FACTORS INFLUENCING CONDOM USE AMONG THAI ADOLESCENTS

by

NATAWAN KHUMSAEN

Submitted in partial fulfillment of the requirements

For the degree of Doctor of Philosophy

Dissertation Advisor: Dr. Faye A. Gary

Frances Payne Bolton School of Nursing

CASE WESTERN RESERVE UNIVERSITY

May, 2008
 CASE WESTERN RESERVE UNIVERSITY

SCHOOL OF GRADUATE STUDIES

We hereby approve the thesis/dissertation of

Natawan Khumsaen
_____________________________________________________

Ph.D.
candidate for the ______________________degree *.

Dr. Faye A. Gary

(signed)_______________________________________________
(chair of the committee)

Dr. Diana L. Morris

________________________________________________

Dr. Barbara A. Cromer

________________________________________________

Dr. Amy Y. Zhang

________________________________________________

________________________________________________

________________________________________________

February 13, 2008

(date) _______________________

*We also certify that written approval has been obtained for any
proprietary material contained therein.
 DEDICATION

This dissertation is dedicated to my parents who educated me for loving

wisdom. They have been my great inspiration to pursue a doctoral degree. Thank you

very much, Dad and Mom.

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TABLE OF CONTENTS

Page

LIST OF TABLES

LIST OF FIGURES

ACKNOWLEDGEMENTS

ABSTRACT

CHAPTER I: INTRODUCTION

Introduction……………………………………………………………………1

Background and Significance……………………………………………….....2

Conceptual Framework………………………………………………………...9

Bandura’s conceptualization of self-efficacy……………………….....9

Bandura’s as adaptive model for adolescents in

Ubonratchathani Province, Thailand…………………………………10

Purpose and Research Questions……………………………………………..12

Definitions of Terms………………………………………………………….13

Significance of the Study to Nursing………………………………………...16

Health Policy…………………………………………………………17

Nursing Research……………………………………………………..17

Nursing Practice……………………………………………………....18

CHAPTER II: LITERATURE REVIEW

Introduction…………………………………………………………………..19

History of HIV/AIDS and the implications…………………………………...21

Adolescent development……………………………………………………...43

Premarital sexual behavior and condom use in adolescents………………….53

Theoretical Framework of the study…………………………………………100

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Summary……………………………………………………………………..130

CHAPTER III: METHODOLOGY

Research design……………………………………………………………....133

Sampling……………………………………………………………………...133

Pilot study for the attitudes toward condom use study……………………...143

Data collection procedure…………………………………………………….144

Measurements………………………………………………………………...148

Data management…………………………………………………………….162

Statistical analyses……………………………………………………………164

Protection of human subjects…………………………………………………169

Summary……………………………………………………………………...170

CHAPTER IV: RESULTS

Section I………………………………………………………………………171

Demographic Characteristics…………………………………………171

Description of the study variables……………………………………176

Analysis of research question 1………………………………………190

Analysis of research question 2………………………………………192

Analysis of research question 3………………………………………192

Analysis of research question 4………………………………………192

Analysis of research question 5………………………………………193

Section II……………………………………………………………………..196

Summary of the findings from two-open-ended questions…………..196

CHAPTER V: DISCUSSION

Discussion of major research findings……………………………………………..... 201

Major research findings………………………………………………201

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Findings from two-open-ended questions…………………………….224

Limitations……………………………………………………………………229

Study implications……………………………………………………………231

Nursing research……………………………………………………...231

Nursing practice………………………………………………………233

Health policy………………………………………………………….234

Recommendations for future research………………………………………. 235

Summary……………………………………………………………………...237

APPENDICES

Appendix A…………………………………………………………………..240

Appendix B…………………………………………………………………..241

Appendix C…………………………………………………………………..242

Appendix D…………………………………………………………………..243

Appendix E…………………………………………………………………..245

Appendix F…………………………………………………………………...246

Appendix G…………………………………………………………………..247

Appendix H…………………………………………………………………..263

Appendix I…………………………………………………………………...266

Appendix J…………………………………………………………………...267

Appendix K…………………………………………………………………..268

REFERENCES……………………………………………………………………....269
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LIST OF TABLES

Page

Table 1: The 1993 Revised Classification System for HIV Infection and

Expanded AIDS Surveillance Case definition for Adolescents

and Adults……………………………………………………………….23

Table 2: Clinical Categories………………………………………………………24

Table 3: Conditions Included in the 1993 AIDS Surveillance Case
Definition………………………………………………………………..25
Table 4: Types and subtypes of HIV……………………………………………..27

Table 5: Descriptive Statistics of the Sample…………………………………….173

Table 6: Descriptive Statistics of the Negative Outcomes of Condom

non-use…………………………………………………………..............175

Table 7: Descriptive Statistics of Independent Variables of the Sample………...176

Table 8: Descriptive Statistics of Self-reported History of Alcohol/Drug

use and Actual Usage of Condoms among Sexually Active

Adolescents……………………………………………………...............178

Table 9: Percentage and Number of responses on Duration of the

current intimate relationship……………………………………………..180

Table 10: Percentage and Number of responses on perceived preventive

behavioral peer norms…………………………………………………..182

Table 11: Percentage and Number of responses on self-efficacy in

condom use……………………………………………………………..185

Table 12: Percentage and Number of responses on actual usage of

condoms………………………………………………………………...187
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Table 13: Differences of actual usage of condoms frequency by gender…………188

Table 14: Bivariate correlation matrix for personal information (gender,

age, self-reported history of alcohol/drug use, duration of the

current intimate relationship, and perceived preventive

behavioral peer norms) and actual usage of condoms………………….191

Table 15: Association between personal information (gender, age, self-

reported history of alcohol/drug use, duration of the current

intimate relationship, and perceived preventive behavioral

peer norms), knowledge of STDs/HIV/AIDS and pregnancy,

attitudes toward condom use, and condom use self-efficacy,

and actual usage of condoms…………………………………………...195

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LIST OF FIGURES

Page

Figure 1: Bandura’s self-efficacy (SE) model of safer sex behavior

(Bandura, 1990)…………………………………………………………241

Figure 2: Adaptive model of Bandura Self-Efficacy (SE) study of

sexual risk behavior among Thai adolescents in

Ubonratchathani Province (Bandura, 1990)……………………………..242

Figure 3: Substruction diagram based on Bandura’s Self-Efficacy (SE)

model of safer sex……………………………………………………… 243

Figure 4: Ubonratchathani Province located in the northeastern region

of Thailand………………………………………………………………245
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ACKNOWLEDGEMENTS

The success of this dissertation lies in the advice, support, and encouragement

of many individuals and organizations. First of all, I wish to express my gratitude to,

Faye A. Gary, EdD, RN, FAAN, my advisor and the chair person of my dissertation

committee, for her concern, thoughtful and continual guidance, prompt feedback,

supports in the proposal development, candidacy preparation, and completion of this

dissertation leading to its successful defense. Throughout the study process, I have

been under her supervision, and I have learned a number of valuable lessons which

have become the most important basis for my profession. She is my role model.

My further sincere thanks are extended to all of the dissertation committee members,

Diana L. Morris, PhD, RN, FAAN, Amy Y. Zhang, PhD, and Barbara A. Cromer,

MD, for their guidance and useful feedback. I am extremely appreciated for their

scholarly input, support, and contributions.

Moreover, I am deeply grateful to Janet S. St. Lawrence, PhD, and Sathja

Thato, PhD, RN, for providing permissions to use the instruments for this study.

A special thank is extended to Petmanee Viriyasuebphong, EdD, RN, for prompt

providing useful materials for my study. I am also really grateful to Gregory Graham,

MA, for his expertise in data analysis and useful feedback. Also, I would like to thank

Karen Young for her friendship and gentle assistance.

Furthermore, I would like to thank the Thai Government and the Thai Ministry

of Public Health. Without their substantial financial support, I would not be able to

get a doctoral degree. In addition, I would like to thank colleagues, and staffs at

Boromarajonani College of Nursing, Sappasitthiprasong, for their support and

sacrifices of hard working when I furthered my education oversea.

 xi

Most importantly, my parents, Paiboon and Khumchant Khumsaen, whose

endless love, inspiration, understanding, and encouragement made me develop self-

confidence, resilience, and to strive for the best possible in my life. Also, my deepest

thanks go to my younger sisters, Sudatip Khumsaen, MA, and Sudawan Khumsaen,

MBA, for their supports and taking care of our family during the period I was away

from home. Thanks to Thanista Peanprasop, MBOA, and MeePooh, for being the

wonderful friends to my family members during my leave time. My gratefulness is

also extended to a younger brother of my mother, Sakorn Lekkla, MPPM, for his

benevolent assistance and supporting me through the process of this dissertation.

I also wish to acknowledge my friends at Case Western Reserve University,

Chiou-Fang Liou, PhD, RN, Amany Farag, PhD, RN, Evanne Juratovac, PhD(c), RN,

Tsay-Yi Au, PhD(c), RN, and Wariya Muensa, PhD student, RN, for their supports

and being very good friends for years. Moreover, I would like to express my hearty

thanks to Thai friends; Kedsaraporn Kenbubpha, MSc, RN, for her assistance in pilot

study; Jariya Kittiyawan, MSN, RN, for her support and understanding; Patcharee

Jaigarun, MNS, RN, for her assistances; and Prangthip Tasanoa, PhD student, RN, for

her huge emotional support. Furthermore, my appreciations and thanks are extended

to friends, and staffs at the National Prion Disease Pathology Surveillance Center,

Case Western Reserve University, for their supports when I was struggling on my

dissertation process. I have been delighted working with them.

In addition, I am tremendously grateful to the vocational school students who

participated in my study as well as to the school directors who provided me with

access to study population. All students provided the valuable data for my study.

Lastly, I wish to express heartfelt thanks to Suppavuth Khambanonda, BSME,

MPPM, for good assistance through my educational journey. Thank you indeed, SPK.
 xii

Factors Influencing Condom Use among Thai Adolescents

Abstract

by

NATAWAN KHUMSAEN

Premarital sexual behavior without using condom among adolescents is a

major health concern all over the world. Although condom has been made available

more than a hundred years, condom use remains inconsistently. This study aimed to

investigate the relationships among attitudes toward condom use, personal

characteristics, condom use self-efficacy, and actual usage of condoms among Thai

adolescents. Also, the predictors of condom use were examined. The model for this

study was based on Bandura’s conceptualization of self-efficacy for the prevention of

HIV/AIDS/STDs. A cross-sectional descriptive correlational design was employed on

a cluster based sample (n=270) of male and female Thai vocational school subjects

(18-21 years of age) in Ubonratchathani Province, Thailand. Data were collected by

using a variety of survey measures.

The results showed that, of all participants, 180 participants (66.66%) have

been sexually active. Among them, the mean age at first sexual intercourse was 16.88

years (SD=1.93). The youngest age at sexual initiation was 11 years-of age (3%). At

the beginning of a sexual relationship, 13.3% reported condom use every time. At the

last few times of a sexual relationship, 16.7% reported condom use every time.

Furthermore, only 16.7% of subjects reported that in general, they used condoms at
 xiii

the times of sexual activity. The main reasons for using condoms were to prevent

pregnancy (30%), and to prevent AIDS (30.4%). The main reasons for not using

condoms included: ‘not natural’ (10.4%), and used other methods (5.6%). Significant

correlations were identified among self-reported history of alcohol/drug use, attitudes

toward condom use, and condom use self-efficacy on actual usage of condoms.

Eleven percent (R2=11.3%) was the variance in actual usage of condoms explained by

gender, age, self-reported history of alcohol/drug use, duration of the current intimate

relationship, and perceived preventive behavioral peer norms, knowledge of

STDs/HIV/AIDS and pregnancy, attitudes toward condom use, and condom use self-

efficacy. The empirical knowledge obtained from this study provide a rationale for

nursing practice to conduct nursing interventions to achieve a change in condom use

behavior among the Thai adolescents. Moreover, this study makes the contributions to

health policy, nursing research, and community-based studies.

 1

CHAPTER I

Introduction

Introduction

Adolescence is a stage of numerous, and often rapid and profound changes in

the transition from childhood to adulthood (Lerner et al., 1996). These maturational

changes involve biological, psychological, and social characteristics of the person.

Physical maturation makes it possible for adolescents to be capable of reproduction,

yet they may be emotionally and cognitively unprepared for the consequences of

parenthood (Brown, 2000). Young teenagers who give birth during their adolescent

years tend to function less effectively in many areas such as educational achievement,

psychological function, parenting knowledge and skills, and they experience less

desirable health outcomes (Ayoola, Brewer, & Nettleman, 2006) than their peers who

delay childbearing. The negative outcomes of adolescent parenthood include low

educational achievement, poorer psychological functioning, greater welfare use, and

higher rates of health problems (Coley & Chase-Lansdale, 1998; Eshbaugh, Lempers,

& Luze, 2006). Adolescence is sometimes described as the genital stage of adult

sexuality, which includes the reawakening of sexual urges that first surfaced during

the phallic stage (3-6 years old) of growth and development (Freud, 1981; Kaufman,

2006). In order to define and understand their own sexual roles and functioning, these

adolescents may practice sexual experimentation. However, sexual experimentation

during adolescence can have detrimental consequences, including contracting

sexually transmitted diseases (STDs) such as gonorrhea, syphilis, and Human

Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS)

(Feldmann & Middleman, 2002). Because of their inability to perceive the potential

short and long term negative consequences of their current risky sexual behaviors,
 2

adolescents might engage in sexual behaviors that have deleterious outcomes (Thato,

Charron-Prochownik, Dorn, Albrecht, & Stone, 2003).

Background and Significance

Sexual Behavior

From a global perspective, adolescents and young adults engage in

unprotected sexual activities (De Silva, 1998). This trend is increasing throughout the

global community (Gage, 1998; World Health Organization [WHO], 2001; Abraham,

2003). For example, more than half (55.7%) of the adolescents in the United States

(US) are sexually active at or around 15 years of age (Dye & Upchurch, 2006). Over

75% of females and 86% of males in the US have had sexual intercourse by the age of

20 (Centers for Disease Control and Prevention [CDC], 1993). Among American

adolescents, during the early nineties, approximately 54% of high school students

reported having been sexually active (Warren et al., 1998). In addition, a large

percentage of sexually active adolescents are practicing unsafe sex. Less than 40% of

sexually active American adolescents reported using condoms during their last

intercourse exposure (Orr & Langefeld, 1993; Civic, 2000).

Likewise, in Southeast Asia countries such as Vietnam, only 15% of sexually

active Vietnamese adolescents reported having ever used any kind of modern

contraception, including birth control pills, birth control shots, and condoms

(Gammeltoft, 2002). The mean age of Vietnamese teenagers when sexual intercourse

first occurred was 19.5 years (De Silva, 1998). In the Philippines, another Southeast

Asia country, an increase of 18% in sexual activities among Filipino high school

students was reported (Cadelina & Cadelina, 1996). The average age at first sexual

experience among Filipino adolescents was 17.6 years (Manalastas, 2005). Still,

adolescents in Thailand, a Southeast Asia country that borders Lao People’s

 3

Democratic Republic (Lao PDR) and Cambodia also reported earlier and more

frequent sexual activities than the two other countries. In particular, in Thailand, the

youngest age of first sexual intercourse experience was 13 years, with an average age

of about 14.5 years (Krisawekwisai, 2003). This reported age is relatively lower than

those reported in the other two identified Southeast Asia countries (Viet Nam and

Philippines). Hence, Thai adolescents are more likely to experience sexual contact at

an earlier age.

Although premarital sexual intercourse is not acceptable by Thai tradition and

is considered a cultural taboo, 64.8% of male and 32% of female adolescents have

reported engaging in premarital sexual intercourse. Despite the availability of

condoms, only 6.3% of these sexually active students reported using condoms every

time when having sexual intercourse. About 10.2% of the population reported using

condoms during the last few times they engaged in sexual intercourses (Thato et al.,

2003). In another study, the usages of condoms during the last sexual intercourse

experience were reported by 61% of sexually active male adolescents

(Lertpiriyasuwat, Plipat, & Jenkins, 2003). Therefore, the early sexual exposure, the

low rate and inconsistent use of condoms among these high risk Thai adolescents

suggest the need for more empirical studies, culturally specific interventions, and

health literacy programs that are available to all of the Thai citizens (Attaveelarp,

2000; van Griensven et al., 2001; Krisawekwisai, 2003; Allen et al., 2003).

Adolescent premarital sexual activity can result in negative consequences,

such as contracting sexually transmitted diseases (STDs), including Human

Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS),

unintended pregnancies, and abortions (Yang, 1995; Lee, Chen, Lee, & Kaur, 2006).

Recent statistics suggested that the rate of unintended pregnancies, STDs, and other
 4

health related problems are becoming major health concerns among Thai parents,

nurses and other health care providers. Local and national policy makers are also

grappling with this urgent public health problem (O’grady, 1993). Dialogue abounds

among government official at all levels regarding unwanted teenage pregnancy, the

impact of abortion on the female, the male, and their families, and the compromises

that could occur in the adolescents’ lives during subsequent years. All segments of the

Thai population are directly or indirectly affected by the adolescents’ sexual health

decision making behaviors (Krisawekwisai, 2003).

Among the numerous negative consequences of unprotected premarital sexual

behavior in Thailand, unintended teenage pregnancy is one of the most significant

problems; it has social, health, and economic consequences (Ayoola, Brewer, &

Nettleman, 2006). In a study conducted in Bangkok, Thailand, 8% of sexually active

boys in the 11th grade reported that they had impregnated a young female, and 72.5%

of these females had elected to have an abortion (Wuttiprasit, 1991). Among 11th

grade females, 4% reported that they had been pregnant, and 75% of these individuals

had reported having had an abortion (Wuttiprasit, 1991). The researcher did not report

data regarding the other 4% of young females in the sample that had been pregnant.

In contrast, in the US, 35% of college female and male students reported that

they had been pregnant or had impregnated somebody else (CDC, 1997b). In 2000-

2001, almost one in every five American women (19%) who had an abortion was

adolescents (Jones, Darroch, & Henshaw, 2002). These data indicate that Thai

adolescents and US college students are sexually active and are receiving abortions at

a rather high rate. Both populations are likely to experience negative health outcomes

associated with abortion and they could easily become infected with one or more

types of STDs.
 5

One of the devastating consequences of unprotected premarital sexual

intercourse is the transmission of STDs among adolescents and youth adults. The high

incidence of STDs among Thai adolescents creates many problems for them and the

Thai society (Ford, 1996). Here are a few examples. The high rate of STDs among

adolescents has resulted in an increased incidence of serious sequelae in reproductive

health such as infertility, pelvic inflammatory disease (PID), ectopic pregnancy, and

cancer of the reproductive system (O-Prasertsawat, 2005). If left untreated,

Chlamydia and gonorrhea infections, for example, can develop into PID (Paavonen &

Lehtinen, 1996). Among Thai adolescents, approximately 23% of high school

students reported having contracted STDs by 11th grade (Wuttiprasit, 1991). This STD

rate is comparable to those in the US, in which 25% of all new annual STD cases are

reported among adolescents (CDC, 1997b). A study conducted by the Thai

government in 2000, estimated that the direct and indirect cost of STDs, and

HIV/AIDS treatment to the nation was $1.2 US billion dollars (Gill & Thompson,

2003). These findings are echoed in other countries, including the United States (US).

In the US, aside from obvious personal costs, the economic costs of PID and PID-

related ectopic pregnancies and infertility were estimated at $4.2 billion greater than

the cost in Thailand (Yeh, Hook, & Goldie, 2003; Chesson, Blandford, Gift, Tao, &

Irwin, 2004). Furthermore, the burden of treating STDs can be further understood by

examining its cost to the general public. The Centers for Disease Control and

Prevention (CDC) has suggested that the US paid about $6.5 billion in year 2000 for

the treatment of STDs through public and community health clinics (Chesson et al.,

2004). This dollar figure does not include the cost of STDs treatment in private

sectors. In the US, data regarding STDs cost in the private sector was not readily
 6

available (CDC, 2004a; Chesson et al., 2004). Although the private sector is required

to report STDs, but frequently do not (St. Lawrence et al., 2002).

Adolescents engaged in unprotected premarital sexual activity are at risk for

acquiring STDs, including HIV/AIDS. Globally, HIV/AIDS is one of the most serious

diseases, though preventable, with which all governments must grapple. Not only

does it appear to be incurable, but it is an inevitable fatal disease. HIV/AIDS affects

people in the years of their reproductive periods and at the time when they could be

productive in the workplace (Mane & McCauley, 2003). Recall that HIV/AIDS is

incurable, but it is also preventable.

Throughout the world community, recent data have suggested that adolescents

have a significantly higher risk of acquiring HIV infections than any other age group

(Garriguet, 2005). Specifically, Thai adults have reported that 20% of HIV infections

were acquired during adolescence and young adulthood with approximate ages

ranging from 13-25 years of age (Ministry of Public Health of Thailand, 1996). A

similar trend has been reported in the US. One fifth of the people with AIDS in the

US were diagnosed when in their twenties (CDC, 1999). These data suggested that

both populations (Thai and US) of young adults were infected during their adolescent

years (Smith, Weinman, & Mumford, 1991). Researchers can reason that since the

latency period between HIV infections and the onset of symptoms is about ten years,

it can be concluded that these American adults probably became infected during early

to late adolescence. Many of these adults, when in the adolescence stage, were no

doubt experimenting with sexual behaviors and activities. The outcome, some ten

years later, could be the manifestation of a lethal disease, HIV/AIDS.

Again, similar trends are evident in Thailand. Major public health campaigns

have been implemented to educate and increase the awareness of all Thai citizens
 7

about the lethality of HIV/AIDS. These campaigns also focus on prevention through

abstinence, and condom use during sexual activity. However, premarital unprotected

sexual intercourse continues to increase among Thai adolescents. As a result, negative

outcomes, such as STDs/HIV/AIDS, and unintended pregnancies are common

diagnoses among this population of vulnerable adolescents (Brown & Brown, 2006).

Despite the current family planning strategies that have been promoted through mass

media, such as radio advertisements, signboards, as well as nationwide campaigns

sponsored by the Thai government, HIV/AIDS continue to proliferate. Furthermore,

condom use remains inconsistent and unreliable despite the high accessibility of

condoms that have been placed in drug stores, super markets, and other convenient

locations (CDC, 2003b; United Nations Program on HIV/AIDS (UNAIDS), 2004).

However, the Thai government has not yet approved of the presence of condoms in

public schools. Neither does the government support health education that includes

reduction of sexual risk taking behavior and condom use (CDC, 2003b; Rewthong,

2001).

The consequence of high sexual risk behavior among Thai adolescents is one

of the country’s major public health problems (Ministry of Public Health of Thailand,

1996). In order to develop prevention and intervention strategies that are culturally

specific to Thai adolescents, this phenomenon must be carefully and sensitively

explored. There are gaps in the scientific and practice literature that address attitudes

toward condom use, the predictors of condom use, and condom use self-efficacy

among Thai adolescents.

Therefore, the purpose of this study is to investigate the relationships between

Thai adolescents’ attitudes toward condom use, the predictors of condom use, condom

use self-efficacy, and safer sexual behavior through condom use among Thai
 8

adolescents. The self-efficacy theory and model related to sexual health decision

making and safer sexual behavior as described by Bandura (1990) are the

underpinning theoretical components of this study. The participants in this proposed

study are late adolescent males and females (18-21 years) recruited from three

vocational schools in Ubonratchathani Province, Thailand (See Appendix A, list of

vocational schools, p.240).

Since sexual activity and contraceptive use are social behaviors, self-efficacy

is an appropriate selection from among theories because of its importance in

explaining social interactions and behavioral change. According to Bandura (1990),

sexual risk behavior happens because people need not only knowledge and skills

about HIV/AIDS to exercise safer sex behavior, but also a process of cognitive

appraisals by which they integrate knowledge, outcome expectancies, and past

experiences to form a judgment about their ability to master a difficult situation.

Therefore, people can practice safer sex to the degree that they believe they can

protect themselves when needed (Bandura, 1990). Besides, Bandura (1990) defined

self-efficacy as “the conviction that one can successfully execute the behavior

required to produce the outcomes (p. 10).” Thus, condom use self-efficacy would be

defined as one’s confidence in one’s capability to use condoms when engaging in

sexual activity (Hanna, 1999). Self-efficacy is proposed to influence behavior and

condom self-efficacy is proposed to persuade condom use (Bandura, 1990). Condom

self-efficacy was reported to be related to the actual usage of condoms (Joffe &

Radius, 1993; Fernandez-Esquer, Atkinson, Diamond, & Useche, 2004; Godin,

Gagnon, Lambert, & Conner, 2005). In this study, the concept of self-efficacy in

condom use is utilized to examine the relationship between condom use self-efficacy,

and condom use behavior. The findings of this study will provide significant
 9

information for further culturally specific intervention programs that emphasize safer

sex during premarital sexual activity. It will also focus on maximizing the benefits

from condom use, and enhancing condom use self-efficacy.

The rationale of this study is explicated. First, reducing and preventing the

high incidence and prevalence of STDs, primarily HIV/AIDS in Thai adolescents and

young adults is paramount for improving the nation’s health. Second, increasing

condom self-efficacy among Thai adolescents who might be at risk for HIV/AIDS and

STDs is essential to improving health outcomes. Third, reducing and eliminating the

negative consequences of premarital sexual intercourse (STDs, HIV/AIDS, and

abortions) is a desired outcome. Lastly, Thai adolescents, their families, and all

individuals in the nation are beginning to become aware of the short and long-term

negative consequences of high risk sexual behavior. Adolescence in Ubonratchathani

Province, Thailand is the focal point of this research (Cash, Anansuchatkul, &

Busayawong, 1999; Jenkins et al., 2002; Rojanapithayakorn & Hanenberg, 1996;

Xenos, Pitaktepsombati, & Sittitrai, 1993).

Conceptual Framework

Bandura’s conceptualization of self-efficacy

Bandura (1990) proposed a self-efficacy (SE) model of safer sex behavior.

This model examines HIV risk reduction from the perspective of self-efficacy theory

(Bandura, 1977, 1986, 1997). The initial application of this theory led to useful

analyses of various health behaviors and generated powerful interventions for

behaviors that are notoriously difficult to change (Wulfert & Wan, 1993) including,

smoking, alcohol abuse, and sexual risk taking behavior (Ramirez, Velez, Chalela,

Grussendorf, & McAlister, 2006; Fiorentine & Hillhouse, 2003; Baele, Dusseldorp, &

Maes, 2001).
 10

In the model, for sexual risk reduction, knowledge and skills to effect safer sex

behavior are necessary but not sufficient for a successful outcome (Bandura, 1990).

Unless people believe that they can produce a desired effect by their own actions, they

have little motivation to act or persevere in the face of obstacles. Self- efficacy

influences the course of action individuals choose, how much effort they put into the

course of action, how long they persevere in the face of barriers, and the level of

accomplishment they realize (Bandura, 1999). Individuals may know how the HIV is

transmitted and have the skills to negotiate condom use but still engage in unprotected

sexual intercourse (Wulfert & Wan, 1993).

According to Bandura’s self-efficacy (SE) model of safer sex, an effective risk

behavior change must involve four components, one of which is self-efficacy. The

four components include: (1) an informational component to increase awareness and

knowledge of health risks; (2) a component to develop the self-regulatory and risk

reduction skills needed to translate risk knowledge into preventive behavior; (3) a

component to increase the level of these skills and an individual’s level of self-

efficacy with respect to them; and (4) a component that develops or engages social

supports for the individual who is making the change, in order to facilitate the change

process and promote maintenance (Bandura, 1990; Wulfert & Wan, 1993) (See

Appendix B, Figure 1, p.241).

Bandura’s as adaptive model for adolescents in Ubonratchathani Province, Thailand

The model for this study is based on Bandura’s conceptualization of self-

efficacy for the prevention of HIV/AIDS/STDs. It consists of three domains: personal

information; attitudes toward condom use; and self-efficacy in condom use. This

component helps to clarify the dynamics that are embedded in self-efficacy condom

use behavior (Hanna, 1999) (See Appendix C, Figure 2, p.242).

 11

Personal information, in this model, includes gender, age, self-reported history

of alcohol/drug use, perceived preventive behavioral peer norms, duration of the

current intimate relationship, and knowledge of STDs/HIV/AIDS and pregnancy. The

second domain, attitudes toward condom use, includes relationship safety, perceived

risks, interpersonal impact, safety, effect on sexual experience, and promiscuity.

Significantly, self-efficacy in condom use, the third domain, consists of consistent

condom use self-efficacy, correct condom use self-efficacy, and communication self-

efficacy with partner. Collectively, it is hypothesized that these three domains will

influence the Thai adolescent’s condom use behavior. In this study, Thai adolescent

condom use behavior is defined as the actual use of condoms during each such sexual

intercourse (See Appendix D, Figure 3. substruction diagram based on Bandura’s self-

efficacy (SE) model of safer sex behavior, p.243).

This study was conducted at three vocational schools in Ubonratchathani

Province, northeastern region of Thailand. The rationale for the selection of the

province for this study is that the average age of the first sexual intercourse among the

adolescents in this province is 14.5 years old (Krisawekwisai, 2003), a time at which

the adolescents are matriculating at the vocational schools. The northeastern region is

compiled of 19 provinces (See Appendix E, Figure 4, p.245). Ubonratchathani

Province is located in the northeastern region of Thailand; this region occupies the

largest land area in Thailand, with more than 170,000 square kilometers (42,007,850

acres) in size or roughly one-third of the country. The city of Ubonratchathani is the

second largest city in the northeastern region. It has a population of 1,765,920

(Ubonratchathani Provincial Statistical Office, 2001). There are approximately

183,926 adolescents living in this region. Situated in a strategic location bordering on

Lao PDR to the east, Cambodia to the south and the west, and the central region of
 12

Thailand to the north, Ubonratchathani Province has in recent years emerged as a

significant region in Thailand. The province is an active trading community where

Thai product such as rice and corn are sold to other countries, providing a financial

base to Thailand. In view of the fact that the early sexual exposure among adolescents

in Ubonratchathani Province occurs about two years before sexual activity begins

among Thai adolescents living in other regions, has brought concern among

community and professional people. That is to say, adolescents who live in

Ubonratchathani Province are at greater risk for STDs in the nation when compared to

their other Thai counterparts.

Purpose and Research Questions

Purpose

The purpose of this study is to investigate the relationships between Thai

adolescents’ attitudes toward condom use, the predictors of condom use, condom use

self-efficacy, and safer sexual behavior through condom use among Thai adolescents.

Research Questions

1. Is there a relationship between personal information (gender, age, self-

reported history of alcohol/drug use, duration of the current intimate relationship, and

perceived preventive behavioral peer norms) and condom use behavior?

2. Is there a relationship between knowledge of STDs/HIV/AIDS and

pregnancy and condom use behavior?

3. Is there a relationship between attitudes toward condom use (relationship

safety, perceived risk, interpersonal impact, safety, effect on sexual experience, and

promiscuity) and condom use behavior?

 13

4. Is there a relationship between condom use self-efficacy (consistent condom

use self-efficacy, correct condom use self-efficacy, and communication self-efficacy

with partner) and condom use behavior?

5. Do the independent variables (gender, age, self-reported history of

alcohol/drug use, duration of the current intimate relationship, perceived preventive

behavioral peer norms, knowledge of STDs/HIV/AIDS & pregnancy, attitudes toward

condom use, and condom use self-efficacy) predict the dependent variable (condom

use behavior)?

In addition to these five quantitative research questions, the researcher also

included two-open-ended questions that should help to explain the relationships

between Thai adolescents’ attitudes toward condom use, the predictors of condom

use, condom use self-efficacy, and safer sexual behavior through condom use among

Thai adolescents. These questions were related to the double standards that exist

among males and females in the Thai culture regarding attitudes toward premarital

sexual activity. The questions are:

1. Tell me what you feel about premarital sexual behavior among Thai

adolescents.

2. Share with me your thoughts about young Thai men having sex before

marriage. Now, tell me what you think about the females.

Definitions of Terms

Adolescence refers to the developmental period of transition between

childhood and adulthood, including biological, psychological, cognitive, and social

transitions where by a young person is invested in establishing a personal sense of

individual identity and feelings of self-worth (Santrock, 2001).

 14

Safer sex means taking precautions during sexual intercourse that can keep

one from contracting sexually transmitted diseases (STDs), or from transmitting the

STD to one’s partner. Precautions include consistent condom use with a sexual

partner for the prevention of diseases such as genital herpes, genital warts, HIV,

Chlamydia, gonorrhea, syphilis, hepatitis B and C, and others (Polizzotto, 2005).

High risk sexual behavior is conceptualized as the sexual behavior that

places one at risk for contracting sexually transmitted diseases (Kelly, St. Lawrence,

& Brasfield, 1991).

Steady or Main partner refers to someone individuals have sex with and they

consider to be the person that they are serious about (Rosengard et al., 2001).

Casual partner refers to anyone individuals have sex with but they do not

consider to be the person that they are serious about (Rosengard et al., 2001).

Developing country is identified as a nation with low-income ($875 or less

per capita) or lower-middle-income economies ($876-$3,465 per capita) (World

Bank, 2006).

Age is the adolescents’ self-reported years of life. In this study age is defined

as 18-21 years.

Alcohol use refers to consuming beverages containing alcohol, and/or a

chemical agent affecting cognitive ability, emotional and behavioral capabilities, if

consumed in a large enough amount (Winger, 2004). Typically, alcohol use refers to

ethanol.

Drug use and abuse refers to the consumption of illicit drugs, e.g.

amphetamine, ecstasy, cocaine, heroin, and inhalants, in combination or individual

use (Winger, 2004).

 15

Duration of the current intimate relationship is defined as the number of

days since he/she had sexual intercourse with his/her current (most recent) partner.

Perceived preventive behavioral peer norms refer to one’s perception of the

peer’s thought of engaging in safe sex behavior including condom use (Thato et al.,

2003).

Knowledge of STDs/HIV/AIDS and Pregnancy refers to the communicative

factual and interpretive information regarding causes and prevention of

STDs/HIV/AIDS, and causes of pregnancy (Thato et al., 2003).

Attitudes toward condom use is regarded as the degree of evaluation of

thoughts related to the relationship safety on condom use, perceived risk on condom

non-use, interpersonal impact on condom use, safety of condom use, effect of condom

use on sexual experience, and promiscuity (Sacco, Levine, Reed, & Thompson, 1991;

St. Lawrence et al., 1994; Jenkins et al., 2002). In this study, six dimensions of

attitudes toward condom use as defined by St. Lawrence and colleagues (1994) will

be measured:

Relationship safety refers to one’s feelings about the safety of the relationship

when using condoms with partner (St. Lawrence et al., 1994).

Perceived risk refers to one’s feelings of vulnerability, and the associated

beliefs that condoms can help (St. Lawrence et al., 1994).

Interpersonal impact refers to as one’s perception about the impact of using

condoms on his/her interpersonal relationship (St. Lawrence et al., 1994).

Safety refers to one’s perception about the safety when condoms are used (St.

Lawrence et al., 1994).

Effect on sexual experience refers to one’s perception about ease or discomfort

associated with using condoms (St. Lawrence et al., 1994).

 16

Promiscuity refers to one’s perception about a person who does not limit

his/her sex life to the cultural norm, typically one partner, or to monogamous sexual

relationships (Wikipedia encyclopedia, 2006).

Self-efficacy in condom use is regarded as the appraisal of one’s capability to

use condoms or to convince her/his partner to use a condom (Hanna, 1999; Bandura,

1992). In this study, three dimensions of self-efficacy in condom use as defined by

Hanna (1999) will be measured:

Consistent condom use self-efficacy is the degree of the adolescents’ consistent

use reported about the ability to use condoms (Hanna, 1999).

Correct condom use self-efficacy is the degree of the adolescents’ correct use

reported about the ability to use condoms (Hanna, 1999).

Communication self-efficacy with partner is the degree of the adolescents’

communication reported related to the ability to use condoms (Hanna, 1999).

Condom use behavior refers to one’s actual self-report about using condom

during sexual relationships (Thato et al., 2003).

Actual usage of condoms refers to the self-reported frequency of actual

condom use at the beginning of his/her sexual relationship experiences and during the

last few times (2-3 times) he/she had sexual intercourse with a partner (Thato et al.,

2003).

Significance of the Study to Nursing

The ultimate goal of nursing science is to build the body of knowledge which

is applicable in health policy nursing practice (Lobo, 2005; Jennings, 2003), while the

ultimate goal of nursing practice has a focus on applying the knowledge to make

changes in either patient situations or practice circumstances to reach the desired

 17

nursing outcomes (Marrs & Lowry, 2006). This study will make the contributions to

health policy, nursing research, and nursing practice.

Health Policy

Health policy is driven by nursing research. Health policy depends on research

based evidence and uses findings from nursing studies as a basis for making decisions

and practice (Prashker, 1996). Furthermore, health policy regulators utilize the results

of nursing research to direct them to appropriate and effective interventions for the

public’s benefit (Njie & Thomas, 2001). Information derived from this study will

benefit health policy analysts in designing programs that are congruent with Thai

culture, and with the adolescents’ attitudes, behaviors, and self-efficacy regarding

safer sex behavior. In addition, this study addresses gaps in the research literature.

Thus, it will help to provide a basis for translating scientific information to health

policy, service and practice.

