Factors associated with self-efficacy for condom use and sexual negotiation among South african youth.

Abstract

To use logistic regression modeling to identify factors associated with high self-efficacy for sexual negotiation and condom use in a sample of South African youth.
The Reproductive Health and HIV Research Unit (RHRU) National Youth Survey examined a nationally representative sample of 7409 sexually active South African youth aged 15 to 24 years. We used logistic regression modeling in this sample to identify factors associated with the main outcome of high self-efficacy.
Among female respondents (n = 3890), factors associated with high self-efficacy in the adjusted model were knowing how to avoid HIV (odds ratio [OR] = 2.30, 95% confidence interval [CI]: 1.05 to 5.00), having spoken with someone other than a parent or guardian about HIV/AIDS (OR = 1.46, 95% CI: 1.01 to 2.10), and having life goals (OR = 1.28, 95% CI: 1.10 to 1.48). Not using condoms during their first sexual encounter (OR = 0.61, 95% CI: 0.50 to 0.76), a history of unwanted sex (OR = 0.66, 95% CI: 0.51 to 0.86), and believing that condom use implies distrust in one's partner (OR = 0.57, 95% CI: 0.51 to 0.86) were factors associated with low self-efficacy among female respondents. Male respondents (n = 3519) with high self-efficacy were more likely to take HIV seriously (OR = 4.03, 95% CI: 1.55 to 10.52), to believe they are not at risk for HIV (OR = 1.38, 95% CI: 1.12 to 1.70), to report that getting condoms is easy (OR = 1.85, 95% CI: 1.23 to 2.77), and to have life goals (OR = 1.30, 95% CI: 1.10 to 1.54). Not using condoms during their first sexual experience (OR = 0.51, 95% CI: 0.39 to 0.67), a history of having unwanted sex (OR = 0.47, 95% CI: 0.34 to 0.64), believing condom use is a sign of not trusting one's partner (OR = 0.63, 95% CI: 0.46 to 0.87), and refusing to be friends with HIV-infected persons (OR = 0.52, 95% CI: 0.32 to 0.85) were factors associated with low self-efficacy among male respondents in the fully adjusted model.
We used the social cognitive model (SCM) to identify factors associated with self-efficacy for condom use and sexual negotiation. Many of these factors are modifiable and suggest potential ways to improve self-efficacy and reduce HIV sexual risk behavior in South African youth.

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EPIDEMIOLOGY AND SOCIAL SCIENCE
Factors Associated With Self-Efficacy for Condom Use
and Sexual Negotiation Among South African Youth
Jennifer N. Sayles, MD,* Audrey Pettifor, PhD,† Mitchell D. Wong, MD, PhD,*
Catherine MacPhail, PhD,‡ Sung-Jae Lee, PhD,§ Ellen Hendriksen, BA,kHelen V. Rees, MD,†
and Thomas Coates, PhD¶
Objectives: To use logistic regression modeling to identify factors
associated with high self-efficacy for sexual negotiation and condom
use in a sample of South African youth.
Methods: The Reproductive Health and HIV Research Unit
(RHRU) National Youth Survey examined a nationally representative
sample of 7409 sexually active South African youth aged 15 to 24
years. We used logistic regression modeling in this sample to identify
factors associated with the main outcome of high self-efficacy.
Results: Among female respondents (n = 3890), factors associated
with high self-efficacy in the adjusted model were knowing how to
avoid HIV (odds ratio [OR] = 2.30, 95% confidence interval [CI]:
1.05 to 5.00), having spoken with someone other than a parent or
guardian about HIV/AIDS (OR = 1.46, 95% CI: 1.01 to 2.10), and
having life goals (OR = 1.28, 95% CI: 1.10 to 1.48). Not using
condoms during their first sexual encounter (OR = 0.61, 95% CI: 0.50
to 0.76), a historyof unwanted sex (OR = 0.66, 95% CI: 0.51 to 0.86),
and believing that condom use implies distrust in one’s partner (OR =
0.57, 95% CI: 0.51 to 0.86) were factors associated with low self-
efficacy among female respondents. Male respondents (n = 3519)
with high self-efficacy were more likely to take HIV seriously (OR =
4.03, 95% CI: 1.55 to 10.52), to believe they are not at risk for HIV
(OR = 1.38, 95% CI: 1.12 to 1.70), to report that getting condoms is
easy (OR = 1.85, 95% CI: 1.23 to 2.77), and to have life goals (OR =
1.30, 95% CI: 1.10 to 1.54). Not using condoms during their first
sexual experience (OR = 0.51, 95% CI: 0.39 to 0.67), a history of
having unwanted sex (OR = 0.47, 95% CI: 0.34 to 0.64), believing
condom use is a sign of not trusting one’s partner (OR = 0.63, 95%
CI: 0.46 to 0.87), and refusing to be friends with HIV-infected
persons (OR = 0.52, 95% CI: 0.32 to 0.85) were factors associated
with low self-efficacy among male respondents in the fully adjusted
model.
