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Predicting the Intention to Use Condoms and Actual Condom Use Behaviour: A Three-Wave Longitudinal Study in Ghana

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Background: Growing cross-sectional research shows that the theory of planned behaviour (TPB) is robust in predicting intentions to use condoms and condom use behaviour. Yet, little is known about the TPB's utility in explaining intentions to use condoms and condom use behaviour over time. Methods: This study used a longitudinal design and latent variable structural equation modelling to test the longitudinal relationships postulated by the TPB. School-going youths in Ghana provided data on attitudes, subjective norms, perceived control, intentions, and behaviour regarding condom use at three time points, spaced approximately three months apart. Results: As predicted by the TPB, the results showed that attitudes were significantly positively associated with intentions to use condoms over time. Contrary to the TPB, subjective norms were not significantly associated with intentions to use condoms over time. Perceived control did not predict intentions to use condoms over time. Moreover, intentions to use condoms were not significantly associated with self-reported condom use over time. Conclusion: These results suggest that school-going youths in Ghana may benefit from sex education programmes that focus on within-subject attitude formation and activation. The theoretical and methodological implications of these results are discussed.
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Predicting the Intention to Use Condoms and
Actual Condom Use Behaviour: A Three-Wave
Longitudinal Study in Ghana
Enoch Teye-Kwadjo*
University of Ghana, Ghana
Ashraf Kagee and Hermann Swart
Stellenbosch University, South Africa
Background: Growing cross-sectional research shows that the theory of planned
behaviour (TPB) is robust in predicting intentions to use condoms and condom use
behaviour. Yet, little is known about the TPBs utility in explaining intentions to
use condoms and condom use behaviour over time. Methods: This study used a
longitudinal design and latent variable structural equation modelling to test the lon-
gitudinal relationships postulated by the TPB. School-going youths in Ghana pro-
vided data on attitudes, subjective norms, perceived control, intentions, and
behaviour regarding condom use at three time points, spaced approximately three
months apart. Results: As predicted by the TPB, the results showed that attitudes
were signicantly positively associated with intentions to use condoms over time.
Contrary to the TPB, subjective norms were not signicantly associated with inten-
tions to use condoms over time. Perceived control did not predict intentions to use
condoms over time. Moreover, intentions to use condoms were not signicantly
associated with self-reported condom use over time. Conclusion: These results
suggest that school-going youths in Ghana may benet from sex education pro-
grammes that focus on within-subject attitude formation and activation. The theo-
retical and methodological implications of these results are discussed.
Keywords: attitudes, condom use, subjective norms, theory of planned behaviour
INTRODUCTION
There is ample evidence that cross-sectional data support the utility of the theory
of planned behaviour (TPB) in understanding young peoples condom use. For
example, see Bryan, Kagee, and Broaddus (2006), Jemmott et al. (2007),
* Address for correspondence: Enoch Teye-Kwadjo, Department of Psychology, University of
Ghana, P.O. Box LG 84, Legon, Accra-Ghana. Email: eteye-kwadjo@ug.edu.gh
APPLIED PSYCHOLOGY: HEALTH AND WELL-BEING, 2016
doi:10.1111/aphw.12082
©2016 The International Association of Applied Psychology
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Montanaro and Bryan (2014), and Schaalma et al. (2009). However, there is lit-
tle evidence regarding the TPBs utility in understanding young peoples inten-
tions to use condoms and actual condom use behaviour over time. The TPB, in
its present form, postulates a longitudinal relationship between its standard con-
structs over time. Specically, that attitudes, subjective norms, and perceived
behavioural control will inuence an individuals intentions towards a given
behaviour (e.g. condom use) over time, and that such intentions will predict the
likelihood of that individual actually engaging in that given behaviour at some
point in the future (Ajzen, 1991). The TPB, therefore, implies a temporal relation
between its standard constructs over time.
Cross-Sectional vs. Longitudinal Designs and the TPB
Whereas cross-sectional data are useful in investigating how outcome variable
measures differ among participants who possess varying levels of a predictor
variable, such cross-sectional data provide little information about the temporal
relations between the variables over time, in theoretical models that describe lon-
gitudinal relationships (Cole & Maxwell, 2003). Related to this, Maxwell, Cole,
and Mitchell (2011) noted that a variable that is found to be a strong mediator
in a cross-sectional analysis may not be a mediator at all in a longitudinal analy-
sis(p. 816). Further, other research has shown that the use of cross-sectional
designs to estimate longitudinal mediation effects can lead to bias in parameter
estimates (Maxwell & Cole, 2007; Shrout, 2011). As noted earlier, the TPB is a
theoretical model that describes longitudinal mediation relationships between its
standard constructs. Arguably, the TPBs utility in understanding young peoples
condom use may be extended by studies that use longitudinal designs.
Although longitudinal designs cannot test true causalassumptions (which
are better tested with experimental designs), they offer many advantages over
cross-sectional designs. Compared with cross-sectional designs, longitudinal
designs allow researchers to better capture the inuence of conceptual third
variables, including putative mediators, and to control for autoregressive rela-
tionships (Maxwell et al., 2011; Shrout, 2011; West, 2011). In the case of the
TPB, a putative mediator would be behavioural intentions. In addition, longi-
tudinal designs aid in testing construct stationarity, a prerequisite in theoretical
models that describe longitudinal relationships (Cole & Maxwell, 2003; Swart,
Hewstone, Christ, & Voci, 2011). Kenny (1979) explained that there is construct
stationarity when the observed sizes of correlations among measures of the same
construct obtained across time (i.e. within-wave correlations) remain unchanged.
Correspondingly, scholars in the eld of health behaviour and theory testing
have recently begun to express concerns about the widespread use of cross-
sectional designs in health behaviour research (see, for example, Weinstein,
2006; Weinstein & Rothman, 2005; West, 2011). For example, Weinstein
(2006) argued that cross-sectional designs used to test the TPB may have
2TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
produced estimates of current and past behaviour, instead of producing estimates
of future behaviour. Moreover, various authors have recommended that psychol-
ogists interested in the processes through which antecedent factors inuence out-
come measures (mediation) should measure each construct at a minimum of
three time points (Cole & Maxwell, 2003; Maxwell & Cole, 2007; Reichardt,
2011). For example, Cole and Maxwell (2003) explained that a minimum of
three waves of data is required to test the stationarity assumption inherent in lon-
gitudinal mediation designs. They argued that a minimum of three waves of data
would allow researchers (a) to conrm that sufcient autoregressive stability
exists for each measure over time, and (b) to control for prior levels of the
dependent variable on itself (autoregressive effects) when testing for cross-
lagged effects (see also Swart et al., 2011). In addition, Cole and Maxwell
(2003) and Selig and Preacher (2009) recommended that researchers measure all
variables at all measurement occasions in order to have the opportunity to partial
out any effects that a variable might have on itself over time (see also Reichardt,
2011). These considerations motivated the choice of the three measurement
occasions used in the present study, and also served to explain why we assessed
all variables at all measurement occasions.
As can be expected, a complete test of the full longitudinal mediation effects
described by the TPB would require rst and second waves of data (Time 1 and
Time 2) to examine the paths from attitudes, subjective norms, and perceived
behavioural control to intentions, and then second and third waves of data (Time
2 and Time 3) to examine the path from intentions to overt behaviour.
The Current Study
Recent national sentinel survey reports have shown that young Ghanaians aged
1524 years accounted for 28 per cent of all new infections of HIV in 2013
(Ghana Aids Commission, 2014). HIV prevalence among young Ghanaians aged
1519 years and those aged 1524 years in 2012 was 0.7 per cent and 1.3 per
cent, respectively (Ghana Aids Commission, 2014). Sexually transmitted infec-
tions (STIs) and unintended pregnancy have also been recorded among young
people in Ghana (Morhe, Tagbor, Ankobea, & Danso, 2012; Ohene & Akoto,
2008). Previous research has shown that heterosexual intercourse is driving the
spread of the HIV virus in Ghana (Ghana Health Service, 2009). Yet, by all
accounts, condom use to reduce ones risk of acquiring sexually transmitted HIV
as well as other STDs remains low among Ghanaian school-going youths
(Abdul-Rahman, Marrone, & Johansson, 2011; Adu-Mireku, 2003; Odonkor,
Nonvignon, Adu, Okyere, & Mahami, 2012; Sallar, 2008).
Beliefs and misconceptions about condom use and HIV that make condom
use unattractive to young people (e.g. HIV is caused by witchcraft, that condom
use results in pleasure loss, that condom use makes sex unnatural and indicates
lack of trust in ones sexual partner) are also reported to be widespread among
INTENTIONS AND BEHAVIOUR IN CONDOM USE 3
©2016 The International Association of Applied Psychology
young Ghanaians (Tenkorang, 2013; Tenkorang, Gyimah, Maticka-Tyndale, &
Adjei, 2011). Meta-analyses and systematic reviews have shown that consistent
condom use prevents sexually transmitted HIV by between 87 per cent and 96
per cent (Weller, 1993; Weller & Davis-Beaty, 2002).