Nursing Research

Nursing research is defined by Burn and Grove (2001) as “a scientific process

that validates and refines existing knowledge and generates new knowledge that

directly and indirectly influences clinical nursing practice” (p.4). The general purpose

of nursing research is to answer questions or solve problems of relevance to the

nursing profession (Polit & Hungler, 1999). Thus, this study will be conducted to

answer questions regarding potential factors influencing condom use among Thai

adolescents. Due to the fact that empirical knowledge concerning condom use in Thai

adolescents is currently limited, Thai nurse researchers could benefit from this study

by being made aware of the factors that influence individual condom use behavior.

Moreover, as guided by the self-efficacy theory, this study could provide significant

information for further intervention studies aimed at sex education to promote

 18

condom use among sexually active adolescents (Bandura, 1990). Lastly, the negative

health outcomes of unprotected premarital sexual intercourse among Thai adolescents

could diminish, through evidence-based practice.

Nursing Practice

The purpose of nursing practice is to implement activity to change natural

outcomes to desired outcomes (Ellis, 1969). When nurses practice nursing, they need

information to support their decisions. Nursing information could be obtained from

different fundamental patterns of knowing, including empirics, aesthetics, personal

knowledge, and ethics (Carper, 1978; Frank, 2002). The results of this study fall

under the empirical knowing that results from research. The empirical knowledge

obtained from this theory-driven study can provide a systematic rationale for nursing

practice, consistent with culture and existing resources to conduct nursing

interventions to achieve a change in condom use behavior among the selected Thai

adolescent population. In addition, the findings of this present study might help to

identify what factors influence condom use among Thai adolescents. Then, at the

practice level, this information could help nurses to design and implement culturally

relevant programs to promote condom use for Thai adolescents. This study will also

provide directions and new approaches that under gird programs for the prevention,

treatment, and overall management of HIV/AIDS. Ultimately, these programs might

help to reduce mortality and morbidity and improve the Thai adolescent’s chances of

having a productive life.

 19

CHAPTER II

Literature Review

Introduction

Premarital sexual activity among adolescents may cause many negative health

outcomes, including infections related to Sexually Transmitted Diseases (STDs) such

as Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

(HIV/AIDS), and unintended pregnancy. All of these negative health consequences

should be of concern to health care providers because of their severe consequences

and threats to the health and well-being of people (Jenkins et al., 2002; Bonell, 2004).

HIV is a pandemic affecting populations almost all countries. Besides, the HIV

pandemic has exploded in different parts of the world. At the global level, the United

Nations Program on HIV/AIDS [UNAIDS] and the World Health Organization

(WHO) have written that by the end of 2005, an estimated 40.3 (between 36.7 and

45.3) million people will be living with HIV worldwide. This astounding figure also

includes about 2.3 (between 2.1 and 2.8) million children under the age of 15

(UNAIDS/WHO, 2005). In Thailand, it had been estimated that by the end of

December 2006, there will be about 28,000 young Thai (15-24 years old) people

living with HIV/AIDS (PLWHA) (Epidemiology Division, Ministry of Public Health,

Thailand, 2006).

The purpose of this chapter is to describe the history of HIV/AIDS and its

implications, adolescent development, and premarital sexual behavior and condom

use in adolescents. The theoretical framework of the study, and summary of the

literature review as it relates to these specific topics will be presented. Collectively,

they illuminate the major areas of concerns related to premarital sexual activity

among adolescents.
 20

1. History of HIV/AIDS and the implications: The first section will briefly

provide information regarding HIV/AIDS infection, including the history of

HIV/AIDS, definitions, etiology, epidemiology, modes of transmission, treatment,

HIV/AIDS in the United States (US), HIV/AIDS in Southeast Asia, and HIV/AIDS in

Thailand. These topics are important because knowing about HIV/AIDS and the

implications can assist the reader in understanding the magnitude of the phenomena,

add to the science, and advance programs for prevention and prompt treatment.

2. Adolescent development: The second section presents information on

adolescent development including physical, cognitive, and psychosocial

developments, sexuality, and sexual risk behaviors. These topics will help to explicate

the tasks of adolescence, and the interpersonal interactions that occur between the

individual and the environment. Knowledge about adolescent development could help

health providers in their overall approach to promoting adolescent health and well-

being.

3. Premarital sexual behavior and condom use in adolescents: The

information provided in this section includes the following: premarital sexual

behavior and condom use in American adolescents; premarital sexual behavior and

condom use among Thai adolescents; two dimensions of communications among

Thai; the major factors influencing premarital sexual practice among Thai

adolescents; the key elements influencing condom use among Thai adolescents;

adolescents’ anal sexual intercourse; sex education in Thailand, the negative

outcomes of premarital sexual behavior and condom non-use among Thai adolescents,

and the official policy in Thailand and AIDS epidemic. One importance of these

topics is that health providers can obtain significant information for further studies

aimed at designing culture-specific programs designed to delay the initiation of

 21

premarital activity among sexually active adolescents and to promote condom use

among them.

4. Theoretical Framework: This section will address self-efficacy theory

(Bandura, 1997), and will demonstrate how self-efficacy theory is used to provide the

framework for the study proposed. Then, the empirical studies concerning self-

efficacy in condom use, attitudes toward condom use, and their relationships with

sexual risk behavior among adolescents in Asian countries, the US, and the other parts

of the world will be discussed, respectively. Self-efficacy theory could be used as a

framework in further studies, and in developing the appropriate prevention programs

for Thai adolescents.

5. Summary: This section provides a summary of the literature review within

the context of available empirical data. The summary also consists of a concise

presentation of the current knowledge and supports the choice of the research

problem. The gaps in the current empirical literature will be identified, with a

discussion of how this proposed study will contribute to the development of nursing

knowledge and help to close the existing scientific gaps.

1. History of HIV/AIDS and the implications

History of HIV/AIDS

AIDS has been described as a collection of symptoms and infections due to a

deficiency of body immune function (Murphy, Brook, & Birchall, 2000). The

causative agent in AIDS is a retro-virus known as Human Immunodeficiency Virus

(HIV). HIV was first identified by Dr. Luc Montagnier and associates in Paris

sometime in 1973 (Montagnier, 2002). They found HIV among homosexual patients

with Lymphadenopathy and named this new-found virus Lymphadenopathy

Associated Virus or LAV. At about the same time, this virus was also identified by
 22

other researchers who used a different terminology to describe it; Human T-cell

Leukemia Virus (HLTV), and AIDS-associated Retrovirus (ARV) were common

terms. Eventually, the scientific community settled on Human Immunodeficiency

Virus after researchers found that characteristics of LAV and other similar recently

discovered viruses were the same (Montagnier, 2002). They also provided the needed

evidence that these viruses caused AIDS (Gallo & Montagnier, 2003).

Definition

AIDS is defined in general terms as a specific group of diseases or conditions

that are indicative of severe immunosuppressions related to infections with HIV

(Centers for Disease Control and Prevention [CDC], 1998). These

immunosuppressions are reflected in a decrease in CD4+ T lymphocytes (T-helper

lymphocytes) below 500/mm3 as well as other abnormalities of immune. In 1982, for

surveillance and reporting purposes, CDC first developed case definitions for AIDS in

children and adults (CDC, 1982). Also, in 1982, CDC defined a case of AIDS as a

disease at least moderately predictive of a defect in cell-mediated immunity occurring

in a person with no known cause for diminished resistance to that disease (Selik,

Haverkos, & Curran, 1984). Such diseases included Kaposi’s sarcoma (in patients

under 60 years of age), lymphoma (limited to the brain), Pneumocystis carinii

pneumonia, and serious opportunistic infections. As knowledge further expanded,

major revisions of the surveillance definition occurred in 1987 (CDC, 1987) and again

in 1993. The 1993 revision, which is in current use, had an impact on case reporting.

A major change in definition and reporting criteria was that a CD4+ cell count below

200/mm3 in a person who was HIV-infected, even without the presence of other

symptoms, was defined as having AIDS. Three conditions were also added to the

AIDS case definition (pulmonary tuberculosis (TB), invasive cervical cancer, and two
 23

occurrences within a year of bacterial pneumonia) (CDC, 1992). HIV-infected

persons are now classified on the basis of CD4+ T-cell count or percent in three

ranges and three clinical categories resulting in a matrix of nine mutually exclusive

categories. These categories are shown in Table 1

Table 1

The 1993 Revised Classification System for HIV Infection and Expanded AIDS

Surveillance Case definition for Adolescents and Adults

Clinical Categories
CD4 Cell Count
(cell/mm3) A B C
(Asymptomatic, acute (Symptomatic; no A (AIDS indicator*)
infection, or no A or C conditions)
persistent generalized
Lymphadenopathy)
>500 A1 B1 C1
200-500 A2 B2 C2
<200 A3 B3 C3

Note: Shading indicates AIDS-defining diagnoses.

*See Table 3 Conditions Included in the 1993 AIDS Surveillance Case Definition

Source: Centers for Disease Control and Prevention [CDC] (1992). 1993 revised classification system

for HIV infection and expanded surveillance case definitions for AIDS among adolescents and adults.

Morbidity and Mortality Weekly Report (MMWR), 41, (No.RR-17), 7.

The clinical categories for adolescents and/or adults are divided into A, B, and

C. The information in the following table will assist the reader in classifying the HIV

infection. These data are shown in Table 2.

 24

Table 2
Clinical Categories
Category A
Category A consists of one or more of the conditions listed below in an adolescent or adult (≥ 13 years)
with documented HIV infection. Conditions listed in categories B and C must not have occurred.
- Asymptomatic HIV infection
- Persistent generalized lymphadenopathy
- Acute (primary) HIV infection with accompanying illness or history of acute
HIV infection
Category B
Category B consists of symptomatic conditions in an HIV-infected adolescent or adult that are not
included among conditions listed in clinical category C and that meet at least one of the following
criteria: (1) the conditions are attributed to HIV infection or are indicative or a defect in cell-mediated-
mediated immunity or (2) the conditions are considered by physicians to have a clinical course or to
require management that is complicated by HIV infection. Examples of conditions in clinical category
B include but are not limited to:
- Bacillary angiomatosis
- Candidiasis, oropharyngeal (thrush)
- Candidiasis, vulvovaginal; persistent, frequent, or poorly responsive to therapy
- Cervical dysplasia (moderate or severe)/cervical carcinoma in situ
- Constitutional symptoms, such as fever (38.5 C) or diarrhea lasting > 1 month
- Hairy leukoplakiam oral
- Herpes zoster (shingles), involving at leas two distinct episodes or more than one dermatome
- Idiopathic thrombocytopenic purpura
- Listeriosis
- Pelvic inflammatory disease, particularly if complicated by tubo-ovarian abscess
- Peripheral neuropathy
For classification purposes, category B conditions take precedence over those in category A.
Category C
Category C includes the clinical conditions listed in the AIDS surveillance case definition (see table
2.3). For classification purposes, once a category C condition has occurred, the person will remain in
category C.

Source: Centers for Disease Control and Prevention [CDC] (1992). 1993 revised classification system

for HIV infection and expanded surveillance case definitions for AIDS among adolescents and adults.

Morbidity and Mortality Weekly Report (MMWR), 41, (No.RR-17), 3-4.

 25

Table 3
Conditions Included in the 1993 AIDS Surveillance Case Definition
- Candidiasis of bronchi, trachea, or lungs
- Candidiasis esophageal
- Cervical cancer, invasive*
- Coccidioidomucosis, disseminated or extrapulmonary
- Cryptococcosis, extrapulmonary
- Cryptosporidiosis, chronic intestinal (>1 month’s duration)
- Cytomegalovirus disease (other than liver, spleen, or nodes)
- Cytomegalovirus retinitis (with loss of vision)
- Encephalopathy, HIV-related
- Herpes simplex: chronic ulcer(s) (>1 month’s duration); or bronchitis, pneumonitis, or
esophagitis
- Histoplasmosis, disseminated or extra pulmonary
- Isosporiasis, chronic intestinal (1 month’s duration)
- Kaposi’s sarcoma
- Lymphamo, Burkitt’s (or equivalent term)
- Lymphamo, primary of brain
- Mycobacterium avium complexor M. kansasii, disseminated or extrapulmonary
- Mycobacterium tuberculosis, any site (pulmonary* or extrapulmonary)
- Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
- Pneumocystis carinii pneumonia
- Pneumonia, recurrent*
- Progressive multifocal leukoencephalopathy
- Salmonella septicemia, recurrent
- Toxoplasmosis of brain
- Wasting syndrome due to HIV

*Added in the 1993 expansion of the AIDS surveillance case definition

Source: Centers for Disease Control and Prevention [CDC] (1992). 1993 revised classification system

for HIV infection and expanded surveillance case definitions for AIDS among adolescents and adults.

Morbidity and Mortality Weekly Report (MMWR), 41, (No.RR-17), 315.

CDC scientists also addressed the rationale for adding the categories of “other

disease conditions” into the 1993 revised classification. The basic rationale is that

AIDS is primarily diagnosed by the appearance of unusual infections of many

 26

diseases that invade the body and helps to create weakened cellular immunity. The

most common initial symptoms are Pneumocystis Carinii Pneumonia (PCP), caused

by a parasite, Kaposi's sarcoma related to a newly identified virus, and human herpes

virus 8. These are examples of some of the other disease conditions added to the 1993

revised classification (CDC, 1992).

Etiology

The etiology agent of AIDS is the human immunodeficiency virus (HIV) of

which there are two categories, Types 1 (HIV-1) and 2 (HIV-2) (Lashley, 2000) are

delineated in this section. HIV-1 is further subdivided into three groups. The first is

called the major group (M group). The second is known as the outliers group (O

group), and the proposed designation for the third group is non M-non O group (N

group) (Wain-Hobson, 1998). Specifically, Group M consists of at least 10 major

subtypes designated as A through J, some of which are very rare (Kanki et al., 1999).

Subtype B is most common in the United States (US) (Janssens, Buve, &

Nkengasong, 1997). The few persons, only 106, in the US possessing group O HIV-1

infection emigrated from Africa (Jaffe & Schochetman, 1998). HIV-2 has at least five

subtypes (Jaffe & Schochetman, 1998). Currently, HIV-1 is responsible for the global

pandemic, except in West Africa, where HIV-2 is most prevalent (Lashley, 2000).

In North America, one of the first people to be identified in the early

development of AIDS was Gaëtan Dugas. He was a French-Canadian flight attendant

who was employed by Air Canada. This person was responsible for infecting several

of the first few reported victims of the disease, but he was not the first person to bring

or spread AIDS to North America. Nevertheless, he was called “Patient Zero” by

epidemiologists after the Centers for Disease Control and Prevention (CDC)
 27

determined that many of Dugas's sexual partners had developed HIV/AIDS (Marx,

1982).

In Thailand, the most prevalent type of HIV is Type 1, subtypes B and E.

Subtype B is found most often among injecting drug users (IDUs). Subtype E has the

greatest prevalence in Thailand (Murphy, Brook, & Birchall, 2000) among young

Thai men group. Furthermore, subtype E has been found in all people living with

HIV/AIDS groups throughout the world (UNAIDS, 2005). Table 4 shows types and

subtypes of HIV.

Table 4

Types and subtypes of HIV

HIV-1 (type 1) HIV-2 (type 2)

Outlier Group (O group) - Subtype 1

Most seen in Central West Africa - Subtype 2
- Subtype 3
Major Group (M group) - Subtype 4
(10 Major subtypes) - Subtype 5
- A
- B (most seen in the US and Europe)
- C
- D
- E (most seen in Central Africa)
- F
- G
- H
- I
- J

Non M-non O Group (N group)

Source: Murphy, S.M., Brook, G., & Birchall, M.A. (2000). HIV Infection and AIDS. Edinburgh, New

York: Churchill Livingstone Press.

 28

According to the 2005 report of the Joint United Nations Program on

HIV/AIDS (UNAIDS) and the World Health Organization (WHO), Acquired Immune

Deficiency Syndrome (AIDS) has caused the mortality of more than 25 million people

since it was first recognized in 1981; it is one of the most destructive epidemics in

recorded history. Despite recent, improved access to antiretroviral treatment and

health care in many regions of the world, the AIDS epidemic claimed 3.1 million

(2.8-3.6 million) lives in 2005; more than half a million (570,000) were children

(UNAIDS/WHO, 2005).Besides, young people (15-24 years of age) accounted for

40% of people living with HIV/AIDS (UNAIDS/WHO, 2005).

The UNAIDS and the WHO data also stated that, at the global level, the total

number of people living with HIV reached its highest level in 2005: an estimated 40.3

million (36.7-45.3 million) people are living with HIV in the world community. Close

to 5 million people worldwide were newly infected with the virus in 2005; 4.2 million

were adults, and 800,000 were children under 15 years of age (UNAIDS/WHO,

2005).

Epidemiology

HIV is spread primarily through heterosexual contact, with women accounting

for more than one half of new HIV infections in adults (UNAIDS/WHO, 2005). In

many developed countries, where transmission through male homosexual contact

dominated for the first decade (1984-1993), the number of persons infected through

heterosexual contact and injecting drug use is progressively increasing. In contrast,

transmission through transfusion of blood and blood products has been virtually

eliminated in developed countries (e.g. the US.); these countries have systematically

instituted HIV antibody screening of donated blood and plasma and heat treatment for

clotting factors. Thus, the risks of transmitting HIV infection by the transfusion of
 29

screened blood are very small. The risk of HIV infection from blood transfusion and

blood products in the US is 1 in 676,000 (Ness, 2000). In developing countries (e.g.

Kenya, Democratic Republic of the Congo, and others), screenings of the blood

supply and cost-effective strategies for reducing HIV transmission have not been

implemented consistently. In these countries, the risks of transmitting HIV infection

by the transfusion of screened blood were estimated about 5-10% (Lackritz, 1998).

Nevertheless, safe blood remains elusive in most resource-constrained

countries and in many, HIV transmission through blood products or contaminated

equipment at the time of donation or plasmapheresis continues to occur (Volkow &

Del Rio, 2005). During the first decade of the AIDS epidemic (1981-1990), the health

status of nearly every person infected with HIV around the world was virtually the

same: most individuals infected with HIV eventually died as a result of AIDS.

However, this scenario began to change in 1996 with the advent of protease inhibitors

and highly active antiretroviral therapy (HAART). In a short time, countries that had

made HAART available to persons infected with HIV had experienced a decrease in

morbidity and mortality from HIV. Nonetheless, the numbers of new infections

worldwide continue to increases and, in some countries like the US, preliminary

evidence suggests that the incidence and prevalence may be rising (CDC, 2005a). As

a result, the figures of people living with HIV infection continue to advance in local

and global communities (Teshale et al., 2005).

Furthermore, UNAIDS/WHO estimated that Sub-Saharan Africa, the most

severely affected region of the world, is home to 25.8 million (23.8-28.9 million)

people living with HIV; this figure suggests that about two thirds of all people living

in the world community with HIV are in this region. During 2003 to 2005, an

estimated 2.4 million (2.1-2.7 million) people died of HIV-related illnesses in this
 30

region, while about 3.2 million (2.8-3.9 million) people became infected with HIV

(UNAIDS/WHO, 2005). More than 95% of all HIV-infected people live in low-

income countries such as Kenya, Pakistan, Cambodia, and Rwanda ($875 or less per

capita), and lower-middle-income countries such as Peru, Philippines, Guatemala, and

Thailand ($876-$3,465 per capita) (UNAIDS/WHO, 2005; World Bank, 2006). Low-

income and lower- middle-income countries are sometimes referred to as developing

countries (World Bank, 2006). This definition is used in most official health-related

world documents and the World Health Organization (WHO) (UNAIDS/WHO,

2005).

Despite the various methods of contracting HIV/AIDS, the major mode of

transmission, worldwide, is heterosexual contact. Thus, women account for nearly

half of the 40 million people living with HIV/AIDS but in places like sub-Saharan

Africa, among young women aged 15-24 years, an estimated 13.5 million (12.5-15.1

million) women are living with HIV (UNAIDS/WHO, 2005). It should be emphasized

that the number of women living with HIV/AIDS is increasing in Sub-Saharan Africa

and the US. In Sub-Saharan Africa, patterns of sexual behavior whereby young

women have sex with older men, in combination with high susceptibility to infection

in very young women, has resulted in extremely high infection rates in maturing

females in some parts of Sub-Saharan Africa, including Botswana, Democratic

Republic of the Congo, and Zambia (Buve, Bishikwabo-Nsarhaza, & Mutangadura,

2002; Glynn et al., 2000). Furthermore, the very high rates of HIV infection among

pregnant women in this region have resulted in a substantial number of children with

perinatally acquired HIV (N’Galy & Ryder, 1988). In 2005, an estimated number of

children (0-14 years) living with HIV in Sub-Saharan Africa was about 2,000,000.

More than 95% of HIV-infected infants acquire HIV from their mothers in utero,
 31

during their delivery, or while being breastfed (World Health Organization (WHO),

2006).

This same trend is being mirrored among other parts of the world, including

countries in Southeast Asia (e.g., Cambodia, Vietnam, and Thailand) (van Griensven

et al., 2001; Kaljee et al., 2005). Furthermore, among all American women in the US,

the proportion of estimated women living with HIV/AIDS has more than tripled, from

8% in 1985 to 27% in 2004 (CDC, 2004b). The epidemic has increased most

dramatically among African American women (CDC, 2004b) who experience about

64% of the malady (CDC, 2006d).

In Eastern Europe countries such as Ukraine, Romania, and the newly

independent states of the former Soviet Union such as Lithuania, Estonia, Latvia, and

Azerbaijan, HIV infections are rapidly increasing. The primary reason for this

increase is related to injecting drug use; the prevalence of HIV among persons who

inject drugs is growing (Del Rio, 2005) in these nations and others in the world

community. Injecting drug use, therefore, is beginning to be a major source of

HIV/AIDS infection and will deserve urgent attention (Gayle & Hill, 2001).

In the US, since its first appearance among urban gay men in 1981, HIV

infection and AIDS have reached pandemic status. As of December 2005, an

estimated 1.04-1.2 million persons living with HIV/AIDS were reported in the nation.

HIV incidence rates are generally higher among men who have sex with men and

injecting drug users, regardless of gender, than among other populations. HIV

incidences among men who have sex with men account for 63% of newly-diagnosed

HIV infections in 2005 (UNAIDS/WHO, 2005). HIV incidence among injecting drug

users varies geographically, but generally it is lower than that among men who have

sex with men (Karon, Fleming, Steketee, & De Cock, 2001).

 32

However, for women living with HIV, unsafe heterosexual intercourse is the

main mode of transmission and an estimated 73% of the women acquired the virus

through this source in 2005 (UNAIDS/WHO, 2005). Half of new HIV infections in

the US are in individuals aged 13 to 24 years. Also in the US, two thirds of infected

young people contract HIV via vaginal sexual intercourse, and more than 60% of new

infections are in young women aged 15 to 24 years (Futterman, 2005). Through the

end of 2005, the estimated number and percentage of HIV diagnoses among women

aged 13-24 years in 33 US states are as follows: 5% (66) of cases were diagnosed in

those aged 13 to 15 years, 29% (418) in those aged 16 to 19, and 66% (970) in those

aged 20 to 24. Among these females, 85% were exposed through heterosexual

contact. Heterosexual transmission is the major mode of transmission among all age

groups of females. HIV incidence rates are higher among African Americans than

among other racial/ethnic groups (Karon, Fleming, Steketee, & De Cock, 2001) in the

US. Despite constituting only 13% of the US population, African Americans

accounted for 40% of the approximately 1,000,000 persons diagnosed with AIDS

since the beginning of the epidemic (Del Rio, 2005). At the end of 2004, the

prevalence rate of people living with AIDS among African Americans was 8.4 times

higher than Whites (CDC, 2005a).

Although the HIV epidemic started later, in 1980s, in South and Southeast

Asia than in Africa and the US, the progression of the HIV epidemic in this region has

been quite rapid. There has been an explosive increase in HIV infections among

injecting drug users, commercial sex workers and other populations of young adults in

India, Cambodia, and Thailand (Jain, John, & Keusch, 1994; Ryan et al., 1998;

Weniger et al., 1991).

 33

In Thailand, as of January 2006, an estimated 288,672 HIV cases were

reported. The majority of people living with HIV are about 30-34 years old (25.83%).

The major mode of transmission is through heterosexual contact (84.01%) (Ministry

of Public Health, Thailand, 2006). Based on the results of the HIV serosurveillance in

2004, the prevalence of HIV among pregnant women was 1.18%, and in conscripts

(young men who serve in the armed forces in Thai military) ages 18-25 years was

0.5%. However, the prevalence of HIV in some specific populations was higher. For

instance, among female commercial sex workers, HIV prevalence was 10.87% and in

injecting drug users who attended treatment clinics, it was 45% (Epidemiology

Division, Ministry of Public Health, Thailand, 2004).

Modes of Transmission

Within the world community, the estimated 57.9 million people who have

been infected with HIV since the pandemic began have, with a few exceptions,

acquired the virus by one of the three modes of transmission: sexual, parenteral, and

mother-to-child (Morison, 2001) modalities. Each of these modes of transmission will

be briefly discussed.

Sexual Transmission

Globally, sexual transmission is by far the most common mode of

transmission. Obviously, the probability of a person being infected via sexual

intercourse depends on the likelihood of unprotected sex with an infected partner.

Hence, sexual behavior patterns and the background prevalence of HIV are of major

importance (Morison, 2001) in curtailing this epidemic. In most developed countries

such as the US, male-to-male sex remains the predominant mode of HIV transmission

(Clarke-Tasker, Wutoh, & Mohammed, 2005). In the US, AIDS was first defined in

homosexual men in June 1981 (CDC, 1981). Until recently, men who have sex with
 34

men (MSM) still represent half of new people living with HIV/AIDS and three-

fourths of new male cases. Additionally, recent evidence suggested a resurgence of

HIV transmission among MSM; during 2001-2005, an estimated 44% of new HIV

infections were in MSM (CDC, 2006a). The growing number of HIV infection among

MSM is obvious in the findings of many studies (Bull, Piper, & Rietmeijer, 2002;

Chen, Gibson, Weide, & McFarland, 2003; Celentano et al., 2006; Millett, Peterson,

Wolitski, & Stall, 2006). In Thailand, a survey published recently showed that using

careful sampling in many different kinds of gay meeting places, HIV prevalence

among MSM in Bangkok had increased from 17.3% in 2003 to 28.3% in 2005 (van

Griensven et al., 2005). Clearly, available health information is not yet impacting

sexual risk taking behaviors among this vulnerable population.

Nonetheless, the predominant mode of transmission worldwide continues to be

heterosexual contact (75% of total spread) (Nicoll & Gill, 1999; UNAIDS/WHO,

2005). Heterosexual vaginal intercourse is of greatest overall importance to the

epidemic; it has increased over time in all regions of the world. As epidemics of HIV

infections fueled largely by heterosexual transmission have developed in resource-

poor countries, the age at which transmission occurs is reported to be at an earlier age:

half of all transmissions are now believed to occur among people under the age of 25

(UNAIDS/WHO, 2005). In Thailand, based on the reported data through August 31,

2006, 83.97% of HIV infections are acquired through heterosexual contact

(Epidemiology Division, the Thai Ministry of Public Health, 2006). It primarily

affects the age group between 15 and 24 year-of-age. As heterosexual transmission

increases, the impact of the pandemic on women is projected to increase (Nicoll &

Gill, 1999).
 35

Mother-to-Child Transmission

Mother-to-child, or perinatal transmission is estimated to account for 15 to

25% of all new infections (UNAIDS, 1999a). Globally, more than 90% of HIV

infections in children are acquired by transmission from mothers to their infants

(UNAIDS, 2000; Gayle & Hill, 2001). An estimated 2.4 million HIV-infected women

give birth each year, resulting in 600,000 new infections in infants annually.

Therefore, 1,600 infants are infected with HIV each day (UNAIDS, 1998; 1999a;

1999b). Nine out of ten babies with perinatally acquired HIV infection have been born

in Africa, where more than 50% of HIV infections occur in women of childbearing

age (UNAIDS, 1999b). Additionally, through perinatal transmission, the number of

cases in children in Southeast Asia seems to be rising rapidly as more women become

infected (Gayle & Hill, 2001). In Thailand, the reported data through August 31, 2006

indicated that 4.01% of HIV infections in children are acquired by transmission from

mothers to their infants (Epidemiology Division, the Thai Ministry of Public Health,

2006).

Parenteral Transmission

Parenteral transmission of HIV occurs most commonly among injecting drug

users (IDUs) when needles are shared. Injecting drug use plays a critical role in the

HIV epidemic in various regions, especially Southeast Asia which includes Thailand

(Gayle & Hill, 2001). The Thai national HIV serologic surveillance surveys revealed

a steady high rate of HIV prevalence in the 30-50% range among IDUs throughout the

nation (Kitayaporn, et al., 1994; Perngmark, Celentano, & Kawichai, 2003).

Parenteral transmission can also occur by the transfusion of infected blood.

Transmission through blood transfusion, once a concern in many countries, has been

nearly eliminated in developed countries by the routine screening of blood donations

 36

(Nicoll & Gill, 1999). In developing countries, including Tunisia, Democratic

Republic of the Congo, Kenya, and Morocco, transmission through the blood supply

has yet to be eliminated, particularly where HIV prevalence rates among blood donors

are high and where screening of blood for HIV has not become routine (Shrestha,

1996; Nicoll & Gill, 1999). In Southeast Asian countries such as Cambodia, the

Philippines, and Thailand, donated blood has been routinely screened for HIV.

However, in Cambodia, it is estimated that 3.5% of people living with HIV/AIDS are

still attributable to contaminated blood. Meanwhile, 2.1% were approximated in the

Philippines (Lifespan/Tufts/ Brown Center for AIDS Research (CFAR), 2006). In

Thailand, based on the available data since 1990 through August 31, 2006, thirty

people living with HIV/AIDS (0.03%) attributable to contaminated blood have been

reported (Isarangkura, Chiewsilp, Tanprasert, & Nuchprayoon, 1993; Epidemiology

Division, the Thai Ministry of Public Health, 2006). The transmission of infection

through blood transfusions remains a major clinical issue in these three countries.

Besides, contaminated needles for injections and needlestick injuries among

health professionals are another source of infection. Health providers are in daily

contact with patients, their body fluids and their blood. Some of these patients or these

fluids may be contaminated with the HIV virus. Hence, contaminated blood products

and infected organs or semen have also been shown to transmit infection (Morison,

2001).

Treatment

At the present, there is no cure for AIDS, although recent advances in the

understanding of the pathogenesis of disease (Bolognesi, 1989; Levy, 1989) and in the

development and clinical evaluation of anti-retroviral therapies have produced

promising new therapeutic agents (Yarchoan & Broder, 1987). Nevertheless,

 37

development of an effective vaccine to prevent infection is not anticipated within the

near future (Koff & Hoth, 1988; Stratov, DeRose, Purcell, & Kent, 2004). The

antiretroviral drug zidovudine (AZT) has been introduced in reducing the

transmission of HIV. It does not cure; instead, it controls and helps individuals living

with HIV/AIDS to manage the disease, live longer, and healthier lives (Anderson,

1998).

HIV/AIDS in the United States (US)

According to available data from the Centers for Disease Control and

Prevention (CDC), (2004b), AIDS was first identified in Los Angeles in 1981. The

epidemic has now spread to every part of the US and to all sectors of society. At the

end of 2005, an estimated 1.04 million-1.2 million persons in the US were living with

HIV/AIDS (CDC, 2005a). Through 2005, the cumulative estimated number of

persons living with HIV/AIDS in the US totals 944,305. Among Americans, 934,862

persons living with HIV/AIDS were estimated in adult and adolescent; 756,399 were

males, and 178,463 were females. Through the same time period, 9,443 persons living

with HIV/AIDS were estimated in children under age 13 (CDC, 2005a).

Nowadays, the HIV/AIDS epidemic is taking an increasing toll on women in

the US (CDC, 2005b). Therefore, the most vulnerable population in this society is

females. Nearly half of the 40 million people living with HIV are female (Kaiser

Family Foundation, 2005a). The percent of people living with HIV/AIDS in the US

adult and adolescent women has risen steadily from 11% in 1990 to 26% in 2003

(CDC, 1991, 2004b). AIDS is now the third leading cause of death in women ages 25

to 44 years, and the leading cause of death in African American women, ages 24 to 34

(Kaiser Family Foundation, 2005b). The primary mode of HIV transmission in both

married and/or unmarried women is unsafe heterosexual intercourse. The main risk
 38

factor for acquiring the virus is the risk behavior of male partners or husbands, who

were most likely infected during paid sexual encounters that occurred before and/or

after marriage (CDC, 2005a). In 2005, an estimated 73% of women living with HIV

acquired the virus from their husbands (UNAIDS/WHO, 2005).

HIV/AIDS in Southeast Asia

The AIDS epidemic in Southeast Asia is expanding rapidly. There is ample

evidence of sharp increases in HIV infections in Indonesia and Viet Nam

(UNAIDS/WHO, 2004). An estimated 7.4 million people have been living with HIV

in Southeast Asia and 1.1 million people became newly infected in 2003

(UNAIDS/WHO, 2004). This fast-growing Southeast Asian epidemic has huge

implications globally. At the present, in Southeast Asia, the HIV epidemic remains

largely concentrated among injecting drug users, men who have sex with men, sex

workers and their clients, and adolescents who participate in sexual risk behaviors

with other adolescents and older men. Southeast Asian countries such as Thailand and

Cambodia, which have chosen to tackle high risk behavior among all of the groups of

population within the country, by providing specific programs for high risk

populations such as sex workers, have been more successful in fighting HIV, as

shown by the reduction in infection rates among sex workers (UNAIDS/WHO, 2004).

The major program in fighting HIV and reducing risky sexual behavior among all

groups in Thailand, the 100% Condom Program, will be discussed in the next section.

HIV/AIDS in Thailand

In Thailand, the initial wave of AIDS apparently began in 1984 when the first

case of AIDS was officially reported in a 28-year-old homosexual Thai male who

traveled to the USA in 1981 for postgraduate work. In 1982-1983, he demonstrated

fever, fatigue, meningitis, and finally Pneumocystis Carinii infection. In 1984, he was
 39

hospitalized in Bangkok with fever, bilateral deafness, and diarrhea. At that time his

symptoms came to the attention of the public health authorities. Lastly, death occurred

in January 1985 (Limsuwan, Kanapa, & Siristonapun, 1986). This package of

symptoms was similar to what the flight attendant, the first person living with

HIV/AIDS in the US, had experienced. Shortly afterwards, in 1988, the prevalence in

injecting drug users (IDUs) skyrocketed from 1% to 43% in a single year (Uneklabh,

Phutiprawan, & Uneklabh, 1988). Since then, surveys began to focus on HIV

infection among IDUs around the country.

HIV infection among Thai IDUs occurred rapidly. An increasing number of

young Thai report injecting drug use, increasing from 1% in 1991 to 4.2% in 1997

(Epidemiology Division, the Thai Ministry of Public Health, 2004). Disturbingly,

IDUs constitute a rapidly growing proportion of new infections and carry the high

infection rate at 40% to 50% among new persons living with HIV/AIDS (Punpanich,

Ungchusak, & Detels, 2004). Therefore, they are becoming a source for transmitting

HIV to other segments of Thai population. Among IDUs, HIV infection is not only

transmitted through the sharing of injecting equipment, but also through sexual

transmission to partners. The reason why HIV spreads from IDUs to other populations

is that a considerable number of IDUs engage into sexual risk behavior, including

having sexual intercourse, both vaginal and anal sex, without condom. IDUs who lack

consistency in condom use are particularly at risk of acquiring and transmitting HIV

(United Nations, Office on Drugs and Crime, 2006). There is evidence from the

existing research regarding sexual risk behavior and HIV transmission among IDUs in

Thailand. Recently, Perngmark and colleagues (2004) studied sexual risks for HIV

transmission among 272 Thai male IDUs at drug treatment clinics in the southern

region, Thailand. The results revealed that 56% of participants were sexually active,
 40

of whom 88% had sex mostly with a non-injecting regular partner (wife or steady

girlfriend). Condom use was reported in a low rate (34%). Among sexually active

IDUs, 43% were HIV infected and only a few were aware of their HIV serostatus.

Multivariate analysis also showed that condom use was related to history of HIV

voluntary counseling and testing (VCT) and poor perceived health status. Unprotected

sex with regular sexual partners is frequent among IDUs in the southern Thailand,

where most IDUs have not sought VCT services. The researchers suggested that

AIDS prevention efforts should focus on access to VCT and condom promotion to

sexually active couples to prevent HIV transmission (Perngmark, Celentano, &

Kawichai, 2004). The promise of VCT is related to the information that can be

received, the condom promotion, and the health status.

The second wave of the AIDS epidemic exploded among female commercial

sex workers (CSWs) in 1989, when the findings from the first national HIV sentinel

surveillance revealed that 44 out of 100 (44%) female sex workers from seven

brothels tested in the northern Thai province of Chiang Mai were infected with HIV.

Univariate analysis showed a significant association between HIV seropositivity and

lower rates of condom use by both men from international communities and Thai

male clients (Siraprapasiri et al., 1991) who would return home to their wives and

children.

Furthermore, the surveillance revealed that HIV infection had steadily

increased in each of the 14 provinces (See Appendix F, p.246) included in the survey

where men were having paid sex with females CSWs (Ministry of Public Health,

Thailand, 2006). By the end of 1989, there was a sharp rise in the reported number of

HIV-seropositive men attending STD clinics in all 14 provinces included in the

sentinel surveillance. Recognizing the possibility of a large-scale epidemic, thus the

 41

national HIV sentinel surveillance was expanded to all 76 provinces in Thailand by

the end of 1990.