Conclusions: We used the social cognitive model (SCM) to identify
factors associated with self-efficacy for condom use and sexual
negotiation. Many of these factors are modifiable and suggest
potential ways to improve self-efficacy and reduce HIV sexual risk
behavior in South African youth.
Key Words: adolescents, condom use, gender, HIV, self-efficacy,
South Africa
(J Acquir Immune Defic Syndr 2006;43:226–233)
H
quarter of women aged 20 to 24 years infected with HIV
compared with 1 in every 14 men of the same age.1–3
Consistent condom use and negotiation of safer sex are the
most effective means of HIV risk reduction for sexually active
youth, yet studies have shown that in South Africa, rates of
condom use are far from ideal and are lower for women (48%)
than for men (53%–57%).1–4In South Africa, condoms are
widely available at no cost,1,3,5,6and most South African youth
report they know that condoms prevent HIV, sexually
transmitted infections (STIs), and unwanted pregnancy.7
Accessibility and knowledge about condoms have not trans-
lated into condom use for many youth, however.
Self-efficacy is having confidence in one’s ability to
perform a particular behavior, and high self-efficacy for
condom use is strongly associated with consistent condom
use.4,8–12Rooted in social cognitive theory, the concept of self-
efficacy is an important component of health-related behav-
ioral change.13,14According to this model, self-efficacy may be
shaped by social norms, knowledge, outcome expectations,
and communication with family and community members.13
Previous studies of HIV risk behaviors and sexual health have
consistently shown that high self-efficacy for condom use is
strongly associated with the behaviors of condom use with
recent partners and consistent condom use.10–12Little is known
about the factors that influence self-efficacy and how they
may differ by gender, however. In addition, few data on
self-efficacy for condom use and sexual negotiation among
IV prevalence in South African youth is alarmingly high
and disproportionately affects girls and women, with one
Received for publication September 16, 2005; accepted May 19, 2006.
From the *Division of General Internal Medicine and Health Services
Research, Department of Medicine, University of California, Los Angeles,
Los Angeles, CA; †Department of Epidemiology, University of North
Carolina at Chapel Hill, Chapel Hill, NC; ‡Reproductive Health and HIV
Research Unit, University of Witwatersrand, Johannesburg, South Africa;
‡Neuropsychiatric Institute, Center for Community Health, University of
California, Los Angeles, Los Angeles, CA;kDepartment of Psychology,
University of California, Los Angeles, Los Angeles, CA; and the
{Division of Infectious Disease, Department of Medicine, University of
California, Los Angeles, Los Angeles, CA.
Funding for the National Youth Survey was provided by the Kaiser Family
Foundation. J. N. Sayles is a National Research Service Award Fellow in
the Division of General Internal Medicine and Health Services Research,
UCLA, and was partially supported by the UCLA Primary Care Research
Fellowship Program.
Reprints: Jennifer N. Sayles, MD, UCLA Division of General Internal
Medicine and Health Services Research, 911 Broxton Plaza, PO Box
951736, Los Angeles, CA 90095–1736 (e-mail: jsayles@mednet.ucla.
edu).
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Page 2

sub-Saharan African youth exist; yet, this population is at
particularly high risk for HIV infection.
We used data from the 2003 Reproductive Health and
HIV Research Unit (RHRU) National Youth Survey, a nation-
ally representative household survey of HIV prevalence and
sexual behavior among South African youth aged 15 to 24
years, to identify factors associated with self-efficacy for
sexually experienced female and male youth. We evaluate the
usefulness of self-efficacy and the social cognitive model
(SCM) for understanding condom use in this population and
explore factors associated with self-efficacy that may inform
the development of interventions to reduce HIV risk behavior.
METHODS
Study Population
The RHRU National Youth Survey used a 3-stage,
disproportionate, stratified sampling design. The 2001
National Census was used as the sampling frame, with census
enumeration areas (EAs) used as the primary sampling unit
(PSU). Households within sampled EAs were enumerated, and
1 eligible young person per household was randomly selected
for the study. A total of 15,414 enumerated and eligible
households (youth between the age of 15 and 24 years old) and
2063 households that were not enumerated but presumed to
have an eligible youth were sampled. A total of 11,904
interviews were completed, resulting in an overall response
rate of 68.2%. The sample for this analysis was restricted to
youth who reported having had vaginal or anal sex, totaling
7686 respondents. After excluding 277 youth because of
missing data (3.6% of the 7686 sexually activeyouth), the final
analytic sample included 7409 youth.