Despite the risks and negative health outcomes associated with young peo-
ples sexual behaviour in Ghana, there is little research effort to examine this
health problem. There is the need to identify and understand psychosocial factors
that determine why some young Ghanaians use condoms but others do not. This
understanding is crucial because the Ghana Aids Commission (2013) has made
the halting and reversing of the spread of sexually transmitted HIV in Ghana a
key national, public health goal. Unfortunately, in Ghana interventions to reduce
young peoples sexual risk behaviour have achieved only limited success
because they have been largely based on non-governmental organisation initia-
tives, which have not been theory-guided. Theory-guided studies are central to
evidence-based research and interventions (Michie et al., 2005). Nevertheless, to
date, there are no known Ghanaian theory-based models advanced to adequately
explain HIV, STD, and pregnancy risk reduction among young people in the
country.
Relatedly, health behaviour researchers have noted that it is important in evi-
dence-based sexual behaviour research to utilise a theory that reects the charac-
teristics of the population and dimensions of the particular behaviour under
investigation (Eaton, Flisher, & Aarø, 2003; Michie, Johnston, Francis,
Hardeman, & Eccles, 2008). Further, they argued that such a theory ought to
have a parsimonious framework and well-dened components; and should not
only be robust but also should be applicable to both men and women. In addi-
tion, they stressed that such a theoretical framework should suggest research
questions or indicate hypotheses to help focus research on key variables of inter-
est to the researcher. One health behaviour theory that appears to satisfy these
requirements is Ajzens (1991) theory of planned behaviour (TPB). These con-
siderations informed the choice of the TPB to guide the present research.
The TPB aims to explain human social behaviour in specic situations by
making two important assumptions. First, it assumes that an individuals inten-
tions to engage in a specied behaviour (e.g. using condoms consistently) is
determined by his or her attitudes, his or her perceived control beliefs, and by
the prevailing normative beliefs within his or her social context regarding that
behaviour. Second, it assumes that the most important determinant of overt beha-
viour (e.g. condom-protected sexual behaviour) is an individuals behavioural
intentions towards that target behaviour. Taken together, Ajzen (1991) argued
that individuals who have favourable attitudes towards a specied behaviour,
positive subjective norms regarding that behaviour, and who perceive themselves
to have the necessary control over performing that specied behaviour, are more
likely to execute their behavioural intentions when the need arises. The aim of
this study was to undertake a three-wave longitudinal study to test the
4TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
longitudinal relationships postulated by the TPB in understanding heterosexual
high school youthsintentions to use condoms and actual condom use behaviour
over time.
Study Hypotheses
Using the theory of planned behaviours framework, we specied the following
longitudinal structural models (see Figure 1, for the hypothesised model):
Hypothesis 1: (a) Attitude towards condom use, (b) subjective norms regarding
condom use, and (c) perceived behavioural control over condom use at Time 1
would each be signicantly positively associated with increased intentions to use
condoms at Time 2, even after controlling for the autoregressive effects of the
intentions to use condoms at Time 1.
Hypothesis 2: Intention to use condoms at Time 2 would be signicantly positively
associated with increased condom use behaviour at Time 3, even after controlling
for the autoregressive effects of condom use behaviour at Time 1 and Time 2.
Hypothesis 3: Intention to use condoms at Time 2 would mediate the relationship
between attitudes, subjective norms, and perceived behavioural control at Time 1,
and condom use behaviour at Time 3.
METHOD
Participants and Procedure
Participants (N=1,023) in this study were recruited from a large municipal,
public senior high school in the Eastern Region of Ghana. The corresponding
author obtained a letter of permission from the Director-General, Ghana Educa-
tion Service and presented it, including a synopsis of the study as well as ethical
approval letters, to the school authorities. Students were recruited at an assembly
forum in the participating school with the help of the school authorities. To be
eligible for participation in the present study, students must never have been
married and must have attained the age of 14 years prior to participation in the
survey at the rst assessment. Also, they must have indicated a willingness to
participate in the study. Of the number recruited, 13 students were below the age
of 14 years and were thus excluded from the study. At the Time 1 assessment,
983 students completed the survey. Twenty-seven potential participants were
absent for various reasons, including illness, other important co-curricular
engagements, and not being in school because of being a day student. Of the
INTENTIONS AND BEHAVIOUR IN CONDOM USE 5
©2016 The International Association of Applied Psychology
983 original participants, 956 and 835 provided the data at Time 2 and Time 3
assessments, respectively.
Surveys were completed in classrooms on the school compound. Participants
completed assent or consent forms depending on their self-declared age. Because
Attitude towards
condom use
Subjective norm
regarding condom
use
Perceived
behavioural control
regarding condom
use
Intention regarding
future condom use
Actual condom use
behaviour
Attitude towa rds
condom use
Subjective norm
regarding condom
use
Perceived
behavioural contro l
regarding condom
use
Intention regarding
future condom use
Actual condom use
behaviour
Attitude towa rds
condom use
Subjective norm
regarding condom
use
Perceived
behavioural contr ol
regarding condom
use
Intention regarding
future condom use
Actual condom use
behaviour
Time 1 Time 2 Time 3
FIGURE 1. Hypothesised longitudinal model of the theory of planned beha-
viour’s (TPB) standard constructs. The three cross-lagged paths coming out of
Time 1 attitude,subjective norm,perceived behavioural control respectively
depicted by the three boldfaced downwardly sloped lines to Time 2 intention
and the single cross-lagged path emanating out of Time 2 intention depicted by
the single boldfaced downwardly sloped line to Time 3 actual condom use
behaviour represent the hypotheses of this study. For ease of reading,
indicators, error terms, and disturbance terms are not shown.
6TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
the majority of the students lived on the school compound, far away from their
parents or guardians, and were fed by school authorities, and also because they
were not allowed to use cell phones on the school compound, school authorities
liaised with the schools parent-teacher association (PTA) to waive parental con-
sent to enable interested students aged 14 to 17 years, who were not legally eli-
gible to sign consent themselves, to participate in the study. Permission,
informed consent and assent were obtained only once at the rst assessment and
had a prospective effect on subsequent assessments.
All participants were provided with instructions to help them generate their
own alpha-numeric string identiers on top of each survey they completed.
These alpha-numeric string identiers were aimed at enabling the research team
to match the responses of the participants across all three waves of data collec-
tion. However, because some participants failed to generate their own alpha-
numeric string identiers, and because other participants provided incomplete
alpha-numeric string identiers or alpha-numeric string identiers that differed
from wave to wave, only a total of 684 surveys with correct alpha-numeric string
identiers were matched across the three waves of data collection. And because
we used only cases that we were able to match across time, the sample size was
reduced from 983 to 684, representing an overall retention rate of 69.6 per cent
for the main analyses. Using Jacksons (2003) ratio of observations (N) to model
parameters to be estimated (q) procedure of (N:q=20:1; i.e. 20 observations per
one estimated parameter), our retained sample size (N=684) was deemed ade-
quate for performing the conrmatory and structural analyses with the maximum
likelihood estimation. In addition, a post-hoc power analysis in G*Power (Faul,
Erdfelder, Buchner, & Lang, 2009) indicated that with an estimated population
effect size of (0.30; medium) and signicance level of (.05), the retained sample
size of 684 was enough to provide us with sufcient statistical power (.99) to
detect correlational effects.
The current analyses relate to the 684 matched sample (n=335 males;
n=349 females). Participants were between the age range of 14 and 20 years.
About 418 of the matched sample were boarding students (i.e. students who lived
on the school compound and were fed by the school) and 266 were day students
(i.e. students who lived at home while attending school). This study was approved
by the Institutional Review Board of the Noguchi Memorial Institute for Medical
Research (#034/12-13), University of Ghana and by the Health Ethics Research
Committee of Stellenbosch University (#S12/06/179), South Africa.
Measures
Attitudes towards Condom Use. Five items adapted from previous research
(Basen-Engquist et al., 1999; Carmack & Lewis-Moss, 2009) assessed partici-
pantsattitudinal beliefs about condom use. Sample items included I believe
condoms should always be used if a person my age has sex, and I believe
INTENTIONS AND BEHAVIOUR IN CONDOM USE 7
©2016 The International Association of Applied Psychology
condoms should always be used if a person my age has sex, even if the two peo-
ple know each other very well.Response scale for the items ranged from 1
(strongly disagree)to7(strongly agree). Scale responses were scored such that
higher scores indicated more favourable attitudinal beliefs about condom use.