At almost the same time, the Survey of Partner Relations and Risk of HIV

Infection, the first national survey on sexual risk behavior in Thailand, was

conducted. The results demonstrated that 28% of Thai men between the ages of 15

and 49 admitted to either premarital or extramarital sex in the past year, with three

quarters of those men having paid sex during that time with females CSWs (Sittitrai,

Phanuphak, Barry, & Brown, 1992). Therefore, it became clear to Thai health care

providers that heterosexual transmission would become the predominant mode of HIV

acquisition (Jenkins et al., 2002).

The third wave of AIDS epidemic was launched among CSWs’ male clients,

as indicated by a prevalence rate of 4% among military conscripts in 1993 (National

HIV Surveillance, Thailand, 1996). In response to the growing prevalence of HIV, in

late 1989, the government of Thailand launched a pilot project, the “100% Condom

Program”, to prevent and control HIV/AIDS, in Ratchaburi Province where the

incidence rates were higher. This is where the military has a larger group of men.

Later, this program was expanded nationally in 1991-1992. The program was initiated

to enforce universal condom use in all commercial sex establishments (Hanenberg,

Rojanapithayakorn, Kunasol, & Sokal, 1994). Information, education, and

communication programs were first initiated to promote consistent condom use

among all Thai people who were engaging in sexual risk activity. Besides, the Thai

government supplied almost 60 million free condoms a year to support this program

(Rojanapithayakorn & Hanenberg, 1996). The free condoms were located at the

family planning department in hospitals. The success of this program was illustrated

by the dramatic decline in the reported number of newly infected male STD patients
 42

visiting public clinics and over a 90% reduction of STDs rates in both male and

female patients (Veneral Diseases Division, Department of Communicable Diseases

Control, MOPH, 2002).

To date, Thailand’s AIDS epidemic prevention program has moved into its

fourth wave (Klunklin & Greenwood, 2005). The AIDS epidemic in this wave

involves the wives of the men who have contracted HIV in the third wave (Rerks-

Ngarm, 1997; Klunklin & Greenwood, 2005). Consequently, husbands were the

source of infections that their wives experienced. As many as half of the new HIV

infections each year are happening within marriages where condom use tends to be

very low (Thai Working Group on HIV/AIDS Projections, 2001). The study of the

National HIV Surveillance, in all of the Thailand provinces, between 1989 and 1996

showed that HIV prevalence among women attending public antenatal clinics

increased from 0.8% in 1991 to 2.3% in 1995 (National HIV Surveillance, Thailand,

1996). According to a report of the United Nations Development Program (UNDP)

(2004), almost one third of adults living with HIV/AIDS in Thailand are women, and

a large proportion of them (83.97%) acquired HIV through heterosexual intercourse

(Ministry of Public Health, Thailand, 2006). One half of the new adult infections in

Thailand are now occurring among women, most of whom are infected by their

husbands or boyfriends, their permanent and consistent partners. Importantly, the

government must shift some of its focus to this vulnerable population and develop

programs that address this dilemma. A study of women in Bangkok revealed that

prevalence of HIV in women has increased steadily from 1991 through 1996. Sex

with current partners was the identified risk exposure for about half (52%) of the

HIV-positive women. Although few HIV-positive women reported high-risk

behaviors, more than one lifetime partner and a partner with high-risk behaviors were
 43

strong risk factors for seropositivity. A number of studies have revealed that women

were merely unaware of their risks and did not take precautions against heterosexual

exposure to HIV virus (CDC, 2001; Futterman, 2005; Morrison, 2006). Condoms

should be used at all times until partner status is confirmed between both men and

women. Women in all age groups, including adolescence, are at risk for HIV because

of the risk behavior of both current and previous partners (Siriwasin et al., 1998;

Sherman & Latkin, 2001; O’Sullivan, Hoffman, Harrison, & Dolezal, 2006). In order

to understand sexual risk behavior in adolescence, the next section will provide a

review of how adolescent development from several perspectives shapes an

individual’s pattern of behavior that has implications for HIV/AIDS.

2. Adolescent development

Adolescence is a period of self-discovery, and multiple and profound changes

occur in transitions from childhood to adulthood (Low, 2006). The onset of

adolescence is considered a crucial developmental transition due to the confluence of

changes across adolescence (Brooks-Gunn, 1984). Entry into adolescence is marked

by the physical development of puberty, cognitive, and psychosocial development.

The interaction of physical, psychological, and social components of development

make adolescence an excellent period to study developmental transitions (Low, 2006).

Physical Development

Physical development of puberty in adolescence is not only the indicator that

adolescence has begun but is also casually linked to many of the other changes at this

time (Brown, 2000). It is important to consider basic information about physical

development in general and sexual maturation in particular because they are directly

associated with the health-risk behaviors of adolescents such as sexual risk-behavior

(Rew, 2005, p.54). The physiological changes of adolescence are referred to as

 44

puberty, a term derived from the Latin word, pubertas, meaning adult (Pickett, 2000).

During puberty, dramatic changes occur in several areas (Neinstein & Kaufman,

2002) including:

- Alterations in the brain and endocrine system that stimulate rapid

acceleration in weight and height, often referred to as the adolescent growth

spurt.

- Primary sexual characteristics develop, including the ovaries in females and

testes in males.

- Secondary sexual characteristics develop, including growth of pubic, body,

and facial hair, as well as changes in the breasts and genitalia.

- Body composition changes, including distribution of muscle and fat.

- The circulatory and respiratory systems change, resulting in increased

strength and physical tolerance.

Puberty marks a phase in human development that is characterized by the

individual’s ability to conceive and produce another human being. Pubertal changes

are controlled by pituitary hormones that lead to rapid changes in body composition,

size, and shape. These changes result in development of mature secondary sexual

characteristics and maturation of the genitalia, with concurrent processes of ovulation

and spermatogenesis (Plant, 2002).

Another hallmark of adolescent physical development is sexual maturation

(Rew, 2005, p.56). This maturation process occurs in predictable stages. Tanner

(1962) described five distinct stages that have become the gold standard for

identifying sexual maturation in adolescence. The two aspects of physical

development that are considered in determining the sexual maturity rating for females

are degree of breast development and pubic hair development. For males, three
 45

aspects are considered in determining the sexual maturity rating including the size of

the testes, the length of the penis, and pubic hair development.

A study conducted by Wiesner and Ittel (2002) showed that girls who mature

early are at risk for engaging in health-risk behaviors, such as unprotected sexual

intercourse. Furthermore, Aten and colleagues (2002) conducted a study of a school-

based intervention designed to delay the onset of sexual intercourse and to continue

abstinence for a period of 1 year following the intervention. The study was conducted

in health education classes in five middle schools in Rochester, New York. The

participants were 1,352 children with a mean age of 13.1 years. The findings revealed

that at pre-intervention, 27% of girls and 62% of boys reported sexual intercourse

experience. At follow-up, 19% and 32%, respectively, of the previously abstinent

girls and boys had ‘transitioned’ to sexual activity. Increasing age, lower

socioeconomic status, and higher general risk behaviors best predicted the transition.

The investigators also found that maintaining abstinence was possible only among

those participants who were abstinent when the study began. Students who were

younger than 13 years old and abstinent when the intervention began were more able

to remain abstinent than older students or than those who had already initiated sexual

intercourse. The investigators concluded that primary preventions were needed before

children become adolescents (Aten, Siegel, Enaharo, & Auinger, 2002) and had begun

to engage in sexual intercourse with males. The investigators did not report whether

the data regarding maintaining abstinence were the same for male and female

participants.

Cognitive development

Cognitive development refers to the adolescents’ emerging ability to think in

adult patterns that begin at the age of 12 years, but adolescents may not be able to
 46

reach full capacity to think in this manner until the age of 15 or 16 years (Brown,

2000). According to Jean Piaget’s framework called genetic epistemology, cognitive

structure was described as the mental and physical actions that under gird intelligence.

This cognitive structure is manifested in skills or schemas that correspond to

predictable stages of development. Cognitive development occurs as the child acts on

the environment and as the environment acts on the child (Piaget & Inhelder, 1973).

Piaget explained this type of cognitive functioning as formal operational thought

(Brown, 2000). The use of logical operations in the abstract has the meaning that the

person is able to engage in hypothetical thinking. This ability to engage in formal

operations contributes to the reasoning that allows the person to investigate and solve

problems systemically (Piaget & Inhelder, 1973). Cognitive functioning is age related

but not age dependent. It is not clear at what level of cognitive complexity is present

without formal testing. All adolescents do not achieve the formal operational thought

at the same time and depth. This ability requires socialization, nurturance and care,

and playing and learning in the family and at school at the appropriate times. Among

many adolescents, worldwide, these critical factors do not easily converge. Among

many adolescents, cognitive functioning might be evident in some areas of

development and not in others.

Nevertheless, it can be estimated that due to the inability to achieve this

thought capacity completely, some early and middle adolescents may not think in an

adult fashion (Brown, 2000). Inability to perceive the future negative consequences of

current risky behaviors, including engaging in premarital sexual behaviors without

practicing safer sex, may be related to lower levels of cognitive functioning (Brown,

2000).
 47

Furthermore, special populations such as those who have developmental

delays (e.g., mental retardation, and autism) can be taught about safer sex behaviors.

These programs are Sexuality Education of Children and Adolescents With

Developmental Disabilities as promulgated by the American Academy of Pediatrics

(information available at www.aap.org); and Sex Education for People with

Developmental Disabilities by Program Development Associates (information

available at www.disabilitytraining.com). Such programs educate adolescents with

developmental delays about sex education, safer sex, the influence of drugs and

alcohol on the individual, and so on. Researchers have documented that adolescents

with developmental delays are easily and frequently sexually exploited, and more

vulnerable with regard to sexual exploitations (Olasov, 1993). Thus, they must be

taught about sexual behavior and how to protect themselves (Kaufman, 2006).

Another dimension of cognitive development is the development of critical

thinking skills which is highly important in understanding adolescent decision making

and subsequent behavior (Rew, 2005). According to Bloom’s critical thinking theory

(1956), taxonomy of learning levels includes knowledge, comprehension, application,

analysis, synthesis, and evaluation. These six level of learning range from lower to

higher levels of cognitive abilities. Critical thinking is said to occur in the levels of

analysis, synthesis, and evaluation (Bloom, 1956). Therefore, when health care

providers develop sex education programs for adolescents, critical thinking ability

should be recognized. For instance, the inability of an adolescent to evaluate the

consequences of his/her current behaviors suggests that sex education programs

should provide clear and concrete short-term rather than long-term consequences

(Thato et al., 2003).

 48

Psychosocial development

Psychosocial development enables an adolescent to view her/himself

realistically, to relate to a significant other in a mature, giving relationship, and the

capacity to demonstrate concern about others in society. Brown (2000) describes four

tasks for adolescents’ socio-emotional transition to adulthood. These tasks include:

(1) effective separation or independence from the family of origin; (2) pursuing a

realistic vocational goal; (3) accomplishing a mature level of sexuality; and (4)

achieving a realistic and positive self-image.

Furthermore, Erik Erikson (1968) proposed a theory of human development

that emphasized the psychosocial crises of developmental stages. Erikson’s

psychosocial developmental stages include: (1) infancy (birth to 18 months); (2) early

childhood (18-36 months); (3) play age (3-6 years); (4) school age (6-12 years); (5)

adolescence (12-18 years); (6) young adult (19-40 years); (7) middle adult (40-65

years); and (8) maturity (65 years-death) (Erikson, 1980). According to Erikson’s

theory of human development, the psychosocial crises are viewed as a continuum of

development with both negative and positive poles. Although most individuals do not

resolve a crisis entirely positively or negatively, they need to come through the stage

more in the positive direction than the negative one to successfully continue on to the

next stage.

In adolescence, the psychosocial crisis that must be resolved is one of identity

versus identity diffusion (Erikson, 1968). This term referred to the confusion and

anxiety engendered by the need to choose from among a variety of alternatives and to

make commitments to a specific set of goals and values. Confronted with physical

growth and sexual maturation as well as imminent choices about education and

careers, adolescents must meet the challenge of integrating their past experiences and
 49

characteristics into a stable sense of self. Also, Erikson (1968) asserted that only in

adolescence does the individual have sufficient “physical growth, mental maturation,

and social responsibility to experience and pass through the crisis of identity (p.91)”.

He also identifies personal identity in adolescence as the process residing within the

core of a person and at the depth of his/her communal culture. The process of identity

formation involves observation and reflection, which occur simultaneously. As

individuals experience this process, they become increasingly more differentiated

from others and, at the same time, are able to strengthen more of their own identity in

the service of self (Erikson, 1968).

Development of sexuality

As the adolescent moves toward adulthood, another task is the development of

a mature level of sexuality. As defined by the Sex Information and Education Council

of the United States, sexuality refers to the totality of being a person. It reflects human

character and the way humans interact with each other. It is a multidimensional

concept that embraces ethical, psychological, biological, and cultural dimensions

(Feldmann & Middleman, 2002). In the U.S. culture, the concept of sexuality is linked

to political, emotional, moral, economic, and psychological concepts (DaGrossa,

2003). Likewise, current views of Thai sexuality are linked with the social

construction of gender which is one component of a boarder system of social relations

and expectations between men and women in Thai society (Knodel, VanLandingham,

Saengtienchai, & Pramualratana, 1996). In Thailand, there was a study conducted to

explore the meaning of sex as a cultural construct for university students in the

northeast region of the country. The study revealed that sexuality was viewed as a

natural part of life. Sexuality is considered natural and desirable for human

reproduction and survival. Sexual satisfaction was an expectation for both man and
 50

woman in a marriage. People were expected to be discreet, but expression of sexuality

was permitted in appropriate contexts such as married life. The researcher concluded

that meanings of sexuality in Thai University students are in some fundamental ways

remarkably similar to meanings of sexuality in the U.S (DaGrossa, 2003) and other

parts of the world.

Thai context, the term ‘sexuality’ refers to all aspects of feeling sexual and

being a unique and distinct individual, including emotions, beliefs, attitudes and

values, as well as a physical dimension. Sexuality from the Thai perspective is similar

to the American view. Consequently, the definition of sexuality defined by the Sex

Information and Education Council of the United States might be fitting for the

citizens of Thailand. Thus, the definition of sexuality in this study has a universal

dimension and is defined as the aspect of feeling sexual and being a unique and

distinct individual which is considered natural and desirable for human reproduction

and survival (Knodel et al., 1996; DaGrossa, 2003).

Stage of adolescence

Early adolescents (11-14 years old) typically do not engage in inter-gender

activities on their own. They tend to “hang out” with similarly aged peers in same-sex

peer groups. Their paths intersect with the opposite gender in school and possibly in

social situations; it is the groups that interact and only rarely does the individual

adolescent engage in distinct acts or events with the opposite sex. Within the past

decade, relationships between the genders are facilitated by non-face-to-face

interactions, such as via the internet, telephone, or telephone text messaging. Even

with these electronic intermediaries, the interchanges are frequently with a third party,

such as a best friend. Teens who manifest homo- or bisexual orientations have similar
 51

interactions because they usually do not overtly identify themselves as being different

at this stage of development (Brown & Brown, 2006).

During middle adolescence (15-17 years old), teens enter into mixed gender

peer groups and dating begins in some form. An adolescent in this specific stage of

development is most concerned, generally, with how she or he is doing in a

relationship and less about how the partner is managing. In middle adolescence, the

adolescent still has the image of an ideal romantic partner and seeks to find an ideal

partner. Romances tend to be intense and relatively brief. Girls have the intent of

finding boyfriends who are approximately 2 years older than they are (Brown &

Brown, 2006) and typically more experienced. This possibility may place the younger

girl at increased risk for early sexual activity and exposure to HIV/AIDS.

Collectively, the adolescent could have multiple romantic partners in a short period of

time (Brown, 2000). This increases the risk for HIV/AIDS.

In late adolescence (18-21 years old), young people start finding partners

based on shared caring and desire to please the partner. Frequently, relationships take

on the characteristics of an adult long-term relationship. Furthermore, although late

adolescence is characterized by formal operative thinking (abstract thought), it is

important to realize that a person in this stage is not always consistent in his or her

thought process. The goal of independence dominates the adolescent’s thinking.

Vocational, educational, and personal issues are major decisions (Gutgesell, 2004).

Even though the adolescent might use logical, formal operative thought process

regarding their vocation, or their career, and other essentials in their lives, they might

not yet be able to regulate their sexuality as well.

 52

Adolescence and sexual risk behavior

Adolescence is a time of self-discovery: physical, cognitive, and social

demands are dominant in their lives. It is within this context that adolescent sexual

behavior is more likely to occur (Feldmann & Middleman, 2002). During this period,

curiosity regarding sexuality’s mysteries is one of the important adventures that

adolescents want to explore. Therefore, curiosity and experimentation concerning

sexual activity can place adolescents at risk for undesirable consequences including

sexually transmitted disease acquisition and pregnancy (Feldmann & Middleman,

2002). A study conducted by Opasawas (1996) revealed that a primary reason for

experimenting with the first sexual activity among Thai vocational students was

curiosity. Moreover, Alexander and associates (1991) stated that some American

adolescents who initiate the first sexual intercourse at an early age do so to satisfy

their curiosity (Alexander, McGrew, & Shore, 1991).

In addition, during adolescence, peers become an important source of

reinforcement, modeling, and support concerning value and belief systems (Forehand

& Wierson, 1993). Therefore, it is not surprising that peers’ behaviors and attitudes

have been found to influence adolescent sexual risk behavior, especially in light of the

findings that adolescents whose peers are sexually active are more likely to be

sexually active (Miller, Forehand, & Kotchick, 2000). Additionally, indicators of

sexual risk-taking behavior among adolescents’ peer groups (e.g. inconsistent condom

use, multi partners) have been shown to relate to increased adolescent sexual risks

(Millstein & Moscicki, 1995). More subjectively, adolescents’ perceptions of their

peers’ behaviors have also been found to relate to sexual risk-taking, as several

studies revealed that consistent condom use is associated with the perception of

condom use among friends (Brown, DiClemente, & Park, 1992; Stanton et al., 1994;
 53

Le & Kato, 2006). Existing research suggests that the relationship between sexual

activity and peers becomes salient owing to increases in peer affiliation during

adolescent years (Whitbeck, Conger, & Kao, 1993). Clearly, peer influence seems to

be an important factor in adolescents’ sexual risk-taking behavior (Brown, Dolcini, &

Leventhal, 1997).

3. Premarital sexual behavior and condom use in adolescents

Premarital sexual behavior and condom use in American adolescents

In the United States (US), prior to the 1900s, few studies were conducted on

premarital sexual behaviors. Any investigation into past sexual behaviors is

complicated by historians’ reluctance to deal with such a “delicate topic” (Bullough,

1976, p.1). Discussions regarding sexual activity were socially prohibited. Until the

twentieth century, sexual activity was commonly regarded as having an exclusively

procreative purpose. This attitude was pervasive among men regarding women, but

somewhat different for men. Attitudes toward sexual desire were repressive, and

sexual repression was also considered a high moral standard for both males and

females (Turner & Rubinson, 1993).

Conducted by Alfred Kinsey, the first study of sexual behavior in the US was

a cross-sectional design and investigated premarital sexual behavior in males and

females aged between 13 to 40 years. The astounding results demonstrated that most

men and nearly 50% of women had engaged in premarital sexual activity. The

findings also revealed that approximately 50% of all married males had some

extramarital relationships at some time during their married lives. Among the sample,

26% of females had had extramarital sex by their forties. Between 1 in 6 males and 1

in 10 females from age 26 to 50 were engaged in extramarital relationships (Kinsey,

Pomeroy, & Martin, 1948). These findings were astounding to the American public.
 54

In 1953, Burgess and Wallin conducted a cross-sectional study regarding

premarital sexual intercourse on adolescents aged 12 to 19 year-olds. The results

showed that 47% of women and 68% of men had experienced premarital sexual

intercourse (Burgess & Wallin, 1953). Data regarding pregnancy and sexually

transmitted diseases were not reported in their findings.

In 1983, Zelnik and Shah explored the age of first intercourse among

American adolescents. Their findings showed that 50% of female adolescents aged

15-19 and 70% of male adolescents aged 17-21 living in metropolitan areas reported

that they had sexual intercourse with someone of the opposite sex. The mean age at

which female adolescents had their first sexual experience was 16.2, and the average

age of their partner was 19. The mean age at first intercourse of the male adolescents

was 15.7, and the mean age of their first partner was 16.4 (Zelnik & Shah, 1983).

In 1988, the CDC’s National Center for Health Statistics (NCHS) conducted a

study by interviewing 8,450 women 15-44 years of age. The major purpose of this

study was to examine trends in age at first premarital sexual intercourse for adolescent

women (15-19 years of age) in the United States during 1970-1988. These adolescent

women were interviewed regarding premarital intercourse. The results showed that

nowadays teenagers engaged in premarital intercourse earlier than did the teenagers in

the past twenty years. More females than ever were having premarital sex in their

mid- to late teens. In 1970, fewer than 5% of 15-year-old girls were having sex.

Besides, in 1988, more than 25% of 15-year-old girls surveyed reported being

sexually active. Among 19-year-olds, the rate has increased from 48% two decades

ago to 75% in 1988. The findings also revealed that the biggest jump in the

percentages related to sexual activity occurred between 1985 and 1988 in the midst of

a growing awareness of the risks of HIV infection. The youngest age of first sexual
 55

intercourse experience among the participants was 15 years. Factors associated with

early initiation of sexual intercourse included peer influence, exposure to media, early

puberty, and poverty (U.S. Department of Health and Human Services/Public Health

Services, 1991).

In 1990, Pratt claimed that by age 15, approximately one-fourth of the female

adolescents in this research had premarital experience which is consistent with the

results claimed by the National Survey of Family Growth (NSFG). By the age of 19,

approximately, four out of five adolescents reported having had premarital sexual

experiences (Pratt, 1990).

In 1995, using retrospective reports of age at first sex for women by birth

cohort, Turner and colleagues discovered that the percentage of women who had

premarital sexual intercourse before the age of 15 years rose from less than 2% of

women born at the start of the twentieth century, to 4% for women born in 1944-

1949, to 12% of women born in 1968-1973. There was also a marked increase in

premarital sex by age 18 years, from less than 10% for the cohort born at the start of

the twentieth century to over 50% for the cohort born 1968-1973 (Turner, Danella, &

Rogers, 1995).

Furthermore, the 2005 Youth Risk Behavior Surveillance (YRBS) showed that

nearly half of all high school students reported a history of engaging in premarital

heterosexual intercourse (46.8%) by age of 15, with males reporting higher rates than

females (48.5% and 42.9%, respectively). Nationwide, 6.2% of students had had

sexual intercourse for the first time before age 13 year, with males reporting higher

rates than females (8.8% and 3.7%, respectively). In addition, the findings indicated

that 37.2% of sexually active high school students (males and females) had not used a

condom at last sexual intercourse (CDC, 2006b).

 56

With regard to condom use, the data between 1982 and 1988 revealed that

condom use at first sexual intercourse among 15-19 year old sexually experienced

women doubled from 23% to 47% (Forrest, 1990). From 1988-1995, the proportion of

sexually active females and males who used condoms at first sexual experience

significantly increased from 50% to 70% for females and from 55% to 69% for males

(Abma & Sonenstein, 2001). In addition, Abma and Sonenstein (2001) stated that

condom use at last sexual intercourse increased substantially, from 31% in 1988 to

38% in 1995 among adolescent females and from 53% in 1988 to 64% in 1995 among

adolescent males. Additionally, data from the 1991-2003 Youth Risk Behavior Survey

(YRBS) indicated that the prevalence of condom use at last sexual intercourse in

sexually active high school students rose substantially from 38% to 57% among

females and from 55% to 69% among males (CDC, 2004c).

In conclusion, American adolescents engaging in premarital sexual activity

and condom use has been increasing in terms of early age of exposure. Most young

people in the US begin having sexual intercourse during their teenage years. The

average age of first sexual experience among American adolescents is 16 years.

Premarital sexual behavior and condom use in Thai adolescents

The adolescent’s expression of sexuality is greatly influenced by the culture in

which he or she lives (Brown, 2000). Culture assigns some very specific but not so

clearly articulated roles to men and to women. When these roles are clearly defined

and reinforced, the choices open to the adolescents to express manhood and

womanhood are framed within societal expectation and reinforcements (Brown,

2000). Cultural ambiguity regarding sexual behavior leaves the adolescents with

many options, but little guidance. In the Thai cultural context, having sexual
 57

intercourse before marriage is considered taboo and unacceptable (Opasawas, 1996).

However, these cultural taboos do not always restrain adolescents’ sexual behaviors.

Over the past two decades, however, Thailand has become more westernized.

Lifestyles, information technology development and its influence, and social practices

have changed rapidly in most sectors of Thai society. These changes are partially due

to Thailand’s economic development proceeding at breakneck speeds (Lyttleton,

1999). However, despite those changes, Thai community norms and attitudes remain,

on the whole, conservative, and sexuality remains a sensitive topic among young

people as well as amid parents and health care providers. Nevertheless, gender double

standards persist (Tangmunkongvorakul, Kane, & Wellings, 2005). Sexual activity

among young women in particular is strongly disapproved (Soonthorndhada, 1992)

among all segments of the society. Pre-marital sexual practice continues to be

considered unacceptable for ‘respectable women’ and highly damaging to the

reputation of the young woman and her family. By contrast, sexual activity is widely

accepted for young men, who are expected to have a strong sexual drive which

demands ‘release’ (Tangmunkongvorakul et al., 2005). For Thai males, premarital

sexual intercourse is much less prohibited, particularly casual relationships between

men and sex workers (Gray & Punpuing, 1999). Thai men are allowed, and indeed

expected to manifest, a significant degree of freedom in their sexual behavior in order

to establish their masculine credentials (Cook & Jackson, 1999). Young men who are

virgins are ridiculed by their peers (Lyttleton, 1999).

In Thai society, Thai parents often hold traditional gender double standards in

the ways in which their children are socialized so that, as a result of norms that

stigmatize sexual activity among unmarried females, adolescent girls are unlikely to

seek the support or assistance of their parents in addressing sexual health problems. In
 58

addition, because of the shrouded approach to sexuality, females are less likely to

share their curiosities and fears with their parents. In addition, parents are unwilling in

several instances to agree to the provision of sex education for their daughters, while

at the same time, they are reluctant to discuss these matters with them directly

(Tangmunkongvorakul et al., 2005). Nowadays, few studies have been conducted

regarding the gender double standards for males and females in Thai society and its

consequences.

Recently, Tangmunkongvorakul and associates (2005) conducted a qualitative

study regarding the gender double standards in young people attending sexual health

services in Northern Thailand. The findings confirm the persistence of gender double

standards and sexual norms that continue to stigmatize premarital sex for females

while condoning it for males. These double standards pervade adolescent sexual

partnerships in ways that make young females particularly vulnerable, unable to rely

on partners, exposed to peer pressure, and unwilling to seek help from parents and

health providers. Adolescent females experiencing unwanted pregnancy or problems

arising from sexual activity often face indifference or the threat of abandonment by

their partners, rejection from their parents and victim blaming attitudes on the part of

providers. Furthermore, sexually active adolescents also fear disclosure of their sexual

activity status to their parents. Instead, they opt for clandestine and unsafe abortions

and seek the counsel of peers and pharmacists at drugstores rather than parents and

health care providers who are knowledgeable and could provide creditable advice. At

the service provider level, young women report facing threatening and judgmental

attitudes, indifferent counseling, and possible violation of confidentiality. Their

parents could be informed about their pregnancy/sexual status. This is in marked

contrast to the treatment of young men, who generally meet with a more sympathetic
 59

and accepting responses (Tangmunkongvorakul et al., 2005) from health care

professionals. These health disparities and unequal treatment have a considerable

influence on the sexual health of young Thai females.

Studies from several countries in Southeast Asia, including Thailand,

suggested that young Asian females would like to access confidential services without

fear of discovery by family or community members. Health services should be

available at convenient locations and times, are affordable and, most important,

provided by staff who are unthreatening, competent, non-judgmental and willing to

respect confidentiality (Gubhaju, 2002; Wissarutrat, 2001; Koff & Cohen, 1983).

Thus, in order to decrease the health disparities and improve services in 1997, the

Thai Ministry of Public Health began the project in government hospitals entitled

“Development Model to Improve Adolescent Reproductive Health Services for Thai

Adolescents” In this project, “adolescent friendly rooms” have been developed in

which services and contraceptive supplies are available without charge and are

offered during extended hours; telephone and face-to-face counseling is provided;

confidentiality is maintained through anonymous record-keeping; and manuals

containing frequently asked questions are available for young clients’ needs

(Jejeebhoy & Bott, 2002). The preliminary findings from the project’s evaluation

suggested that establishing adolescent-friendly services at government hospitals might

be feasible and sustainable; however, it remained difficult to attract adolescents to

hospital settings. Therefore, efforts should be made to establish services outside the

hospital settings. Indeed, “adolescent friendly rooms” should be established at

acceptable locations such as department stores, youth centers, public schools, private

schools, and colleges (Poonkhum, 2002).

 60

During the later part of the twentieth century, the prevalence of premarital

sexual activity of Thai adolescents seemed to increase. Beginning in the 1980s, Thai

high school students began to engage in more frequent premarital sexual activities at

an early age (O-Prasertsawat & Petchum, 2004). This may be due to Thai adolescents

becoming more liberated and more individualistic and also the change in norms about

sexuality and the loosening of family control over the behavior of adolescents

(Santelli, Lindberg, Abma, McNeely, & Resnick, 2000; Singh, Wulf, Samara, &

Cuca, 2000). From 1980 to 1989, the prevalence of Thai adolescents engaging in this

precocious behavior was dramatically high among students. The dawning of the 1990s

is considered the initiation of the highest point of premarital sexual behavior among

Thai adolescents. The decade of the 1990s in Thailand is marked with phenomenal

social changes as the country shifted away from a predominantly rural-based to more

urbanized culture, and a less family-bound society (Klausner, 1997). As Thailand has

become more westernized, Thai adolescents, including vocational students, who are in

a pivotal phase of their development, are among the generation that most easily adopts

and integrates into their life styles. These changes include the rapid development of

information technology, improved living conditions, and social practices that reflect

the values and behaviors of western nations. One of the downsides of the phenomenon

of economic and social globalization has been the adoption of unhealthy life styles

including unsafe sexual practice among adolescents (Tangmunkongvorakul et al.,

2005). The following section will provide a brief chronological ordering of research

studies that reveal premarital sexual behavior and condom use among Thai

adolescents.

One of the first studies conducted in 1988, Prasatkul conducted a descriptive

study on premarital sexual behavior among 361 Thai adolescents, both in urban and
 61

rural areas. The participants consisted of 14 to 20 years-old adolescents who were not

in school. The findings demonstrated that 66% of male adolescents and 9% female

adolescents reported having engaged in premarital sexual intercourse. The average

age at first sexual encounter was reported at 16 years (Prasatkul, 1988).

In 1990, Ratanapaichit studied the prevalence of sexual experiences and

condom use of 320 male vocational students aged 15-26 years in Songkhla province,

in the rural southern region of Thailand (See Appendix E, Figure 4, p.224). The

results showed that 51.2% of the male students reported having premarital sexual

intercourse. Of the sexually experienced male students, 24% reported having sex with

commercial sex workers, 34% with their flirtatious female friends, and 42% with their

girlfriends. Reported condom use was as follows: 59% used condoms and 41% did

not use condoms. Both the consistency of condom use and using alcohol/drug before

engaging in sexual intercourse was not reported in their research. The researcher

concluded that the fear of HIV/AIDS has caused many young Thai men to shift away

from commercial sex to non-commercial casual sex (Ratanapaichit, 1990). However,

the actual sexual activities have not decreased.

In 1992, Boontham studied adolescent sexual behavior and condom use in 851

male senior high school students in Supanburi province, (See Appendix E, Figure 4,

p.224) a rural area in the central region of Thailand. The findings showed that 24.7%

of the students reported having premarital sexual intercourse. Reported condom use

was as follows: 16.7% used condoms every time; 45.7% used condoms sometimes;

and 37.6% never used condoms. The consistency of their sexual activities was not

reported (Boontham, 1992).

In addition, Chanakok and Youwapanon (1993) investigated adolescent sexual

behavior and condom use among 461 male vocational rural students aged 15 to 25
 62

years in Chiang Mai province, the largest province in the northern region of Thailand.

The findings demonstrated that 48% of the participants reported experiencing

premarital sexual intercourse. Condom uses were reported as follows: 26% used

condoms every time; 47% used condoms sometimes; and 27% never used condoms.

Among those who reported using condoms, 80% indicated that they used condoms

incorrectly with 24% reporting leakage or rupture of condoms during sexual activity

by purpose or of accident. The average age at first sexual experience was reported at

16.5 years. Thus far, the studies have been about adolescent males in vocational

schools. The particular reason why the studies were on this population is that based on

the previous existing evidences, this population has engaged in sexual risk activity,

including condom non-use, more often than the adolescents in high schools

counterparts (Jenkins et al., 2002; Boontham, 1992; Xenos, Pitaktepsombati, &

Sittitrai, 1993; Wuttiprasit, 1991).

In 1998, Siriwattanakan studied sexual behavior and factors predicting coitus

among 433 single females. The participants were students aged 15 to 24 years who

were studying in secondary schools at Udonthani province, rural area of northeast

region, Thailand. The results showed that 25.4% of female youth had coitus. The

mean age at first sexual experience was 17 years. Contraception was occasionally

used and was the contraceptive choice. Besides, the results also revealed that 26

percent of female youth who had coitus were infected with sexually transmitted

diseases, including gonorrhea, chlamydial infection, syphilis, and chancroid

(Siriwattanakan, 1998). This is additional evidence that they were not using condoms.

In 1999, another study was conducted among final-year secondary school

students in Supanburi province, a rural area in the central region of Thailand (See

Appendix E, Figure 4, p.245). The results showed that 40.6% of male and 6.6% of
 63

female respondents had experienced sexual intercourse (Gray & Sartsara, 1999). In

addition, this study found that the average age at first sexual intercourse was around

16 years for male adolescents and 18 years for female adolescents (Gray & Sartsara,

1999). Besides, Piya-Anant and others (1999) studied premarital sexual intercourse

among 350 Thai male vocational school students aged 18 to 20 years in Bangkok. The

results indicated that 151 participants (43%) were having premarital sexual

intercourse. Among these adolescents, 50% never used condoms, 26% used condoms

sometimes, and 24% reported using condoms every time. The average age of first

sexual intercourse was 16.6 years (Piya-Anant, Kositanon, Leckyim, Patrasupapong,

& Watcharaprapapong, 1999).

In 2000, Attaveelarp conducted a cross-sectional study of sexual behavior and

related factors among 426 rural students of high school age in Phuket province, in the

southern region of Thailand. The results showed that 12.7% of students had

experienced intimate sexual affairs. A majority of respondents (75%) had sexual

intercourse with their boyfriend or girlfriend and the average age of the first sexual

experience was 15 years (Attaveelarp, 2000).

In 2001, van Griensven and colleagues performed a study of sexual behavior,

HIV/STDs, and drug use among northern Thai rural adolescents. Of a sample of 1,725

adolescents, 48% of the male students and 43% of the female students reported ever

having had sexual intercourse. Overall, the mean number of lifetime sexual partners

was 4.6 among male participants and 2.8 among female participants. Consistent use of

condoms with steady partners was reported by 16% of male participants and 11% of

female participants who had such partners. Among women with a history of sexual

intercourse, 27% reported at least 1 pregnancy over 3 years. Of these pregnancies,

83% were terminated (van Griensven et al., 2001). Two years later, Allen and
 64

colleagues (2003) examined factors that may place female Thai adolescents and

young adults (n=832) at risk for HIV/STDs and unintended pregnancies. The findings

revealed that 359 women (43.1%) reported sexual intercourse history, with an average

age at first sex of 17.6 years, and a 2.6 mean number of lifetime sex partners. Among

those with sexual intercourse experience, 27.3% had been pregnant and the majority

of their most recent pregnancies were terminated by illegal abortions performed by

the traditional birth attendants. There was no reported information about deaths or

serious illnesses as associated with these abortions in the study. With respect to

condom use, a minority of the young women in the sample reported condom use. One

fourth of those with sexual experience reported a condom had been used during their

first sexual encounter. Interestingly, among women who had been sexually active

during the previous 3 months, only 2 (0.7%) had always used a condom during every

sexual encounter, whether with a steady or causal partner. The main reason for non-

use of condoms reported by the study participants was lack of self-perceptions of their

vulnerability to HIV and STDs risk (Allen et al., 2003).

In addition, in 2003, Thato and others examined the prevalence of premarital

sexual behavior and condom use among vocational students in Bangkok, Thailand. Of

425 participants, only 6.3% reported using condoms every time in the beginning of

the relationship (the first one/two dates) and 10.2% during the last few times. In

addition, 24% of those sexually active adolescents experienced unplanned

pregnancies. Interestingly, 83% of pregnancies ended in illegal abortion. Seven

percent of sexually active teenagers had contracted STDs (Thato et al., 2003).

Additionally, in a cross-sectional study of coital behavior and related factors

among 473 students of rural high schools in Ubonratchathani province,

Krisawekwisai (2003) found that the youngest age of first sexual intercourse
 65

experience of the participants was 13 years, with an average age of about 14.5 years.

In most instances (80%), their first sexual partner was their boyfriend, girlfriend, or

close friend.