Experienced interviewers aged 18 to 35 years underwent
aweek-long training session and were matched to interviewees
on the basis of gender, language, and race. Interviews were
conducted in private. All questionnaires used in the face-to-
face interviews were translated from English into 8 official
South African languages and then back-translated to ensure
accuracy. The survey collected information about demograph-
ics; general attitudes about health, relationships, and sexual
behaviors; attitudes about relationships, sexual behaviors, and
HIV/AIDS; health-seeking behavior; alcohol and drug use;
STIs; and pregnancy. Anonymous oral fluid specimens were
collected for HIV testing (Orasure HIV-1 Specimen Collection
Device; Orasure Technologies, Inc.). Informed consent was
obtained for all participants, and parental consent was also
obtained for youth aged 15 to 17 years old. The study was
approved by the Committee for the Protection of Human
Subjects, University of the Witwatersrand, Johannesburg,
South Africa.
Measures of Self-Efficacy for Condom Use and
Sexual Negotiation
A self-efficacy index for condom use and sexual
negotiation was created using the 5 questions listed in Table
1. This scale was constructed in part from a previously
validated 14-item scale of condom self-efficacy.15Questions
regarding condom use all loaded on the communication self-
efficacy factor from the previously validated scale. Response
scores ranged from 1 to 4 for each question in the self-efficacy
index, resulting in a 20-point scale (Cronbach a of 0.64 for
women and 0.60 for men). Persons who had a total self-
efficacy index score of 16 to 20 (ie, on average, answered
‘‘yes’’ to each of the 5 self-efficacy questions listed in Table 1)
were categorized as having ‘‘high self-efficacy,’’ and those
with a score less than 16 were categorized as having ‘‘low self-
efficacy.’’ We chose this cutoff because high self-efficacy
would be reflected in affirmative (yes) answers to each
question. Because of the positively skewed responses, a con-
tinuous outcome with linear regression was not an appropriate
model; thus, the cutoff point of 15 was chosen based on the
distribution of the data. The results were similar in a sensitivity
analysis using an alternative cutoff of 10 (dichotomized scores
TABLE 1. Self-Efficacy Scale Responses and Condom Use Consistency in Female and Male South African Youth
Self-Efficacy Scale Items
Female Respondents
Consistent Condom Use
Male Respondents
Consistent Condom Use
No YesNo Yes
Would you be able to avoid sex any time you didn’t want it?
No
Yes
Would you be able to use a condom every time you have sexual intercourse?
No
Yes
Would you be able to use a condom during sex after you have been drinking or
taking drugs?
No
Yes
Would you be able to refuse to have sex if your partner will not use a condom?
No
Yes
Would you be able to talk about using condoms with your partner?
No
Yes
12.5
86.5
8.3
91.7
15.5
84.4
11.0
89.0
32.9
67.1
3.5
96.5
31.9
68.1
4.6
95.4
56.2
43.8
31.6
68.4
49.5
50.5
29.6
70.4
42.1
57.9
16.8
83.2
34.0
66.0
15.9
84.1
10.4
89.6
2.2
97.8
8.9
91.1
2.6
97.4
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Page 3

of 0–10 vs. 11–20, indicating that a respondent, on average,
answered ‘‘probably yes’’ to each question).
Measures of Sociodemographic Characteristics
Sociodemographiccharacteristics
(male or female), age (range: 15–24 years), race (categorized
as black or not black, because 86% of the sample reported
black race), history of completing high school, being
unemployed and not in school, urban versus rural residence,
and having no electricity in the home. Based on our previous
experience, youth do not have reliable information about their
household income; thus, we used lack of electricity in the
home as a marker of poverty.
includedgender
Measures of Condom Use (Behavior
of Interest)
Condom use consistency with the last sexual partner and
condom use at the last sexualencounter were assessed for male
(n = 3519) and female (n = 3890) respondents who reported
having sex in the past 12 months. Respondents were asked:
‘‘How often did you use condoms with your last sexual
partner?’’ Response optionswere ‘‘always,’’ ‘‘more than half of
the time,’’ ‘‘half of the time,’’ ‘‘less than half of the time,’’ and
‘‘never.’’ Based on the distribution of responses, we di-
chotomized those who responded ‘‘always’’ versus all others.