Composite mean score, standard deviation, and coefcient alpha for the attitudes
towards condom use were, Time 1 (M=5.64, SD =0.06, a=.64); Time 2
(M=5.72, SD =0.13, a=.66); and Time 3 (M=5.97, SD =0.15, a=.69).
Subjective Norms Regarding Condom Use. Five items adapted from previ-
ous research (Basen-Engquist et al., 1999; Carmack & Lewis-Moss, 2009)
assessed participantsperception of descriptive normative inuences on them
regarding condom use. Sample items included Most of my friends believe con-
doms should always be used if a person my age has sex, even if the two people
trust each other very well, and Most of my friends will say noto sex if a boy-
friend or girlfriend wont use a condom.Response scale for the items ranged
from 1 (strongly disagree)to7(strongly agree). Scale responses were scored
such that higher scores indicated greater perceived normative inuence and moti-
vation to comply with peer norms regarding condom use. Composite mean
score, standard deviation, and coefcient alpha for the subjective norms regard-
ing condom use were, Time 1 (M=5.55, SD =0.04, a=.62); Time 2
(M=5.66, SD =0.15, a=.66); and Time 3 (M=5.82, SD =0.03, a=.71).
Perceived Behavioural Control over Condom Use. Four items adapted
from previous research (Carmack & Lewis-Moss, 2009; Jemmott et al., 2007)
assessed participantsperceived behavioural control over condom use. Sample
items included I can use a condom correctly, and I can get my boyfriend or
girlfriend to use a condom, even if he or she doesnt want to do so.Response
scale for the items ranged from 1 (strongly disagree)to7(strongly agree). Scale
responses were scored such that higher scores reected a greater perceived ef-
cacy or controllability over condom use. Composite mean score, standard devia-
tion, and coefcient alpha for the perceived behavioural control over condom
use were, Time 1 (M=5.25, SD =0.90, a=.67); Time 2 (M=5.43,
SD =0.23, a=.66); and Time 3 (M=5.66, SD =0.14, a=.75).
Behavioural Intentions towards Future Condom Use. Six items adapted
from previous research (DeHart & Birkimer, 1997) assessed participantsinten-
tions to use condoms in the future (i.e. over the coming three months). Sample
items included I am determined to use condoms in the next 3 months, if I have
sex, and I planned to use condoms, if I were going to have sex in the next
3 months.Scale responses were scored such that higher scores indicated more
favourable intentions towards condom use over the next three months. Response
scale for the items ranged from 1 (strongly disagree)to7(strongly agree).
Composite mean score, standard deviation, and coefcient alpha for the
8TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
intentions to use condoms were, Time 1 (M=5.59, SD =0.19, a=.78); Time
2(M=5.74, SD =0.18, a=.78); and Time 3 (M=5.85, SD =0.13, a=.84).
Self-Reported Condom Use Behaviour. Seven items adapted from previous
research (Holland & French, 2012; Walsh, Senn, Scott-Sheldon, Vanable, &
Carey, 2011) assessed participantsself-reported condom use over the past three
months. Multiple items that sought to tap relevant aspects of condom use such as
condom use frequency (e.g. How often have you had sex with your regular boy-
friend/girlfriend with a condom in the past 3 months?), condom non-use fre-
quency (e.g. How often did you refuse to have sex with a partner because they
would not use a condom in the past 3 months?), and type of partners (e.g.
How often have you had sex with someone who is not your boyfriend/girlfriend
(casual sex) with a condom in the past 3 months?) were used in this study. The
response scale for this construct ranged from 1 (never)to7(all the time). Scale
responses were coded such that higher scores indicated greater self-reported con-
dom use behaviour over the past three months. Composite mean score, standard
deviation, and coefcient alpha for the self-reported condom use behaviour were,
Time 1 (M=2.91, SD =0.14, a=.88); Time 2 (M=3.06; SD =0.19,
a=.90); and Time 3 (M=3.33, SD =0.15, a=.89).
RESULTS
Preliminary Analyses
To test for attrition effects, we compared participants who completed all three
waves of data (completers) with those who dropped out after Time 1 and those
who dropped out after Time 2 (attriters). Taking a pair of waves, we dened
attriters as those participants who provided data at Time 1 but not at Time 2, and
then those who provided data at Time 1 but not at Time 3, by creating a missing
data indicator. We ran two multivariate analyses of variance on the continuous
variables, using the missing data indicator as a grouping variable. We then ran
two binary logistic regression analyses on the categorical variables, using the
missing data indicator as an outcome variable.
Continuous Variables. Attrition analyses revealed signicant differences
between the longitudinal sample (completers) and those who dropped out after
Time 1 (attriters), Wilksk=.961, F(5, 975) =7.97, p<.001, partial g
2
=.04.
However, there were no signicant differences between completers and Time 2
attriters, Wilksk=.996, F(5, 976) =815, p=.539, partial g
2
=.004. An
inspection of the univariate differences between completers and Time 1 attriters,
using a Bonferroni adjusted alpha level of (p<.01), showed that only subjective
norm, F(1, 979) =16.80, p<.001, partial g
2
=.02; perceived behavioural
INTENTIONS AND BEHAVIOUR IN CONDOM USE 9
©2016 The International Association of Applied Psychology
control, F(1, 979) =27.57, p<.001, partial g
2
=.03; intention, F(1,
979) =23.29, p<.001, partial g
2
=.02; and condom use behaviour, F(1,
979) =9.55, p<.01, partial g
2
=.01, reached statistical signicance. As per
the Bonferroni adjusted alpha level, there were no signicant univariate differ-
ences between completers and Time 1 attriters in attitudes towards condom use,
F(1, 979) =4.81, p=.028, partial g
2
=.01.
Moreover, inspection of the mean scores indicated that completers scored
slightly higher on subjective norms (M=46.38, SD =.62) than did Time 1
attriters (M=43.63, SD =.62). Completers perceived slightly greater control
over condom use (M=51.88, SD =.34) than did Time 1 attriters (M=47.26,
SD =.81). In addition, completers possessed slightly greater intentions towards
condom use (M=46.38, SD =.30) than did Time 1 attriters (M=42.62,
SD =.72), and completers reported slightly more condom-protected sexual
behaviour (M=30.26, SD =.50) than did Time 1 attriters (M=26.29,
SD =1.18). We note that despite the signicant univariate differences, Cohens
(1988) effect size calculation criteria showed that these differences were small,
suggesting that completers did not differ signicantly from Time 1 attriters. As
can be expected, our attrition analyses seemed to indicate that data were missing
at random.
Categorical Variables. Logistic regression analyses, using the missing data
indicator as outcome variable and gender, age, and student status (day or board-
ing) as predictor variables, distinguished between completers and Time 1 attriters
v
2
(3) =14.89, p=.002. Only age made a signicant contribution to the model
(p=.001). Participant gender (p=.377) and student status (day or boarding;
p=.099) did not contribute signicantly to the model. Compared with Time 1
attriters, completers were 2.14 times more likely to be older (age; odds ratio
(OR) =2.14, 95% CI [1.39, 3.28], p=.001). However, there were no signi-
cant differences between completers and Time 2 attriters, v
2
(3) =5.27,
p=.153.
Further, the matched sample (N=684) was compared with the full Time 1
sample (N=983) along the continuous and categorical variables of interest in
this research. Multivariate analysis of variance showed that the matched sample
did not differ signicantly from the full Time 1 sample, Wilksk=.990, F(5,
977) =1.93, p=.087, partial g
2
=.01. In addition, logistic regression revealed
a non-signicant difference between the matched sample and the full Time 1
sample along our categorical variables of gender, age, and student status (day or
boarding), v
2
(3) =4.61, p=.203.
Following the attrition analyses, we rst screened the study variables for nor-
mality at each time point, using West, Finch, and Currans (1995) cut-off criteria
of skewness (2.00 and +2.00) and of kurtosis (7.00 and +7.00) in IBM SPSS
Statistics (v20). All variables under consideration were normally distributed.
Second, we checked construct dimensionality at each time point by conducting
10 TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
exploratory factor analyses, using maximum likelihood estimation. Each con-
struct demonstrated adequate unidimentionality at each time point. We then used
item-parcelling (Little, Rhemtulla, Gibson, & Schoemann, 2013) to reduce the
number of items on scales with more than four items. Bivariate correlations were
examined across time. Generally, items demonstrated signicant intra-construct
correlations. The correlation matrices are available from the corresponding
author on written request.
Main Analyses
Latent Variable Structural Equation Model. All structural equation analy-
ses were conducted in Mplus (v6.0) with maximum likelihood robust (MLR)
estimation. As noted earlier, the monotone pattern of drop-out in this study cou-
pled with the results from our attrition analyses suggested that data were missing
at random. Research has shown that when data are missing at random, the full
information maximum likelihood (FIML) estimation provides unbiased parame-
ter estimates (Enders, 2001). Missing data were handled using the FIML estima-
tion in Mplus. Parameter estimates were calculated using robust maximum
likelihood (MLR) estimation.