Premarital sexual behavior and condom use in adolescents in the Mekong

sub-region

Situated within the northeastern part of Thailand, Ubonratchathani province,

the setting for this study, has also shared the borders with Lao People’s Democratic

Republic (Lao PDR) to the east, and Cambodia to the south and the west, an area

known as ‘the Mekong sub-region’. The reported sexual risk behavior of adolescents

in the Mekong sub-region started among young men and young women at the

beginning of the 1990s. It was almost the same time that the reporting of sexual

behaviors among other Thai adolescents in various regions of the nation appeared in

the scientific literature (United Nations, 2001).

Lao People’s Democratic Republic (Lao PDR)

In Lao People’s Democratic Republic (Lao PDR), evidence suggests that Lao

adolescents engage in premarital sexual risk behavior because of societal values that

support premarital sex for men. In 2000, Sananikhom and others assessed the

reproductive health in young Laotians. The results revealed that the percentage of

Laotian adolescents who engaged in unsafe sexual activity was increasing. Male

teenagers reported frequent sexual activity outside of their villages; they sometimes

had multiple sex partners. Youth in the lowland or in the towns where its inhabitants

have earned income were more likely to visit sex workers compared to youth from the

highland that lacked the resources to purchase goods and services. This lack of

resources prohibited easy access to commercial sex workers who provide a sexual

service for a fee. Nonetheless, they might experience premarital sex with multiple sex
 66

partners within their villages (Sananikhom, Reerink, Fajans, Elias, & Satia, 2000)

without the fee for service component. Recall that Lao men are exposed to more

sexual risk than women because it is socially acceptable for them to have multiple sex

partners (United Nations of Education Save Children Organization, 2002).

Furthermore, their preference is to have sexual activity without condoms. The

common reasons for not using condoms included partner trust, and reduced sensation

while using condoms (Sananikhom et al., 2000). As a result, the female partners

become at risk persons because of the males’ preferences. Cultural norms generally

have granted sexual freedom to males, but imposed constraints on female sexual

attitudes and behavior. Young unmarried males usually have more partners,

particularly more casual partners, than their female counterparts (Liu et al., 2006).

In 2002, Sychareun studied sexual attitudes and behaviors among urban

unmarried youth in Vientiane Capital City, Lao PDR. This community-based cross-

sectional study was conducted among 1,200 (700 males and 500 females) young

people to ascertain levels and patterns of sexual attitudes and behaviors among

unmarried youth (18-24 years). The results showed that the majority of respondents

held liberal attitudes toward sexual behaviors for males, agreeing that premarital sex

is acceptable for young males in Lao society. In addition, the findings also revealed

that slightly over one-half of sexually active young people reported condom use at last

sexual experience among males and females. It appeared that almost one-half (48%)

of young Laotians, males and females, lacked frequent use of condoms. In addition,

more than fifty percents of young Laotians in this study were not aware of condom

use. Nevertheless, approximately 75% of the adolescents had heard about STDs,

including HIV/AIDS (Sychareun, 2002). Knowledge on preventive behaviors is very

low (25%) as they had misinformation regarding taking medicine and washing
 67

genitals after having sexual intercourse (Sychareun, 2002; Lao PDR national

statistical center, 2001).

In 2005, Manivone studied gender and sexuality, and their implications on

sexual reproductive health including HIV/AIDS: a case study of young female factory

workers in Vientiane, Laos. The results revealed that young females are at a cross-

road between their own traditional sexual culture and gender values and modern

culture and values that are part of their exposure to an urban, modern, and globalized

life. Many young women had been involved in premarital sex, reasoning their

behavior as being ‘modern’, ‘up to date’, and ‘new age’. There was evidence in the

low condom use and casual sex, indicating that young women were involved in unsafe

sexual practices. This study also found that the young women were facing the risk of

reproductive health problems including HIV/AIDS (Manivone, 2005). They are also

at risk for other stigmatizing labels such as “amoral women” and additional negative

labels that they might have to endure. The researcher did not report whether other

women’s attitudes were also negative toward the adolescents who become active “too

soon and too often.”

Cambodia

In Cambodia, to date, few studies have been conducted regarding Cambodian

adolescents engaging in premarital sexual risk behavior. In 1999, Glaziou and

associates surveyed knowledge, attitudes and practices of university students

regarding HIV infection, in Phnom Penh, Cambodia. This study was conducted

among 679 students by using a self-administered questionnaire. The results revealed

that the students showed a high level of HIV/AIDS knowledge. All students had

received information on HIV on several occasions via lecture presentations,

television, and newspapers. The students also reported that condoms were costly
 68

(18%), difficult to find (17%), difficult to use (24%), and that they reduced the

pleasure during sexual intercourse (44%). Of the male students, 44% had experienced

a sexual relationship. The mean age at first intercourse was 20 years of age. During

the first intercourse, 67% of male students used a condom, 73% used condoms if the

partner was a prostitute (63% of first sexual partners were prostitutes). During the last

intercourse with a prostitute, 76% of male students used a condom. The ages of the

prostitutes were not reported in the study. Of the female students, 3% had experienced

sexual relations. The mean age at first intercourse was 18 years old. During first

intercourse, 10% of the female students used a condom. Among these who reported

condom use, types of relationships or partners were not reported (Glaziou et al.,

1999).

In summary, based on the empirical data available in Thailand, it can be

concluded that among unmarried young Thai people, sexual behavior norms have

changed substantially over the last two decades (Attaveelarp, 2000; van Griensven et

al., 2005). Notably, Thai adolescents engaging in premarital sexual activity has been

increasing. In particular, vocational students in rural areas have engaged in premarital

sexual encounter in the high proportions. The average age at the time of the first

sexual intercourse among Thai adolescents is 15 year-of-age. Compared to the

neighboring countries, Lao PDR and Cambodia, it is clear that the premarital sexual

risk behavior among Thai adolescents is rising sharply. Furthermore, a number of

studies regarding premarital sexual behavior and condom use among Thai adolescents

indicated that most of these adolescents participate in sexual risk behavior, and are not

likely to use condoms every time while having sexual intercourse. As mentioned

above, available studies of sexual experience among adolescents in Thailand indicated

that Ubonratchathani Province, with its incidence of premarital sexual risk behavior,
 69

is an important locale for conducting a study regarding sexual risk-taking behavior

among unmarried vocational education adolescents.

Two dimensions of Communications among Thai

Deeply embedded within the Thai culture is its traditions and folklore

surrounding gender rights and taboos that are related to intimate relationships and

sexual expressions. Often times these unspoken, but frequently practiced values and

behaviors might be in conflict with the formal or spoken values and behaviors. These

phenomena can be explained by an elucidation of the two dimensions of

communications that are evident throughout the nation. The first of the two

dimensions of communications relates to expressions of intimacy. According to

traditional norms and social sanctions that are still prevalent to a substantial degree in

Thai society, public touching and embracing between male and female is not

common. In certain situations this type of overt expression would be considered as

rude or inappropriate. In addition, Thai women are expected to be virgins when they

marry (Isarabhakdi, 1997). Marriage remains the accepted form of obtaining access to

sexual relationships for women. However, for men, there are other options. Men have

access to prostitutes whose services are considered to be socially approved

alternatives (Porapakkham, Vorapongsathorn, & Pramanpol, 1986). Men can engage

the services of prostitutes and still remain in “good standing” with the female with

whom he wishes to marry. This is an accepted practice, but it is not openly

acknowledged. The women, however, are bound by a different set of expectations and

regulations.

Loss of virginity for a woman is seen as detracting from her attractiveness as a

potential wife for another suitor. If she develops a reputation of having had sexual

relations with a man, she is not considered as a good candidate for marriage. This
 70

could be very upsetting for her and her family. On the other hand, virginity for single

men is considered an oddity and thus not expected as a characteristic for a future

husband (Knodel, VanLandingham, Saengtienchai, & Pramualratana, 1996).

Therefore, women participate in the perpetuation of this double communication. In

this sense, gender double standards regarding sexuality continue to exist.

From a traditional and historical perspective, premarital sex was considered an

offense to the ancestor spirits unless the male compensated the female’s family

(Wawer, Podhisita, Kanungsukkasem, Pramualratana, & McNamara, 1996) for her

services. The loss of virginity was the same as the loss in market value for the Thai

woman in terms of her marriageability (Morrison, 1999). In the past, young Thai

women were influenced by their parents who taught them traditional Thai values that

helped them to preserve their market value. Klausner (1997) noted that over time, the

prohibition of dating without chaperones and the restriction on hand holding in the

public between young males and females was taboo.

From that traditional and historical perspective, among most Thai women, the

topic of sexuality remains a restriction, a repression, and a dangerous topic. These

same values and folkways are evident in the society today. According to an article

entitled “Youth Sexuality in Thailand” by Ford and Kittisuksathit (1995), there is a

belief that “a good woman” (respectable, virtuous) should abstain from premarital

intercourse. Among the young Thai females in this study, there is a strong belief that

women who engaged in premarital coitus will damage their and their families’

reputation.

During the past two decades, the second communication emerged. Numerous

studies on sexual behavior among Thai adolescents and young adults reveal a sharp

increase in premarital sexual activity and more widespread experiences with

 71

premarital sex. As in most modern societies, norms and social sanctions toward

premarital sex are shifting in the direction of greater permissiveness (Asadi, 2000).

The attitude that premarital sexual intercourse is acceptable for both young Thai

males and females if it is part of a stable and affectionate relationship has gained

some approval (Isarabhakdi, 1997). Among unmarried young people in Thailand,

sexual behavioral norms have changed substantially over the past few years. One

important change has been the increased acceptability of premarital sex among young

women, which has resulted in a trend toward earlier sexual initiation for Thai females

(Liu et al., 2006). A nationwide partner relations survey conducted in 1990 found that

13% of female participants aged 15-19 reported having had sexual intercourse,

compared with 34% of males (Sittitrai et al., 1992). Another study from the same

period found that young Thai women had higher levels of sexual experience, though

they were still less likely to be as sexually experienced than their male counterparts

(Xenos, Pitaktepsombati, & Sittitrai, 1993). This is also evident in the study

conducted by Prasartkul and others (1988). In this study, forty percent of male

adolescents and 36 percent of female adolescents endorsed premarital sexual activity

within a committed relationship (definition not provided). Furthermore, not only is

premarital sex increasing throughout the nation, but the incidence of cohabitation

among young Thai students is also expected to continue to rise dramatically (Yeoh,

Lutz, Prachuabmoh, & Arifin, 2003; Weruvanaruk, 2001). Outside the confines of the

instructional hours at vocational schools, pre-marital liaisons are evident in the

students’ lives, including their school-based apartments. The sexual expressions take

various forms, including casual sex between consenting partners without

commitment, and unmarried cohabitation with and without commitment. There are
 72

instances where the male and the female live together as husband and wife. In most

cases the happy twosomes break up after graduation (Tripathi, 2001).

Overall, the differences between the first and the second communication

dimensions among young Thai is that nowadays, premarital sex happens more

frequently, despite the traditional folkways and the societal silence about the

traditional and the new intimate/sexual behaviors among the young males and

females. Importantly, many of young Thai people do readily admit that they cohabit

as a couple, without the sanction of marriage or approval by the society. These young

Thais do not see their behaviors as taboo, or in conflict with the market price for the

female (Tripathi, 2001; Knodel et al., 1996). They may be challenging the traditional

thoughts and behaviors with the realities of current the sexual practices in the nation.

Nevertheless, at this juncture, the two dimensions of communication continue to be

evident among many segments of Thai society.

Major factors that influenced premarital sexual practice among Thai adolescents

Although premarital sexual intercourse is not acceptable in Thai traditional

norms, there is evidence that large proportions of young Thai people now report pre-

marital sexual experience with their sexual partners (Chaipak, 1987; Nuchanart, 1988;

Srisupan, 1990; Thevadithep, 1992; Puthapuan, 1994; Siriwattanakan, 1998;

Attaveelarp, 2000; Jenkins et al., 2002; Krisawekwisai, 2003). Based on the findings

of empirical studies on sexual risk behavior among Thai adolescents, the major

factors that influence Thai adolescents’ decisions to engage in premarital sexual

activity are identified below, and include such factors as the influence of western

culture, the media, peer pressure, and substance use.

 73

Influence of western culture

Traditionally, Thai culture regarded sexual activity as having only a

procreative purpose. A high premium was placed on virginity, particularly for the

bride, and premarital sexual intercourse was taboo among families and the culture

(Opasawas, 1996). Attitudes toward sexuality were controlling and sexual repression

was considered a high moral standard. Arranged marriage was considered as an

appropriate way to have a better family. This traditional cultural norm has been

changing gradually since Thailand has become a newly industrialized country which

started around 1987 (Surasiengsunk et al., 1998). The young Thai generation has

more chances to have higher education, better jobs, and consequently greater

independence in their lives. The path to marriage has also changed. Adolescents have

been exposed to a variety of lifestyle changes, including a western lifestyle of sexual

freedom. Behaviors of western adolescents often strongly influence Thai adolescent

behaviors as well, including premarital sexual behavior. The influences of western

adolescents’ behavior affect the Thai adolescents’ attitudes and behaviors toward

premarital sexual behavior through several types of media, such as television,

magazines, movies, the internet, and direct experiences through world travel and the

recent tourism industry that is growing within the country (Opasawas, 1996). Being

exposed to a variety of these various influences, the Thai adolescents might find

themselves in conflict with tradition and contemporary thought. Even though Thai

adolescents have been raised within a family of strong Thai culture and beliefs, they

are strongly influenced by western values and behaviors. Engaging in premarital

sexual activity is a symbol of modern fashion and “good living” for some Thai

adolescents. In particular, in large cities such as those that are located in the

Ubonratchathani province, cohabitation is increasing in popularity and frequency

 74

(Weruvanaruk, 2001; Krisawekwisai, 2003). However, this practice it is not yet

accepted within the larger Thai culture.

Media influence

Nowadays, adolescents are exposed to a variety of lifestyles and risk taking

behaviors through the general media that is local and global. They encounter many

temptations, such as drug and alcohol use, delinquent behaviors, as well as sexual

activity. Mass media, including pornographic magazines, entertainment

establishments, pornographic movies, and adult web sites, also have a strong

influence on promoting premarital sexual behavior among Thai adolescents

(Siriwattanakan, 1998; Attaveelarp, 2000; Rathnawardana-Guruge, 2004). Exposure

to these kinds of media may encourage adolescents to practice premarital sexual

experimentation. In the study conducted by Rathnawardana-Guruge (2004), the

findings showed that all of these media were significantly related to inappropriate and

risky sexual behavior among adolescents in Wattanakorn district, Sakaeo province,

Thailand. Adolescents could easily purchase all of these media at a low price on the

“black-market” in Thailand. These media are sex driven inducements that contribute

to adolescents being more prone to engage in premarital sexual activities

(Rathnawardana-Guruge, 2004) and accepting these behaviors as a new and

“upgraded” way of life.

Peer pressure

Another factor influencing premarital sexual practice among adolescents

concerns the increasing significance of peer pressure. Growing social acceptance of

premarital sex plays a major role in reproductive health-related decision making

among adolescents (Gubhaju, 2002). As adolescence is a developmental period of

physical transition and identity information, the struggles for individual autonomy and
 75

the social construct of masculinity or femininity render teenagers susceptible to peer

pressure (Gubhaju, 2002). Peers typically provide a means of social comparison and a

source of information about the world outside the family, including information about

sex and sexual experimentation. Within the context of curiosity, peers are the second

source of sex information for adolescents, in addition to the first source, parents

(Gubhaju, 2002). Peers may influence adolescents to explore entertainment

establishments, read pornographic magazines and watch pornographic movies

(Rathnawardana-Guruge, 2004). Pertaining to sexual activity, peer pressure exerts a

powerful effect toward premarital sexual behavior. Adolescents who have friends

engaging in premarital behavior tend to engage in this behavior (Rathnawardana-

Guruge, 2004). Adolescents who are virgins are ridiculed by their peers who are

sexually active (Gray & Punpuing, 1999).

The influence of peer pressure is increasing in the context of the erosion of

traditional parental control over premarital sexual attitudes and behaviors, and the

declining role of family members, particularly grandmothers, in providing adolescent

girls with premarital instruction and advice on appropriate sexual and marital

behavior (Gage, 1998). A study on the sexual experience of rural Thai youth revealed

that peer influence was one of the main motivations for engaging in first premarital

intercourse (Isarabhakdi, 2000). In another study conducted by Watronachai (2004),

the results revealed that peer norms and social support of peers were significantly

related to safer sex practices among male vocational students in Nakhonpathom

province, Thailand.

While parents are expected to be the logical source of information, they often

do not discuss sexual issues with their children because they are embarrassed by the

subject. Perhaps this is one of the reasons why the family is no longer the prime
 76

reference group in reproductive health-related decisions (Gubhaju, 2002). Instead,

teenagers tend to value the opinions of their friends more highly (Gubhaju, 2002) and

parents are reluctant to have these conversations with their adolescent children

(Eastman, Corona, Ryan, Warsofsky, & Schuster, 2005).

Substance use

Individuals are attracted to drugs because drugs help them to adapt to an ever-

changing environment or it is a maladaptation (Gerra et al., 2004). Smoking, drinking,

and taking drugs reduces tension and frustration, relieves boredom and fatigue, and in

some cases helps adolescents to escape the harsh realities of their world (Santrock,

1998). There are several kinds of drugs being used by Thai adolescents nowadays:

alcohol, marijuana, cocaine, and tranquilizers (Santrock, 1998) are just a few

examples. Among these drugs, alcohol is the most widely used substance among Thai

adolescents (Sangkarat, 1997). van Griensven and colleagues (2001) studied sexual

behavior, drug use, and HIV/STDs in northern Thai youths. The results revealed that

92.5% of male and 80.5% of female participants reported using alcohol in the last 3

months. Furthermore, 22% of male and 3.6% of female participants reported having

ever used marijuana (van Griensven et al., 2001). Even when used in a low amounts,

alcohol could decrease the ability to make a decision and further compromise the

adolescent’s well being. Consequently, adolescents may engage in sexual risk

behaviors while under the influence of this substance. The prior use of any kind of

substance is related to the initiation of sexual risk behavior (Kaiser & Hays, 2005;

So, Wong, & DeLeon, 2005; van

Griensven, Thanprasertsuk, Jommaroeng, Mansergh, Naorat, & Jenkins, et al., 2005).

In summary, to date, the influences of major factors (western culture, media,

peer pressure, and substance use) that contribute to Thai adolescents’ decisions to
 77

engage in premarital sexual activity are increasing. Eliminating the influences of these

major factors is difficult. Therefore, Thai healthcare providers and other influential

decision makers will need to have a more in-depth understanding of the pressures and

problems that Thai adolescents confront on a daily basis, and develop program that

are culturally specific to their needs.

The key elements influencing condom use among Thai adolescents

Nowadays, one of Thailand’s challenges is to revitalize and adapt prevention

strategies to match sexual attitude and behavior changes. This will require revamping

safe sex campaigns in a context where patterns of sexual behavior have changed.

Therefore, the reasons for nonuse of condoms should be investigated to provide

significant background information and provide a framework for developing safer sex

education programs for Thai adolescents. The major psychosocial factors that

influence condom uses among adolescents include communication skills regarding

condom use, societal acceptance of contraception, and attitudes toward condom.

These psychosocial factors are also embedded in Bandura’s Self-Efficacy theory.

Communication Skills

Communication with sexual partners regarding contraception, especially

condom use, has been found to predict sexual behavior. In 1999, Cash,

Anansuchatkul, and Busayawong (1999) studied the psychosocial aspects of

HIV/AIDS prevention for 61 northern Thai single adolescent migratory female

laborers aged 15 to 24. They were young Thai people who follow the work seasons in

Chiang Mai City, the northern of Thailand. The respondents reported that they are less

open communication regarding using condoms because condoms were “men’s

business”. There are irreconcilable social costs if a single woman talks about using

condoms. Social costs are manifested in stigma related to shame and embarrassment.
 78

These findings are consistent with Thai culture. Within Thai culture, communication

with sexual partners regarding condom use is difficult. Especially for Thai girls,

having conversations with partners regarding condom use may help them to appear

sexually experienced (Alan & Punpuing, 1999) or they could run the threat of being

classified as sex workers or prostitutes. Social sanctions have continued to make it

difficult for young single women to initiate discussions about condoms with their

male partners (Havanon, 1996). Therefore, the difficulty in communicating with

sexual partners regarding condom use creates continuing barriers to condom use in

sexual relationships (Jenkins et al., 2002).

Societal Acceptance of Contraception

Moreover, societal acceptance or rejection of any private intimate behavior,

including contraception (condom), is likely to affect that behavior profoundly

(Lagana, 1999). According to Hall (1990), some instructional books and women’s

magazines provide contradictory messages regarding condom use. Particularly, they

portray the condom either as a symbol of pleasure and of a life associated with

responsible sexual intercourse, or as a symbol of promiscuity and disease. In Thai

culture, seeking contraception is not a culturally appropriate behavior for respectable

Thai women because this preventive behavior implies a history of being sexually

active (Ford & Kittisuksathit, 1996). In general, young Thai women do not consider

seeking or requesting contraception, in particular condoms, because they would fear

being stigmatized as sexually active and promiscuous females (Alan & Punpuing,

1999). The outcome could be rejection by other potential partners, the family and

significant others. In a study conducted by Cash and associates (1999), one female

participant expressed that “if a young Thai woman shows she knows about sex, for

example enough to discuss condom use issues, other people might think badly of her.
 79

She could risk stigmatization”. Most young women in this study were worried their

behavior would be scrutinized or criticized by peers or other people; they would

suffer from negative gossip. In Thailand, even though condoms could be purchased

over the counter in a drug store, the lack of societal acceptance of contraception

prevents condom sales from occurring without difficulty. For example, if a single

Thai female adolescent is seen purchasing or possessing condoms, she is usually

suspected of prostitution because it is still uncommon for contraception to be utilized

in single Thai female adolescents (Thato et al., 2003). Helping to overcome societal

and personal obstacles to condoms use may decrease the immense consequences and

costs of sexually transmitted infections, and unintended pregnancies (“Closing the

Condom Gap,” 1999). From empirical studies, it can be concluded that societal

acceptance of contraception could have an effect on contraceptive behaviors by

influencing one’s intention to obtain condoms.

Attitudes toward condom use

Besides, adolescents’ attitudes toward condom use can predict sexual

behavior. Kantawang (1994) examined the determinants of intentions to engage in

HIV-related sexual risk behavior among Thai adolescent males. The subjects were

306 randomly selected sexually experienced male students aged 14-21 attending a

major public vocational school in Chiang Mai, Thailand. The results revealed a high

prevalence of condom non-use with non-prostitute females (girlfriends) (98.7%). In

addition, positive attitudes toward condom use were significantly associated with

intentions to use condoms. Findings support those of their study conducted by Jenkins

and colleagues (2002). This study investigated condom use and its psychosocial

correlates in a sample of 1,725 male and female vocational students aged 15-21 years

in northern Thailand. The significant finding suggested that condom use is not
 80

becoming widely established in these young Thai adolescents. The reduction in sexual

pleasure when using condoms was the most commonly identified reason among the

male adolescents for not embracing the consistent use of condoms (46%). In

conclusion, adolescent condom use is influenced by the adolescent’s attitudes toward

condoms.

From the empirical evidence, it can be concluded that communication skills

regarding condom use, societal acceptance of contraception, and attitudes toward

condom use are the main psychosocial factors influencing condom use among Thai

adolescents.

Adolescents’ anal sexual intercourse

Among many sexual risk practices that could put adolescents at risk for

infection by HIV, anal intercourse has consistently been identified as one of the

highest-risk behaviors (Stanton, Li, Black, Ricardo, & Galbraith, 1994; Baldwin &

Baldwin, 2000). Some previous studies showed that HIV is more easily contracted

through anal sexual intercourse than vaginal or oral intercourse (Silverman & Gross,

1997; Baldwin & Baldwin, 2000). Although anal intercourse has been widely

recognized as an activity that greatly increases the risks for HIV transmission, anal

sexual intercourse among adolescents as an HIV/AIDS risk behavior has received less

attention. Undoubtedly, considerably less research on this topic has been done among

the adolescent population (Baldwin & Baldwin, 2000). In Thailand, it is still a taboo

issue among Thai people. Polite conversation leads most people to leave this sexual

attitudes and practices among the unspoken aspects of social life (Baldwin &

Baldwin, 2000). From anecdotal clinical records and available research, few studies

have been well documented. Most Thai researchers and health educators do not pay
 81

much attention to this topic. Therefore, in this section, only the studies regarding anal

intercourse among American adolescents will be reviewed.

Jaffe and associates (1988) investigated anal intercourse and knowledge of

AIDS among minority-group female adolescents. A questionnaire was administered to

148 largely black and Hispanic female adolescents at an adolescent health center in

New York City. One hundred and eleven of the girls reported that they were sexually

active. Twenty-eight girls (25.2%) acknowledged having had anal sex, nineteen of

them within the preceding 3 months. Condoms were far less likely to be used during

anal intercourse than during vaginal sex. Accurate knowledge about AIDS increased

with age, but there was no relationship between age and any change in sexual

behavior to avoid the disease despite the increase in knowledge. Nevertheless, little

changes in sexual behavior reported were strongly linked to fear of contracting AIDS.

The researchers concluded that given the high incidence of anal intercourse practice

by black and Hispanic females, their infrequent use of condoms during anal

intercourse, and a large and increasing HIV infection rate among black and Hispanic

males, it can be seen that adolescent minority group females are at increasing risk of

heterosexual exposure, through anal sexual practices, to HIV infection (Jaffe,

Seehaus, Wagner, & Leadbeater, 1988).

In their survey, Stanton and colleagues (1994) determined the frequency of

anal intercourse among 351 low-income urban African American preadolescents aged

9 to 15 years. A questionnaire assessing self-reported AIDS-risk behavior was

administered through a talking computer. The results showed that among 137 youths

(39%) who had engaged in any sexual intercourse (vaginal or anal), 50 (36%) had

engaged in anal intercourse, including 41 (35%) sexually active boys and 9 (43%)

sexually active girls. Female adolescents who had engaged in anal intercourse were
 82

significantly more likely to report having been sexually molested than were virgins or

female adolescents who had engaged in coitus only. The researchers concluded that

efforts at preventing AIDS among low-income urban African-American early

adolescents should embrace the high-risk nature of anal intercourse (Stanton et al.,

1994). Although the researchers questioned anal intercourse among adolescents, the

specific report on activity such as condom use during anal intercourse was not

reported in the study.

Baldwin and Baldwin (2000) studied heterosexual anal intercourse among

college students. The participants were non-virgin undergraduate students under 30

years of age. A questionnaire was mailed to 1,779 random sample undergraduate

students and 893 students responded. The purposes of the study are as follows: (a) to

examine the prevalence of anal intercourse among college students; and (b) to analyze

various behaviors concerning anal intercourse. The results showed that 23% of non-

virgin students had engaged in anal intercourse. Approximately 21% reported condom

use during anal intercourse in the previous 3 months. Astoundingly, 76% reported no

condom use for anal intercourse in that period of time. Also, the participants reporting

that they engaged in anal intercourse were more likely to report having had at least

one sexually transmitted disease (STDs) and to have been tested for HIV than did

people who did not report engaging in anal intercourse. Regression analysis indicated

that people who had participated in anal intercourse were more likely than people

without anal experience to use less effective contraceptive methods, and to have used

no condom at last coitus. The researchers concluded that people who engage in anal

intercourse take more sexual risks when engaging in vaginal intercourse than do

people without anal experience (Baldwin & Baldwin, 2000).

 83

In conclusion, the empirical studies indicate that as adolescents use condoms

less for anal than vaginal intercourse, they have not learned enough about the risk of

anal sex. Perhaps, health educators have not presented enough scientific data to

convince this population about the risks of anal intercourse and the need to abstain

from this activity or use condoms to protect themselves. Hence, in the era of

HIV/AIDS, education about anal intercourse is essential for all adolescents, because

even those who do not engage in anal intercourse activity can be peer sex educators

for others (Baldwin & Baldwin, 2000).

Sex education in Thailand

Nowadays, the Thai Ministry of Public Health, is aiming to make condoms

available for young people more freely, since it is estimated that less than 50% of

teenagers use condoms, and reflect a high-risk group among adolescents in this nation

(CDC News Update, 2003). The Thai Ministry of Public Health is also aiming to buy

26 million condoms to distribute at health offices and they are also adding more

condom vending machines in some public places such as bathrooms in department

stores. Unfortunately, their efforts do not include schools because of fearing that

condom machines may promote promiscuity among adolescents (CDC, 2003b;

Treerutkuarkul, 2005).

In the midst of the threat of AIDS epidemic to Thai people’s health, available

data showed that many Thai, especially adolescents, tend to practice risky sexual

behaviors. Although sex education to raise the Thai consciousness concerning sexual

risk and safer sex behavior are crucial, nowadays, sex education occupies an

ambivalent position among Thai people (Timrod, 2003). According to the 2005

international sex survey carried out in Thailand by the United Kingdom (UK) based

condom maker, Durex, the results showed that most Thai people are still conservative
 84

when it comes to sex education. More than a quarter of 6,843 Thai correspondents

stated that sex education should start at the age of 12. Among Thai correspondents,

the average age when individuals first received sex education was 14.4 years; nearly

25% of the correspondents first received sex education at the age of 15, and more than

20% did not receive it until they were 17 years old. This seems a bit late. Besides, this

survey revealed that Thailand was rated near the bottom end in the important area of

sex education. Meanwhile, Germany, Austria, and the Netherlands were rated at the

top in the important area of sex education (Durex, 2005). The rationale is that, in Thai

society, sex and sexuality are mostly perceived as a personal intimacy and is shrouded

with secrecy (Gray & Punpuing, 1999). Although sexual behavior of Thai people,

particularly men, reported in the previous discussion may appear permissive, they do

not imply that Thai people are generally open-minded toward or accept certain trends

in sex and sexuality. For instance, unmarried females do not have premarital sex

without censure, and education for girls regarding sex and sexuality is restricted. The

intent is to protect the young girls from overexposure of sensual activities, but this

attitude does not occur without a price.

When cultural values and norms prevent an open discussion of sex, the idea of

promoting sexual and reproductive health and enhancing individual’s sexual

autonomy through sex education raises serious issues for Thai educators. For instance,

whether current sex education is adequate, when should sex education be introduced

to children, at what age; or who should teach it; and how to teach it without public

resistance and taboo.

In Thailand, although sex education has been taught for many years in

secondary schools at grades 8 and 9, there are no such specific courses on sex

education (Gray & Sartsara, 1999). Sex education in Thai schools includes human
 85

physical development, human reproductive system, hygiene, sexual acts, and child

birth (Rewthong, 2001). The curricula do not seem to respond to the needs of young

people. Aspects related to positive sexual practices, such as skills to negotiate for

safer sex, understanding of sexuality and so forth, are not provided in any curriculum.

Besides, teachers neither have the skills nor the training to teach about sex (Gray &

Sartsara, 1999). Many teachers also think that sex education could encourage students

to have sex at a younger age (Rewthong, 2001). Thus, it is critical that sex education

curricula address the issues with the implications that they may influence young

people’s lives (Manopaiboon, 2003). There are a number of reasons for adolescents to

become more knowledgeable about sexual topics. For example, Masters and

colleagues (1992) stated that becoming well informed about sex can help individuals

deal more effectively with certain types of potential sexual problems such as the

prevention of sexual transmitted diseases, including HIV/AIDS. They also posit that

studying sexuality is even more important in terms of helping learners become more

sensitive to and aware of their interpersonal relationships.

In a study of factors influencing premarital sex among 350 late adolescents in

Bangkok, the results revealed that premarital sex was related to predisposing factors

such as attitudes toward condom, values about premarital sex, and perception of the

results of premarital sex (unintended pregnancy, STDs/HIV/AIDS). The opinions and

behavior of close friends, and the sex information received from mass media, also

played parts. The findings further revealed that sex education could play a major role

in reducing premarital sex (Poonsanasuwansri, 1997). Furthermore, Suparp and

colleagues (1992) studied the actual and preferred sources of sexual information

among adolescent factory workers who dropout of schools. It was found that while

most sexual education had been given by teachers or instructors, the respondents
 86

thought that doctors and nurses gave the most valid information. They felt that

teaching or individual counseling by these two professional groups was the best way

to provide sex education (Suparp, Srisorrachat, & Sunthavaja, 1992). Besides,

Yamarat and associates (1992) studied attitudes toward sex education of 283

secondary school students. The results revealed that among students, 82% agreed that

sex education programs should be provided at secondary school levels. They reasoned

that sex education would compliment efforts being made towards the control of

unsafe sexual behavior. Fifty-six percent (56%) of the students agreed that it should

be provided at elementary levels. Furthermore, 43% agreed that sex education should

be provided in the family structures (Yamarat, Chumpootaweep, Poomsuwan, &

Dusitsin, 1992).

Recently, Wangwon and Prajongkarn (2004) explored patterns of

communication about sex education among Thai parents. They found that most of the

parents stated that parents should be the primary and important source of sex

education knowledge. Also, communication about sex education should be provided

at the school age. Nevertheless, as stated earlier, open discussions about sex are rather

unusual for most Thai people and their families. Many Thai parents feel awkward

about discussing any issues related to sex with their children (Timrod, 2003). In

contemporary Thai society, some Thai parents may talk about hygienic practice

during menstruation with their daughters. They, however, are not likely to discuss

contraception for the purpose of planned premarital sex with their children

(Udompuech, 2003). Consequently, Thai adolescents who exhibit sexual

permissiveness or interest will receive negative signals and messages from their

parents, including strong disapproval, and, sometimes, a scornful comment. This also

makes it difficult for Thai children to communicate with their parents about sex. The
 87

findings from the study among young Thai people revealed that unmarried young

Thai women faced a host of obstacles in their efforts to seek information about

sexuality, and communication with parents on sexual matters. Some young women

reported that parents would be the last resource they sought in case of unwanted

pregnancy or sexually transmitted infection because their parents refused to discuss

sexual matters in family, for fear that such discussions might lead young girls to

experiment with sex (Tangmunkongvorakul et al., 2005). From the findings of this

study, parents are seen as a hindrance to promote sexual health in Thai female

adolescents. However, in Thailand, little research has examined how the Thai male

adolescents get information of sexuality from their parents. Therefore, the roles of

parents in providing sex education to male adolescents, particularly in the era of

HIV/AIDS are not well understood.

Although many sex education programs, such as family planning, and AIDS

education programs, are provided outside school settings in Thailand, these types of

educational programs are often provided only for specific targeted groups, including

married people, commercial sex workers and commercial sex clients; intervention

planners view this group as a high risk in sexual practices. Such programs are rather

limited or sometimes inaccessible to most adolescents (O-Prasertsawat & Petchum,

2004). The lack of realistic knowledge about sex, together with a number of

interrelated factors, such as peer group pressure and increased access to sexually

stimulating materials, can lead adolescents to practice sexual risk behavior

(Poonsanasuwansri, 1997)

In summary, based on the available data, it can be concluded that sex

education in Thailand should be provided to children at an early age. Sex education

with a content that promotes positive attitudes toward sex and sexuality can provide a
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strong basis for the promotion of sexual health among Thai adolescents. It is an initial

approach to prepare young Thai people for being responsible sexual partners. Being

knowledgeable about sex and sexuality will encourage Thai adolescents to achieve a

greater level of well-being with less mortality and morbidity in their society and

throughout the world.

The negative outcomes of premarital sexual behavior and condom non-use in

adolescents

The negative outcomes of premarital sexual behavior and condom non-use

include unintended pregnancies, and contracting STDs, including HIV/AIDS

(Whaley, 1999; Brown & Brown, 2006). At the global level, the increased rate of

unintended pregnancies and STDs, including HIV/AIDS infection, among adolescents

are growing to be major health concerns (Bonell, 2004).

The United States and Sexually Transmitted Diseases

In the US, induced abortion is experienced by a substantial proportion of

American women. More than one-fifth of all pregnancies end in abortion, a reflection

of the fact that nearly half of pregnancies in the US are unintended (Finer & Henshaw,

2003). This statistic implies that these unintended pregnancies attribute to unsafe sex

practice, including condom non-use (Jones, Darroch, & Henshaw, 2002).

Besides, as of the mid-1990s, the US had one of the top three highest reported

rates of STDs (e.g. Syphilis, Gonorrhea, and Chlamydia) among 15-19 year olds when

compared with other developed countries (Panchaud, Singh, Feivelson, & Darroch,

2000). Almost half of the approximately 18.9 million new cases of STDs in 2000

occurred among 15-24 year olds (Weinstock, Berman, & Cates, 2004). Also, the rate

of AIDS cases per 100,000 populations in 2000 for young American males aged 13-

24 years was 3.80, for young American females aged 13-24 years the rate was 3.10
 89

(CDC, 2003a). Some studies showed very little change in the estimated numbers of

diagnoses of HIV/AIDS between 1999 and 2002 among 13-24 year olds (Karon,

Fleming, Steketee, & Decock, 2001; CDC, 2003a).

Although the development of sexuality in adolescent prepares them for their

roles as future intimate partners and parents, there are potential negative consequences

as well. Those include unintended pregnancy, contracting STDs, and contracting

HIV/AIDS. In the following paragraphs, the negative outcomes of premarital sexual

behavior and condom non-use (an unintended teenage pregnancy, contracting STDs,

and contracting HIV/AIDS) in Thai adolescents will be discussed.