Condom use at the last sexual encounter was determined by
asking respondents: ‘‘The last timeyouhad sexwithyour most
recent sexual partner, did you use a condom?’’ Response
options were ‘‘Yes’’ or ‘‘No.’’
Measures of Candidate Factors Associated
With Self-Efficacy
Candidate variables were identified using the Bandura
SCM (conceptual model and variables in Fig. 1), where self-
efficacy and its effects on condom use are influenced by the
individual’s knowledge of HIV (whether the respondent takes
HIV seriously, has ever been tested for HIV, or has knowledge
that there is something one can do to avoid HIV), prior sexual
experiences (early sexual debut at age ,15 years old; use of
condoms the first time the respondent had sex; or history of
unwanted, forced, or threatened sex), outcome expectations
(risk of HIV or condom use as a sign of distrust), socio-
demographic characteristics of the individual, sociostructural
facilitators (ability to talk with parents or others about HIV,
easy access to condoms, or relationship control), socio-
structural impediments (partner makes decisions about
condom use, would not be friends with someone with HIV
[representing HIV stigma], peer pressure to have sex, or
having ever used alcohol or drugs), and life goals.
Measure of Relationship Control
The relationship control variable was based on the
previously published relationship control index score16from
these survey data that was adapted from the Sexual Relation-
ship Power Scale.17,18The questions in the relationship control
index included agree or disagree responses to the questions:
‘‘Your partner has more control than you do in important
decisions that affect your relationship,’’ ‘‘When you and your
partner have an argument, your partner gets their way most of
the time,’’ ‘‘Your partner has more control than you do over
whether or not you use condoms,’’ and ‘‘Your partner has more
control than you do over whether or not you have sex.’’ The
4-point scale (Cronbach a of 0.69) was dichotomized for
analytic purposes, with score of 0 to 2 indicating high
relationship control and 3 to 4 indicating low control.
Additional details for the scale can be found elsewhere.16
Measure of Life Goals
The variable of life goals was constructed from 4
statements concerning the futuregoals and opportunities of the
respondent. The statements were: ‘‘I have long-range goals for
FIGURE 1. Paths of influence in the
SCM. Beliefs of personal efficacy for
condom use and sexual negotiation
affect the behavior of condom use
directly by their impact on goals,
outcomeexpectations,
ceived facilitators and impediments.
Knowledge about HIV infection as
well as sociodemographic character-
istics and prior sexual experiences
also may influence self-efficacy for
condom use (Adapted from Bandura
A. Health promotion by social cog-
nitive means. Health Educ Behav.
2004;31:145; with permission.)
andper-
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Page 4

myself,’’ ‘‘I think I will have many opportunities in life,’’ ‘‘I
know what I want out of life,’’ and ‘‘I have a good idea of
where I am headed in the future.’’ Responses to all statements
were ‘‘agree/disagree,’’ and each respondent was given a point
on the scale for each ‘‘agree’’response for a score ranging from
0 to 4. The Cronbach a for this scale of life goals was 0.70 for
women and men.
Statistical Analysis
The sample for this analysis was restricted to sexually
experienced youth, defined as any youth who has ever engaged
in anal or vaginal sex (n = 7409). The sample was weighted to
account for differential sampling probabilities and to represent
the distribution of young people aged 15 to 24 years living in
South Africa based on the 2001 National Census data. All
analyses were conducted using STATA 8.0 (College Station,
TX) and used the svy commands to adjust for the sampling
strata, PSUs, and population weights. We first report
participant characteristics by self-efficacy status for the sample
(Table 2). Next, we stratified our sample by gender and show
the proportion of respondents reporting consistent condom use
according to their answers for each question of the self-
efficacy scale (see Table 1). We then performed bivariate
logistic regression to determine the association between the
variables identified by our conceptual model and the outcome
of high self-efficacy (Tables 3, 4). Bivariate logistic regression
was also performed to determine the association between the
independent variable of high self-efficacy and the dependent
variable of condom use consistency by gender, which is the
behavior of interest in our conceptual model (see Fig. 1).