We conducted all model comparisons with the Satorra-Bentler scaled chi-
square difference test (Bryant & Satorra, 2012). In accordance with Anderson
and Gerbings (1988) two-step approach, we rst tted the longitudinal measure-
ment model and then tted the longitudinal structural model. We used multiple
goodness-of-t indices to determine model t: chi-square test statistic (v
2
) with
degrees of freedom, chi-square/degrees of freedom (v
2
/df <3.0) ratio, compara-
tive t index (CFI .95), root mean square error of approximation (RMSEA
<.07) with condence interval, and the standardised root mean square residual
(SRMR <.05). We did not carry out any suggested model modications in these
structural analyses.
Longitudinal Measurement Model. We tted the longitudinal measurement
model including all observed and latent variables across time, using longitudinal
conrmatory factor analysis (CFA; Little, Preacher, Selig, & Card, 2007). The
longitudinal measurement model demonstrated adequate measurement across
time, v
2
(1102, N=684) =1850.95, p<.001, v
2
/df =1.68, CFI =.949,
RMSEA =.032; 90% CI [.029, .034]; SRMR =.040, suggesting that the hypothe-
sised structural relationships among the latent constructs of the theory of planned
behaviour could be tested. All factor loadings were signicant at (p<.001).
Factorial Invariance Model. Invariance constraints (Widaman, Ferrer, &
Conger, 2010) were imposed by constraining the factor loadings for the respec-
tive indicators of a given construct to equality over time. The factorial invariance
model showed a good t to the data, v
2
(1126) =1850.95, p<.001, v
2
/
INTENTIONS AND BEHAVIOUR IN CONDOM USE 11
©2016 The International Association of Applied Psychology
df =1.67, CFI =.949, RMSEA =.031; 90% CI [.029, .034], SRMR =.042. A
comparison between the factorial invariance model and the longitudinal CFA
model, using the Satorra-Bentler scaled chi-square difference test, showed that
the factorial invariance model did not differ signicantly from the longitudinal
CFA model, Dv
2
(24) =21.75, p>.05.
Longitudinal Structural Model of the Theory of Planned Behaviour. Using
the better-tting longitudinal measurement model (i.e. the model with partial
measurement invariance) as the starting point, a series of longitudinal structural
models was tted to the data. The tted longitudinal models addressed questions
of direct effectsautoregressive effects and cross-lagged effects. The cross-
lagged effects constitute the longitudinal hypotheses of the current analyses.
Autoregressive longitudinal structural model of the TPB: To assess autore-
gressive stationarity among the ve TPB constructs under consideration over
time, a series of increasingly restrictive autoregressive models was tted to the
data (see Table 1). These models set various equality constraints on the within-
construct relationships over time. The best-tting longitudinal autoregressive
structural model exhibited partial stationarity and showed acceptable model t,
v
2
(1195) =1996.59, p<.001, v
2
/df =1.67, CFI =.945, RMSEA =.031;
90% CI [.029, .034], SRMR =.053 (see Figure 2).
In the best-tting autoregressive structural model, the within-construct rela-
tionships between attitudes and subjective norms were constrained to equality
with one another over time, whereas the within-construct autoregressive relation-
ship of behaviour was constrained to equality over time. The within-construct
autoregressive relationships of perceived behavioural control and intentions were
freely estimated over time. This is because it was not possible to achieve accept-
able model t by imposing within-construct equality constraints on perceived
behavioural control and intentions over time.
Cross-lagged longitudinal structural model of the TPB: The cross-lagged
structural paths that constituted the longitudinal hypotheses of the current
analyses were added to the best autoregressive longitudinal model illustrated in
Figure 2. These cross-lagged structural paths test whether, beyond the within-
construct autoregressive effect that each TPB construct has on itself over time,
there also exist between-construct (cross-lagged) relationships among the latent
constructs of the TPB over time. To test the cross-lagged longitudinal structural
effects (i.e. longitudinal hypotheses), a freely estimated cross-lagged longitudinal
model was rst tted to the data. This model demonstrated adequate t, v
2
(1187) =1977.00, p<.001, v
2
/df =1.67, CFI =.946, RMSEA =.031; 90%
CI [.029, .034], SRMR =.050.
Next, to establish parsimony all cross-lagged structural paths in the longitudi-
nal model were constrained to between-construct equality across time. This con-
strained cross-lagged longitudinal structural model described the data well, v
2
(1191) =1985.45, p<.001, v
2
/df =1.67, CFI =.946, RMSEA =.031; 90%
12 TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
TABLE 1
Comparison between Autoregressive and Cross-lagged Longitudinal Models
Model Model t
Model
comparisons
Corrected chi-square
difference test
1a v
2
(1191) =1989.53***; CFI =.95; RMSEA =.031; SRMR =.055
1b v
2
(1196) =2018.34***; CFI =.94; RMSEA =.032; SRMR =.053 1b vs. 1a Dv
2
(5) =18.20, p<.05
1c v
2
(1195) =2007.52***; CFI =.95; RMSEA =.032; SRMR =.053 1c vs. 1a Dv
2
(4) =10.57, p<.05
1d v
2
(1194) =1997.44***; CFI =.95; RMSEA =.031; SRMR =.053 1d vs. 1a Dv
2
(3) =7.16, p>.05
1e v
2
(1195) =1996.59***; CFI =.95; RMSEA =.031; SRMR =.053 1e vs.1d Dv
2
(1) =.37, p>.05
2a v
2
(1187) =1977.00***; CFI =.95; RMSEA =.031; SRMR =.050
2b v
2
(1191) =1985.45***; CFI =.95; RMSEA =.031; SRMR =.051 2b vs. 2a
2b vs. 1e
Dv
2
(4) =6.04, p>.05
Dv
2
(4) =10.04, p<.05
Note:CFI =comparative t index; RMSEA =root mean square error of approximation; SRMR =standardised root mean square residual. 1a =autoregressive model (freely esti-
mated theory of planned behaviour (TPB) model relationships); 1b =autoregressive model (within-construct equality constraints for all ve TPB components); 1c =autoregressive
model (within-construct equality constraints for attitude, subjective norm, intention, and behaviour with perceived behavioural control freely estimated); 1d =autoregressive model
(within-construct equality constraints for attitude, subjective norm, and behaviour with intention and perceived control freely estimated); 1e =autoregressive model (within-construct
equality constraints for behaviour, with between-constraints for attitude and subjective norm, and intention and perceived control freely estimated). 2a =cross-lagged structural model
(all ve TPB components freely estimated); 2b =cross-lagged structural model (within-construct equality constraints for all ve TPB components).
a
How to determine which comparison model describes the data well: (a) when you compare two versions of a model with one being less restrictive (has no equality constraints,
freely estimated) and the other being more restrictive (has equality constraints) from the same category (e.g. autoregressive models), the more restrictive model should yield a non-
signicant p-value (p>.05) for the model t to be considered acceptable, and (b) when you compare two models from two different categories (e.g. autoregressive model versus
cross-lagged structural model) the model that improves model t(p<.05) is the one to be accepted.
***p<.001; all relative v
2
statistic <3.1; N=684.
INTENTIONS AND BEHAVIOUR IN CONDOM USE 13
©2016 The International Association of Applied Psychology
Time 1 Time 2 Time 3
R2=.23 R2=.42
R2=.23 R2=.36
R2=.13 R2=.37
R2=.14 R2=.30
R2=.40 R2=.65
x3
.52*** .52***
.52*** .52***
.33*** .58***
.35*** .53***
.69*** .69***
Attitude
Norm
Control
Intention
Attitude Attitude
Behaviour
Norm
Control
Norm
Control
Behaviour
Intention
Intention
Behaviour
x1x2
x4x5x6
x13
x12
x11
x1
x16
x15
x14
x7x8x9x1
y17
y16
y15
y14 y34
y33
y3
y31
y13
y12
y11 y30
y29
y28
y7y8y9y10 y24 y25 y2y27
y21 y22 y23
y4y5y6
y18 y19 y20
y1y2y3
FIGURE 2. Autoregressive longitudinal structural model showing unstandard-
ised parameter estimates and explained variances. For ease of reading, within-
wave correlations among the error terms, disturbance terms, and within-wave
between-construct correlations are not shown. Model fit: v
2
(1195, N=684) =
1996.59, p<.001, relative v
2
=1.67, comparative fit index =0.945, root mean
square error of approximation [90% CI] =0.031 [0.029, 0.034], standardised root
mean square residual =0.053. *p<.05; *** p<.001.