Unintended teenage pregnancy in Thai Adolescents

Unintended teenage pregnancy is one of the most significant public health

problems attributed to engaging in premarital sexual intercourse (East & Felice, 1996;

Ayoola, Brewer, & Nettleman, 2006). Consequentially, unintended pregnancies are

terminated by induced abortion (Husfeldt, Hansen, Lyngberg, Noddebo, & Petersson,

1995; Bankole, Singh, & Haas, 1998) by illegal abortionists.

In the US, in 2000-2001, 2% of American women in the reproductive age (15-

44 years) had an abortion. Almost one in every five women (19%) who had an

abortion was an adolescent. Women who are aged 18 to 29, unmarried, Black or

Hispanic, or economically disadvantaged have high induced abortion rates (Jones,

Darroch, & Henshaw, 2002).

In Thailand, under section 301-305 of the Thai Criminal Code of 1957,

induced abortion is illegal, with two exceptions. First, if the pregnancy either

jeopardizes a woman’s health, an abortion can be sought. Second, abortion is

necessary, if it is the result of rape and/or incest (Gray & Punpuing, 1999). In

developing countries, including Thailand, induced abortions among adolescents were

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performed without parental consent or parental notification (WHO, 2006b). Induced

abortion refers to any actions deliberately terminate a pregnancy resulting in the

intentional death of the fetus, prior to normal or spontaneous delivery

(Lerdmaleewong & Francis, 1998). Also, legal abortion is defined as a procedure,

performed by a licensed physician or someone acting under the supervision of a

licensed physician, to induce the termination of a suspected or known intrauterine

pregnancy and to produce a nonviable fetus at any gestational age (CDC, 2006c).

Legal abortion is performed only to save the woman's life or also to protect the

woman’s health, and in cases of fetal malformation, rape and /or incest (Warakamin,

Boonthai, & Tangcharoensathien, 2004). Prosecutions of woman procuring abortion

and the person terminating the pregnancy are subjected to legal penalty. Currently,

there is no readily available data to verify that whether these individuals likely to be

nurses. The woman procuring an abortion can be prosecuted to three years in prison

and a fine of 6,000 Baht (approximately 150 U.S. dollars). Heavier prison

prosecutions and fines are prescribed for the person conducting the illegal abortions

(Gray & Punpuing, 1999). Nonetheless, research in many areas of Thailand indicates

that, despite its illegality, abortion is widespread. A recent study carried out by health

professions of the Thai Ministry of Public Health demonstrated that among 1,854

women who had an induced abortion, 78% (1,438 cases) had their abortions

performed by unqualified providers outside the hospitals such as traditional birth

attendants. Of these women, 61.3% were less than 25 years of age, of whom 30%

were adolescents. Among these women, the serious complications of induced abortion

include septicemia (21.6%), uterine perforation (0.4%), and others. Also, there were

14 deaths (0.11%). The main reasons (61%) among young women who had induced

abortions outside hospitals were not medical, but socio-economic indications,

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including lack of money, premarital pregnancy, and student status (Warakamin et al.,

2004).

In Thailand, nationwide, an estimated 300,000 abortions occur annually

(Intaraprasert & Boonthai, 2005). A study conducted by Manopaiboon and associates

(2003) revealed that among 1,725 vocational school students (893 males, 832

females) in northern Thailand, 48% of the male and 43% of the female students

reported ever having had premarital sexual intercourse. Among those who had had

intercourse, 27% of the women and 17% of the men said they or their partners had

been pregnant at least once. Of those, about 24% reported multiple pregnancies and

abortions by illegal means. Among the last reported pregnancies, 95% were aborted;

the other 5% were not reported (Manopaiboon et al., 2003).

In a study of 391 Thai vocational school students between 18 and 22 years old,

Thato and associates (2003) assessed risky sexual health behavior among adolescents

in Bangkok, Thailand. The results showed that 24% of sexually active teenagers had

experienced unintended pregnancies and had sought abortions. Interestingly, 83% of

pregnancies ended in abortion. Of these adolescents who had an induced abortion,

20% of them had an abortion conducted in private hospitals, 40% in private clinics by

health care providers, and 40% in private clinics by non-medical personnel such as

traditional birth attendants (Thato et al., 2003). Costs associated with conducting

illegal abortions were not reported in this study.

Additionally, Narkavonnakit (1979) conducted another study regarding

abortion in Thailand among 81 traditional birth attendants. The findings showed that

the main reason cited for abortion was the inability of the young women who were

unmarried to raise a child alone. That was the economic reason. The reported average

youngest age of the pregnant women was 18. The most frequently mentioned
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background of young pregnant women was high school students. The traditional birth

attendants also revealed that they regularly determined pregnancy duration by using a

manual sizing technique that provides with information about pregnant gestation and

through questionings the pregnant women concerning a menstrual history. Accurate

estimation of the stage of pregnancy is important in order to identify cases with a high

risk of complications and to determine a fee, since traditional birth attendants charged

on a per-month-pregnant basis (Narkavonnakit, 1979). The cost of abortion dependent

on the gestation age of pregnancy at the time the abortion was sought. This means that

the more months of pregnant gestation, the more fees will be charged on performing

illegal abortion. Abortion fee did not vary by age of the pregnant women (Ganatra &

Hirve, 2002). Until nowadays, no systematical data are available regarding a median

cost of conducting illegal abortion in Thailand (Narkavonnakit, 1979).

In addition, a 1999 hospital-based survey of 787 hospitals conducted by the

Ministry of Public Health, Thailand, showed that among a total of 45,990 women

admitted for the treatment of complications arose from abortions. Interestingly, the

proportions of females in the age group 24 and below seeking abortions constituted at

least 33% of the total survey (Ministry of Public Health (MOPH), Thailand & World

Health Organization (WHO), 2003). The study did not report whether there is any

support or involvement from their male partners in the abortions. These figures were

confirmed by the findings from another study. A 2000 survey revealed that 46% of

women seeking assistance in public health facilities as a result of abortion

complications were below 25 years of age (MOPH, Thailand & WHO, 2003). For

young women, the concern of interrupting education was a reason for abortion.

Obviously, from the findings of the previous studies, unintended teenage pregnancies

have a considerable impact on the ability of young women to continue or complete the
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education. Young women who experienced negative outcomes of unprotected

premarital sex rarely consulted or confided in their partners, fearing rejection or

abandonment (Tangmunkongvorakul et al., 2005). These young women usually talk

to their close friends when they have sexual problems, particularly unintended

pregnancy. Then, they secretly get the abortion by themselves. Thus, they lacked

partner involvement in the decision making and were without support for their male

sexual partners (Tangmunkongvorakul et al., 2005).

Illegal abortions frequently result in serious, long-term negative health

complications including bleeding, infection, uterine perforation, infertility, and

maternal death (Warakamin et al., 2004). Narkavonnakit and Benett (1981) studied

health consequences of induced abortion among Thai women in Chaiyaphum

province, in the rural northeast region of Thailand. The results showed that one-tenth

of the women who had illegal abortions by untrained practitioners experienced

complications serious enough to require hospitalization. Among the participants, 25%

of them experienced some form of complications and morbidity but did not seek

hospital care (Narkavonnakit & Benett, 1981). Another study conducted by

Koetsawang (1993) found that among 968 women with illegal abortions in five

provincial hospitals across Thailand, 1% (13 women) died owing to subsequent

complications. Heavy bleeding was reported in 13% of the total cases. Hysterectomies

to remove a severely infected or perforated uterus were performed in 22 women and a

blood transfusion was required in 104 women. Twenty-five percent of women

admitted to hospitals for such complications are students. The researcher also stated

that the cost to the health system of managing the complications of unintended

teenage pregnancy, including illegal abortion is substantial (Koetsawang, 1993).

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The findings of this study call for the urgent need for a curriculum in sex education in

schools in Thailand.

Furthermore, premarital pregnancy and abortion among young women,

particularly, adolescents, has other social consequences. The females have been found

to face greater negative psychosocial outcomes from their adult mothers (MOPH,

Thailand & WHO, 2003). The emotional and psychological impact of abortion for

young women manifests itself in stigma that negatively impacts the females in

particular (Bennett, 2001). Several Thai studies have documented the incidence of the

emotional and psychological health impact of abortion, in particular stigma. The

outstanding information emerged from the qualitative study by Lerdmaleewong

(1998), conducted in 2 general hospitals in Bangkok, Thailand. The study focused on

attitudes toward abortion. Eleven post-induced abortion patients aged 15 to 44 years

were interviewed. The results showed that all of these participants, all of whom were

Buddhist, knew that induced abortion was illegal and that it went against Buddhist

teachings. When making the decision to terminate their pregnancy, the women

subsequently experienced mixed emotions: 64% were worried, 55% were fearful of

exposure, and 36% were afraid of the ensuing bad kamma (sin/demerit)

(Lerdmaleewong, 1998). Similarly, in others studies, more than half of women who

have undergone induced abortion procedures felt uneasy and sinful, or were sad and

sorry for the aborted fetus (MacRae, 1983; Population Council, 1981). Being socially

stigmatized can lead to negative consequences including depression, social isolation,

lowered self-esteem, and poorer academic performance (Nolen-Hoeksema, & Girgus,

1994; Wiemann, Rickert, Berenson, & Volk, 2005). However, in Thailand, there are

no readily available data regarding whether wealthy girls are able to escape the stigma

of unintended pregnancy. Also, there are no studies regarding whether poor girls have
 95

a change for a successful and productive life after pregnancy/abortion. Besides, data

concerning the frequency of substance abuse among these females are not readily

available.

Contracting STDs

Another consequence of premarital sexual behavior and condom non-use is

that adolescents are increasingly vulnerable to STDs infection. In Thailand, STDs is

still posing epidemic concern, causing significant health problem and economic

burdens for both government and family members (O-Prasertsawat, 2005). Even

though there is improvement in drug therapy that provides the new possibilities in the

fight against STD infection, the epidemic continues to increase in numbers and

negative consequences. The trend of STD infection is still increasing, in particular,

among adolescent groups. It is increasing partly due to the lack of formal sex

education coupled with the reduction of risk taking sexual behaviors, the use of

substances that impair judgment, and the developmental age of experimentation. The

prevalence of STDs has contributed to the serious sequelae in reproductive health

such as infertility, ectopic pregnancy, and cancer of reproductive tracts (O-

Prasertsawat, 2005). In KhonKaen province, Thailand, 16.10% of 761 sexually active

vocational school students reported having contracted STDs (Sakondhavat,

Tongkrajai, Werawatakul, Kuchaisit, & Kukieattikool, 2000). With regard to

symptoms of STDs, 5.5% of 502 sexually active vocational students in KhonKaen

province, Thailand reported having had symptoms of STDs (Sakondhavat, Kanato,

Leungtongkum, Kuchaisit, & Kukieattikool, 1988).

Contracting HIV/AIDS

Another negative outcome of premarital sexual behavior and condom non-use

in adolescents is contracting HIV/AIDS. In Thailand, nowadays, the number of HIV-

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infected adolescents continues to grow at alarming rates. Within a 6-year period

beginning in 1993, the number of adolescents with HIV increased dramatically by

34%, making AIDS one of the leading causes of death among youths 15 to 24 years of

age (Rotheram-Borus, 2000; Rotheram-Borus, O’Keefe, Kracker, & Foo, 2000). In

this country, as of January 2006, the Thai Ministry of Public Health (MOPH) reported

9.70% of HIV infections occurring among adolescents and young adults (Ministry of

Public Health, Thailand, 2006). Among Thai adolescents, of the total AIDS cases

reported through January 2006, 27,726 individuals (9.70% of all AIDS cases) were

between ages 15 to 24. Furthermore, 70,927 were between ages 25 to 29 (24.81% of

all AIDS cases) (MOPH, 2006). Interestingly, because of a long and variable latency

period, adolescents who are HIV-infected may not manifest symptoms until their

twenties, masking the fact that a number of individuals were infected in the earlier

adolescent years (Diclemente, 1990).

Official policy in Thailand and AIDS epidemic

A number of behavioral interventions have significantly reduced HIV/AIDS

transmission in research projects (Merson, Dayton, & O’Reilly, 2000) throughout the

world and in Thailand. Yet, to date there are very few developing countries in which

there is strong evidence that the nation’s official policy has had an impact on the

prevention, early treatment, and compassionate care as related to the HIV/AIDS

epidemic.(Kilian et al., 1999). Thailand’s official policy on HIV/AIDS is widely cited

as one of the few examples of an effective national AIDS prevention program

anywhere in the world (Ainsworth, Beyrer, & Soucat, 2003). These policies, including

the Prostitution Policy, the 100% Condom Policy, and the Abortion Policy, have been

implemented since the mid of 1980s.

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The Prostitution Policy

In most societies, prostitution has been viewed with a combination of

disapproval, taboo, moral condemnation, hypocrisy, and pragmatic toleration

(Wolffers, Kelly, & van der Kwaak, 2000; Ford & Koetsawang, 1999). Fundamental

to the approaches to sex work in all countries are the competing influences of

pecuniary profit, disapprobation, and the need to control sexually transmitted diseases

(STDs) (Ford & Koetsawang, 1999). In Thailand, policies to control STDs related to

prostitution have existed long before acquired immunodeficiency syndrome (AIDS)

appeared. These policies have oscillated between pragmatic efforts to control STD

related infections and a more fundamental approach to attitudes and beliefs, the moral

underpinnings that are associated with the eradication of sex work in the nation (Ford

& Koetsawang, 1999). Nowadays, in response to the gravity of the threat from

HIV/AIDS, Thai official health policies have become much more prominent, the

citizens are more aware of the threat of disease, and action plans are being developed

throughout the country.

In 1985, governmental and non-governmental agencies in Thailand introduced

the policy concerning prostitution. One outcome associated with the prostitution

policy includes the right for prostitutes to develop negotiating skills for protected sex

through the use of condoms. This program is aptly named EMPOWER (Education

Means Protection of Women Engaged in Recreation). EMPOWER is a non-profit

community organization in Thailand that helps prostitutes through empowering them

to request and practice safer sexual activities during recreation. This non-profit

organization also provides free classes in languages (English, Japanese, etc.), health

essentials, law, and pre-college education, as well as individual counseling to

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prostitutes (Wawer, Podhisita, Kanungsukkasem, Pramualratana, & McNamara,

1996).

The 100% Condom Policy

In late 1989, the Thai government launched the 100% condom program in all

Thai communities. The initial effort was to reduce transmission of HIV, especially by

prostitutes who had an enormous impact on the course of the AIDS epidemic

(Ainsworth et al., 2003). The program enlisted the cooperation of sex establishment

owners and prostitutes; the intent was to encourage all clients and prostitutes to use

condoms when engaging in sexual activity (Punpanich, Ungchusak, & Detels, 2004).

After the introduction of the 100% condom program, consistent condom use with

prostitutions increased significantly. Thai men endorsed the program and were willing

to use condoms (Kitsiripornchai et al., 1998). The feasibility and success of this

program was replicated and expanded nationally to all Thai age groups. In the early

1990s programs that encouraged condom use were evident throughout the country.

However, at the turn of the century, 2000 and later, Thai health policy makers are

raising the question about whether condom use is continuing among young Thai men

and women in the here and now. A related and troublesome issue is whether the

decline in HIV prevalence since the mid-1990s has made the present generation of

young Thai men and women feel less vulnerable to HIV/AIDS. If this is the

prevailing attitude and belief system, condom use will probably be inconsistent, not

negotiated in the relationship, and the incidence and prevalence of HIV/AIDS is likely

to become more evident within the population (Jenkins et al., 2002). In addition to this

concern, there is yet another policy that deserves national attention.

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The Abortion Policy

Regarding the abortion policy in Thailand, the reader should understand that it

is considered an illegal act in Thailand. The exceptions are considered when it is

necessary to perform an abortion in the service of preserving the woman’s health or in

the case of rape (Gray & Punpuing, 1999). Yet, abortion remains an important health

issue for Thai women. In Thailand, women who wish to terminate an unintended

pregnancy are left with few options. They seek the services of individuals who

perform illegal abortions. Many consequences could occur: mortality and morbidity

outcomes; infections, inadvertent sterilization, and others. Despite the evidence of

widespread acceptance of a more liberal abortion law among the Thai citizens,

attempts to amend the abortion law in the country have failed. Interestingly, advocacy

to amend abortion legislation has evolved from women’s groups, medical and legal

professional groups, and women in all walks of life. These groups are especially

visible in Bangkok, the capital city of the nation (Whittaker, 2002). The efforts of

these groups are met with resistance from other well organized and recognized

groups. Opponents to reform cite religious philosophy and moral guidelines and use

this framework to develop oppositional positions to a more liberal abortion policy for

the country. The Thai government tends to favor the tenets embedded in these groups’

policies. It states that any amendment changes is likely to lead to an acceptance of

‘free abortions’ under any circumstances, less sexual responsibility, and, ultimately,

an increase in the numbers of abortions among Thai people (Whittaker, 2002). Along

with the attempts to reform the abortion law, many groups such as the Thai

Reproductive Health Advocacy Network, the Foundation for women, and some

members working with the Ministry of Public Health stress the need for better

counseling for Thai women and men. At the same time, they also advocate for the
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need from Thai people to support the removal of stigma from young Thai women who

have had abortions. Better sex education for young Thai people is also needed

(Whittaker, 2002). A study conducted in Chiang Mai and Lamphun Provinces, the

northern region of Thailand, revealed that sexually active young Thai women who

experience unintended pregnancy reported extreme difficulties with family members

and friends. Victim blaming by their family members, including parents, occurred

frequently and made life unpleasant for these young women. Because of their fear of

disclosure of their sexual activities to the Thai community, including their parents,

they opted for illegal abortions. The other important finding is that these young

adolescents sought the counsel of peers rather than parents and professionals

(Tangmunkongvorakul, Kane, & Wellings, 2005). Few studies have focused on the

attitudes and behaviors of the male, the putative father of the child.

In summary, these official policies (the Prostitution Policy, the 100% Condom

Policy, and the Abortion Policy) remain in the daily debates and conversations of Thai

people. Furthermore, the Thai government has put efforts to implement these official

policies to Thai community for years. The success of these policies requires a special

response from all health sectors. Therefore, the official health policies need to be

directed at bringing about the culture changes of health care to create a sustainable

health among Thai nationwide.

4. Theoretical framework of the study

During adolescence, the developing cognitive abilities change in remarkable

ways. Adolescents develop the ability to think in multiple dimensions simultaneously

and are able to consider things as relative (Rew, 2005). The changes in cognitive

ability have vast implications for behavior in general and health behavior in

particular. In order to understand health behavior in adolescents, especially sexual risk

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behavior, this section will address self-efficacy theory (Bandura, 1997), and will

demonstrate how self-efficacy theory is used to provide the framework for the study

proposed.

Self-Efficacy Theory

Bandura (1997) referred to his conceptualizations of self-efficacy both as a

theory and as the self-efficacy component of the social cognitive theory (Bandura,

1997, p. 34). He distinguished between the two by saying that “Social cognitive

theory posits a multifaceted casual structure that addresses both the development of

competencies and the regulation of action” (p. 34). According to Bandura (1997),

self-efficacy was defined as one’s perception of confidence in one’s ability to perform

a given behavior. The purpose of self-efficacy theory is to provide a framework that

explains the origin, structure, function, and processes of how an individual’s beliefs

influence his or her actions. Furthermore, this theory purports to offer guidelines for

people to learn how to have more control in their lives and thus effect desired change

(Bandura, 1997), including practicing safer sexual behaviors.

Bandura (1997) identified self-efficacy as the critical element operating in

human agency or the ability of one to take action on one’s own behalf. He asserted

that individuals who judge their capacity to perform a specific action as high level are

more likely to be motivated to perform and actually accomplish the specified action.

The corollary to this is that individuals who believe they are not capable of

performing a particular action will avoid that activity. Bandura further asserted that

the self-referent aspect of efficacy was a perception of one’s judgment that one could

perform a particular task rather than that one possessed a global trait of capacity. Self-

efficacy also refers to the amount of effort individuals will put into performing a
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particular behavior and how much time they will spend in this endeavor (Wulfert &

Wan, 1993).

Individuals’ belief in their ability to exhibit some control over what happens in

their lives provides a framework for their actions. “Perceived self-efficacy refers to

beliefs in one’s capabilities to organize and execute the courses of action required to

produce given attainments” (Bandura, 1997, p.3). Although much of human behavior

is determined by multiple factors, people contribute their beliefs to this dynamic

mixture. Behavior that is volitional is affected by the beliefs held by the actor. Beliefs

of self-efficacy influence a person’s motivation to acquire a knowledge base on which

performance skills are based. These beliefs also contribute to self-regulation and

motivation by “shaping aspirations and the outcomes expected for one’s efforts”

(Bandura, 1997, p.35).

Beliefs in personal efficacy are developed most effectively through mastery

experiences. Self-efficacy beliefs can also be developed vicariously by watching other

people who are successful at the targeted behavior. Another way to enhance self-

efficacy is through social persuasion. Through encouragement, people are able to

mobilize and sustain the efforts needed to master the behavior. Lastly, people relate

their self-efficacy to internal awareness of stress and tension. Therefore, self-efficacy

can be enhanced through stress reduction and positive emotional states (Bandura,

2000).

Beliefs about self-efficacy have been shown to regulate human behavior and

emotions through four processes: cognitive, affective, motivational, and selective

(Bandura, 1997). In addition to having an impact on behaviors, then, self-efficacy, or

rather the lack of it, can contribute to a person’s feelings of sadness and despair. For

instance, individuals who lack the confidence in their ability to perform a skill or to
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develop satisfying social relationships may be unable to attain desired goals and may,

consequently, experience feelings of disappointment and depression. At the cognitive

level, such people may also be unable to control negative or depressing thoughts, thus,

compounding their feelings of disappointment and despair (Bandura, 1997).

Bandura’s self-efficacy model of safer sex (Bandura, 1990)

According to Bandura (1990), a self-efficacy model of safer sex consists of

four components. They are as follows: (1) an informational component; (2)

development of self-regulatory and risk reduction skills; (3) enhancement of self-

regulatory and risk reduction skills and an individual’s self-efficacy; and (4) social

supports for personal change. The description of each critical component is described

below.

With respect to HIV risk behavior change, the information component of an

intervention should highlight the types of behavior that can cause individuals to

acquire HIV, stress what constitutes effective preventive behavior, and include

information that disposes individuals to believe that they could effectively engage in

prevention (Bandura, 1992b; 1994). In effect, an intervention must inform people that

their current behavior may pose a danger, instruct them in how to be safer, and foster

a sense of self-efficacy concerning HIV prevention. Bandura believed that the degree

of self-efficacy instilled by the informational component of an intervention is a good

predictor of whether or not people will attempt to change unhealthy behavior. He

further contends that the information component should emphasize that successful

change requires perseverance; therefore one’s feelings of self-efficacy are not eroded

by a setback. The content of the information component must be well crafted. For

example, it must be understandable, believable, and culturally component. Also, it

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must be targeted to reach the group at focus; for instance, different groups respond to

different media, and messages.

In addition to an information component, an effective HIV prevention must

have an element that develops in individuals the necessary self-regulatory skills to

engage in prevention. Self-regulatory skills include knowing one’s risk triggers, being

able to remind oneself about how important safer behavior is, and reinforcing oneself

for practicing it. In effect, self-regulation involves recognizing the behavioral

consequences that lead to risk, developing internal standards, using self-incentives to

motivate oneself, and employing other types of cognitive self-guidance. Having these

skills creates the ability for an individual to motivate and guide his/her actions. Self-

regulation skills determine the types of risky situations in which people find

themselves, how well they deal with them, and how well they can resist social factors

(e.g., recalcitrant partners) that force them into risky behavior. Once a person’s risk

triggers have been identified, self-regulatory skills can be trained through cognitive

rehearsal (e.g., practicing how to tell oneself that risk triggers should be avoided, and

practicing reinforcing oneself for successful risk avoidance). Showing people role

models effectively displaying self-regulatory skills can assist in their development.

When individuals have effective self-regulatory skills, they can realize that they are in

a risky situation and disentangle themselves before engaging in dangerous behavior.

According to Bandura (1994), the earlier that one removes him/herself from a

sequence that can ultimately culminate in risky behavior, the more likely it is that

he/she will succeed in avoiding risk.

Additionally, it is critical for individuals to develop risk reduction skills. Risk

reduction skills can be technical (e.g., knowing how to use a condom), social (e.g.,

knowing how to negotiate condom use, or how to exit unsafe situations), or both (e.g.,
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knowing how to eroticize safer sex). Until one has developed risk reduction skills and

a sense of self-efficacy regarding their use, it is best for the individual to stay out of

risky situations entirely. For adolescents, this option is not realistic and therefore, they

always get involve in the risky situations. HIV risk reduction skills can be acquired by

exposing individuals to videos of actors enacting the skills at focus, showing them

live role models displaying these skills. People generally learn best and develop a

greater sense of self-efficacy from exposure to role models similar to themselves in

terms of gender, age, or type of HIV risk behavior (Bandura, 1992b; 1994).

Once individual has developed the necessary skills, according to Bandura

(1994), the third essential component is an element to increase the level of critical

HIV prevention skills and to build on individuals’ sense of self-efficacy. To increase

skills and self-efficacy, an individual needs to practice the behavior at focus (e.g.,

negotiating safer sex) in progressively more difficult contexts ranging from those in

which he/she does not fear making mistakes or appearing inadequate, to more difficult

situations that they may encounter in their environment, to the most difficult

situations they can imagine. In each practice situation, they should receive

constructive feedback on how they could improve their enactment of the necessary

skills. According to Bandura (1994), such procedures lead both to greatly enhanced

skills and to a greater sense of self-efficacy. The stronger the senses of self-efficacy

that results, the more apt people are to use their new skills and to maintain their use in

the face of adverse conditions. Beyond the practice that can occur in interventions,

using one’s skills successfully over time in challenging, real-life situations can result

in an even greater sense of self-efficacy.

The fourth component involves developing a context of social support for the

behavior change at focus. According to Bandura (1994), since change often occurs in
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a social context, social influence, particularly normative social influence, can assist or

distract from its initiation and maintenance. Behavior that violates social norms is

generally punished by others, while actions that are consistent with social norms are

rewarded (Fisher, 1988). Over time, individuals’ sensitivity to social norms results in

their developing internal self-standards of conduct and internal self-regulation system.

When they conform to these standards, they feel good; when they fail to conform,

they feel bad. Because having pro-prevention sources of support affects the

development of pro-prevention self-standards and directly reinforces one’s enactment

of preventive behavior, they can play a major role in the initiation and maintenance of

safer behavior.

In conclusion, a self-efficacy model of safer sex can be applied to studies

concerning sexual risk behavior, including the study of safer sex behaviors. All of the

four principal components (an informational component, development of self-

regulatory and risk reduction skills, enhancement of self-regulatory and risk reduction

skills and individuals’ self-efficacy, and social supports for personal change) work

together to assist with the development of and also the influence on individual’s

personal judgment of efficacy regarding a safer sex behavior.

Self-efficacy in condom use and relationship with sexual risk behavior

Bandura (1990) addressed that persons lacking a sense of self-efficacy will not

manage situations effectively despite knowing what to do and having needed skills. A

belief in whether or not individual can carry out a preventive behavior may be based

on information concerning the desired behavior and/or experience performing the

behavior (Kaemingk & Bootzin, 1990). From a practical standpoint, at least one

sexual partner needs to know how to use a condom if a condom is to be used. Within

this section, self-efficacy in condom use will be addressed first. Then, the empirical
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studies concerning self-efficacy in condom use and its relationship with sexual risk

behavior among adolescents in Asian countries, the US, and the other parts of the

world will be explored, respectively.

Self-efficacy in condom use

Since the epidemic spread of the human immunodeficiency virus (HIV) was

first recognized, massive educational campaigns have informed the public how the

virus is transmitted and how sexual transmission can be prevented. An emerging body

of literature documents that the response to these educational efforts has been varied.

Apparently, risk reduction efforts among young people have been much less

successful (Wulfert & Wan, 1993). Particularly, many non-monogamous heterosexual

men and women do not even consider themselves at risk for HIV infection and are not

changing their behavior (Leigh, 1990; Seigel & Gibson, 1988). These findings

underscore the need for a better understanding of why so many people persist in

sexual high-risk practices. Unfortunately, to date a few studies that sought to elucidate

sexual risk behavior were conducted within the framework of several theories. These

are the Health Belief Model (Rosenstock, 1974), the Theory of Reasoned Action

(Ajzen & Fishbein, 1980), and the Social Interaction Theory (Patterson, Reid, &

Dishion, 1992). Interestingly, the empirical studies, based on these frameworks, have

arrived at conflicting results (Montgomery et al., 1989). The conflicting findings have

led some researchers to conclude that sexual risk behavior in adolescents may not fit

well within the conceptual framework of the Health Belief Model, the Theory of

Reasoned Action, and the Social Interaction Theory (Brown, DiClemente, &

Reynolds, 1991). Therefore, Bandura (1977) has stated that self-efficacy influences

behavior.
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According to Bandura (1990), sexual risk behavior happens because behavior

is not directly a result of knowledge or skills. Rather, it is mediated by a process of

cognitive appraisal by which people integrate knowledge, outcome expectancies, and

past experiences to form a judgment of their ability to master a difficult situation.

Besides, Bandura (1990) defined self-efficacy as “the conviction that one can

successfully execute the behavior required to produce the outcomes.” Thus, condom

self-efficacy would be defined as one’s confidence in one’s capability to use condoms

(Hanna, 1999). Self-efficacy is proposed to influence behavior (Bandura, 1992a;

Bandura, 1994), in particular, condom self-efficacy is proposed to influence condom

use (Bandura, 1992a; Wulfert & Wan, 1993). Condom self-efficacy was reported to

be associated with actual use of condoms (Joffe & Radius, 1993; Soet, Diiorio, &

Dudley, 1998; Diiorio, Dudley, Lehr, & Soet, 2000).

Self-efficacy in condom use and sexual risk behavior among adolescents in Asian

countries

Although youth surveys in Asian countries have found that sexual risk taking

behavior among adolescents is sharply increasing, there is relatively little information

available regarding self-efficacy in condom use and condom use behavior among

Asian adolescents (Agrawal, 2005).

Selvan and associates (2001) studied the intended sexual and condom

behavior patterns among 1,260 teenage higher secondary school students in Mumbai,

the largest city in India. A conceptual model was framed based on the theory of

reasoned action, health belief model and self-efficacy theory. Data were collected by

using a Center for Disease Control (CDC) questionnaire and adapted to suit the Indian

teenage population. Besides, the AIDS Social Assertiveness Scale was administered.

The results revealed that perceived norms and perceived peer group norms have a
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significant association with intended sexual and condom behavior. Risk behavior such

as drug and alcohol usage appeared to be associated with engaging in sexual

activities. In addition, those teenagers of more highly educated parents are less likely

to engage in sexual activities in their adolescent years (Selvan, Ross, Kapadia,

Mathai, & Hira, 2001).

Wong and Tang (2004) studied sexual practices, condom use, and

psychosocial factors related to condom use in a convenience sample of 187 Chinese

young gay men in Hong Kong. Among those who were sexually active, 22% never

used condoms, 39% were inconsistent condom users, and 39% used condoms every

time they engaged in sexual activities in the past 6 months. Compared to inconsistent

and non-condom users, consistent condom users had more positive feelings toward

condom use, perceived greater vulnerability to STD/AIDS infections, and showed

greater self-acceptance and disclosure of their homosexual sexual orientation. Results

of a logistic regression analysis showed that positive feelings toward condom use

were the most salient correlate of consistent condom use (Wong & Tang, 2004).

Kaljee and colleagues (2005) conducted a randomized-controlled trial to

examine the effectiveness of a theory-based risk reduction HIV prevention program

for rural Vietnamese adolescents. Four hundred eighty adolescents aged 15-20 years

old were randomized into control and intervention groups. Evaluation data were

collected using the Vietnamese Youth Health Risk Behavior Instrument. The findings

showed that there were the significant differences in knowledge of severity and

vulnerability of HIV/AIDS, the self-efficacy in condom use, and intention to use

condom between control and intervention groups at immediate and 6-month post-

intervention. The intention to use condoms in possible future sexual encounters

increased significantly for the intervention youth compared to control youth between
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baseline, and both immediate post-intervention, and six month follow-up (Kaljee et

al., 2005).

Yamamoto (2006) conducted a cross-sectional study on attitudes toward sex

and sexual behavior among 785 Japanese college students. The subjects anonymously

completed a 55-item questionnaire which assessed their attitudes toward sex and

sexual behavior. The results showed that both male (90%) and female (83%) students

expected to have sexual intercourse before marriage, while 8% of male students and

3% of female students indicated that it was not wrong to have extramarital sexual

intercourse after marriage. Besides, 75% of sexually experienced students reported

ever used a condom during their first sexual intercourse, while 73% reported using a

condom during their most recent sexual intercourse. The results also revealed that the

more sexual partner students had, the less condom use they reported for both their

first and most recent sexual intercourse. The investigators concluded that the

proportion of condom use among Japanese students is high in comparison to that of

students in other Asian countries. As Japanese adolescents are prone to have sexual

intercourse with non-steady, casual partners, more efforts are needed to promote safe

sex practices among adolescents in Japan (Yamamoto, 2006).

Self-efficacy in condom use and sexual risk behavior among adolescents in the US

Biglan and colleagues (1990) examined the relationships among risky sexual

behaviors, other problem behaviors, and the family and peer context among the two

samples of adolescents. The results showed that many adolescents reported behaviors

(e.g., promiscuity or condom non-use) which risked HIV or other sexually transmitted

disease infection. Such risky behaviors were significantly inter-correlated. Consistent

condom use was rare among those whose behavior otherwise entailed the greatest risk

of infection. In both samples, an index of high-risk sexual behavior was significantly

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related to antisocial behavior, cigarette smoking, and alcohol or illicit drug use. Social

context variables, including family structure, parenting practices, and friends’

engagement in problem behaviors, were associated with high-risk sexual behavior.

For sexually active adolescents, problem behaviors and social context variables were

predictive of condom non-use. As the socio-economic status was not reported in this

study, so it is difficult to make the conclusion that whether the socio-economic status

plays any role on the adolescents’ decision making in engaging into sexual risk

behavior (Biglan et al., 1990).

Kasen, Vaughan, and Walter (1992) conducted a study to measure past year

involvement in sexual intercourse and condom use, beliefs about self-efficacy for

AIDS preventive behaviors, beliefs about susceptibility to and severity of AIDS, and

outcome efficacy of AIDS preventive actions. The 181 tenth grade students residing

in or near an AIDS epicenter completed a survey. The findings demonstrated that

students with lower self-efficacy for refusing sex were twice as likely to have had

sexual intercourse. Similarly, those students with lower self-efficacy for correct,

consistent condom use were five times less likely to have used condoms consistently.

Also, the researchers suggested that a prevention program that emphasizes skills-

building should be developed rather than the traditional knowledge-only approach.

Furthermore, Joffe and Radius (1993) examined self-efficacy theory’s ability

to explain condom use among entering college freshman. The 1,077 adolescents (673

males and 404 females) completed health surveys measuring self-efficacy regarding

condom use. The results revealed that perceived self-efficacy differed by gender and

sexual experience. Regression analysis showed that frequency of past condom use,

perceived ability to talk with new partner about condoms and to enjoy sex using

condoms explained 16% of sexually active males’ intent to use condoms. For sexually
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active females, 29.8% of intention to use condoms’ variance was explained by

frequency of past use and perceived ability to enjoy sex with condoms. For never

sexually to active males, perceived ability to convince partner to use condoms and to

buy condoms explained 16.1% of intention to use condoms. Among never sexually

active females, only perceived ability to convince partner to use condoms was a

significant predictor of intention to use condoms. The researchers recommended that

efforts to increase condom use should enhance perceptions of ability to negotiate

aspects of condom use.

Wulfert and Wan (1993) investigated psychological factors associated with

sexual risk behavior. This study was conceptually guided by Bandura’s Social

Cognitive theory. A cross-sectional survey of 212 undergraduate students was

employed to examine whether Bandura’s self-efficacy model is capable of predicting

condom use from outcome expectancies, social influences, attitudes, risk perception,

and AIDS-related knowledge. The results showed that judgments of self-efficacy and

effects attributable to peers explained 46% of the variance in condom use. Moreover,

the investigators stated that the findings of this study indicated that the self-efficacy

paradigm is a useful conceptual framework for understanding important psychological

factors involved in sexual risk behavior.

Heinrich (1993) studied the relationship between the theory of self-efficacy

and its effect on contraceptive use along with other variables in 250 predominantly

white female sexually active college students. The results demonstrated that

contraceptive self-efficacy (CSE) was significant highly correlated with effective use.

Logistic regression analysis showed that contraceptive self-efficacy was the most

important predictor of contraceptive use for this sample. The investigators

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summarized that self-efficacy played an important role in predicting contraceptive use

and effecting behavior change.

Hanna (1999) primarily developed and validated an adolescent and young

adult condom self-efficacy scale. A 19-item scale was administered to 209

participants (13 to 26 years old) who voluntarily completed. One of the major

significant findings was that this scale could explain 42% of condom use’s variance.

The developer also stated that this scale could be utilized to assess perceived condom

self-efficacy and to evaluate the effectiveness of strategies to increase perceived

condom self-efficacy among adolescents and young adults.

Polacsek and colleagues (1999) surveyed attitudes, beliefs, and practices

concerning condom use among 812 African Americans with regular sex partners and

of reproductive age in Baltimore. Multiple logistic regression analysis revealed that

condom use self-efficacy with the partner, a partner’s reaction to condom use,

condom use outcome expectancy with the partner, perceived partner risk, length of

relationship, sterility, cohabitation, perceived vulnerability to HIV infection and

perceived peer norms about condom use were significantly related to condom use.