TABLE 2. Participant Characteristics According to Self-Efficacy Status in a Sample of 7409 Sexually Active South African Youth
Stratified by Gender (Reported as Proportions)
Respondent Characteristic (n = 7409)
Female Respondents (n = 3890)Male respondents (n = 2519)
% Low Self-Efficacy* % High Self-Efficacy* % Low Self-Efficacy* % High Self-Efficacy*
Sociodemographics
Black race
Other race
15–19 years of age
20–24 years of age
Completed high school
Unemployed (and not a student)
Urban residence
No electricity in the home
HIV-positive
Behavior of interest
Condom use at last sex
Always uses a condom
Knowledge
Takes HIV seriously
Has been tested for HIV ever
Knowledge of how to avoid HIV
Prior sexual experiences
First sexual experience ,15 years old
No condom the first time he/she had sex
History of having sex when didn’t want to
History of having sex because he/she was threatened
History of being physically forced to have sex
Outcome expectations
Believes he/she is at no risk for HIV infection
Believes condom use is sign of not trusting partner
Sociostructural factors
Has spoken to parent/guardian about HIV/AIDS
Has spoken with other person about HIV/AIDS
Reports easy to get condoms if wants/needs them
Would not be friends with person with HIV/AIDS
Perceives pressure from friends to have sex
High relationship control
Has had alcohol/drugs ever
Goals
Respondent has life goals
88.7
11.3
42.0
58.0
23.8
48.3
48.3
22.5
19.4
86.0
14.0
44.7
55.3
29.7
38.0
57.0
17.7
19.2
86.9
13.1
48.2
51.8
21.5
28.7
50.7
22.0
6.0
83.2
16.8
49.7
50.3
25.4
27.7
55.7
16.7
6.2
41.7
19.9
65.5
45.9
54.3
32.9
75.0
55.4
97.1
30.1
94.2
98.9
33.1
98.0
96.7
15.8
95.2
99.4
20.2
97.5
24.9
58.6
29.0
6.4
9.2
21.5
39.5
18.4
6.1
7.2
32.8
62.4
17.8
2.6
1.9
28.4
42.8
10.0
1.6
1.5
25.5
34.9
26.8
21.9
29.8
34.4
39.3
24.8
43.4
82.1
88.8
12.9
86.9
61.6
46.6
51.8
88.4
91.6
7.0
89.6
66.5
50.1
38.0
85.5
90.1
11.9
73.5
60.4
76.7
43.0
86.7
93.6
6.2
77.8
56.5
76.6
64.8 81.271.9 82.6
*All differences in proportions between high and low self-efficacy for each gender are significant at the P , 0.05 level.
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Page 5

Finally, we used a multiple logistic regression model to
examine the association between the outcome of high self-
efficacy and the candidate factors from our conceptual model
in female and male respondents, controlling for sociodemo-
graphic variables (see Tables 3, 4). Odds ratios (ORs) and 95%
confidence intervals were computed for each variable in the
bivariate and multivariate models. Because the data are cross-
sectional, our modeling is not able to establish causality or the
direction of association between self-efficacy and candidate
variables from our conceptual model.
RESULTS
Characteristics by self-efficacy status of the sample of
7409 sexually active South African youth are reported in Table
2. HIV prevalence in the sample reached 19.3% for female
respondents and 6.1% for male respondents, and HIV status
did not vary significantly according to self-efficacy status.
Approximately 42% of female respondents with low self-
efficacy reported using a condom during their last sexual
encounter, whereas 65.5% of female respondents with high
self-efficacy reported using a condom at their last sexual
encounter. For male respondents, 54.3% versus 75.0%
reported using a condom at their last sexual encounter for
low and high self-efficacy, respectively. The prevalence of the
respondent characteristics is shown in Table 2. In bivariate
analysis, female and male respondents with high self-efficacy
were more likely to use condoms with their most recent partner
than those with low self-efficacy (female respondents: OR =
2.37, 95% CI: 1.43 to 3.91; male respondents: OR = 3.11, 95%
CI: 2.39 to 4.04).
Table 1 shows the responses to the 5 questions
comprising the self-efficacy index and the proportion of
respondents reporting consistent condom use, stratified by
gender. For each of the 5 self-efficacy questions, female and
male respondents with high self-efficacy reported higher
proportions of consistent condom use than those with low self-
efficacy.