14 TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
CI [.029, .034], SRMR =0.051. Compared with the freely estimated cross-
lagged longitudinal structural model, the Satorra-Bentler scaled v
2
-difference test
revealed that the constrained cross-lagged longitudinal model did not differ sig-
nicantly from the freely estimated model, Dv
2
(4) =6.04, p>.05 (see Table 1
[2b vs. 2a]). Further, a comparison between the best cross-lagged longitudinal
structural model and the best autoregressive longitudinal structural model
showed that the best cross-lagged longitudinal structural model tted the data
signicantly better than did the best autoregressive longitudinal structural model,
Dv
2
(4) =10.04, p<.05 (see Table 1 [2b vs. 1e]).
The results of the best cross-lagged longitudinal structural model suggest that
the hypothesised longitudinal structural relationships between the theory of
planned behaviours constituent components achieved limited support (see Fig-
ure 3). Specically, the path from attitudes towards condom use at Time 1 to
intentions to use condoms at Time 2 was statistically signicant (b=.11,
p<.05), even after controlling for prior effects of intentions to use condoms at
Time 1. On the contrary, the specic path from subjective norms regarding con-
dom use at Time 1 to intentions to use condoms at Time 2 was not statistically
signicant (b=.06, p=.261).
Similarly, the specic path from perceived behavioural control over condom
use at Time 1 to intentions to use condoms at Time 2 did not reach statistical
signicance (b=.03, p=.537), at least after controlling for prior levels of
intentions to use condoms at Time 1. The path from intentions to use condoms
at Time 2 to self-reported condom use behaviour at Time 3 was nonsignicant
(b=.04, p=.318), at least after controlling for prior levels of self-reported
condom use behaviour at Time 2. On the basis of these results, the longitudinal
mediation hypothesis (i.e. Hypothesis 3) of the current study was not supported.
Despite the limited support obtained for the longitudinal structural relationships
postulated by the theory of planned behaviour, the cross-lagged longitudinal
structural model accounted for a substantial portion of the variance in attitudes
towards condom use (Time 2: R
2
=24%, Time 3: R
2
=44%), subjective norms
regarding condom use (Time 2: R
2
=24%, Time 3: R
2
=38%), perceived beha-
vioural control over condom use (Time 2: R
2
=13%, Time 3: R
2
=38%),
intentions to use condoms (Time 2: R
2
=15%, Time 3: R
2
=31%), and self-
reported condom use behaviour (Time 2: R
2
=40%, Time 3: R
2
=65%) over
time.
DISCUSSION
Pathway between Attitude and Intention
This study simultaneously tested the theory of planned behaviours (TPB) utility
in explaining adolescent condom use over time. Overall, the results demonstrated
INTENTIONS AND BEHAVIOUR IN CONDOM USE 15
©2016 The International Association of Applied Psychology
only limited support for the postulated longitudinal relationships of the TPBs
constituent components. Consistent with the TPB, attitudes towards condom use
at Time 1 were longitudinally associated with intentions to use condoms three
.47***
Time 1 Time 2 Time 3
.53*** .53***
.53*** .53***
.34*** .60***
.29***
.68***
.68***
.11* .11*
x3
Attitude
Norm
Control
Intention
Attitude Attitude
Behaviour
Norm
Control
Norm
Control
Behaviour
Intention
Intention
Behaviour
x1x2
x4x5x6
x13
x12
x11
x1
7
x16
x15
x14
x7x8x9x1
0
y17
y16
y15
y14 y34
y33
y32
y31
y13
y12
y11 y30
y29
y28
y7y8y9y10 y24 y25 y26 y27
y21 y22 y23
y4y5y6
y18 y19 y20
y1y2y3
-.03
.06
-.03
.06
.04 .04
FIGURE 3. Cross-lagged longitudinal model showing structural paths with
main longitudinal hypotheses depicted by downwardly sloped paths between
theory of planned behaviour components across time (bold). All structural paths
are indicated. Unstandardised parameter estimates are reported. Model fit: v
2
(1191) =1985.45, p<.001, v
2
/df =1.67, comparative fit index =.946, root mean
square error of approximation =.031; 90% CI [.029, .034], standardised root
mean square residual =.051. *p<.05; *** p<.001; N=684.
16 TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
months later at Time 2, and attitudes towards condom use at Time 2 were
longitudinally associated with intentions to use condoms another three months
later at Time 3. This result is consistent with a recent two-wave panel study in
sub-Saharan Africa that found attitude to be the strongest predictor of intentions
to use condoms among young people (Molla,
Astrøm, & Brehane, 2007).
The current nding is consistent with a systematic review among African adoles-
cents that found attitudes to be a more reliable predictor of condom use inten-
tions, and behavioural intentions to be a poor predictor of actual behaviour
(Paul-Ebhohimhen, Poobalan, & van Teijlingen, 2008).
In addition, a previous meta-analysis revealed that attitude is an important pre-
dictor of intentions to use condoms (Albarracin, Johnson, Fishbein, & Mueller-
leile, 2001). Similarly, our results are consistent with ndings from other
previous longitudinal studies using structural equation modelling with high
school adolescents (Beadnell et al., 2007). Moreover, the current nding regard-
ing attitudeintention correspondence compared favourably with those reported
in a longitudinal investigation by Morrison, Baker, and Gillmore (1998) and by
Reinecke, Schmidt, and Ajzen (1996), using the theory of planned behaviours
(TPB) framework. To our knowledge, as far as the TPB sexual behaviour litera-
ture is concerned, this is the rst research to examine the longitudinal association
between the TPBs components with three waves of data, using latent variable
structural equation modelling. Consequently, the nding relative to attitude
strength would contribute signicantly to our current knowledge of attitude
intention correspondence.
Pathway between Subjective Norms and Intention
In the present analyses, the longitudinal pathways between subjective norms and
behavioural intentions were not supported. And neither were the longitudinal
pathways between perceived behavioural control and behavioural intentions. The
current ndings regarding subjective norms and perceived behavioural control
contrast with those of Beadnell et al. (2007). The differences in these results
may reect a methodological difference between their research and the present
study. This is because Beadnell et al.s (2007) research was a two-wave panel
study with data collection spaced one year apart, predicting the intentions to
have sex, compared to the present study that used three waves of data collection
spaced three months apart, predicting the intentions to use condoms. Also,
Beadnell et al. (2007) assessed intentions to have sex only at Time 1 but not at
Time 2, as compared to the present study that assessed all TPB model constructs
at all three time points.
In this study, items measuring the subjective norm construct focused on
descriptive norms, specically peer norms (what friends say and do) and not on
injunctive norms (what signicant others expect the adolescent to do). It is possi-
ble that descriptive peer norms are not salient for condom use intentions and
INTENTIONS AND BEHAVIOUR IN CONDOM USE 17
©2016 The International Association of Applied Psychology
behaviour for the current sample. Correspondingly, there is evidence that the cul-
tural and societal restrictions on adolescent sexual behaviour in Ghana are mak-
ing sexual relations among young people strictly private and condential affairs
(Darteh, Doku, & Esia-Donkoh, 2014).
Pathway between Perceived Behavioural Control and
Intention
The current study did not conrm the longitudinal relationship between per-
ceived behavioural control over condom use and intentions to use condoms. This
result is comparable to the ndings of a previous panel study (Reinecke et al.,
1996). A possible explanation for the nonsignicant longitudinal associations
between perceived behavioural control and intentions may be traced to the dya-
dic nature of sexual behaviour. That is, since sexual intercourse involves two
people, it is possible for one partner to perceive greater control to use condoms,
but the non-availability of a sex partner or even failure to convince a sex partner
regarding the advantages of condom use may prevent this perception of control
from being enacted. Therefore, ones sex partners cooperation is a central aspect
of condom negotiation and may serve to reinforce the notion held by sexual
behaviour researchers that condom use requires more than an individual sex part-
ners volitional control.
Pathway between Intention and Behaviour
Moreover, the hypothesised longitudinal relationship between intentions to use
condoms and condom use behaviour was not supported in the present study.
Although this nding is contrary to the postulate of the TPB, it is consistent with
other structural equation modelling investigations of condom use that reported
nonsignicant longitudinal associations between intentions and behaviour
(Carvajal, Estrada, & Estrada, 2005). The Ghanaian high school system pro-
scribes adolescent sexual behaviour. For example, high school students are not
allowed to use cell phones while in school, and pregnant students are often
excluded from school (Ghana News Agency, 2014). It is most likely that
students with intentions to engage in protected sexual behaviour may not have
adequate time to undertake preparatory behaviours (such as purchasing condoms
for an intended sexual activity), for fear this preparatory behaviour may expose
them to school authorities. This situation may serve to attenuate the effect of
behavioural intentions to use condoms on actual condom use behaviour. Relat-
edly, in an attempt to explain why some people act on their intentions and others
dont, Fishbein, Hennessy, Yzer, and Douglas (2003) noted that although inten-
tion is viewed as the primary determinant of behaviour, the model recognizes
that a lack of skills (or abilities) and/or environmental constraints may prevent
one from acting on his or her intentions. Thus, intentions alone are not the sole
18 TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
determinant of behaviour, and different factors may attenuate or enhance the
intention/behaviour relationship(p. 3).