Gender differences in the relationship of these independent variables with stages of

change in condom use were found. The investigators concluded that the differential

treatment by gender and stage of change in condom use should be considered for

intervention (Polacsek, Celentano, O’Campo, & Santelli, 1999).

In addition, Colon, Wiatrek, and Evans (2000) explored the relationship

between psychosocial factors and condom use in African-American adolescents. A

health behavior survey was administered to 229 males, aged 14 to 19 years. The

variables, including HIV knowledge, sexual self-efficacy, perceived certainty of

future condom use, present and past use of condoms, and intention to use condoms in
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the next 6 months, were measured. Multiple linear regression analysis indicated that

sexual self-efficacy predicted perceived certainty of condom use and intention to use

condoms. The researchers stated that the findings highlight the need to develop HIV

prevention curricula for African-American male adolescents that include components

to enhance sexual self-efficacy.

Posner and colleagues (2001) studies the psychosocial factors associated with

self-reported male condom use that relate to a history of sexually transmitted disease

(STD) among 1,159 women, aged 18 to 34 years, attending public health clinics. The

participants completed a survey that assessed sexual behavior, STD history, and

psychosocial characteristics. Binomial regression results indicated that high condom

use self-efficacy, high convenience of condom use, and high frequency of condom use

requests were significantly associated with increased condom use among women with

or without a history of STD. The investigators concluded that the pattern of

psychosocial factors determining condom use was modified by a positive history of

STD (Posner, Pulley, Artz, Carbal, & Macaluso, 2001).

Salazar and associates (2004) conducted a study to examine the relationships

between self-concept and unwanted, unprotected sex refusal among 335 African

American adolescent girls. The study was framed within the context of the social

cognitive theory and theory of gender and power. Self-concept was composed of self-

esteem, ethnic identity, and body image, whereas attributes of partner communication

about sex was conceptualized as frequency of communication, fear of condom use

negotiation, and self-efficacy of condom use negotiation. Structural equation

modeling was used to analyze data. The results showed that self-concept was

associated with partner communication attributes about sex, which in turn, was

associated with frequency of unprotected sex refusal. The investigators suggested that
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STD-HIV preventive interventions for this population may be more effective if they

target self-concept as opposed to only self-esteem, incorporate an Afrocentric

approach, and focus on enhancing several attributes of partner communication about

sex (Salazar et al., 2004).

Wilson and colleagues (2004) investigated the potential predictors of

consistent condom use (CCU), including the influence of hormonal

contraception/surgical sterilization (HC/SS). The regression methods were used to

predict CCU and other measures of condom use among 214 sexually active, 18- to 45-

year-old women previously diagnosed with a sexually transmitted infection. The

results showed that CCU was significantly associated with younger age, African

American ethnicity, having casual partners, recent HIV testing, condom use self-

efficacy, and concern about partner relationship. The investigators concluded that

choice of condom use measure and control of confounding variables can substantially

affect results when studying potential predictors of condom use such as HC/SS

(Wilson et al., 2004).

Fernandez-Esquer and associates (2004) investigated the influence of condom

use self-efficacy on the reported condom use among US-and foreign-born Latinos in

Houston, Texas. A total of 152 participants completed the survey. Regression results

revealed that education and gender influenced condom use self-efficacy, which in turn

influenced condom use in the last sexual encounter and with the primary sexual

partner. Nonetheless, gender and relationship risk were stronger predictors of condom

use. The investigators concluded that there are differences in condom use self-efficacy

and sexual risk behaviors between Latino men and women (Fernandez-Esquer,

Atkinson, Diamond, & Useche, 2004).

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Recently, Godin and associates (2005) conducted a study to identify the

determinants of condom use during each sexual intercourse in 574 single heterosexual

individuals. The results revealed that attitude, perceived behavioral control, self-

efficacy, and moral norm explained 65% of the variance in condom uses

(Godin, Gagnon, Lambert, & Conner, 2005).

Self-efficacy in condom use and sexual risk behavior among adolescents in the other

countries

Peltzer (2000) investigated factors affecting condom use among 460 students

in grade 12 in three rural schools of South Africa. The study was a cross-sectional

survey. The participants were male (170) and female (290) students aged 16 to 30

years. The results showed that about half of those sexually active adolescents (52.6%

males and 40.5% females) reported never having used condoms. Knowing someone

with HIV/AIDS was significantly related to current condom use. AIDS beliefs were

significantly related to self efficacy in condom use. Behavioral norm to use condoms,

attitudes toward condom use, normative beliefs to use of condoms, and subjective

norm to use condoms were significantly related to condom use intention.

Baele, Dusseldorp, and Maes (2001) investigated the effect of condom use

self-efficacy on intended and actual condom use among 424 male and female sexually

experienced and inexperienced adolescents in Belgium. The participants were asked

to fill out a questionnaire concerning condom use self-efficacy and intended and

actual condom use. The effect of self-efficacy, both as a global measure and in terms

of specific scales, on condom use intention and consistency was assessed. Multiple

hierarchical regression analyses indicated that in the sexually inexperienced

adolescents, significant predictors of intention to use condom were gender, age, global

self-efficacy, and purchasing skills. In the sexually experienced adolescents, global

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self-efficacy, emotion control, assertiveness, image confidence, and sexual control

were the significant predictors of intention to use condom. Gender, age, global self-

efficacy, emotion control, assertiveness, and purchase significantly predicted

consistency of condom use in the sexually experienced adolescents.

The investigators concluded that intended and actual condom uses in adolescents were

best predicted by self-efficacy that included both global and relevant specific aspects

of condom use.

Meekers and Klein (2002) examined the determinants of having ever used

condoms and on current condom use with regular and casual partners among 1,284

unmarried adolescents aged 15-24 years in Cameroon. The study utilized secondary

analysis and based on data from the 2000 Cameroon Adolescent Reproductive Health

Survey. Logistic regression was used to analyze data. The results showed that while

most adolescents had tried condoms at least once, condom use remained inconsistent.

Only 45% of males and 34% of females reported that they used a condom at their last

sexual intercourse with a regular partner. About 45% of males and 31% of females

reported that they used condoms with their casual partners. Perceived self-efficacy,

especially the perceived ability to convince partners to use condoms and the belief in

one’s own ability to use them correctly, were the only factors associated with higher

levels of condom use with regular partners for both male and female. Parental

support, personal risk perception, and self-efficacy were found to be associated with

higher levels of condom use.

Park and associates (2002) examined the relationship of HIV knowledge,

demographics, and psychosocial factors with HIV risk behavior among 805 high

school students in grades 10 to 12 in urban and rural areas of Ecuador. The

participants were asked to fill out a self-administered paper-and-pencil survey. The

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results showed that 43% of the participants reported being sexually experienced. Of

these sexually experienced participants, 50% reported never using condoms for sexual

intercourse, and 70% did not use condoms at the last intercourse. A small proportion

(18.5%) of the participants felt that they were at risk for contracting HIV. High self-

efficacy for condom use and strong refusal skills to unsafe sex were significantly

associated with decreased HIV risk (Park, Sneed, Morisky, Alvear, & Hearst, 2002).

Taffa and colleagues (2002) examined the psychosocial determinants of sexual

activity and condom use intention among 561 youth in Addis Ababa, Ethiopia. The

Attitude, Social influences, and Self-efficacy (ASE) model was used as a theoretical

framework. An out-of-school youth (15-24 years) completed a self-administered

questionnaire. The resulted showed that 33% of the participants reported previous

sexual intercourse in the past and only 51% of the sexually active adolescents used

condoms during last intercourse. Being out-of-school, male, aged 20-24 years, and

alcohol/substance use predicted the likelihood of engaging in sexual activity. Self-

efficacy, skills, and barriers significantly predicted 23% of the variance in intentions

to use condoms. Self-efficacy was also associated with past condom use. Overall,

self-efficacy was found to be the strongest predictor of the condom use intention. The

investigators concluded that HIV/AIDS prevention programs for young people in

Ethiopia needed to emphasize building assertive communication skills in sexual

negotiations and condom use. Minimizing the gender gap in sexual relationships

forms the cornerstone for such educational strategies (Taffa, Klepp, Sundby, & Bjune,

2002).

Holschneider and Alexander (2003) conducted a cross-sectional study to

examine HIV/AIDS prevention-related sexual behaviors and identify potential

predictors of those behaviors among 491 adolescents, aged 15–19 years, attending 12
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primary and secondary schools in Haiti. The participants were asked to fill out a self-

administered questionnaire. Multiple logistic regressions indicated that only 18% of

sexually active adolescents reported always or sometimes using condoms and 27%

reported having used a condom the last time they had sex. Forty-three percent had had

three or more lifetime sex partners. High levels of self-efficacy to communicate about

condom use significantly associated with consistent condom use and condom use at

last sexual intercourse. The investigators concluded that HIV prevention programs for

young people in the study communities were needed to enhance effective sexual

communication, condom use negotiation skills, and self-efficacy in condom use.

Meekers, Silva, and Klein (2006) examined the key determinants of condom

use with regular and casual partners among youth in Madagascar. The study utilized

secondary analysis and based on data from the 2000 reproductive health survey

conducted among 2,440 youth aged 15-24 living in Toamasina province. Logistic

regression was used to assess the effect of AIDS awareness, personal risk perception,

condom access, perceived condom effectiveness, self-efficacy, and social support on

condom use. The results showed that among sexually experienced youth, only about

40% of males and 29% of females have ever used condoms. Less than 15% of youth

used a condom in last intercourse with their regular partner. The perceived

effectiveness of condoms for family planning, access to a nearby condom source,

parental support for condom use, and patterns of risky sexual behavior had significant

effect on condom use. Young males’ likelihood of using a condom with a regular

partner increased significantly if they perceived condoms to be effective for family

planning. For females, it increased with level of self-efficacy and having discussed

HIV prevention with someone in the last year. Among males, condom use with casual

partners was significantly higher among those who perceived themselves to be at high
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risk of sexually transmitted infections, who believed condoms were effective for

family planning, who had good access to condoms, and who perceived their parents

support condom use. The investigators concluded that very few youth in Toamasina,

Madagascar were using condoms, highlighting the need to continue and expand

adolescent reproductive health interventions.

In summary, supported by the scientific findings, condom self-efficacy plays

an important role in adolescents’ condom use. Therefore, condom self-efficacy is

included into this study as one of the major independent variables.

Attitudes toward condom use and relationship with sexual risk behavior

Attitudinal measures can be highly predictive of behavior when designed to be

specific to the behaviors in question (Fishbein & Ajzen, 1975). Hence, one way of

promoting condom use might be to promote “procondom use” attitudes or attitudes

found in individuals who consistently use condoms (Kaemingk & Bootzin, 1990).

There are evidence that attitudes toward condom use associate with sexual risk

behavior, in particular condom non-use. Thus, within this section, the empirical

studies concerning attitudes toward condom use and its relationship with sexual risk

behavior among adolescents in Asian countries, the US, and the other parts of the

world will be explored, respectively.

Attitudes toward condom use and sexual risk behavior among adolescents in Asian

countries

In Indonesia, Merati and colleagues (1997) conducted a cross-sectional study

to assess the feasibility of using traditional Balinese youth groups as a vehicle for

peer-led AIDS education among 375 youth 16 to 25 years of age. The results revealed

that the average age at first intercourse was 19 years for males and 20 years for

females. For 46% of sexually active males, intercourse was accompanied by alcohol
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consumption. Although youth had adequate knowledge of AIDS before the

intervention, only 10% of sexually active males reported consistent condom use.

Follow-up interviews with 97 youth from 3 areas of Bali who were exposed to the

peer-led intervention showed significant increases in communication about sexual

matters with friends and family, more positive attitudes toward condoms, and

increased condom use. Youth who participated in focus group discussions expressed a

preference for peer-led interactive activities over lectures. Also, they felt more

comfortable asking their peers questions about sex. The investigators concluded that

use of peer educators from Balinese youth groups appears to represent an efficient

way to reach young people before the initiation of sexual activity as well as those at

high risk of AIDS and other STDs as a result of unprotected sex, alcohol

consumption, and multiple sexual partners.

Lui and associates (1998) conducted a cross-sectional survey among 1,057

Chinese aged 15 to 49 in Anhui province, rural China. The results showed that 23% of

sexually active respondents (27% of men and 19% of women) acknowledged having

premarital sex. Two percent of participants had had a sexually transmitted disease and

8% reported having multiple sexual partners. Regarding condom uses, 12% used them

for every sexual intercourse, 31% used them only during ovulation, and 58% used

them occasionally. Logistic regression analysis indicated that younger age at first

sexual intercourse, a desire to have multiple partners, more than two coital acts per

week, exposure to pornography, higher income, and older age at marriage

significantly predicted high-risk sexual behaviors. The investigators concluded that

the specific HIV/AIDS prevention programs should be designed and focused on

delayed onset of sexual activity and consistent condom use in rural China.
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O-Prasertsawat and Koktatong (2002) conducted the study to compare

knowledge about condoms, attitude towards condom use and skill in condom

application between the experimental group who received hands-on and the control

group who had look-on demonstrations of condom application onto the penile model

of the third year Thai male vocational students. A self administered questionnaire was

used to collect data on knowledge and attitude. Skill was separately evaluated by a

skill evaluation form. Pretest and posttest of knowledge, attitude and skill were done

separately at 2 week intervals in the same subjects. Unpaired t-test was used to

compare scores between the two groups. The results showed that skill in condom

application score was significantly different in both groups. However, the skill score

increased in the experimental group more than in the control group. The investigators

concluded that condom application skill increased with the hands-on than look-on

instructional model. Thus, the hands-on should be used to improve skill to prevent

condom user failure and nonuse.

Timpan (2005) conducted a qualitative study regarding thoughts, beliefs, and

sexual behavior among urban Thai male students aged 17 to 29 in Chiang Mai

province. The participants were students studying in vocational certificate level,

senior high school level, and adult education system. The results revealed that male

adolescents did not have a risk perception of STDs and HIV/AIDS if they had a

sexual relationship with their girlfriend. In contrast, they would have a risk perception

of STDs and HIV/AIDS when they had a sexual relationship without condom use

with an easy-going girl. Concerning condom use, it was found that male adolescents

did not use a condom with their girlfriend or lover because they were certain that their

girlfriend or lover was free from diseases. Moreover, they used a condom with their

temporary sex partners and easy-going girls to prevent STDs and HIV/AIDS. The
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researcher concluded that there should be an adjustment to male adolescents’ attitude

to condom use, based on discrimination because such attitudes can make male

adolescents use or not use a condom for various reasons.

Douthwaite and Saroun (2006) examined sexual behavior and condom use

among 665 unmarried young men aged 15 to 24 in marginal areas of Phnom Penh and

Kratie town, Cambodia. The study focused on factors associated with condom use at

last intercourse. The results showed that 33% of participants reported that the average

age at first sexual intercourse was 23. Of these, 39% had given money or gifts in

exchange for sex. Transactional sex often occurred in the company of other males,

and condom use was higher among those males compared with those who were alone.

Of all sexually active participants, 50% reported having three or more partners, and

71% used a condom at last sexual intercourse. Regression analyses indicated that

condom use varied by type of partner, was less likely among males outside the

education system and higher among those more positive and informed about

condoms. The investigators concluded that there were the needs for HIV prevention

efforts to encourage young men to use condoms with all intimate partners, promote

advantages of condoms for both disease and pregnancy prevention, and address the

needs of young men no longer in education.

Attitudes toward condom use and sexual risk behavior among adolescents in the US

In 1992, Pendergrast, Durant and Gaillard (1992) assessed sexual behaviors

and attitudes of 105 urban adolescent males aged 13 to 20 attending an adolescent

clinic. Stepwise multiple regressions indicated that four variables (perceived hassle of

use, perceived girlfriend’s attitude toward condom use, age, and self-confidence in

correct use) significantly explained 28% of amount of variation in condom use.

Intention to use free condoms was significantly associated with past use, girlfriend’s
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attitude toward use, self-confidence in correct use, perceived hassle, and degree of

exposure to STD education. Three variables (self-reported past use, girlfriend’s

attitude, and self-confidence in correct use) in a regression model significantly

explained 51% of amount of variation in intention to use free condoms. The

investigators concluded that positive attitudes toward condom use by female partners

had significant effect on male condom use.

Moreover, changes in attitudes toward condom use were confirmed by the

study conducted by Pleck, Sonenstein, and Ku (1993). They used the data from the

National Survey of Adolescent Males who were interviewed in 1988 at ages 15-19

and re-interviewed in 1990-1991 at ages 17-22. Multivariate analyses revealed that

respondents’ attitudes about the effects of condoms on partner appreciation, sexual

pleasure and embarrassment became more favorable toward condom use over time.

They concluded that change in condom use was affected by female partner’s

appreciation of condom use and by change in perceived reduction in sexual pleasure

(Pleck, Sonenstein, & Ku, 1993).

Moreover, Santelli and associates (1995) explored combined use of condoms

with other contraceptive methods in 717 women, aged 17-35 years in two inner-city

Baltimore communities. Logistic regression analyses showed that positive attitudes

toward safer sex, ever having refused sex without a condom and believing in condom

efficacy all significantly predicted use of the condom with another method (Santelli,

Davis, Celentano, Crump, & Burwell, 1995).

Findings are consistent with the studies carried out by Cole and Slocumb

(1995). They conducted an exploratory study to examine variables characterized as

predisposing to the practice of safe sexual behaviors among 227 heterosexual late

adolescent collegiate males in southeastern New England. Multiple regression

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analyses indicated that students holding a positive attitude towards condoms scored

higher on safer sex behaviors. Attitude towards condom use was the best predictor of

safe sex behavior (usage of condom) among the participants. The investigators

concluded that attitude towards condom use could be incorporated into interventions

to reduce sexual exposure to HIV.

Findings support those of the study conducted by Minoia and Rose (1996).

The study was conducted among 47 female college students attending a rural county

family planning clinic. The purpose of the study was to explore attitudes toward

condom use, identify the frequency of condom usage, and examine the relationship

between attitudes and condom use among sexually active female college students. The

results showed that students who reported condom use had significant higher scores

on condom attitudes than those not using condoms. The investigators concluded that

the interventions to improve safer sexual behavior for college populations were

needed.

Also, Serovich and Greene (1997) explored predictors of adolescent sexual

risk taking behavior which put them at risk for contracting HIV. Participants included

230 students in grade 8, 106 students in grade 11 and 12, and 156 college students in

the 1st and 2nd year. Results of regression analyses indicated that the best predictor of

sexual risk behavior (condom use) was attitude towards risky behavior while

predictors of other behaviors (e.g., number of sexual partners) varied by sample

group. The investigators concluded that community educators and teachers needed to

design the HIV/AIDS message interventions to improve safer sexual behavior for this

population.

Related to attitudes toward condom use, Murphy and Boggess (1998) used

data from the 1988 and the 1995 National Survey of Adolescent Males to survey
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changes in attitudes toward condoms, pregnancy and HIV/AIDS preventions. The

findings showed that between 1988 and 1995, young men’s embarrassment about

condom use, pleasure reduction from condom use, and partner appreciation of

condom use changed in a direction suggestive of more consistent condom use.

However, attitudes related to pregnancy prevention and AIDS avoidance changed in a

direction suggestive of less-consistent condom use. The investigators concluded that

many of the significant changes in young males’ attitudes toward condoms did not

explain the increase in consistent condom use among adolescent males that occurred

between 1988 and 1995.

In addition, several researchers also have documented the findings that

adolescent attitudes toward condom use are associated with their use. Adolescents

with more positive attitudes toward condoms tend to report greater use of condoms

(DiClemente et al., 1992; Pendergrast, Durant, & Gaillard, 1992; Reitman et al.,

1996).

Attitudes toward condom use and sexual risk behavior among adolescents in other

countries

Ross and McLaws (1992) examined the attitudinal and normative

determinants of condom use. The questionnaires were distributed to 173 Australian

sexually active young men to assess attitudes toward and intentions to use condoms,

behavioral beliefs about condoms, and subjective norms and normative behavior

regarding condom use. Results revealed that subjective norms accounted for most of

the variance associated with condoms use, whereas attitudes had little impact on

condoms use. Previous condom use was a good predictor of intention to use. The

investigators concluded that interventions which emphasize peer-based education

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were likely to be more useful than those which attempted to alter behavioral beliefs

about and attitudes toward condoms.

Nguyen and associates (1996) examined the relationship between attitudes

toward condom use and other variables on intention to use condoms among 879 male

adolescents aged 12-19 years in secondary schools in Quebec, Canada. The results

showed that attitudes toward condom use significantly associated with intention to use

condoms in the adolescents. The information on condoms provided by peers was

significantly associated with the intention to use condoms. The information provided

by schools was positively associated with younger adolescents’ intention to use

condoms. The investigators concluded that the results of this study underscored the

importance of peer instructors as a source of information on condoms, as well as that

of teachers and health professionals from the school environment. Other channels of

communication, however, needed to be developed particularly for older adolescents.

The findings also underlined the necessity to make these adolescents more aware of

their potential vulnerability to STDs and AIDS (Nguyen, Saucier, & Pica, 1996).

Moreau-Gruet and colleagues (1996) conducted the study to determine gender

differences regarding sexuality among Swiss adolescents, in order to improve the

adjustment of prevention programs to boys’ and girls’ specific needs. Data were

collected as part of the Swiss Multicentric Adolescent Survey on Health. The 9,300

participants (15 to 20 years old) were asked to fill out a questionnaire. The results

showed that 45% of the participants reported a previous sexual experience.

Differences between boys and girls were identified by means of bivariate and

multivariate analyses. A higher proportion of Swiss girls reported intra-family

discussions about sexuality, having had a previous sexual experience, having sexual

intercourse regularly, having had only one partner, and using contraception regularly.
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A higher proportion of Swiss boys reported positive attitudes towards condoms and

using condoms regularly. The investigators concluded that prevention programs

should emphasize, among boys, responsibility in contraception and the need for

protection in situations of multipartnership, and among girls, a positive attitude

towards condom use and an increased familiarity with condoms presented both in a

perspective of contraception and prevention of STDs (Moreau-Gruet, Ferron, Jeannin,

& Dubois-Arber, 1996).

In the United Kingdom (UK), Sheeran, Abraham, and Orbell (1999) used

meta-analysis to quantify the relationship between psychosocial variables and self-

reported condom use. Six hundred and sixty correlations distributed across 44

variables were from 121 empirical studies. Findings showed that attitudes toward

condoms were one of the most important predictors of condom use. The investigators

addressed that the findings supported a social psychological model of condom use

highlighting the importance of behavior-specific cognitions, social interaction, and

preparatory behaviors rather than knowledge and beliefs about the threat of infection.

Kinsman and associates (2001) conducted a cross-sectional study to examine

knowledge, attitudes toward condom use and intended use of condoms among 1,821

pupils from 27 primary and secondary schools in rural southwestern Uganda. Also,

gender and religious contrasts among these pupils were investigated. The findings

showed that although condom education was not provided in Ugandan schools, but

both boys and girls had relatively high overall levels of knowledge, and boys

demonstrated a higher level than girls. This suggested that the participants had

successfully obtained reliable information from other sources. Boys and girls had

similar and fairly positive attitudes toward condoms, although considerable shyness

was expressed, both about discussing condoms with a partner and buying them. Fifty-
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eight percent of the participants expressed that they themselves would use a condom

if one were available, but girls were far less likely than boys to say so. Roman

Catholics (46% of the participants) were less knowledgeable and less positive about

condoms than non-Catholics, and the boys in this group, but not the girls, were also

much less likely to say they would use one. The investigators concluded that a

research agenda for the delivery of assertiveness training to girls was needed

(Kinsman, Nakiyingi, Kamali, & Whitworth, 2001).

Rahlenbeck and Uhagaze (2004) investigated the attitudes toward condoms

and intentions to use condoms among 474 secondary school students (213 females

and 261 males) in three secondary schools in rural Rwanda. The results showed that

male students and those with sexual experience had more favorable attitudes toward

condom utilization than female students and those without prior sexual contacts. Of

the 44% with reported sexual experience, reported age at first intercourse was lower

in males (16.8 years) than in females (18.3 years); 73 students (36%) reported regular

use of condoms. Having more than one sexual partner was reported by 42 (9%), of

whom 20 (48%) claimed regularly using a condom. Intention to use condoms was

reported by 77% of the male and 53% of the female students. Furthermore, those with

prior use of condoms and those having multiple partners were more likely to report

future use intentions than others. The investigators concluded that future campaigns in

Rwanda should focus on sensitizing adolescents to a more positive attitude towards

condoms and include modules to reduce condom misconceptions.

Lazarus and colleagues (2006) examined knowledge, attitudes and practices

among Somali and Sudanese immigrants in Denmark concerning HIV/AIDS and

condom use. A 78-item questionnaire was given to 192 purposively selected Sudanese

and Somalis of both sexes, aged 18-49, who had lived in Denmark for one or more
 130

years. The results showed that education, sex, and nationality were significantly

positively associated with knowledge about HIV/AIDS. Men had a more negative

attitude towards condoms than women, but greater knowledge about them. Thirty-

three percent of the women reported never having seen or heard of a condom, and

almost 50% had never received information about condoms. Both sexes preferred

receiving such information from the televisions or friends instead of family doctors or

HIV-positive individuals. The investigators concluded that knowledge about

HIV/AIDS was low in these two Danish immigrant groups, while condom knowledge

was particularly low among poorly educated women, and men had a negative attitude

to condom use. The findings indicated a need for targeted, culturally sensitive

HIV/AIDS information and advice (Lazarus, Himedan, Ostergaard, & Liljestrand,

2006).

From the empirical evidence, it can be concluded that adolescents’ condom

use is influenced by the adolescent’s attitudes toward condom. Young people who

have positive attitudes toward condom use are more likely to use condoms than

adolescent who have negative attitudes toward them (Moreau-Gruet, Ferron, Jeannin,

& Dubois-Arber, 1996; Rahlenbeck & Uhagaze, 2004).

5. Summary

Sexual risk behavior among adolescents, particularly premarital sexual

behavior without using condom, is a major health concern all over the world (Laguna,

2004). Although condom has been made available more than a hundred years

(Youssef, 1993), the usage of condom remains inconsistent. The negative

consequences of condom non-use, including contracting STDs/HIV/AIDS, and

unintended pregnancy, continue to be high among adolescents when condom is not

used. Thus, understanding the phenomenon of condom use is important to identify

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what factors actually influence the phenomenon. Then, interventions can be designed

appropriately to minimize this problem.

Psychosocial factors influencing condom use have been studied for decades. A

review of the literature on adolescent sexual behavior reveals that condom use is

influenced by social and demographic characteristics, knowledge about reproductive

health, self-efficacy and attitudes regarding condoms, and issues of access and

affordability. Unfortunately, there are few systematical published studies in Thailand

regarding condom use behavior among Thai adolescents. Furthermore, less attention

has been devoted to which factors are related to condom use among Thai. On the basis

of the limited information available, the small number of Thai studies makes it

difficult to draw conclusions. Although the evidence in Thailand is limited, the

findings from the studies in the US and the other countries suggest that condom use

among adolescents is much more likely to increase when attitudes toward condom

use, and/or self-efficacy in condom use increase.

Evidence suggests that additional studies are needed to explore factors

influence condom use and to increase the validity of the studies. Factors influence

condom use deserve more attention because knowing these factors can provide

significant information to guide policymakers’ decisions or help program managers

design interventions to enhance condom use among young people in Thailand.

Furthermore, intervention studies, a theoretical approach, and standard measurements

should be employed to make the findings on condom use valid and generalizable to

adolescents as the target population.

The validity of the studies regarding condom use in Thai adolescents is also

limited due to the lack of both theoretical approach and standardized measurements.

Most of the researchers developed their own instruments which make it difficult to
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compare results across studies. Besides, few of the previous studies were based on a

theoretical approach. None of the previous studies in Thailand have examined

condom use among this population particularly using self-efficacy theory as a

conceptual framework. Therefore, the study guided by this framework should be

conducted in order to gain a better understanding of sexual risk behavior among Thai

adolescents.
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CHAPTER III

Methodology

This study explored the relationships among personal information, attitudes

toward condom use, condom use self-efficacy, and condom use behavior among Thai

vocational school adolescents in Ubonratchathani Province, the northeastern region of

Thailand. The chapter presents the methodological approaches in relation to the study

including: (a) research design; (b) sampling; (c) pilot study for the attitudes toward

condom use study; (d) data collection procedure; (e) measurements; (f) data

management; (g) statistical analyses; (h) protection of human subjects; and (i)

summary.

A. Research Design

The design chosen for this study is a cross-sectional descriptive correlational

plan because the main purpose of this study was to examine the relationships among

attitudes toward condom use, condom use self-efficacy, and condom use behavior

among Thai vocational school adolescents. Burns and Grove (2001) stated three basic

purposes of a correlational study: describing a relationship, predicting relationships

among variables, and testing relationships suggested by theoretical propositions.

Additionally, the assumption of the design is congruent with the proposed study as

there is no manipulation among independent variables (Wood & Brink, 1998). In

other words, the independent variables are measured as they naturally exist (Polit &

Hungler, 1999).

B. Sampling

Specifying the sample

In general, the accessible population refers to the substitute cases with study

participants that match the designated criteria and are available to the researcher as a
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pool of subjects for the investigation (Polit & Hungler, 1999). The target population

of the study was 18 to 21 year-old male and female vocational education students who

were studying in both private and public vocational schools in Ubonratchathani

Province, Thailand. Wood and Brink (1998) suggested that the best sample for a

correlational study design is one that is randomly selected from the target population.

However, this study used a multistage cluster sampling method because it is

considerably more economical and practical than other types of probability sampling,

particularly when the population is large (Polit & Hungler, 1999).

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria were specified to obtain the desired sample

(Burns & Grove, 2001). Generally, inclusion criteria define the required

characteristics for each element of the sample, while exclusion criteria eliminate

characteristics that might interfere with the explanation of the results (Woods &

Catanzaro, 1988). The inclusion criteria for this study were as follows: (a) Thai

adolescent males/females; (b) being 18 to 21 years old; (c) single marital status; and

(d) having the ability to speak, read, and write in Thai. The exclusion criteria

included: (a) Thai adolescents who are not able to speak, read, and write Thai; and (b)

Thai adolescents who are unable to participate because of evidence of a

developmental disability, a cognitive disability, or manifestation of psychotic

symptoms that could prohibit their ability to respond to items in the measurements. To

determine if these conditions existed among the students, the teacher was asked to

help with the elimination process (The elimination process is discussed in the subject

recruitment section). Rationales for recruiting adolescents 18 years old and older into

this study were the followings. First, the findings from the previous study in

Ubonratchathani Province revealed that the youngest age of first sexual intercourse
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experiences among adolescents in this province was 13 years, with an average age of

about 14.5 years (Krisawekwisai, 2003). Second, the results from another previous

study conducted in this province showed that among 400 adolescents aged 15 to 24

years, 16.2% had engaged in premarital sexual activities (Weruvanaruk, 2001).

Factors significantly affecting sexual relationships and experiences in sexual

intercourse included opinions on premarital sex and conformity to peer groups

(p<.01) (Weruvanaruk, 2001). Furthermore, late adolescents are in the second phase

of autonomy which includes becoming an independent and self-governing person

(Rew, 2005). They are advancing toward becoming independent thinkers. Their next

developmental stage is or soon will be early adulthood where sexual expressions and

commitments are a major component of life (Brown & Brown, 2006; Brown, 2000).

Therefore, vocational male and female students aged 18 to 21 years were invited to

participate in the study.

Sample Size Determination

Sample size plays a major role in the precision of a study (Pedhazur &

Schmelkin, 1991). Although the determination of sample size depends on the number

and type of variables and the method of planned statistical analysis, power analysis is

the most powerful approach for indicating sample size (Cohen, 1988). Power analysis

for multiple regression analysis was used for determining sample size in this study.

There are three parameters for power analysis: power, effect size (gamma), and the

significance criterion (alpha (α)) (Cohen, 1988).

Power refers to the capacity of the study to detect differences or relationships

that actually exist in the population (Burns & Grove, 2001). Thus, power analysis is

the likelihood of achieving a statistical significant difference that exists (Burns &

Grove, 2001). The purpose of power analysis is to evaluate the risk of a beta or type II
 136

error, which occurs when a significant difference actually exists but the study analysis

fails to find it. Incorrectly rejecting a true difference could potentially lead to false

conclusions (Burns & Grove, 2001). Adequate sample size is important to achieve the

study power to reduce the risk of Type II errors (Kraemer & Thiemann, 1987).

According to Cohen (1988), a minimum acceptable power of 0.80 is posited as a

convention. Due to the purpose of this study, the investigation of condom use

behavior, a sensitive issue, it was hypothesized that some participants might feel

uncomfortable and might neglect to complete some items in the questionnaires.

Hence, the response rates might be decreased. Subsequently, condom use behavior

might be underreported. All of these elements contribute to missing or skewed data

(Dashiff, 2001). Another concern was that the researcher would like to reduce the

probability of type II error. Thus, for this study, the power was set at 0.85. This level

of power would help to assure that the study would be able to detect a significant

difference that existed (Burns & Grove, 2001).

Effect size (ES) is the magnitude to which the phenomenon is present in the

population or the magnitude to which the null hypothesis is false (Cohen, 1988).

Methodologists have suggested that a researcher should use available evidence from

previous studies or a pilot study to estimate the magnitude of the effect size (Burns &

Grove, 2001). Thus, the effect size in this study was calculated from the previous

study by Thato and colleagues (2003), predictor of condom use among adolescent

Thai vocational students (Thato et al., 2003). Results from the Thato and colleagues

study reported that the full predictor set (perceived benefits of condom use,

perceived barriers to condom use, and interactions among knowledge of

STDs/HIV/AIDS/pregnancy and perceived preventive behavioral peer norms)

explains 12% of the variance in condom use (R2 = 0.12) (Thato et al., 2003).
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The effect size of 0.13 was estimated when using the formula of R2/1- R2 (Cohen,

1988). The effect size of 0.13 is considered a medium effect size (Cohen, 1988).

Thus, by using a power primer table (Cohen, 1988), the effect size was set as medium

(0.15) which would help the researcher to minimize the risk of type II error (Cohen,

1988), which was of greater concern.

The significance level (alpha) or type I errors refers to the probability of

rejecting a null hypothesis when it should not be rejected (Pedhazar & Schmelkin,

1991). Cohen (1988) stated that the significance criterion represents the standard of

proof that the phenomenon exists, or the risk of mistakenly rejecting the null

hypothesis is minimal. Since it is the rate of rejecting a true null hypothesis, it is taken

as a relatively small value. It follows then that the smaller the value, the more

rigorous the standard of null hypothesis rejection or, equivalently, of the proof of the

phenomenon’s existence (Cohen, 1988). The more stringent the significance level, the

greater the necessary sample size (Burns & Grove, 2001). In this study, the

significance level (alpha) was set at 0.05. The alpha level 0.05 is the convention for

the minimum basis for rejecting the null hypothesis in behavioral science research

(Cohen, 1988).

For this study, there were eight independent variables, including age, gender,

self-reported history of alcohol/drug use, perceived preventive behavioral peer norms,

duration of the current intimate relationship, knowledge of STDs/HIV/AIDS and

pregnancy, attitudes toward condom use, and self-efficacy in condom use. All of these

independent variables were used in the regression analysis. GPower program

(Erdfelder, Faul, & Buchner, 1996) was used to calculate the sample size. By using

these 4 parameters, including 8 independent variables, power=0.85, alpha (α)=0.05,

medium effect size=0.15, the sample size was 120.

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However, since the cluster randomization method was used in this study, when

clusters consist of an equal number of subjects, n, the appropriate sample size can be

calculated by multiplying the number of subjects required under individual

randomization (n=120) by a variance inflation factor, [1 + (n - 1)rho]; where rho is

the intracluster correlation coefficient (ICC) (Campbell, Grimshaw, & Elbourne,

2004). The ICC can be interpreted as the proportion of the total variance in the data

that is due to the clusters (Donner, 1992). Unfortunately, the range of ICC that one

might expect to observe is not generally well known. What is known, suggests that

ICC tends to be small, about 0.01-0.05 between the clusters (Donner, 1992; Campbell,

Mollison, & Grimshaw, 2001). To allow for the effect of this clustering and to be

conservative, ICC=0.05 was used (Donner, 1992; Campbell, Mollison, & Grimshaw,

2001) and the variance inflation factor was calculated:

Variance Inflation Factor = [ 1+ (n-1)rho ]

= 1 + (8-1)(0.05)

= 1.35

where n, (n=8), is the number of subjects required from each school if the simple

random sampling is used.

The appropriate sample size = (number of subjects required under individual

randomization)*(variance inflation factor)

= (120)*(1.35)

= 162

Thus, the total sample size in this study was 162.

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Settings

This study was conducted at the vocational schools in Ubonratchathani

Province located in the northeast region of Thailand. There are fifteen provinces in

northeast region, Thailand. Significantly, Ubonratchathani Province was selected

because the average age of the first sexual intercourse among the adolescents in this

province was 14.5 years (Krisawekwisai, 2003), a time at which the adolescents are

matriculating at the vocational schools. In Ubonratchathani Province, there are two

types of vocational schools: public and private. They have similar curricula, degrees,

and periods of study. Within the study program, there are different areas of academic

concentration, including electrical power, electronics, building construction, and

mechanical programs. In the Ubonratchathani Province, there are fifteen vocational

schools, ten are public vocational schools and five are private vocational schools. All

of these vocational schools are located in Ubonratchathani Province. All fifteen

vocational schools, public and private, are regulated by the Ministry of Education

(Ministry of Education, Thailand, 1998). The pubic vocational schools are totally

subsidized by the Thai government. The private vocational schools are subsidized in

part by the Thai government; hence, students in private vocational schools pay about

twice the tuition than their counterparts in the federal system (Ubonratchathani

Technical College’s Director, 2007). However, the general characteristics (age,

residence, peer relationships, values, and behaviors) of the student population in

federal and private vocational schools are the same, and both groups were invited to

participate in this research study.