We then examined the factors associated with self-
efficacy for young women and men. Young women who
reported having knowledge of how to avoid HIV infection,
who havespokenwith someoneother than a parent orguardian
TABLE 3. Unadjusted and Adjusted Logistic Regression Models for Candidate Factors Associated With High Self-Efficacy for
Condom Use in Young Women
Candidate Factors Associated With High Self-Efficacy for Condom UseUnadjusted ORs (95% CI)Adjusted ORs (95% CI)
Sample size
Sociodemographics
Black race
Age (15–19 vs. 20–24 years)
Completed high school
Unemployed (and not student)
Urban residence
No electricity in the home
Knowledge
Take HIV seriously
Have been tested for HIV ever
Knowledge of how to avoid HIV
Prior sexual experiences
First sexual experience ,15 years old
No condom the first time he/she had sex
History of having sex when didn’t want to
History of having sex because he/she was threatened
History of being forced to have sex
Outcome expectations
Believes he/she is at no risk for HIV infection
Believes condom use is a sign of not trusting partner
Sociostructural factors
Has spoken to parent/guardian about HIV/AIDS
Has spoken with other person about HIV/AIDS
Reports easy to get condoms if wants/needs them
Would not be friends with person with HIV/AIDS
Perceives pressure from friends to have sex
High relationship control
Has had alcohol/drugs ever
Goals
Respondent has life goals
n = 3890n = 3890
0.78 (0.53 to 1.15)
1.03 (0.96 to 1.10)
1.88 (1.29 to 2.74)
0.65 (0.51 to 0.82)
1.91 (1.18 to 3.12)
0.36 (0.18 to 0.73)
1.00 (0.72 to 1.41)
1.08 (0.85 to 1.37)
1.10 (0.85 to 1.44)
0.81 (0.64 to 1.02)
1.06 (0.80 to 1.41)
0.64 (0.40 to 1.03)
1.96 (1.00 to 3.83)
1.27 (0.98 to 1.64)
3.96 (2.13 to 7.35)
1.47 (0.71 to 3.00)
1.02 (0.80 to 1.30)
2.30 (1.05 to 5.00)*
0.64 (0.39 to 1.05)
0.44 (0.35 to 0.55)
0.45 (0.29 to 0.68)
0.77 (0.53 to 1.13)
0.79 (0.54 to 1.14)
0.88 (0.63 to 1.24)
0.61 (0.50 to 0.76)‡
0.66 (0.51 to 0.86)†
0.98 (0.51 to 1.87)
1.07 (0.61 to 1.90)
1.26 (0.89 to 1.78)
0.36 (0.24 to 0.55)
0.96 (0.75 to 1.23)
0.57 (0.43 to 0.75)‡
1.38 (1.10 to 1.74)
2.70 (1.52 to 4.79)
1.19 (0.78 to 1.83)
0.30 (0.16 to 0.57)
0.53 (0.32 to 0.90)
1.41 (1.00 to 1.99)
0.95 (0.71 to 1.27)
0.96 (0.77 to 1.20)
1.46 (1.01 to 2.10)*
1.13 (0.79 to 1.64)
0.78 (0.48 to 1.28)
0.84 (0.62 to 1.15)
1.07 (0.85 to 1.36)
0.92 (0.72 to 1.17)
1.50 (1.26 to 1.79)1.28 (1.10 to 1.48)‡
*P , 0.05; †P , 0.01; ‡P , 0.001.
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Page 6

about HIV/AIDS, and who have life goals were more likely to
have high self-efficacy in the adjusted model (see Table 3).
Factors significantly associated with low self-efficacy for
young women in the adjusted model included not using
condoms the first time they had sex, a history of having sex
when they did not want to, and believing that condom use is
a sign of not trusting one’s partner.
Among young men, factors that were significantly
associated with high self-efficacy in the adjusted model
included taking HIV seriously, believing that they are at no
risk of HIVinfection, reporting that it is easy toget condoms if
they want or need them, and having life goals. Young men with
low self-efficacy were more likely not to use condoms the first
time they had sex, to have a history of having sex when they
did not want to, and reporting that they would not be friends
with a person with HIV/AIDS in the adjusted model.