Implications of Results
The current results suggest that school-aged adolescents in eastern Ghana possess
attitudinally controlled intentions. Consequently, it seems clear that sexual risk
reduction programmes in Ghana that target the antecedents of attitude formation
and activation may help strengthen positive attitudes towards condom use. Hav-
ing positive attitudes towards condom use may be an important rst step for sex-
ual behaviour modication. This study raised theoretical questions relating to the
construct validity of some of the TPB components. In the present study, attitudes
explained variance in intentions to use condoms over time, as postulated by the
TPB. Conversely, subjective norms and perceived behavioural control each failed
to predict intentions to use condoms over time, contrary to the postulate of the
TPB. Also, there was no longitudinal association between intentions to use con-
doms and actual condom use behaviour. These nonsignicant results are incon-
sistent with the postulated model relationships of the TPB. In accordance with
the current results, other ndings from an experimental test of the TPB (using a
different health behaviour) questioned the postulated relations between intentions
and behaviour (Sniehotta, 2009; see also Sniehotta, Presseau, & Ara
ujo-Soares,
2014). Thus, our results seem to call into question the sufciency assumption of
the TPB, and may provide opportunities for theory renement.
Empirical questions raised by our results reect the methodological quality of
previous tests of the TPB in the extant sexual behaviour literature. The limited
support obtained for the postulated relationships of the TPB in the current analy-
ses cannot be attributed to measurement artefacts. This is because our longitudi-
nal measurement model and the factorial invariance model both tted the data
well. Again, the latent variables of the TPB exhibited adequate autoregressive
stationarity over time. From an empirical perspective, it seems plausible that the
current results contrast with most previous ndings reported in the TPB test liter-
ature because of variations in study design, measurement, and in analytic strat-
egy. Strikingly, Reinecke et al. (1996) evaluated their longitudinal research
ndings by concluding that had we relied solely on the cross-sectional data
available at the end of the 12-month period, we would have been led to the con-
clusion that the theory of planned behaviour accounts for a substantial amount of
variance in intention to use condoms with new sex partners, as well as in actual
condom use(p. 765).
Limitations and Future Research
This study used self-report measures and a convenience sampling technique. It
also used global constructs of the TPB to investigate adolescent condom use.
INTENTIONS AND BEHAVIOUR IN CONDOM USE 19
©2016 The International Association of Applied Psychology
The TPB test literature may benet from future research in Ghana that employs
differentiated/decomposed constructs of the TPB. Moreover, we did not carry
out an elicitation study to identify condom use relevant beliefs as recommended
by Ajzen (1991). Instead, general measures of adolescent condom use, obtained
from previous research, were used to assess participantsintentions to use con-
doms and condom use behaviour. It is possible that the use of the general mea-
sures, global constructs, and the non-use of an elicitation study accounted for the
fairly low internal consistency reliabilities, for example, attitudes (a=.64, at
Time 1) and subjective norms (a=.62, at Time 1), reported in this study. How-
ever, we note that the latent variable structural modelling procedures used in this
study took into account the measurement error associated with items on each
scale as well as the scale as a whole by way of the disturbance terms and mod-
elled them. Thus, the fairly low reliability coefcients reported were not
expected to bias the parameter estimates.
In addition, methodologists have recently suggested that longitudinal data
may provide opportunities for disaggregating between-person and within-person
effects (see, for example, Curran & Bauer, 2011; Hoffman & Stawski, 2009).
For theoretical and methodological reasons, the current research did not use
advanced modelling statistical techniques such as multilevel models or latent
growth statistical models to elucidate within-person associations (stability) from
between-person effects (change). We note that within-person effects may not
occur in a vacuum. Thus, there appears to be the need for future research to over-
come this limitation by considering the capabilities offered by multilevel and
growth statistical models to clarify the dependencies associated with between-
person and within-person effects in longitudinal autoregressive models. Further,
although we believe that the participant attrition rate in this study emanated from
a design issue, we suspect that the participant-generated alpha-numeric string
identier used to match the data across time in this study may have contributed
to the reduction in the nal sample size used in the analysis. We note that the
errors associated with some of the identiers on completed surveys may have
emanated from the rather long string identiers required of participants (i.e.
between 10 and 15 strings). Future research should consider the possibility of
using shorter string identiers to help reduce participant errors.
Another possible limitation to note is the three monthstime lag between mea-
surement occasions used in this study. Reviews of the TPB literature indicated
that time lags of three months were preferable and optimal (Noar, Cole, &
Carlyle, 2006; see also Dormann & Grifn, 2015). However, given that the pre-
sent participants were in-school youths, it would seem that a longer time lag
may have been more appropriate to provide enough time for the effect of one
variable on another to manifest (e.g. effect of intention on behaviour). Given the
limited support obtained in the present study for the TPB components, future
research may focus on clarifying the intentionbehaviour correspondence longi-
tudinally, using appropriate study designs and robust statistical techniques. This
20 TEYE-KWADJO ET AL.
©2016 The International Association of Applied Psychology
research may further our current understanding of the psychosocial constraints
preventing adolescents from acting on their intentions. Arguably, an immediate
next step may be to replicate and validate the current ndings in a sample of
public high school students drawn from a cluster of schools in Ghana.
ACKNOWLEDGEMENT
This work was supported by the Graduate School of Arts and Social Sciences at
Stellenbosch University in the form of a doctoral scholarship to the correspond-
ing author. The research reported on here emerged from the doctoral dissertation.
Thus, opinions expressed and conclusions arrived at are those of the authors and
are not to be attributed to the Graduate School or Stellenbosch University.
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INTENTIONS AND BEHAVIOUR IN CONDOM USE 25
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... Evidence shown that there are multiple psychosocial factors that directly or indirectly influence potential condom use, including which sexual communication (Javier et al., 2018), perceived risk (Elshiekh et al., 2020), type of sexual partner (formal or informal) (Bryan et al., 2017), previous condom use, knowledge, self-efficacy, and attitude toward condom use (Sheeran et al., 2016;Janulis et al., 2017;Teye-Kwadjo et al., 2017). While all these characteristics impact condom use, the factor that has evidenced the most significant impact on condom use is attitude (Sheeran et al., 1999;Mbelle et al., 2018). ...
... This exception could be attributed to the involvement of other variables of relevance to condom use (i.e., risk perception, knowledge of risky sexual behaviors, communication with sexual partners) that overlap with people's affective attitudes toward condom use. Therefore, it is possible that people who manifest a negative attitude might not necessarily reduce condom use, especially if they believe they are susceptible to the risk of transmission or are aware of the risks associated with non-use (Sheeran et al., 2016;Janulis et al., 2017;Teye-Kwadjo et al., 2017;Elshiekh et al., 2020). ...
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Condom use is the most effective preventive behavior against HIV transmission, and its inadequate use is a public health problem that occurs mostly among youth and young adults. Although there are scales that measure condom use, those that exist correspond to English-speaking developments or do not have psychometric evidence to support them, so it is possible that the available adaptations of instruments do not adequately reflect the phenomenon in the Chilean population. Thus, the study aims to develop a scale to assess attitudes toward condom use in Chilean youth and young adults. Initially, a sample of students between 18 and 39 years (n = 520) was used for debugging the instrument. Then, a second sample was taken from the general population aged 18 to 40 (n = 992) to confirm the factor structure of the proposed model. The final scale has 10 items and 3 attitudinal dimensions (affective, cognitive, and behavioral). The results show that the identified structure provides adequate levels (ω > 0.7) or at least sufficient of reliability (ω > 0.6) and presents evidence of validity, based on the internal structure of the test, through ESEM (CFI = 0.993; TLI = 0.984; RMSEA = 0.056). In addition, evidence of validity was obtained based on the relationship with other variables and strong invariance between the scores of men and women. It is concluded that the scale developed has adequate psychometric properties to assess, in brief form, condom use attitudes in equal samples for research and screening purposes.
... In general, positive attitudes towards FP have been associated with postpartum contraceptive use among expectant inner-city women in the United States [27], use of long-acting and permanent contraception in Southern Ethiopia [28] and contraceptive use in Nepal [29], while unfavorable attitudes towards modern contraceptive methods has been found to impede demand for contraception and to be significantly associated with unmet need for FP [30]. Similarly, positive attitudes towards condom use had significant direct effects on condom use intentions and/or actual use [31][32][33][34][35]. ...
... Previous studies demonstrated that perceived behavioral control had a weaker contribution to predicted intentions than self-efficacy (see Albarracin et al. [66] for a meta-analysis of 96 studies conducted largely in Europe and the United States). While our conclusions were similar to the latter findings and to the results of a study by Kalolo and Kibusi [33] showing that perceived behavioral control predicted intentions to use condoms among adolescents in rural Tanzania, some studies found that higher perceived control was not associated with condom use intentions [32] or condom use over time [34]. ...