Sampling procedure

The sample of vocational students participating in this study was obtained

through a multistage cluster sampling procedure. Within this study, a sampling frame
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was developed that included a list of all vocational schools. A total of 10,500 students

from fifteen vocational schools were eligible to participate. Within these fifteen

vocational schools, ten are public schools, and five are private schools. Of these ten

public schools, two schools were randomly selected; among the five private schools,

one school was randomly selected. Hence, to attain a sample size of 162 for this

study, three vocational schools were randomly selected as units from which to obtain

elements for the sample. For each randomly selected school, two programs out of four

specific academic programs (electrical power, electronics, building construction, and

mechanical programs) of study were randomly selected. Next, from each randomly

selected academic program, one classroom was randomly selected from the pool.

Thus, two classrooms were recruited from each randomly selected school.

A classroom size of 20 was expected as it was the average class size of each of the

classrooms. Thus, a sample size of 40 was drawn from each randomly selected school

to represent 18 to 21 year-old vocational students who were studying in vocational

schools in Ubonratchathani Province.

Subject recruitment

In this study, all subjects in each randomly selected classroom were invited to

participate. Then, the investigator went to each random selected classroom, had a

face-to-face discussion with the student groups, described the scope of the study in a

class and assured class members that whether or not one participates in the study did

not affect his/her academic achievement. After discussion with the student groups in

each classroom, the researcher was able to determine if the students fit the inclusion

criteria and the teacher was asked to help with the elimination process that was based

on the predetermined selection criteria.

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To help with the elimination process, the teacher was asked to identify the

students who have been determined to manifest a developmental disability, a

cognitive disability, or manifestation of psychotic symptoms that could prohibit their

ability to respond to items in the questionnaires. Then, these students were not

included into the study. The discussion about the elimination process was occurred

only between the researcher and the classroom teacher. Those students who did not

meet the criteria were escorted to a designated classroom area in the school where

they were provided with educational materials in Thai and at their developmental

levels that addressed the topic of HIV/AIDS prevention. A school employee

(teacher/counselor) was in the classroom with the students during this time. The

researcher obtained these materials from the district public health department. After

the data had been collected, the researcher provided opportunities for the students

who did not meet the criteria to discuss HIV/AIDS prevention and asked questions

about ways to prevent HIV/AIDS.

When the necessary number of the subjects in the randomly selected

classroom did not fit the criteria, the investigator again randomly selected other

classrooms. The process was identical to the procedure that is detailed in step 3 in

page 135. Through the sample selection, the identical process was used when

selecting school and/or subjects. Subjects who agreed to participate in the study were

asked to review, discuss, and then signed the written informed consent form. After the

subjects had signed the written informed consent form, they were given a self-

administered questionnaire. Because of peer influence, the seating pattern had a

consistent format that included one seat between each student and about 4 feet apart

from side to side and from front to back. The distance of seating was emphasized to

assure participants did not see responses of others in the classroom setting. The
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investigator clearly discussed the purpose of the study, why it was important to the

adolescents and young adults of this province, and then described the instructions for

completing the questionnaire (See Appendix G for instructions for the completion of

the questionnaire, p.247). All students received the same instructions in the pre-

determined format as presented. During the data collection period in the classroom,

only the researcher was in the classroom to respond to the questions and concerns that

students had that were associated with the completion of the questionnaires. The

teacher was asked to leave the classroom when the study was being described, and the

students were asking questions or verbalizing concerns about the study. This

procedure was implemented to assure the students’ confidentiality, and to protect their

privacy. Hence, the teachers or other administrators in the school system were out of

the classroom during the time that the students completed the questionnaire. After the

students had completed the questionnaires, they were asked to place the

questionnaires in an envelope that accompanied each questionnaire. The researcher

collected each of the students’ envelopes that contained the completed questionnaire.

Then, these envelopes were placed in a locked box. Anonymity of the participants on

the questionnaires was emphasized by asking the students to refrain from placing their

names of the questionnaire. Therefore, the students’ names were not placed on the

questionnaires. All questionnaires were numbered before they were distributed to the

students. Each randomly selected classroom had a specific set of numbers that could

be used to determine the classroom source of the data, but not the individual

respondent. The researcher also assured the students that the teachers and the

principal did not have any access to the questionnaires and their answer. The

envelopes contained the questionnaires and the answers were sealed tightly before the

researcher left the classroom; the data remained in the researcher’s possession at all
 143

times. While in Thailand, the data was stored in the locked cabinet at the researcher’s

office. When the researcher returned to Case Western Reserve University, the data

was stored in a locked file drawer. In addition, an electronic form of the data was

entered and stored in the researcher’s computer and in a locked file drawer at the

University. A series of passcodes was required to access the data and this passcode

was known only by the researcher and her advisor. These measures helped to bolster

security and confidentiality of the research data.

C. Pilot study for the attitudes toward condom use study

Prior to data collection in the actual research plan, a pilot study was first

conducted to pretest the Condom Attitude Scale-Thai version (CAS-T). This

instrument was pre-tested because it was translated from English version to a Thai

version (The procedure of instrument translation will be discussed in the instrument

translation section). A pilot study is very important and is critical to the validity and

the reliability of the study (Burns & Grove, 2001). In order to study health care

behaviors of people with diverse cultural backgrounds, research instruments must be

reliable and valid in each culture studied (Munet-Vilar’o & Egan, 1990;

Maneesriwongkul & Dixon, 2004). Hence, a pilot study should be carried out after

instrument translation is completed in order to ensure that future users of the target

language version can complete all questions and procedures (Maneesriwongkul &

Dixon, 2004). The Thai-version of the Condom Attitude Scale (CAS) was

administered to a randomly selected convenience sample of 32 vocational school

students who had the same characteristics as the study population. The purpose of the

pilot study was to examine the cultural appropriateness and to assure the readability,

clarity, and meaning of the translated version (Maneesriwongkul & Dixon, 2004). It

was also a method of testing the procedure for data collection and determining any
 144

unforeseen difficulties with the instrument, the procedure, or other mechanical

components of the process. After signing a consent form, subjects completed the

translated questionnaire. These thirty-two subjects were not included in the final

study. Lastly, the findings from the pilot testing were used to edit the instrument in

the Thai language to ensure that the participants understood the items. Besides, the

researcher examined these questionnaires for internal consistency. Cronbach’s alpha

coefficient was calculated for the subscales, and the total scale (Burns & Grove,

2001).

The results of the pilot study indicated that the vocational school students

clearly understood the context of the instrument. The internal consistency of the

attitudes toward condom use-Thai version was examined in a sample of 32 vocational

school students. Cronbach’s alpha coefficient was 0.81 for the total scale: 0.70 for

relationship safety, 0.51 for perceived risk, 0.57 for interpersonal impact, 0.50 for

safety, 0.63 for effect on sexual experience, and 0.43 for promiscuity.

D. Data Collection Procedure

Data collection in schools occurs when large numbers of adolescents are

necessary to study phenomena such as adolescent health risk behavior (Dashiff,

2001). In this study, self-administered questionnaires were distributed in person to

participants who were in a classroom setting. Self-reported data was collected using

the following steps (See Appendix H for the diagram of data collection procedure,

p.263):

Step 1: The researcher first had a meeting with the superintendent of the 15

vocational schools and explained the purpose, intent, and importance of the study.

Next, the researcher again contacted all of the administrators by letter and again asked

for the approval of the study in the form of a written approval. A follow up visit from
 145

the researcher occurred within a 10 day period. After the superintendent and central

school officials approved the study, a formal letter was sent to each school director to

ask for their approval of the study and to allow the researcher to conduct the study at

the particular vocational schools (See Appendix I for a sample of the letter to the

vocational school directors, p.266). Also, the researcher wrote a formal letter to the

teachers that briefly described the study, its importance and intent. The letter outlined

the specific actions that the students were asked to participate in. Each school director

also had the opportunity to have a face-to-face dialogue with the researcher about the

study before any data collection began.

Step 2: In this step, the approval letters were attained from all of the schools

that involved in the study (See Appendix J for a sample of the letter of permission

from the Thai vocational school directors, p.267). These letters were placed in a

confidential file in the researcher’s possession.

Step 3: This step involved the researcher randomly selecting three vocational

schools (two out of ten public schools, and one out of five private schools) by using

Microsoft Excel program (for public school: data analysis→random→number

generation→variable number=1, numbers of random number=2, range between 1 to

10 with uniform distribution); (for private school: data analysis→random→number

generation→variable number=1, numbers of random number=1, range between 1 to 5

with uniform distribution).

By using Microsoft Excel program to randomly select schools in the region

provided and objective method of selecting the schools, that is to say, each school in

the province has the equal of being selected. This process helped to eliminate or

control of the bias of selection of the school (Burns & Grove, 2001).
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Step 4: The study was proposed to the Institutional Review Board (IRB) of

Case Western Reserve University (Case) and approval was requested. The letters of

approval from three randomly selected vocational schools in Ubonratchathani

Province were included in the package to the Case IRB.

Step 5: After getting approval from the IRB of Case Western Reserve

University (See Appendix K for IRB Approval Letter, p.268), the researcher again

contacted the directors of three randomly selected schools to explain details of the

study. An additional letter followed that contained the details about the data collection

plan, including dates and times and a work plan for the study. In addition, the

executive summary of the study including the materials that were submitted to IRB

and a copy of the IRB approved study was forwarded to each school director because

these documents represented the actual approval of the study.

Step 6: For each randomly selected school, two out of four programs in the

school system were selected by using Microsoft Excel program to select a random

sample. This procedure is very much like the random selection process that was

described in step 3, the selection of school.

Step 7: One classroom was randomly selected by using Microsoft Excel

program from each of the academic programs. Hence, two classrooms were randomly

selected in each school system, private and public.

Step 8: The researcher cooperated with the superintendents, the school

directors, teachers, and students associated with each of the randomly selected

classrooms to schedule a convenient period for data collection, which included

adherence to IRB procedures.

Step 9: The researcher provided a brief explanation of the study and its

purpose to the students in each classroom. Also, the researcher gave some time for
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questions and answers to assure that the students understood what was being asked of

them. Only after the students stated that they understood what was being asked of

them, the data collection process began.

Step 10: In each classroom, 20 students who met the inclusion criteria and

agreed to participate in the study were recruited. To get the information about the

students and to determine if the students met the inclusion criteria, the teacher was

asked to help with the elimination process that occurred before the data collection

process started. The teacher was asked to identify the students who have been

diagnosed or were in the process of being evaluated for a developmental disability, a

cognitive disability, or a manifestation of psychotic symptoms that could prohibit

their ability to respond to items in the questionnaires. Then, these students were

excluded from the study. After twenty students had been recruited, the teacher was

asked to leave the classroom and joined the students who did not meet the exclusion

criteria who were in a classroom at the school. Then, the written informed consent

was discussed again with the students; they were invited to ask questions about the

study, and to agree to participate. Confidentiality and anonymity of the questionnaires

were emphasized to the participants by the researcher. The students were asked to

refrain from placing their names of the questionnaire. The researcher also assured the

students that the teachers and the director did not have any access to the

questionnaires and their responses. They were also assured that the researcher did not

discuss any component of the discussion about HIV/AIDS with the school teachers

and officials.

Step 11: The questionnaires were be distributed to the subjects in the

classroom setting. The distance of seating was emphasized to assure participants

could not see responses of others in the classroom setting.

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Step 12: Subjects completed the questionnaires in a classroom setting. The

completion time was estimated to be about 50-60 minutes.

Step 13: Upon completion, the instruments were placed in the provided

envelopes that each student had. The completed questionnaire was placed in the

envelope by the student and handed to the researcher. The researcher collected each of

the students’ envelopes that contained the completed questionnaire. The researcher

sealed the envelope tightly, placed it in a locked box, thanked the students, distributed

HIV/AIDS prevention materials to the students, and then thanked them again. The

researcher exited the classroom and informed the teacher that the data collection

activities had ended.

E. Measurements

Instrument Translation Process

In this study, six instruments were used (demographic questionnaire,

perceived preventive behavioral peer norms, knowledge of STDs/HIV/AIDS and

pregnancy, attitudes toward condom use, condom use self-efficacy, and actual usage

of condoms). They were originally developed in English and were used with English

speakers. Among them, four instruments were translated into a Thai version, so they

were available prior to the study. Only one instrument, the Condom Attitude Scale

(CAS), was translated into a Thai version for this study. As suggested by Jones and

Kay (1992), the most common and highly recommended procedure for translating an

instrument from the source language to the target language is back-translation and two

interpreters should be used (Jones & Kay, 1992). In back-translation, a target

language version is translated back into the source language version in order to verify

translation of the research instrument (Maneesriwongkul & Dixon, 2004). On the

translation process, the original English version was translated into Thai language by
 149

two experts from Thailand who were fluent in both languages and familiar with the

content. Next, the Thai version was back-translated into English by another two

persons who were fluent in both languages and blinded to the original version. Then,

comparison between the back-translated one and the original one was made. As an

aspect of the translation process, it was necessary that the versions of the instrument

be systematically compared (Tang & Dixon, 2002). Lastly, an agreement between two

versions was reached. The description of the instruments will be discussed in the next

section.

In this study, the following instruments were used to collect data. Each

instrument is a self-administered-Likert type questionnaire (See Appendix G for

instruments, p.247). Within this study, there were eight independent variables,

including gender, age, self-reported history of alcohol/drug use, duration of the

current intimate relationship, perceived preventive behavioral peer norms, knowledge

of STDs/HIV/AIDS & pregnancy, attitudes toward condom use, and condom use self-

efficacy. They were measured as follows:

Demographic Questionnaire. The demographic characteristic questionnaire

was developed to gather the demographic characteristics of the subjects, including age

in years, gender, their living arrangement, family income, having girl/boyfriends,

premarital sexual experience, age at first intercourse, use of hormonal contraception,

abortion experience, self-reported history of alcohol/drug use, and duration of the

current intimate relationship. This information was collected from the subjects using

self-report items. The self-administered form was distributed to the participants.

Gender. Gender was categorized into male or female.

Age. Age was assessed by asking the participants to give age in years.
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Self-reported history of alcohol/drug use. Use of alcohol is defined as

consuming beverages containing alcohol, or a chemical agent affecting cognitive

ability, emotional and behavioral capabilities, if consumed in a large enough amount

(Winger, 2004). Typically, alcohol use refers to ethanol. Besides, drug is defined as

the consumption of illicit drugs, e.g. amphetamine, ecstasy, cocaine, heroine, and

inhalants, in combination or individual use (Winger, 2004). The participants were

asked whether they consumed alcohol and/or used drugs before engaging into sexual

relationship. This variable was measured by using the two-item self-administered

questionnaire. Alcohol consuming was measured by one item asking, “Have you ever

had sexual intercourse after drinking alcohol (e.g., beer, wine, wine coolers and hard

liquor)?” Use of drugs was measured by one item asking, “Have you ever had sexual

intercourse after using drugs (e.g., amphetamine, ecstasy, cocaine, heroine, and

inhalants)?” Score for each item ranges from “0=never, 1=once in a while, 2=half of

the time, 3=most of the time, 4=all of the time”. Then, self-reported history of

alcohol/drug use scores was combined. The total composite score of self-reported

history of alcohol/drug use was calculated by summing the scores of two items. And

the composite score was used for analysis. The total composite score of self-reported

history of alcohol/drug use ranges from 0 to 8. A higher score is indicative of greater

use of alcohol and/or drugs.

Duration of the current intimate relationship. Duration of the current intimate

relationship is defined as number of days since he/she had sexual intercourse with

his/her current (most recent) partner. This variable was measured by asking the

participants to give or estimate the number of days of the current sexual relationship.

Perceived preventive behavioral peer norms. Perceived preventive behavioral

peer norms were measured by using the five-item self-administered questionnaire

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originally developed in English by Shafer and Boyer (1991). The instrument assessed

what adolescents believe their friends thought about engaging in safer sex behavior,

including condom use. The adolescents were asked to indicate the degree to which an

item described what they believed on a 5-point Likert scale ranging from none of my

friends (0) to all of my friends (4). The total composite score of perceived preventive

behavioral peer norm was calculated by summing the scores of all five items. Besides,

the composite score was used for analysis. The total composite score of perceived

preventive behavioral peer norm ranges from 0 to 20. Among five items, three items

were inversely scored. A higher score is indicative of greater perceived preventive

behavioral peer norms. This instrument was translated into a Thai version by Thato

and colleagues in 2003 and the original and back- translated versions were

systematically compared (Thato et al., 2003).

Reliability

Internal consistency The perceived preventive behavioral peer norms have

acceptable reliability. It was examined for internal consistency in a sample of 985

American high school students who were in grade 9 (Shafer & Boyer, 1991).

Cronbach’s alpha coefficient was 0.79. In this study, the perceived preventive

behavioral peer norms scale was examined for internal consistency in a sample of 270

vocational school students. Cronbach’s alpha coefficient for the total score was 0.47.

According to Nunnally and Bernstein (1994), Cronbach’s alpha coefficient for the

measurement should be ≥ 0.70. By using this criterion, the perceived preventive

behavioral peer norms scale demonstrated insufficient reliability. Details will be

discussed in chapter 5.
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Validity

Content Validity The perceived preventive behavioral peer norms scale was

originally developed based on a related literature of preventive health behaviors

(Thato et al., 2003). The researchers who developed the original instrument provided

evidence of the validity of the perceived preventive behavioral peer norms scale

(Shafer & Boyer, 1991).

Knowledge of STDs/HIV/AIDS and Pregnancy. This instrument is comprised

of 2 parts, including STDs and HIV knowledge and the pregnancy knowledge. This

instrument was translated into a Thai version by Thato and colleagues in 2003. The

original and back-translated versions were systematically compared (Thato et al.,

2003). The description of this instrument is as follows:

STDs and HIV/AIDS knowledge. The STDs and HIV/AIDS knowledge self-

administered questionnaire was originally developed in English by Shafer and Boyer

(1991). The original version consisted of 25 items. Then, this instrument was

modified by the authors (Thato et al., 2003). As a result, the modified version

consisted of 28 items (18 items for HIV/AIDS and 10 items for STDs). For this study,

the modified version was utilized. Moreover, this instrument composes of three

components, including clinical knowledge of AIDS, transmission and prevention of

HIV, and misconceptions concerning AIDS as a causal contagion. The participants

were asked to answer “yes”, “no”, or “don’t know” which was coded as incorrect. The

“don’t know” answer was coded as incorrect because it might be used by the

respondents to mean different things, including indecision, ignorance, or uncertainty

about their answer to the question asked (Sanchez & Morchio, 1992). The total

composite score of STDs and HIV/AIDS knowledge was calculated from the correct
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responses ranging from 0 to 28. A higher score is indicative of higher knowledge of

STDs and HIV/AIDS.

Reliability

Internal consistency The original version of STDs and HIV/AIDS knowledge

was examined for internal consistency in a sample of 544 adolescents who were 9th

graders in high schools (Shafer & Boyer, 1991). Cronbach’s alpha coefficient was

0.81. Regarding the modified version, internal consistency was examined among a

sample of 391 adolescents who were Thai vocational school students in Bangkok. For

the total scale, Cronbach’s alpha coefficient was 0.79, 0.72 for AIDS knowledge, and

0.62 for STDs knowledge. In this study, internal consistency of the STDs and

HIV/AIDS knowledge was examined in a sample of 270 vocational school students.

Cronbach’s alpha coefficient was 0.76 for the total scale: 0.68 for AIDS knowledge,

and 0.62 for STDs knowledge.

Validity

Content Validity Evidence for content validity of the STDs and HIV/AIDS

knowledge scale was reported. The STDs and HIV/AIDS knowledge was developed

based on STDs, HIV and AIDS literature (Thato et al., 2003). The content validity

was conducted to ensure conceptual clarity, style and readability of the instrument by

Shafer and Boyer (1991).

The pregnancy knowledge The pregnancy knowledge questionnaire is a

modified version of the reproductive and contraceptive knowledge scale originally

developed for the 1988 and 1990 National Survey of Adolescents Males (NSAM)

(Pleck, Sonenstein, & Ku, 1993). The modified version consisted of 11 items. The

examples of the items were “a sexually active girl can become pregnant if she forgot

to take her birth control pills for several days in a row” and “a young man cannot
 154

make a girl pregnant the first few times he has sex”. The participants were asked to

answer “yes”, “no”, or “don’t know” which was coded as incorrect. The “don’t know”

answer was coded as incorrect because it might be used by the respondents to mean

different things, including indecision, ignorance, or uncertainty about their answer to

the question asked (Sanchez & Morchio, 1992). The total composite score of

pregnancy knowledge was calculated from the correct responses ranging from 0 to 11.

A higher score is indicative of higher knowledge of pregnancy.

Reliability

Internal consistency The pregnancy knowledge has acceptable psychometric

properties. The internal consistency was examined among a sample of 391

adolescents who were Thai vocational school students in Bangkok. Cronbach’s alpha

coefficient was 0.71 (Thato et al., 2003). In this study, internal consistency of the

pregnancy knowledge was examined in a sample of 270 vocational school students.

Cronbach’s alpha coefficient was 0.72 for the total scale.

Validity

Evidence for content validity of the pregnancy knowledge scale was reported.

This scale was developed based on a review of literature concerning pregnancy

knowledge. The researchers who worked on the 1988 and 1990 National Survey of

Adolescents Males (NSAM) (Pleck, Sonenstein, & Ku, 1993) reviewed the items for

this scale. Hence, content validity was conducted to ensure conceptual clarity, style

and readability of the instrument (Pleck, Sonenstein, & Ku, 1993).

The total composite score of the STDs/HIV/AIDS and pregnancy knowledge

could be calculated by summing the scores of all three area of knowledge (STDs,

HIV/AIDS, and pregnancy knowledge). Besides, the composite score was used for
 155

analysis. The total composite score ranges from 0 to 39. A higher score is indicative

of higher knowledge of STDs/HIV/AIDS and pregnancy.

Attitudes toward condom use. According to St.Lawrence and associates

(1994), attitudes toward condom use is the magnitude of the evaluation of thoughts

related to the relationship safety, perceived risk, interpersonal impact, safety, effect on

sexual experience, and promiscuity (St.Lawrence et al., 1994). To measure attitudes

toward condom use, the Condom Attitude Scale–Adolescent Version (CAS-A) (St.

Lawrence et al., 1994) was employed. Originally, the Condom Attitude Scale (CAS)

was first developed in English for use with young adults by Sacco, Levine, Reed, and

Thompson (1991) containing 57 items. Then, in 1994, the original version was

modified for using with adolescents by St. Lawrence and colleagues (1994).

Consequently, the final revision of the Condom Attitude Scale – Adolescent Version

(CAS-A) contained 23 items. This measure was a self-administered-Likert type

questionnaire containing multiple choice questions scored for analysis.

It consisted of six subscales: relationship safety (5 items), perceived risk (5 items),

interpersonal impact (4 items), safety (3 items), effect on sexual experience (3 items),

and promiscuity (3 items). First, relationship safety was measured by using 5 items of

the Condom Attitude Scale – Adolescent Version (CAS-A) (St. Lawrence et al.,

1994). The examples of the items were “I wouldn’t use a condom if my partner

refused,” or “A condom is not necessary if you know your partner”. Second,

perceived risk was measured by using 5 items of the Condom Attitude Scale –

Adolescent Version (CAS-A) (St. Lawrence et al., 1994). The examples of the items

were “If I’m not careful, I could catch a sexually transmitted disease,” or “I am

concerned about catching AIDS or some other sexually transmitted disease”. Third,

interpersonal impact was measured by using 4 items of the Condom Attitude Scale –
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Adolescent Version (CAS-A) (St. Lawrence et al., 1994). The examples of the items

were “If my partner suggested using a condom, I would respect him or her,” or “Other

people should respect my desire to use a condom”. Fourth, safety was measured by

using 3 items of the Condom Attitude Scale – Adolescent Version (CAS-A) (St.

Lawrence et al., 1994). The examples of the items were “Condoms create a sense of

safety,” or “Condoms protect against sexually transmitted diseases”. Fifth, effect on

sexual experience was measured by using 3 items of the Condom Attitude Scale –

Adolescent Version (CAS-A) (St. Lawrence et al., 1994). The examples of the items

were “Condoms take away the pleasure of sex,” or “Condoms are messy”. Lastly,

promiscuity was measured by using 3 items of the Condom Attitude Scale –

Adolescent Version (CAS-A) (St. Lawrence et al., 1994). The examples of the items

were “People who use condoms sleep around a lot,” or “People who carry condoms

are just looking for sex”. A 7-point Likert scale was used to rate the item from

“strongly disagree” (scored as 0), “mostly disagree” (scored as 1), “somewhat

disagree” (scored as 2), neither agree nor disagree (scored as 3), “somewhat agree”

(scored as 4), “mostly agree” (scored as 5), and “strongly agree” (scored as 6). The

total composite score of attitude towards condom use ranges from 0 to 138.

The total composite score of the attitudes toward condom use was calculated

by summing the scores of all six subscales (relationship safety, perceived risk,

interpersonal impact, safety, effect on sexual experience, and promiscuity). Besides,

the composite score was used for analysis with higher scores indicating a positive

attitude about condoms (St. Lawrence et al., 1994). Subscale scores ranging from 0 to

30 for relationship safety, from 0 to 30 for perceived risk, from 0 to 24 for

interpersonal impact, from 0 to 18 for safety, from 0 to 18 for effect on sexual

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experience, and from 0 to 18 for promiscuity (St. Lawrence et al., 1994) were used.

This instrument was translated to Thai version by using a back-translation technique.

Reliability

Internal consistency

The Condom Attitude Scale–Adolescent Version (CAS-A) has acceptable

psychometric properties. It was examined for internal consistency in a sample of 102

African American adolescents aged about 16 years. The coefficient alpha was 0.84 for

the total scale. Test-retest correlations for the subscales are also very good, ranging

from 0.67 to 0.89 (.84 for total score; .82 for relationship safety; .78 for perceived

risk; .67 for interpersonal impact; .74 for safety; .84 for effect on sexual experience;

and .89 for promiscuity) (St. Lawrence et al., 1994). In this study, internal consistency

of the attitudes toward condom use was examined in a sample of 270 vocational

school students. Cronbach’s alpha coefficient was 0.74 for the total scale: 0.76 for

relationship safety, 0.59 for perceived risk, 0.83 for interpersonal impact, 0.60 for

safety, 0.57 for effect on sexual experience, and 0.58 for promiscuity.

Validity

Construct validity

An iterated principal-components factor analysis with squared multiple

correlations as initial communality estimates was performed on all subjects’ responses

to the 57 condom attitude scale (CAS) items, followed by a varimax rotation to obtain

underlying factors which are uncorrelated. The varimax rotation is the most

commonly used among three types of orthogonal rotation procedure (Mertler &

Vannatta, 2002). Six factors were retained. The 57 CAS items were then reduced to a

smaller subset of 23 items. Six condom attitude factors emerged: relationship safety

(5 items), perceived risk (5 items), interpersonal impact (4 items), safety (3 items),

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effect on sexual experience (3 items), and promiscuity (3 items) (St. Lawrence et al.,

1994).

Self-efficacy in condom use. According to Hanna (1999), self-efficacy in

condom use is the appraisal of one’s ability to use condom or to persuade her partners

to use them (Hanna, 1999). To measure self-efficacy in condom use, the Condom Use

Self-efficacy Scale (Hanna, 1999) was used. This instrument is a 14-item scale firstly

developed by Hanna (1999). Three subscales are contained within the measure. These

three subscales measure consistent condom use self-efficacy, correct condom use self-

efficacy, and communication self-efficacy with partner. Firstly, consistent condom

use self-efficacy was measured by using 3 items of the Condom Self-Efficacy Scale

(Hanna, 1999). The examples of the items were “I could carry a condom with me in

case I need one,” or “I could use a condom each time I and my partner had sex”.

Secondarily, correct condom use self-efficacy was measured by using 6 items of the

Condom Self-Efficacy Scale (Hanna, 1999). The examples of the items were “I could

use a condom without it slipping,” or “I could stop to put a condom on myself or my

partner”. Lastly, communication self-efficacy with partner was measured by using 5

items of the Condom Self-Efficacy Scale (Hanna, 1999). The examples of the items

were “I could talk about using a condom with any sexual partner,” or “I could say no

to sex if my partner refused to use a condom”. A 5-point Likert-type response ranging

from “very unsure” (scored as 0), “unsure” (scored as 1), “somewhat sure” (scored as

2), “sure” (scored as 3), “very sure” (scored as 4) was designed. The total composite

score of condom use self-efficacy was calculated by summing the scores of all three

subscales (consistent condom use self-efficacy, correct condom use self-efficacy, and

communication self-efficacy with partner). Moreover, the composite score was used

for analysis with higher scores indicating higher self-efficacy in condom use (Hanna,
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1999). The total composite score of condom use self-efficacy ranges from 0 to 56.

Subscale scores, ranging from 0 to 12 for consistent condom use self-efficacy, from 0

to 24 for correct condom use self-efficacy, and from 0 to 20 for communication self-

efficacy with partner, were derived (Hanna, 1999). This instrument was translated to

Thai version by Thato and associates and the original and back-translated versions

were systematically compared (Thato, Hanna, & Rodcumdee, 2005).

Reliability

Internal consistency

The Condom use self-efficacy scale was examined for internal consistency in

a sample of 209 adolescents and young adults aged 13 to 26. The Cronbach’s alpha

was 0.85 for the total scale (Hanna, 1999). Furthermore, Thato and associates (2005)

translated the 14-item Condom Self-Efficacy Scale (CSES) into Thai and validated

the Thai version of the Condom Self-efficacy Scale (CSES-T) among Thai

adolescents and young adults. They reported that the Cronbach's alpha coefficients

were 0.85 for the total scale, 0.70 for consistent use subscale, 0.79 for correct use

subscale, and 0.80 for communication with partner subscale (Thato, Hanna, &

Rodcumdee, 2005). In this study, internal consistency of the self-efficacy in condom

use was examined in a sample of 270 vocational school students. Cronbach’s alpha

coefficient was 0.92 for the total scale: 0.84 for consistent condom use self-efficacy,

0.86 for correct condom use self-efficacy, and 0.87 for communication self-efficacy

with partner.

Validity

Content validity

Condom use self-efficacy items were developed based on a review of

literature on adolescents’ and young adults’ condom use (Hanna, 1999). Three experts
 160

who were familiar with the literature and who were working with adolescents and

young adults regarding condom use were asked to review the items for specific

behaviors involved in condom use (Hanna, 1999).

Construct validity

Principal axis factor analysis was performed with varimax rotation to

maximize the variance between factors (Hanna, 1991). Three self-efficacy factors

emerged: (a) communication abilities with partner related to condom use (5 items),

(b) consistent condom use abilities (3 items), and (c) correct condom use abilities (6

items) (Hanna, 1991). In addition, Thato and colleagues (2005) conducted principal

factor analysis with varimax rotation to identify latent factors. The factor analysis

indicated three factors: consistent use, correct use, and communication with partner.

Items loading on the original CSES also loaded on the same factors of the CSES-T

except one item. The investigators concluded that based on psychometric properties,

the CSES-T is a valid and reliable tool. It is culturally appropriate for Thai

adolescents and young adults (Thato et al, 2005).

In this study, the dependent variable was actual usage of condoms. It was

measured as follows:

Actual usage of condoms. In this study, the dependent variable was actual

usage of condoms at the time that sexual contact occurs between two people. Actual

usage of condoms is defined as “the self-reported frequency of actual condom use at

the beginning of his/her sexual relationship experiences and during the last few times

(2-3 times) he/she had sexual intercourse with a partner” (Thato et al., 2003). To

measure actual usage of condoms, three items were asked. The first question “At the

beginning of a relationship with your current partner, how often did you or your

partner use a condom when having sexual intercourse?” was asked. The second
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question was “The last few times when you had sex with your current partner, did you

or your partner use condoms?” The third question “In general, when you had sex with

your current partner, did you or your partner use condoms?” was asked. These

questions were answered with a 5-point Likert-type response ranging from “never

use” (scored as 0), “sometimes use” (scored as 1), “often time use” (scored as 2),

“most of the time” (scored as 3), and “every time use” (scored as 4). The total

composite score of actual usage of condoms was calculated by summing the scores of

three questions. Moreover, the composite score was used for analysis. The total

composite score of actual usage of condoms ranges from 0 to 12, with higher scores

indicating higher actual condom use (Thato et al., 2003). This instrument was

translated to Thai version by Thato and associates and the original and back-translated

versions were systematically compared (Thato et al., 2003).

Reliability

The actual usage of condoms has acceptable psychometric properties. Internal

consistency was investigated for the actual usage of condoms in a sample of 391 Thai

students aged 18-22 years. Cronbach’s alpha coefficient was 0.69 (Thato et al., 2003).

In this study, internal consistency of the actual usage of condoms was examined in a

sample of 180 sexually active vocational students. Cronbach’s alpha coefficient was

0.90 for the total scale.

Validity

Evidence for content validity of the actual usage of condoms was reported.

The actual usage of condoms was developed based on a review of literature on

adolescents’ condom use behavior (Thato et al., 2003). Content validity was

conducted for the actual usage of condoms by 10 experts to ensure conceptual clarity,
 162

style and readability of the instrument (Buunk, Bakker, Siero, van den Eijnden, &

Yzer, 1998).

Furthermore, there are two-open-ended questions that helped to explain the

relationship between the independent variables and the dependent variable. The two-

open-ended questions embedded in this study follow:

1. Tell me what you feel about premarital sexual behavior among Thai

adolescents.

2. Share with me your thoughts about young Thai men having sex before

marriage. Now, tell me what you think about the female.

The findings related to these two questions will be presented in Chapter 4.

F. Data Management

For this study, data management was processed with the SPSS (version 15) for

Windows statistical software package. To obtain data integrity during data collection,

all instruments were numbered. Computer column numbers were included on each

form in order to facilitate data entry. Data coding began shortly after data collection.

Maintaining data integrity during the coding and entering phase was facilitated by

following a step-by-step procedure. First of all, all decisions made during coding were

recorded in the codebook, thus there was a consistency in decision-making. Secondly,

data were independently double-coded and entered twice by the researcher. To

prevent losing of data, a backup file of data was made on a flash drive after each data

entry. Then, the researcher compared two files to identify inconsistencies. All

discrepant entries were verified by reviewing the raw data. Third, all coding errors

and discrepancies were corrected. Finally, a printout of the data, including descriptive

statistics and frequencies, was examined for missing data lines and values outside the

appropriate range of the variables (Tabachnick & Fidell, 2001).

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Data screening for missing observations was inspected by using descriptive

statistics, such as frequencies. According to Cohen and Cohen (1983), up to ten

percent of missing data on particular variables is acceptable. However, it is

recommended to investigate the pattern of missing data in order to choose the

appropriate procedure to manage it. The statistical literature addressed that patterns of

missing data can roughly be categorized into two types: missing at random (MAR)

and systematic missing data (Hair, Anderson, Tatham, & Black, 1998). Missing

observations are called “missing at random (MAR) when the probability of the

presence versus absence of scores on some variable is unrelated to subjects’ true

status on that variable” (Kline, 1998, p.73). Contrarily, nonrandom missing data

implies that missing data differ systematically from those with scores on that variable

(Kline, 1998). Following the examination of the missing data, mean substitution, the

use of the average on mean score for completed items on a scale versus the use of

sample mean for demographics, such as age, would be employed in the study. Mean

substitution is one of the widely used methods for estimating missing values.

In this study, missing values, both univariate and multivariate, were assessed

for their amount and their patterns. Missing values were expected to be missing

completely at random. For all variables in this study, cases with missing values

greater than 10 percent in a scale would be treated as missing, and then would be

excluded from the analyses. However, there were no cases with missing values greater

than 10 percent; therefore, no cases were excluded from the analysis for that reason.

Since the investigator collected data and the completion of the questionnaires were

emphasized to the participants during data collection period, therefore missing data

were not anticipated and did not present an analytical concern.

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Then, the total scores on perceived preventive behavioral peer norms,

knowledge of STDs/HIV/AIDS and Pregnancy, attitudes toward condom use, self-

efficacy in condom use, and actual usage of condoms were computed. This

computation command was re-checked by the researcher to ensure that the correct

variables were included. Some items on perceived preventive behavioral peer norms,

knowledge of STDs/HIV/AIDS and Pregnancy, attitudes toward condom use, self-

efficacy in condom use were reversed before computing the total scores. Frequencies

for each variable were inspected for inappropriate values and outliers. Lastly, while

entering data, the researcher needed to avoid distractions. The data entry period was

limited to two hours at a time to reduce errors. Backup of the data was made after

each data entry period and stored at a separate protected site to prevent loss of data.

The pass codes were used to protect data that were on the computer. The

questionnaires, the raw statistical sheets, and the coding files were labeled and kept in

a locked file drawer in the researcher’s office for five years.