DISCUSSION
Using the SCM as a framework to explore self-efficacy,
we were able to identify factors associated with self-efficacy
for young women and men. The model was successful in
identifying factors in each of the 6 domains of the SCM, many
of which are potentially mutable factors that may be amenable
to interventions aimed at increasing self-efficacy and condom
use in South African youth. In the domain of knowledge,
young women who reported knowledge of how to avoid HIV
and young men who said they take HIV seriously had higher
self-efficacy scores. Interestingly, this study found that most
men and women in the sample stated that they take HIV
infection seriously and that they have knowledge of how to
avoid HIV. Yet, less than half of the young men and less than
one third of the young women in this nationally representative
study reported consistent condom use. These results suggest
that although knowledge of the risks of HIV/AIDS may be an
important component of campaigns to promote condom use,
we must also focus efforts on understanding and exploring the
complex construction of sexuality among adolescents and
movebeyond the traditional assumption that sexual behavior is
the result of rational decisions based on knowledge.19–21For
example, participatory HIV prevention programs that are peer
based and understand sexuality in youth to be a socially
TABLE 4. Unadjusted and Adjusted Logistic Regression Models for Factors Associated With High Self-Efficacy for
Condom Use in Young Men
Candidate Factors Associated With High Self-Efficacy for Condom Use Unadjusted ORs (95% CI)Adjusted ORs (95% CI)
Sample size
Sociodemographics
Black race
Age (15–19 vs. 20–24 years)
Completed high school
Unemployed (and not student)
Urban residence
No electricity in the home
Knowledge
Take HIV seriously
Have been tested for HIV ever
Knowledge of how to avoid HIV
Prior sexual experiences
First sexual experience ,15 years old
No condom the first time he/she had sex
History of having sex when didn’t want to
History of having sex because he/she was threatened
History of being forced to have sex
Outcome expectations
Believes he/she is at no risk for HIV infection
Believes condom use is a sign of not trusting partner
Sociostructural factors
Has spoken to parent/guardian about HIV/AIDS
Has spoken with other person about HIV/AIDS
Reports easy to get condoms if wants/needs them
Would not be friends with person with HIV/AIDS
Perceives pressure from friends to have sex
High relationship control
Has had alcohol/drugs ever
Goals
Respondent has life goals
n = 3519n = 3519
0.65 (0.45 to 0.93)
1.01 (0.95 to 1.07)
1.45 (1.01 to 2.08)
0.90 (0.70 to 1.16)
1.46 (0.91 to 2.35)
0.45 (0.23 to 0.87)
0.95 (0.68 to 1.33)
0.82 (0.66 to 1.05)
1.10 (0.83 to 1.45)
1.03 (0.80 to 1.33)
0.84 (0.63 to 1.13)
0.71 (0.45 to 1.11)
2.72 (0.92 to 8.06)
1.35 (1.04 to 1.75)
2.53 (0.96 to 6.69)
4.03 (1.55 to 10.52)†
1.20 (0.93 to 1.56)
1.17 (0.59 to 2.34)
0.62 (0.40 to 0.97)
0.37 (0.25 to 0.55)
0.38 (0.26 to 0.54)
0.70 (0.33 to 1.50)
0.83 (0.35 to 1.98)
0.76 (0.58 to 1.01)
0.51 (0.39 to 0.67)‡
0.47 (0.34 to 0.64)‡
0.93 (0.44 to 1.94)
1.11 (0.45 to 2.70)
1.51 (1.21 to 1.87)
0.53 (0.37 to 0.76)
1.38 (1.12 to 1.70)†
0.63 (0.46 to 0.87)†
1.16 (0.95 to 1.43)
1.27 (0.68 to 2.35)
1.57 (1.15 to 2.67)
0.33 (0.16 to 0.64)
0.75 (0.54 to 1.07)
0.91 (0.73 to 1.14)
1.27 (0.72 to 2.29)
1.02 (0.82 to 1.28)
0.82 (0.56 to 1.21)
1.85 (1.23 to 2.77)†
0.52 (0.32 to 0.85)†
0.83 (0.63 to 1.08)
0.96 (0.75 to 1.24)
1.29 (0.92 to 1.83)
1.54 (1.27 to 1.86)1.30 (1.10 to 1.54)†
*P , 0.05; †P , 0.01; ‡P , 0.001.
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Page 7

negotiated phenomenon as opposed to an individual decision
may be more appropriate for this adolescent population. Such
programs seek to provide an intellectual understanding of how
certain social conditions (eg, gender identity, poverty) may
contribute to the risk of HIV and to provide a context for the
collective renegotiation of dominant norms of behavior that
may be placing young people’s sexual health at risk.22–24
The domain of outcome expectations in the SCM
revealed that beliefs about condoms were an important factor
influencing self-efficacy. Consistent with other studies in South
Africa and in developed countries, such as the United Kingdom
and Australia, we found that for young women and men, low
self-efficacy is associated with the belief that using condoms is
a sign of not trusting one’s partner.19,25–27These results suggest
that young men and women who believe that condom use
impliesdistrustoftheir partnerarelesslikelytobelievethatthey
can successfully negotiate condom use in sexual encounters.
The issue of trust in relation to condom use in South Africa is
complex and has been extensively debated. Studies of
adolescent sexuality show that trust is viewed as desirable in
adolescent relationships, yet it is claimed for relationships in
which traditional notions of trust (eg, monogamy) are known to
be absent.25,27,28Thus, a young woman with knowledge of her
partner having multiple other sexual partners may still report
that she trusts him and that requesting the use of condoms
wouldbeseentoviolatethistrust.Wehypothesizefromourdata
that young women who are able to challenge such beliefs about
condoms have higher self-efficacy for condom use and sexual
negotiation,which,inturn,mayleadtomoreconsistentcondom
use.Thesewomenmay providevaluableinsight astoalternative
ways to think about condom use as an acceptable part of
negotiating sexual encounters among South African youth.