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Unintended pregnancy is an important global health problem and frequently occurs during the immediate postpartum period. However, few studies have examined postpartum family planning (PPFP) intentions among adolescent girls and young women. This study assessed whether perceived norms and personal agency predicted PPFP intentions among first-time mothers age 15-24 in Kinshasa, the Democratic Republic of Congo. Data were derived from the 2018 Momentum Project baseline survey. Analysis was based on 2,418 nulliparous pregnant women age 15-24 who were approximately six months pregnant with their first child in six health zones of Kinshasa. Overall PPFP intentions were low and ten to thirteen percent of women stated they were very likely to discuss PPFP next month with (a) their husband/male partner and (b) a health worker, and to (c) obtain and (d) use a contraceptive method during the first six weeks following childbirth. The results of multivariable linear regression models indicated that the PPFP intention index was predicted by description norms, perceptions of the larger community's approval of PPFP, normative expectations, perceived behavioral control, self-efficacy, and autonomy. Rejection of family planning myths and misconceptions was also a significant predictor. Interaction terms suggested that the association of normative expectations with PPFP intentions varied across ethnic groups and that the positive association of injunctive norms with PPFP intentions was significantly increased when the larger community was perceived to disapprove of PPFP use. Normative expectations and PPFP-related self-efficacy accounted for two-thirds of the variance in PPFP intentions. The results suggested that understanding different normative influences may be important to motivate women to use contraception in the immediate postpartum period. In addition to addressing institutional, individual, and social determinants of PPFP, programs should consider integrating norm-based and empowerment strategies.
... In general, positive attitudes towards FP have been associated with postpartum contraceptive use among expectant inner-city women in the United States [27], use of long-acting and permanent contraception in Southern Ethiopia [28] and contraceptive use in Nepal [29], while unfavorable attitudes towards modern contraceptive methods has been found to impede demand for contraception and to be significantly associated with unmet need for FP [30]. Similarly, positive attitudes towards condom use had significant direct effects on condom use intentions and/or actual use [31][32][33][34][35]. ...
... Previous studies demonstrated that perceived behavioral control had a weaker contribution to predicted intentions than self-efficacy (see Albarracin et al. [66] for a meta-analysis of 96 studies conducted largely in Europe and the United States). While our conclusions were similar to the latter findings and to the results of a study by Kalolo and Kibusi [33] showing that perceived behavioral control predicted intentions to use condoms among adolescents in rural Tanzania, some studies found that higher perceived control was not associated with condom use intentions [32] or condom use over time [34]. ...
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Unintended pregnancy is an important global health problem and frequently occurs during the immediate postpartum period. However, few studies have examined postpartum family planning (PPFP) intentions among adolescent girls and young women. This study assessed whether perceived norms and personal agency predicted PPFP intentions among first-time mothers age 15-24 in Kinshasa, the Democratic Republic of Congo. Data were derived from the 2018 Momentum Project baseline survey. Analysis was based on 2,418 nulliparous pregnant women age 15-24 who were approximately six months pregnant with their first child in six health zones of Kinshasa. Overall PPFP intentions were low and ten to thirteen percent of women stated they were very likely to discuss PPFP next month with (a) their husband/male partner and (b) a health worker, and to (c) obtain and (d) use a contraceptive method during the first six weeks following childbirth. The results of multivariable linear regression models indicated that the PPFP intention index was predicted by description norms, perceptions of the larger community's approval of PPFP, normative expectations, perceived behavioral control, self-efficacy, and autonomy. Rejection of family planning myths and misconceptions was also a significant predictor. Interaction terms suggested that the association of normative expectations with PPFP intentions varied across ethnic groups and that the positive association of injunctive norms with PPFP intentions was significantly increased when the larger community was perceived to disapprove of PPFP use. Normative expectations and PPFP-related self-efficacy accounted for two-thirds of the variance in PPFP intentions. The results suggested that understanding different normative influences may be important to motivate women to use contraception in the immediate postpartum period. In addition to addressing institutional, individual, and social determinants of PPFP, programs should consider integrating norm-based and empowerment strategies.
... Las opciones de respuesta tienen un continuo de 1 (nada probable) a 7 (totalmente probable). Norma subjetiva de amigos y padres sobre el uso del condón: percepción de lo que otros significativos piensan sobre usar condón (Teye-Kwadjo et al., 2017). Se preguntó, "Mis mejores amigos/as piensan que yo debería de usar condón en mis relaciones sexuales", y "Mis padres piensan que yo debería de usar condón en mis relaciones sexuales" (cf. ...
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Background: The theory of Planned Behavior (TPB) is used to predict condom use. The present study assessed the causal relationships of the TPB in a cultural context different from the one that was proposed. Objective: To assess the causal relationships among the variables proposed by the TCP to determine if they predict consistent condom use in two groups of Latina women and to identify the inter-group similarities in both groups and the discrepancies with what the model proposes for the North American population. Method: A set of variables were evaluated in two samples of Latina women (Mexican and Argentine): consistency of condom use, intention to use condoms in the next sexual encounter, the subjective norm of friends and parents, attitudes towards condoms, and perceived behavioral control to use con-doms. We used the Linear regression analysis. Results: Intention to use condoms was found to be the best predictor of condom use. Subjective norm was more important than attitudes; although the latter variable was not configured as a predictor in Argentine women. Conclusion: The associations between the CTP variables and the predictive values of the variables may change according to the cultural group evaluated; perceived behavioral control, in both samples, was not a direct predictor of condom use behavior, but it was a predictor of intention to use condoms. In addition, we discussed the relevance of the variables proposed by the TCP about the cultural context of Latinos and the critical use of the model in populations other than North America.
... This led to the acceptance of the third hypothesis (H3). The finding of this study is supported by previous studies (Guo et al., 2014;Sacolo et al., 2013) but contrary to Teye-Kwadjo et al. (2017a, 2017b and Jemmott III et al. (2007) who found that normative beliefs were not statistically significantly associated with condom use intention. ...
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Knowledge with respect to adolescents’ intentions to engage in protective sexual behaviours is still deficient in numerous countries around the world, particularly in Sub-Saharan Africa (SSA) where HIV prevalence is the highest. Increasing cross-sectional research suggests that the theory of planned behaviour (TPB) is robust in predicting condom use intentions. This study used secondary, baseline data from a study involving 794 in-school adolescents. A structural equation model was applied to the data. Latent variables were used to validate the applicability of the TPB in HIV/AIDS prevention among adolescents in the Botswana context. The predictors of interest were all derived from the TPB. The results revealed that the TPB predictors, apart from affective and instrumental attitude, were predictive of condom use intention among Batswana adolescents. The independent variables explained 57% of the variance in the model. These results suggest that the TPB is recommended as a framework to establish the predictors of condom use intention among Batswana in-school adolescents. Policy makers working on developing HIV education programmes or interventions targeted at adolescents should improve the intention to use condoms via promotion of positive instrumental attitudes, subjective norms and perceived behavioural control beliefs of condom use.
... A person's intentions to engage in a specific behavior (e.g., not attending a scheduled ANC visit, delivering at home) can also be determined by her attitude towards the behavior, her perceived ability (control) to perform a behavior (e.g., to manage her pregnancy or deliver by self at home), and the prevailing normative and subjective beliefs regarding that behavior (e.g., about pregnancy and child birth) within her larger cultural or social context [12,13]. The individual's intention or motivation to perform or execute a certain behavior (e.g., deliver at home) can further be facilitated by the presence of enabling factors and/or enabling environment (perceived power) within which they live, and such intentions (over time) "will predict the likelihood of that individual actually engaging in that given behavior at some point in the future" [12,14]. ...