Ultimately, a better understanding of these issues may inform
the development of interventions that challenge the perception
of condoms and the social context within which condom use is
negotiated in South Africa.
In the domain of goals of the SCM, having life goals was
associated with high self-efficacy for young men and women.
To our knowledge, no nationally representative studies of
sexual risk behavior and condom use in adolescents have
examined the relation between life goals and self-efficacy,
despite frequent use of the SCM for exploring such behaviors.
In the United States, small studies of Latinoyouth have shown
that having educational goals is a significant negative predictor
of intentions to have sex and sexual experiences in the prior 3
months.29,30Similar studies of sexual experiences and life
goals in African-American youth have not demonstrated the
same associations, however.31Further investigation of the
relation between life goals, self-efficacy, and risky sexual
behavior is warranted, because we are limited in drawing
conclusions about causality between these factors with our
cross-sectional data. These results lead us to hypothesize that
programs aimed at helping adolescents to create future goals
may also foster the development of strong self-esteem and self-
efficacy for the individual, which may, in turn, result in less
risky sexual behavior and improved condom use consistency.
In the domain of sociostructural factors, communication
about HIV/AIDS was associated with self-efficacy in young
women. Female respondents who spoke with someone other
than a parent or guardian about HIV/AIDS were more likely to
have high self-efficacy, although this was not true among male
respondents. This is consistent with research from Europe and
America, which has suggested that youth are more likely to
practice safe sex if they have opportunities to communicate
openly about sex with sexual partners, peers, and parents or
other significant adults.26,32,33A study of college students in the
United States showed that discussion of safe sex with friends
was a strong predictor of practicing safer sex.34In this same
study, gender differences were also found, because women were
more likely than men to pressure their friends to use condoms.34
Studies from South Africa have demonstrated that women who
are unable to communicatewith their partners are more likely to
be involved in risky sexual behavior.16,22,27This relation
between communication with a partner and condom use has
not been found in South African men. We hypothesize that this
may be the case because gender norms within predominant
South African culture establish men as the decision makers
about manyaspects ofthe sexualencounter,includingthe use of
condoms.27,35,36In this role, men have the ‘‘right’’ to make
decisionsaboutusingcondomswithoutanydiscussion,whereas
women who want to use condoms must enter into a process of
negotiation with partners that runs contrary to accepted
constructions of female sexual norms. In such situations,
women who communicate about the risks associated with not
using condoms, such as HIV/AIDS and pregnancy, may be
more likely to use condoms. In this context, self-efficacy for
condom use and sexual negotiation would be expected to be
associatedwithcommunicationabout HIV/AIDSforwomen,as
has been found in our study. These results indicate that
particularly for female youth, emphasis on communication with
friends and partners regarding the risks of HIV/AIDS and the
use ofcondomsmaybeanimportant component of intervention
programs aimed at improving self-efficacy and condom use
among young women in South Africa.
There were some limitations in our study. First, because
of the cross-sectional nature of our data, we are not able to
draw conclusions about causal relations between the variables
in our conceptual model and self-efficacy. Second, sensitive
sexual behaviors might have been underreported because of
social desirability bias. Third, the study results may not be
generalizable to other countries, although we believe that
global lessons can be learnt from these results.
In this study, we found the SCM to be useful in
identifying factors associated with self-efficacy for condom
use in South African youth. The model captured significant
factors associated with self-efficacy in each of the 6 domains
of the SCM and highlighted differences in the sociostructural
factors that influence young women and men. The findings in
this study have important implications, because they inform
researchers, communities, and policy makers that a broad
range of factors related to self-efficacy may influence condom
use and that knowledge of and access to condoms is only
a small component of ensuring consistent use. In addition, the
results of this study emphasize the importance of considering
the unique social and cultural context of adolescent sexuality
and gender roles in South African youth, with the goal of
tailoring interventions to young men and women separately
when addressing condom use and improved self-efficacy.
232
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Page 8

ACKNOWLEDGMENTS
The authors acknowledge the adolescent research team
at the RHRU, University of the Witwatersrand, Johannesburg,
South Africa, for the study design, development, and implemen-
tation. They also thank Development Research Africa, Durban,
South Africa, for data collection and entry and Contract
Laboratory Services of the University of the Witwatersrand,
Johannesburg, South Africa, for all laboratory work.
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