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Background. Utilization of perinatal services in Uganda remains low, with correspondingly high rates of unskilled home deliveries, which can be life-threatening. We explored psychosocial and cultural factors influencing birthing choices for unskilled home delivery among postpartum women in rural southwestern Uganda. Methods. We conducted in-depth qualitative face-to-face interviews with 30 purposively selected women between December 2018 and March 2019 to include adult women who delivered from their homes and health facility within the past three months. Women were recruited from 10 villages within 20 km from a referral hospital. Using the constructs of the Health Utilization Model (HUM), interview topics were developed. Interviews were conducted and digitally recorded in a private setting by a native speaker to elicit choices and experiences during pregnancy and childbirth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive categories using inductive content analytic approach. Results. Eighteen women (60%) preferred to deliver from home. Women’s referent birth location was largely intentional. Overall, the data suggest women choose home delivery (1) because of their financial dependency and expectation for a “natural” and normal childbirth, affecting their ability and need to seek skilled facility delivery; (2) as a means of controlling their own birth processes; (3) out of dissatisfaction with facility-based care; (4) out of strong belief in fate regarding birth outcomes; (5) because they have access to alternative sources of birthing help within their communities, perceived as “affordable,” “supportive,” and “convenient”; and (6) as a result of existing gender and traditional norms that limit their ability and freedom to make family or health decisions as women. Conclusion. Women’s psychosocial and cultural understandings of pregnancy and child birth, their established traditions, birth expectations, and perceptions of control, need, and quality of maternity care at a particular birthing location influenced their past and future decisions to pursue home delivery. Interventions to address barriers to healthcare utilization through a multipronged approach could help to debunk misconceptions, increase perceived need, and motivate women to seek facility delivery. 1. Introduction An estimated 300,000 women die each year from preventable causes related to pregnancy and childbirth: approximately 95% occur in developing countries [1, 2]. Almost two decades ago, low maternity service utilization and high maternal deaths in Uganda were attributed to lack of skilled staff at health facilities, poor or inadequate maternity care services, and community’s adherence to traditional birthing practices and beliefs that pregnancy was a test of one’s endurance and that maternal death was a sad but normal event [3]. With improved community education and engagement over the years, plus increased skilled capacity at health facilities, perinatal service utilization in Uganda remains unacceptably low with correspondingly high rates of unskilled home deliveries, which can be life-threatening [2, 4, 5]. Uganda has one of the highest maternal (>360 for every 100,000 women) and perinatal (41 deaths per 1000 births) mortality ratios in the world [6]. Uganda’s public health system is organized in seven tiers with national and regional referral hospitals, general district hospitals, and four levels of health centers (HCs) at community (HC1), parish (HC2), subcounty (HC3), and county (HC4) levels. Staffing and available services vary across the four levels: HC3 and HC4 should offer Emergency Obstetrics Care (EMOC), whereas HC1 and HC2 serve as low resource referral units which are not able to provide EMOC and have no ambulances and blood transfusion services [7, 8]. CSOs and private providers operate in parallel to the public system, and in the case of maternal health, the services of CSOs often cut across several activities at various levels of health care provision [9]. With the increasing availability of maternity services, over 90% of women attend at least one ANC visit, and less than 60% attend at least 4 ANC visits, of the 8 recommended by the WHO [6, 10]. Only 70% of women deliver in a health facility or in the presence of a skilled health personnel, depicting a high disparity in maternity service utilization despite the government’s effort to improve accessibility to these services. Many beliefs and misconceptions about pregnancy and childbirth may influence women’s birth choices, which in turn affects health outcomes of both the mother and the baby [11], with risks increasing in lower resourced settings, where birth preparedness and/or infection prevention is not paramount. A person’s intentions to engage in a specific behavior (e.g., not attending a scheduled ANC visit, delivering at home) can also be determined by her attitude towards the behavior, her perceived ability (control) to perform a behavior (e.g., to manage her pregnancy or deliver by self at home), and the prevailing normative and subjective beliefs regarding that behavior (e.g., about pregnancy and child birth) within her larger cultural or social context [12, 13]. The individual’s intention or motivation to perform or execute a certain behavior (e.g., deliver at home) can further be facilitated by the presence of enabling factors and/or enabling environment (perceived power) within which they live, and such intentions (over time) “will predict the likelihood of that individual actually engaging in that given behavior at some point in the future” [12, 14]. To avert maternal and perinatal deaths, the WHO has called for the development and evaluation of adaptable and context-specific health solutions to promote ANC uptake and empower women to overcome barriers to care and facility delivery [15]. Identifying and scaling up such interventions to improve access to quality healthcare in pregnancy and childbirth have great potential to prevent a substantial number of the annual 823,000 stillbirths, 1,145,000 neonatal deaths, and 166,000 maternal deaths in the 75 highest burden countries [16–19]. Despite some successes in pilot studies and enthusiasm from the public sector, interventions to motivate improved outcomes among pregnant women often neglect to base interventions in behavioral theory and have therefore not been brought to scale [20–22]. According to several scholars, motivating health care utilization is a key element of developing effective behavior change interventions [3, 23–28]. Understanding psychosocial and cultural factors that motivate women to choose and/or participate in unskilled home delivery is needed to inform theory or interventions targeting women in rural southwestern Uganda. 2. Methods 2.1. Study Design This study used a qualitative interview study design to identify and understand psychosocial and cultural factors that motivate women to choose and/or participate in unskilled home delivery among postpartum women in Mbarara district, rural southwestern Uganda. 2.2. Study Settings The study was conducted between December 2018 and March 2019 in the Mbarara district of rural southwestern Uganda. Mbarara district is one of the densely populated districts in the Ankole region with one of the highest maternal mortality ratios of 489 per 100,000 women in Uganda [29]. Uganda’s public health system is organized into seven tiers with national and regional referral hospitals, general district hospitals, and four levels of community health centers (HC). The village level (HC1) is operated by village health teams (VHTs). The VHTs are community volunteers identified by their community members and are given basic training on major health programs, so they can mobilize and sensitize communities to actively participate in utilizing health services [30]. According to the Uganda Ministry of Health, VHTs also act as an important link between the communities and health facilities and can provide treatment of uncomplicated diseases like malaria, pneumonia, worm infestations, diarrhea, and mass drug administration for Neglected Tropical Diseases. VHTs mobilize communities during specific health campaigns and community disease surveillance activities through active data collection and reporting. Staffing and available services vary across the four levels: HCIII and HCIV should offer Emergency Obstetrics Care (EMOC), whereas HCI and HCII serve as low resource referral units which are not able to provide EMOC and have no ambulances and blood transfusion services [7]. In total, there are about 10 public facilities within a 20 km radius from Mbarara Regional Referral Hospital, the main teaching hospital for the Mbarara University of Science and Technology. Private providers operate in parallel to the public system to provide maternal health care. 2.3. Research Team The research team comprised of seven senior investigators, inclusive of epidemiologists (ECA and CO), an obstetrician (GRM), a medical anthropologist (NCW), a maternal/reproductive health expert (LTM), a nurse (JN), and a health informatics specialist (AM). Based on our previous research and working experiences in maternal health in Uganda, the team sought to explore reasons for low utilization of maternity services in Uganda. The two male and female research assistants were both social scientists, independently hired and trained to conduct research in human subjects. These two research assistants generated transcripts but were not involved in concept development or coding of data. This multidisciplinary team leveraged on their expertise and experience with maternal health issues in Uganda to design, conduct, analyze, and present findings from this study. 2.4. Participants and Recruitment Contact with one of the VHTs based in each of the study villages was initiated by a trained research assistant from the list of VHTs provided by the district health office. A purposive qualitative sampling strategy was used to construct a sample of postpartum women with varied knowledge and experiences of pregnancy, antenatal care, and childbirth. Women who had had their last delivery within the last three months were identified with the help of an existing VHT contact person found in each of the 10 villages located within 20 km from Mbarara Regional Referral Hospital. Trained research assistants initiated a telephone contact to the identified women to seek for permission to visit them for an interview. Research assistants obtained voluntary written informed consent from all eligible participants in the local language in a private area of their homes, communities, or study office. All consenting participants gave written informed consent, or for those who could not write, a thumbprint was made on the consent form. Three women from each of the 10 villages with different home or facility birthing experiences were purposively selected and recruited. The total sample included 15 women who had delivered from their homes and 15 who had delivered from a health facility. Eligible women (1) were adults of childbearing age (18-49 years), (2) had delivered a child in the previous three months, (3) had access to a mobile phone, and (4) were able and willing to give informed consent. 2.5. Data Collection Interview topics were developed using HUM. Data collection consisted of individual, open-ended interviews with each of the study participants ( interviews). A preliminary interview guide was developed and pilot tested by the primary author among women in one of the 10 participating villages using the constructs of the Healthcare service Utilization Model that demonstrates the factors that lead to the use of health services (Figure 1). The guide was revised based on the results of the pilot test. Topics included in the final version of the guide were as follows: (1) perceptions of pregnancy and childbirth, (2) experiences of previous pregnancy or pregnancies, (3) experiences of ANC, (4) engagement with health care providers within a facility, (5) social support, and (6) childbirth experiences. Individualized probes were used to elicit details corresponding to each topic. As the interviews were conducted, emerging content was continuously reviewed by the primary and senior authors to sharpen the interview questions and identify new probes. Demographic information (e.g., age, occupation, and educational background) was collected at the outset of each interview.
... This theory suggests that one's behavior is determined by one's intention to perform certain behavior, and the intention is determined by the following: attitude toward behavior, subjective norm, and perceived behavioral control (PBC). The theory has been used in several studies for explaining health behavior among adolescents such as in dieting [24] and condom use [25]. ...
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http://www.tandfonline.com/doi/full/10.1080/17437199.2013.869710
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