G. Statistical Analyses

Preliminary data analysis was first conducted to identify potential outliers and

influential cases, as well as to verify assumptions underlying statistical analysis. To

examine outliers and influential data, data were examined. The observations that have

very high or very low values are called outliers. Outliers may or may not affect the

estimation of the regression line. If, however, the outliers affect the regression line,

they referred to as influential cases (Tabachnick & Fidel, 2001). In this study, data

were examined for outliers for each variable to evaluate possible data entry errors.

Outliers were examined using the standardized deleted residuals and leverage values.

There were no standardized deleted residual values that exceeded the three standard

deviation indicators, suggesting that no outliers were observed. To identify influential

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data points, Cook’s Distance was observed. Cook’s Distance was less than 1.0,

indicating that no influential data (Tabachnick & Fidel, 2001) were observed in this

sample. Thus, no cases were excluded from the analysis for that reason.

Furthermore, descriptive statistics (frequency, percentage, mean, and standard

deviation) were analyzed for demographic variables (such as age, gender), and for all

other study variables, such as self-reported history of alcohol/drug use, duration of the

current intimate relationship, perceived preventive behavioral peer norms, knowledge

of STDs/HIV/AIDS and pregnancy, attitudes toward condom use, self-efficacy in

condom use, and condom use behavior.

Assumptions underlying the statistical analysis were assessed to assure that no

violations existed. Because this study employed multiple regression techniques to

answer research questions, three general assumptions must be met. In order to test

common assumptions, the values of independent (x) and dependent (y) variables must

be random quantities. Hence, three general assumptions that need to be tested are:

normality, linearity, and homoscedasticity (Mertler & Vannatta, 2002). There are

several ways to assess normality. A simple graphical method involves the

examination of the histogram for each variable. The statistical options for assessing

normality are the use of skewness and kurtosis coefficients. When the distribution is

normal, the values for skewness and kurtosis are both equal to zero. If a distribution

has a positive skew (i.e., a skewness value > zero), there is a clustering of cases to the

left and the right tail is extended with only a small number of cases. On the other

hand, if a distribution has a negative skew (i.e., a skewness value < zero), there is a

clustering of cases to the right and the left tail is extended with only a small number

of cases (Mertler & Vannatta, 2002). In this study, the normality of distribution was
 166

determined by examining the histogram of each variable. All the independent

variables were normally distributed.

The second assumption, that of linearity, presupposes that there is a straight

line relationship between two variables. The method of assessing linearity is

inspection of the bivariate scatterplots. If both variables are linearly related, the shape

of the scatter plots will be elliptical (Mertler & Vannatta, 2002). In this study, the

assumption of linearity was also met. The scatter plots revealed linear relationships

among each independent variable and the dependent variable.

The last assumption, homoscedasticity, is the assumption that the variability in

scores for one continuous variable is roughly the same at all values of another

continuous variable (Mertler & Vannatta, 2002). Homoscedasticity is related to the

assumption of normality because if the assumption of multivariate normality is met,

the two variables must be homoscedastic (Tabachnick & Fidell, 2001). The failure of

the relationship between two variables to be homoscedastic is caused either by the

non-normality of one of the variables or by one of the variables may have some sort

of relationship to the transformation of the other variables (Tabachnick & Fidell,

2001). Besides, errors in measurement may cause a lack of homoscedasticity (Mertler

& Vannatta, 2002). In this study, homoscedasticity assumption was not violated since

the scatter plots of the standardized deleted residuals (Y) and the standardized

predicted scores (X axis) against the independent variable showed random scatter

around the zero line.

Another concern is multicollinearity. Multicollinearity refers to a problem that

arises when there is the moderate to high intercorrelations among predictor variables

(independent variables) to be employed in a regression analysis (Mertler & Vannatta,

2002). Multicollinearity could be examined among predictors by using correlation

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statistic. This problem would be created when two independent variables are highly

correlated (r≥.80) with each other. Thus, they measure the same thing and this tends

to increase the variances of the regression coefficient, which ultimately results in a

more unstable prediction equation (Mertler & Vannatta, 2002). In this study,

multicollinearity does not exist. No bivariate correlations were greater than 0.80

(Mertler & Vannatta, 2002). Therefore, multicollinearity was not an issue of this

study.

After completing the preliminary data analysis, the main data analysis was run

by using SPSS software package (version 15). The following research questions were

analyzed:

Question # 1: Is there a relationship between personal information (gender,

age, self-reported history of alcohol/drug use, duration of the current intimate

relationship, and perceived preventive behavioral peer norm) and condom use

behavior? To answer research question number 1, Pearson’s product moment

correlation coefficient (r) was employed to examine the relationships between the

independent variables (gender, age, self-reported history of alcohol/drug use, duration

of the current intimate relationship, and perceived preventive behavioral peer norm)

and dependent variable (condom use behavior) in research question.

Question # 2: Is there a relationship between knowledge of STDs/HIV/AIDS

and pregnancy and condom use behavior? To answer research question number 2,

Pearson’s product moment correlation coefficient (r) was used to examine the

relationships between the independent variable (knowledge of STDs/HIV/AIDS and

pregnancy) and dependent variable (condom use behavior) in research question.

Question # 3: Is there a relationship between attitudes toward condom use

(relationship safety, perceived risk, interpersonal impact, safety, effect on sexual

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experience, and promiscuity) and condom use behavior? To examine the relationships

between the independent variable (attitudes toward condom use, including

relationship safety, perceived risk, interpersonal impact, safety, effect on sexual

experience, and promiscuity) and the dependent variable (condom use behavior),

Pearson’s product moment correlation coefficient (r) was utilized.

Question # 4: Is there a relationship between condom use self-efficacy

(consistent condom use self-efficacy, correct condom use self-efficacy, and

communication self-efficacy with partner) and condom use behavior? To examine the

relationships between the independent variable (condom use self-efficacy, including

consistent condom use self-efficacy, correct condom use self-efficacy, and

communication self-efficacy with partner) and the dependent variable (condom use

behavior), Pearson’s product moment correlation coefficient (r) was employed.

According to Tabachnick and Fidell (2001), Pearson’s product moment correlation

coefficient (r) is used to examine bivariate relationships between continuous

variables.

Question # 5: Do the independent variables (gender, age, self-reported history

of alcohol/drug use, duration of the current intimate relationship, perceived preventive

behavioral peer norm, knowledge of STDs/HIV/AIDS & pregnancy, attitudes toward

condom use, and condom use self-efficacy) predict the dependent variable (condom

use behavior)? To answer research question number 5, multiple regressions were also

employed to estimate the magnitudes of the total effects of age, gender, self-reported

history of alcohol/drug use, duration of the current intimate relationship, perceived

preventive behavioral peer norms, knowledge of STDs/HIV/AIDS and pregnancy,

attitudes toward condom use, and self-efficacy in condom use on the outcome

variable, condom use behavior. According to Munro (2005), multiple regressions are
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possible when there is a measurable multiple correlation between a group of predictor

variables and one dependent variable.

H. Protection of Human Subjects

To assure the protection of the rights of the subjects, several methods were

involved in this study and were planned in advance and maintained throughout the

study. Prior to conducting the study, approval by the Institutional Review Board

(IRB) of Case Western Reserve University was obtained. In Thailand, since the

Vocational School Institutional Review Board has not yet been established, therefore

the directors of each school served as an advocate for human rights (Ubonratchathani

Technical College’s Director, 2007). Besides, parental consent to participate in this

study was not required because most adolescents who are 18 year-of-age and older

have the legal right to provide independent consent to participate in research (Fisher,

2004). Hence, these individuals could provide self-consent to participate in research.

The researcher explained all aspects of the study, including risks of uncomfortable

feelings due to the sensitive nature of some items. Descriptions of the purpose, risk,

and benefits of the study were provided. Assurances of confidentiality and freedom to

stop participation at any time were explained to subjects prior to giving written

consent for participation. The subjects were assured that their participation was

voluntary. The refusal to participate did not adversely affect their grade point average

or their study.

Regarding confidentiality, because of the sensitive issue of sexual behavior, all

subjects participating in the study were assigned an identification number by the

researcher. The subjects were informed not to post their name on the questionnaire.

All questionnaires were coded with only an identification number. Additionally, all

data were analyzed and reported as aggregate. All subjects’ responses were kept in a
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locked file cabinet and stored in computer files. Only the researcher could have an

access to data. Following completion of the study, all subject records were retained in

the locked file drawer in the researcher’s office in Thailand for five years. Then, they

would be destroyed afterward. Nevertheless, for scientific knowledge, information

concerning responses to questionnaires might be published based on group findings,

not individual responses.

I. Summary

The purpose of this chapter was to provide a comprehensive methodology for

the study. The content of the chapter had been clearly illustrated to cover and link all

of the steps, which were utilized in the study. The chapter began with the research

design. Then, the sampling section, including specifying the sample, inclusion and

exclusion criteria, sample size determination, settings, sampling procedure, and

subject recruitment, were presented. Next, pilot study for the attitudes toward condom

use study, data collection procedure, and the description of instruments were

described. After that, the data management, statistical analyses followed. Lastly, the

chapter ended with protection of human subjects.

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CHAPTER IV

Results

This cross-sectional descriptive correlational study was designed to examine

the relationships among personal information, attitudes toward condom use, condom

use self-efficacy, and condom use behavior among Thai vocational school adolescents

in Ubonratchathani Province, Thailand. Specifically, the study purported to determine

if the demographic characteristics (gender, age, self-reported history of alcohol/drug

use, duration of the current intimate relationship, and perceived preventive behavioral

peer norms), knowledge of STDs/HIV/AIDS and pregnancy, attitudes toward condom

use, and condom use self-efficacy predict condom use behavior, actual usage of

condoms. The findings of this study will be presented in two sections. The first

section consists of the descriptive personal information of the participants, description

of the study variables, and analysis of research questions. The second section will

detail the responses of 2 open-ended-questions regarding premarital sexual behavior

among Thai adolescents. SPSS version 15.0 for Windows was used to analyze data in

this research study.

Section I

Demographic Characteristics of the study participants

The demographic characteristics of the adolescents in this study are presented

in Table 5. The demographic questionnaire was used in collecting the participants’

personal information data. Descriptive statistics were used to describe the sample

characteristics of gender, age, self-reported history of alcohol/drug use, and duration

of the current intimate relationship. The study was conducted on a multistage cluster

sample of 270 vocational school students from three randomly selected vocational

schools in Ubonratchathani Province, Thailand. Participants included 174 males

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(64.4%) and 96 females (35.6%). Fifty-two participants (19.3%) were 18 years of age.

One-hundred and thirty-seven participants (50.7%) were 19 years of age, while fifty-

nine participants (21.9%) were 20 years of age, and twenty-two participants (8.1%)

were 21 years of age. Over sixty percent (61.5%) lived in dormitory/apartment. The

majority of the sample (34.4%) lived with friends. Some of them were from families

of low-socioeconomic status. Fifty percent of the sample indicated that their parents

had monthly income less than 5,000 baths (34 baths=$1, minimum wage=191 baths a

day). The majority of subjects in this study (48%) had monthly income of between

1,001-2,000 bahts. Most of them (71.5%) received their monthly stipends from their

parents (See Table 5 for detailed description of the sample).

As mentioned earlier, there were 270 participants in this study. A responded

rate of participants was 100%. All of them identified their sexual orientation as

heterosexual. Of the 270 subjects, 180 participants (66.66%) have been sexually

active and 90 participants (33.34%) never been sexually active. Data from all of 270

subjects (174 males, 64.40%; 96 females, 35.60%) were utilized for data analysis in

this study.
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Table 5

Descriptive Statistics of the Sample

Characteristics Overall Male Female

(n=270) (n=174) (n=96)
n(%) n(%) n(%)

Gender 270(100) 174(64.4) 96(35.6)

Age
18 years 52(19.3) 27(15.5) 25(26)
19 years 137(50.7) 82(47.1) 55(57.3)
20 years 59(21.9) 45(25.9) 14(14.6)
21 years 22(8.1) 20(11.5) 2(2.1)
Living status
Dormitory/apartment 166(61.5) 114(65.5) 52(54.2)
Parents’ house 79(29.3) 43(24.7) 36(37.5)
Relatives’ house 23(8.5) 15(8.6) 8(8.3)
Temple 2(0.7) 2(1.1) -
Who do you live with?
Myself 44(16.3) 31(17.8) 13(13.5)
Parents 81(30) 46(26.4) 35(36.5)
Friends 93(34.4) 67(38.5) 26(27.1)
Girl/boyfriend 21(7.8) 12(6.9) 9(9.4)
Relatives 31(11.5) 18(10.3) 13(13.5)
Parental income (in bahts, 34 bahts = $1)
<5,000 134(49.6) 81(46.6) 53(55.2)
5,000-10,000 82(30.4) 55(31.6) 27(28.1)
10,001-15,000 20(7.4) 13(7.5) 7(7.3)
15,001-20,000 8(3.0) 7(4.0) 1(1)
>20,000 26(9.6) 18(10.3) 8(8.3)
Monthly income (in bahts, 34 bahts = $1)
<1,000 42(15.6) 25(14.4) 17(17.7)
1,001-2,000 130(48.1) 89(51.1) 41(42.7)
2,001-3,000 63(23.3) 36(20.7) 27(28.1)
3,001-4,000 24(8.9) 15(8.6) 9(9.4)
>4,000 10(3.7) 8(4.6) 2(2.1)
Source of monthly income
Parents 193(71.5) 122(70.1) 71(74)
Girl/boyfriends 3(1.1) 2(1.1) 1(1)
Parents & work 50(18.5) 38(21.8) 12(12.5)
Parents &
girl/boyfriends 17(6.3) 8(4.6) 9(9.4)
Work &
girl/boyfriends 2(0.7) 2(1.1) -
Relatives 5(1.9) 2(1.1) 3(3.1)
 174

As shown in Table 6, overall, 10% (n=27) of sexually active participants

reported experiencing pregnancy: 14% (25) of males had impregnated someone and

2% (n=2) of females had been pregnant. Of the 27 participants who experienced

pregnancy, 6% (n=15) had had an abortion once, 1.5% (n=4) had had it twice, 1.5%

(n=4) had had it three times, and 1.5% (n=4) had had it more than three times. Twelve

percent (n=12) of the participants who decided to terminate their pregnancies had the

abortion done at a private hospital. Another negative outcome of condom non-use

among sexually active participants is contracting STDs. Of the 180 sexually active

participants, 0.7% (n=2) having had syphilis, 0.7% (n=2) having had genital warts,

0.7% (n=2) having had herpes in the genital area, and 5.2% (n=14) having had pelvic

inflammatory disease (PID) or urethritis (See Table 6).

Regarding age at first sexual intercourse, the overall mean age was 16.88 years

with a standard deviation of 1.93 and an age range of 11 years to 20 years. Among

sexually active participants, 3% (n=8) initiated the first sexual intercourse at age of 11

which is considered as the youngest age among this group. With regards to the

reasons for using condoms, where participants could select from more than one

option, 30% of sexually active participants reported that they used condoms to

prevent pregnancy, 30.4% to prevent AIDS, 28.1% to prevent STDs, and 10.4% to

please girl/boyfriend’s need. Alternatively, sexually active participants who have

“never” used condoms reported that the major reason not using them was that

condoms were “not natural” 10.4%, they used other methods (i.e. birth control pills, &

injection birth control) (5.6%), 4.8% thought that condoms were “not convenient”,

they were at no risk for pregnancy 4.4%, 4.1% reported that they did not have condom

when needed, 3.7% reported that their partners disliked condoms, no risk for STDs

3%, and no risk for AIDS 3%.

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Table 6

Descriptive Statistics of the Negative Outcomes of Condom non-use (n=180)*

Characteristics Overall Male Female

n(%) n(%) n(%)

Pregnancy 27(10) 25(14.4) 2(2.1)

Abortion(s)
Once 15(5.6) 13(7.5) 2(2.1)
Twice 4(1.5) 4(2.3) -
Three times 4(1.5) 4(2.3) -
More than three times 4(1.5) 4(1.5) -
Place of having an abortion
Private hospital 12(4.4) 12(6.9) -
Federal hospital 2(0.7) 2(1.1) -
Clinic by physician 4(1.5) 2(1.1) 2(2.1)
Clinic by illegal person 4(1.5) 4(2.3) -
Done at clinic by physician first,
then went to hospital 6(2.2) 6(3.4) -
Done at clinic by illegal person first,
then went to hospital 2(0.7) 2(1.1) -
Contracting STDs
Syphilis 2(0.7) 2(1.1) -
Genital warts 2(0.7) 2(1.1) -
Herpes in the genital area 2(0.7) 2(1.1) -
PID/Urethritis 14(5.2) 12(6.9) 2(2.1)

* Includes only those reported to be sexually active

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Description of study variables:

As shown in Table 7, the overall mean age of participants was 19.18 years

with a standard deviation of 0.83 and an age range of 18 to 21 years. The mean item

score of perceived preventive behavioral peer norm was moderate at 2.31 on a scale

of 0 to 4. The mean score of knowledge of STDs/HIV/AIDS and pregnancy was low

at 24.96 with a standard deviation of 6.54 (possible range: 0 to 39). The mean item

knowledge score was 64% of the total knowledge score. The mean item score of

attitudes toward condom use was moderate at 3.92 on a scale of 0 to 6. The mean item

score of self-efficacy in condom use was moderate at 2.34 on a scale of 0 to 4 (See

Table 7).

Table 7

Descriptive Statistics of Independent Variables of the Sample (n=270)

Characteristics Mean SD Actual Possible Mean

Total score range range item score

Age 19.18 0.83 18-21 18-21 -

Perceived preventive
behavioral peer norms 11.58 3.17 3-17 0-20 2.31
Knowledge of STDs/
HIV/AIDS & Pregnancy 24.96 6.54 5-36 0-39 64%
Attitudes toward
condom use 90.35 15.71 61-130 0-138 3.92
Condom use self-efficacy 32.83 12.60 0-56 0-56 2.34
 177

As shown in Table 8, self-reported history of alcohol/drug use was measured

by the two-item-self-administered questionnaire; one item for alcohol consuming and

another one for drug use. Score for each item ranges from 0=never to 4=all of the

time. Then, self-reported history of alcohol/drug use scores will be combined. A

higher score is indicative of greater use of alcohol and/or drugs. Participants obtained

a minimum score of 0-point and a maximum of 8-points out of 8 possible points

(M=1.08, SD=1.29). The mean item self-reported history of alcohol/drug use score

was 54% of the total scores (See Table 4). Furthermore, overall, seventy participants

(25.90%) reported that they never consumed alcohol or used drugs before engaging in

a sexual intercourse. Eighty-four participants (31.10%) reported that they consumed

alcohol or abused drugs once in a while before engaging in a sexual intercourse.

Twenty-four participants (8.90%) reported drinking alcohol or using drugs half of the

time before engaging in a sexual intercourse. Only 2 participants (0.70%) reported

drinking alcohol or using drugs all of the time before engaging in a sexual intercourse

In this study, actual usage of condoms is a dependent variable. The mean score

of actual usage of condoms was 1.71 on a Likert scale of 0 to 4, which was almost in

the mid range of a scale. More details on condom use behavior, actual usage of

condoms, will be provided in Table 8.

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Table 8

Descriptive Statistics of Self-reported History of Alcohol/Drug use and Actual Usage

of Condoms among Sexually Active Adolescents (n=180)*

Characteristics Mean SD Actual Possible Mean

Total score range range item score

Self-reported history of
of alcohol/drug use 1.08 1.29 0-8 0-8 54%

Actual usage of condoms 5.15 3.99 0-12 0-12 1.71

* Includes only those reported to be sexually active

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In regards to duration of the current intimate relationship, this variable was

measured by asking the participants to give or estimate the number of days of the

most recent or current sexual relationship ranged from 7-15 days to more than 90

days. Overall, seventy-three participants (40.6%) reported that they had been involved

in current sexual active with their most recent or current partner for 7-15 days.

Twenty-one participants (11.7%) reported that they had been involved in current

sexual active with their most recent or current partner for 16-30 days. Whereas,

fifteen (8.3%) participants reported that they had been involved in current sexual

active with their most recent or current partner for 31-45 days. Besides, the

percentage (5.5%) and number of participants (n=10) who reported that they had been

involved in current sexual active with their most recent or current partner for “46-60

days” and for “60-90 days” are the same. Fifty-one participants (28.4%) reported that

they had been involved in current sexual active with their most recent or current

partner more than 90 days (see Table 9).

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Table 9

Percentage and Number of responses on Duration of the current intimate relationship

(n=180)*

Characteristics Overall Male Female

n(%) n(%) n(%)

Duration of the current

intimate relationship
7-15 days 73(40.6) 63(46.0) 10(23.3)
16-30 days 21(11.7) 13(9.5) 8(18.6)
31-45 days 15(8.3) 15(10.9) -
46-60 days 10(5.5) 8(5.8) 2(4.6)
60-90 days 10(5.5) 6(4.4) 4(9.3)
> 90 days 51(28.4) 32(23.4) 19(44.2)

* Includes only those reported to be sexually active

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As shown in Table 10, perceived preventive behavioral peer norms were

measured by using the perceived preventive behavioral peer norm questionnaire. Five

items with a 5-point Likert scale was used with 0 (none of my friends) and 4 (all of

my friends); 20 points were possible, and the higher score, the greater the perception

of preventive behavioral peer norms. Overall, the participants (30.4%) reported that

some of their friends think it is best for teens to wait to have sex until they are older.

One hundred and twenty six (46.7%) reported that a few of their friends think that

teens should use condoms when they have sex. One hundred and seventy-four

(64.4%) reported that none of their friends think that it is okay for teens to get

pregnant. One hundred and eleven (41.1%) reported that a few of their friends think

that it is okay for teens to drink alcohol. Also, one hundred and eleven (41.1%)

reported that none of their friends think that it is okay for teens to use drug (See Table

10).
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Table 10

Percentage and Number of responses on perceived preventive behavioral peer norms

(n=270)

Variable Overall Male Female

n(%) n(%) n(%)

Wait to have sex until they are older

None of my friends 57(21.1) 52(29.9) 5(5.2)
A few of my friends 50(18.5) 31(17.8) 19(19.8)
Some of my friends 82(30.4) 44(25.3) 38(39.6)
Most of my friends 7(2.6) 5(2.9) 2(2.1)
All of my friends 74(27.4) 42(24.1) 32(33.3)
Teens should use condoms when they have sex
None of my friends 15(5.6) 13(7.5) 2(2.1)
A few of my friends 126(46.7) 92(52.9) 34(35.4)
Some of my friends 31(11.5) 16(9.2) 15(15.6)
Most of my friends 49(18.1) 24(13.7) 25(26.0)
All of my friends 49(18.1) 29(16.7) 20(20.9)
It is okay for teens to get pregnant
None of my friends 174(64.4) 103(59.2) 71(74.0)
A few of my friends 22(8.1) 20(11.5) 2(2.1)
Some of my friends 38(14.2) 23(13.2) 15(15.6)
Most of my friends 2(0.7) 1(0.6) 1(1.0)
All of my friends 34(12.6) 27(15.5) 7(7.3)
It is okay for teens to drink alcohol
None of my friends 38(14.1) 25(14.4) 13(13.5)
A few of my friends 111(41.1) 87(50.0) 24(25.0)
Some of my friends 38(14.1) 19(10.9) 19(19.8)
Most of my friends 16(5.9) 13(7.5) 3(3.1)
All of my friends 67(24.8) 30(17.2) 37(38.6)
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Table 10 (continued)

Percentage and Number of responses on perceived preventive behavioral peer norms

(n=270)

Variable Overall Male Female

n(%) n(%) n(%)

It is okay for teens to use drug

None of my friends 111(41.1) 52(29.9) 59(61.4)
A few of my friends 27(10.0) 25(14.4) 2(2.1)
Some of my friends 59(21.8) 42(24.1) 17(17.7)
Most of my friends 5(1.9) 5(2.9) -
All of my friends 68(25.2) 50(28.7) 18(18.8)
 184

As shown in Table 11, self-efficacy in condom use was measured by using the

Condom Self-Efficacy questionnaire. This questionnaire is comprised of three

subscales, including consistent condom use self-efficacy, correct condom use self-

efficacy, and communication self-efficacy with partner. Fourteen items with a 5-point

Likert scale was used with 0 (very unsure) to 4 (very sure); 56 points were possible.

The higher score indicated the greater self-efficacy in condom use. Overall, One

hundred and two participants (37.8%) reported that they are sure to use condom

consistently. One hundred and seventeen (43.4%) reported that that they are sure to

use condom correctly. One hundred and thirteen (41.4%) reported that they are sure to

communicate about condom use with partner (See Table 11).

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Table 11

Percentage and Number of responses on self-efficacy in condom use (n=270)

Self-efficacy in condom use Overall Male Female

n(%) n(%) n(%)

- Consistent condom use self-efficacy

Very unsure 18(6.7) 11(6.3) 7(7.3)
Unsure 22(8.1) 15(8.6) 7(7.3)
Somewhat sure 58(21.4) 29(16.6) 29(30.2)
Sure 102(37.8) 60(34.6) 42(43.7)
Very sure 70(25.9) 59(33.9) 11(11.5)
- Correct condom use self-efficacy
Very unsure 12(4.4) 6(3.4) 6(6.3)
Unsure 23(8.5) 12(6.8) 11(11.4)
Somewhat sure 79(29.3) 49(28.3) 30(31.3)
Sure 117(43.4) 81(46.6) 36(37.5)
Very sure 39(14.4) 26(14.9) 13(13.5)
- Communication self-efficacy with partner
Very unsure 12(4.5) 7(4) 5(5.2)
Unsure 17(6.5) 14(8) 3(3)
Somewhat sure 57(21.2) 38(21.9) 19(19.7)
Sure 113(41.4) 69(39.6) 44(45.9)
Very sure 71(26.4) 46(26.5) 25(26.2)
 186

As shown in Table 12, actual usage of condom was measured by 3 items,

including condom use at the beginning of a sexual relationship, condom use at the last

few times of a sexual relationship, and condom use in general of a sexual relationship.

The three items with a 5-point Likert scale were used with 0 (never use) and 4 (every

time use); 12 points were possible, and the higher score, the greater actual usage of

condom. Overall, fifty one participant (28.3%) reported that they never used condom

at the beginning of a sexual relationship. Fifty seven (31.7%) reported that they never

used condom at the last few times of a sexual relationship. Forty six (25.6%) reported

that in general, they never used condom in a sexual relationship (See Table 12).
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Table 12

Percentage and Number of responses on actual usage of condoms (n=180)*

Actual usage of condoms Overall Male Female

n(%) n(%) n(%)

At the beginning
Never use 51(28.3) 35(25.5) 16(37.2)
Sometimes use 42(23.3) 33(24.1) 9(21.0)
Often time use 23(12.8) 17(12.4) 6(13.9)
Most of the time use 40(22.3) 36(26.3) 4(9.3)
Every time use 24(13.3) 16(11.7) 8(18.6)
The last few times
Never use 57(31.7) 40(29.2) 17(39.5)
Sometimes use 44(24.4) 38(27.8) 6(14)
Often time use 18(10.0) 10(7.3) 8(18.6)
Most of the time use 31(17.2) 27(19.7) 4(9.3)
Every time use 30(16.7) 22(16.0) 8(18.6)
In general
Never use 46(25.6) 32(23.4) 14(32.6)
Sometimes use 37(20.5) 30(21.9) 7(16.3)
Often time use 27(15) 21(15.3) 6(13.9)
Most of the time use 40(22.2) 34(24.8) 6(13.9)
Every time use 30(16.7) 20(14.6) 10(23.3)

* Includes only those reported to be sexually active

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In Table 13, the gender difference on actual usage of condoms is indicated in

that 25.6% of females and 18.2% of males reported using condoms occasionally

(sometimes use). Also, 18.7% of females, compared to 29.1% of males, used condoms

often, while 14.0% of females and about 21.8% of males used condoms most of the

time. More females (18.4%) than males (12.7%) used condoms every time they were

involved in sexual activity. Furthermore, more females (23.3%) than males (18.2%)

had never used condoms during sexual intercourse. This finding might be related to

the double standards that exist among the genders.

Table 13

Differences of actual usage of condom frequency by gender (n=180)*

Frequency of condom use Male Female

n(%) n(%)

Never use 25(18.2) 10(23.3)

Sometimes use 25(18.2) 11(25.6)

Often time use 40(29.1) 8(18.7)

Most of the time use 30(21.8) 6(14.0)

Every time use 17(12.7) 8(18.4)

2
*Includes only those reported to be sexually active; χ = 22.775, df = 12, p <0.05
 189

Knowledge of STDs/HIV/AIDS and Pregnancy

The knowledge of STDs/HIV/AIDS and Pregnancy questionnaire was used to

measure knowledge of STDs/HIV/AIDS and pregnancy. The questionnaire contained

39 items. The questionnaire is comprised of 2 parts, including STDs and HIV

knowledge (28 items) and the pregnancy knowledge (11 items). Thirty-nine items

with “yes”, “no”, or “don’t know” answers were used with 0 (no and don’t know) and

1 (yes); 39 points were possible. The higher score is indicative of higher knowledge

of STDs/HIV/AIDS and pregnancy. The mean score of STDs/HIV/AIDS knowledge

was 18.26 with a standard deviation of 4.63 (possible range: 0 to 28). The mean item

STDs/HIV/AIDS knowledge score was 65% of the total STDs/HIV/AIDS knowledge

score. In addition, the mean score of pregnancy knowledge was 6.70 with a standard

deviation of 2.66 (possible range: 0 to 11). The mean item pregnancy knowledge

score was 60% of the total pregnancy knowledge score.

Attitudes toward condom use

The Condom Attitude Scale - Adolescent Version (CAS-A) (St. Lawrence et

al., 1994) was used to determine attitudes toward condom use. This questionnaire is

comprised of six subscales, including relationship safety, perceived risk, interpersonal

impact, safety, effect on sexual experience, and promiscuity. Twenty-three items with

a 7-point Likert scale was used with 0 (strongly disagree) to 6 (strongly agree). The

higher score indicated the positive attitudes about condoms. Overall, the participants

reported positive attitudes towards condom use; the average sum of the attitudes

toward condom use is 90.35 and a standard deviation of 15.71 on a scale with a

possible range of 0 to 138. On a relationship safety subscale, scores ranged from 0 to

30, with a mean of 17.65 and a standard deviation of 7.34. On a perceived risk

subscale, scores ranged from 0 to 30, with a mean of 22.45 and a standard deviation
 190

of 5.20. On an interpersonal impact subscale, scores ranged from 0 to 24, with a mean

of 18.93 and a standard deviation of 4.95. On a safety subscale, scores ranged from 0

to 18, with a mean of 13.70 and a standard deviation of 3.48. On an effect on sexual

experience subscale, scores ranged from 0 to 18, with a mean of 9.80 and a standard

deviation of 3.92. On a promiscuity subscale, scores ranged from 0 to 18, with a mean

of 7.81 and a standard deviation of 4.18.

In the next sections, the findings of this study are presented to answer the

following research questions:

Research Question 1: Is there a relationship between personal information

(gender, age, self-reported history of alcohol/drug use, duration of the current

intimate relationship, and perceived preventive behavioral peer norms) and

condom use behavior?

Pearson’s correlation analysis was used to examine the bivariate relationships

between personal information (gender, age, self-reported history of alcohol/drug use,

duration of the current intimate relationship, and perceived preventive behavioral peer

norms) and dependent variable, actual usage of condoms. The value of statistical

significant was set at the alpha level of 0.05. There was a significant negative

relationship between self-reported history of alcohol/drug use and actual usage of

condoms (r=-0.18, p=0.009) indicating that the more adolescents used alcohol/drug,

the less likely they used condom. However, the correlation between gender (r=0.045,

p=0.550), age (r=-0.002, p=0.982), duration of the current intimate relationship (r=-

0.005, p=0.948), and perceived preventive behavioral peer norms (r=0.045, p=0.548)

and actual usage of condoms were not statistically significant. A summary on the

bivariate relationships between personal information (gender, age, self-reported

history of alcohol/drug use, duration of the current intimate relationship, and

 191

perceived preventive behavioral peer norms) and actual usage of condoms are

presented in Table 14.

Table 14

Bivariate correlation matrix for personal information (gender, age, self-reported

history of alcohol/drug use, duration of the current intimate relationship, and

perceived preventive behavioral peer norms) and actual usage of condoms (n=180)

Actual usage of condoms

Variable Correlation coefficient (r) p-value

Gender 0.045 0.550

Age -0.002 0.982

Self-reported history of alcohol/drug use -0.18 0.009**

Duration of the current intimate relationship -0.005 0.948

Perceived preventive behavioral peer norms 0.045 0.548

** significant at p<0.01
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Research Question 2: Is there a relationship between knowledge of

STDs/HIV/AIDS and pregnancy and condom use behavior?

Pearson’s correlation analysis was utilized to examine the bivariate

relationships between knowledge of STDs/HIV/AIDS and pregnancy and actual usage

of condoms. The value of statistical significant was set at the alpha level of 0.05. The

result showed that knowledge of STDs/HIV/AIDS and pregnancy was not

significantly correlated to actual usage of condoms (r=0.028, p=0.707).

Research Question 3: Is there a relationship between attitudes toward condom

use (relationship safety, perceived risk, interpersonal impact, safety, effect on

sexual experience, and promiscuity) and condom use behavior?

Pearson’s correlation analysis was used to examine the bivariate relationships

between attitudes toward condom use (relationship safety, perceived risk,

interpersonal impact, safety, effect on sexual experience, and promiscuity) and actual

usage of condoms. The value of statistical significant was set at the alpha level of

0.05. The result showed that there was a positive significant correlation between

attitudes toward condom use (relationship safety, perceived risk, interpersonal impact,

safety, effect on sexual experience, and promiscuity) and actual usage of condoms

(r=0.261, p=0.001). That is to say, adolescents who had the positive attitudes about

condoms were more likely to use condom.

Research Question 4: Is there a relationship between condom use self-efficacy

(consistent condom use self-efficacy, correct condom use self-efficacy, and

communication self-efficacy with partner) and condom use behavior?

Pearson’s correlation analysis was used to examine the bivariate relationships

between condom use self-efficacy (consistent condom use self-efficacy, correct

condom use self-efficacy, and communication self-efficacy with partner) and actual
 193

usage of condoms. The value of statistical significant was set at the alpha level of

0.05. The result showed that there was a positive significant correlation between

condom use self-efficacy (consistent condom use self-efficacy, correct condom use

self-efficacy, and communication self-efficacy with partner) and actual usage of

condoms (r=0.233, p=0.001). In other words, adolescents who had higher condom use

self-efficacy were likely to use condom more frequently.

Research Question 5: Do the independent variables (gender, age, self-reported

history of alcohol/drug use, duration of the current intimate relationship,

perceived preventive behavioral peer norms, knowledge of STDs/HIV/AIDS &

pregnancy, attitudes toward condom use, and condom use self-efficacy) predict

the dependent variable (condom use behavior)?

The Multiple Regression statistic was applied to examine the association

between the independent variables (gender, age, self-reported history of alcohol/drug

use, duration of the current intimate relationship, perceived preventive behavioral peer

norms, knowledge of STDs/HIV/AIDS & pregnancy, attitudes toward condom use,

and condom use self-efficacy) and the dependent variable, actual usage of condoms.

The independent variables explained 11.3% (R2=11.3%) of the variance in condom

use. The overall regression equation was significant (F=3.85, p=0.001).

Self-reported history of alcohol/drug use (B=-0.160, t=-2.145, p=0.033),

attitudes toward condom use (B=0.298, t=3.498, p=0.001), and condom use self-

efficacy (B=0.183, t=2.382, p=0.018) significantly predicted the actual usage of

condoms, when controlling for gender, age, duration of the current intimate

relationship, perceived preventive behavioral peer norms, knowledge of

STDs/HIV/AIDS and pregnancy. Self-reported history of alcohol/drug use was

significantly (p=0.033) associated with a decrease (B=-0.160) in actual usage of

 194

condoms. A unit increase in attitudes toward condom use was significantly (p=0.001)

associated with an increase (B=0.298) in actual usage of condoms. A unit increase in

condom use self-efficacy was significantly (p=0.018) associated with an increase

(B=0.183) in actual usage of condoms. Nevertheless, gender (B=0.157, t=1.916,

p=0.057), age (B=-0.004, t=-0.056, p=0.955), duration of the current intimate

relationship (B=-0.017, t=-0.240, p=0.811), perceived preventive behavioral peer

norms (B=0.000, t=-0.002, p=0.999), and knowledge of STDs/HIV/AIDS and

pregnancy (B=-0.104, t=-1.238, p=0.217) were not significantly associated with actual

usage of condoms, when controlling for self-reported history of alcohol/drug use,

attitudes toward condom use, and condom use self-efficacy. The association between

the independent variables, and dependent variable was summarized in Table 15.
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Table 15

Association between personal information (gender, age, self-reported history of

alcohol/drug use, duration of the current intimate relationship, and perceived

preventive behavioral peer norms), knowledge of STDs/HIV/AIDS and pregnancy,

attitudes toward condom use, and condom use self-efficacy, and actual usage of

condoms (n=180)

F = 3.85 p = 0.001** R2 = 11.3%

Variable B t-value p-value

Gender 0.157 1.916 0.057

Age -0.004 -0.056 0.955

Self-reported history of alcohol/drug use -0.160 -2.145 0.033*

Duration of the current intimate relationship -0.017 -0.240 0.811

Perceived preventive behavioral peer norms 0.000 -0.002 0.999

Knowledge of STDs/HIV/AIDS & pregnancy -0.104 -1.238 0.217

Attitudes toward condom use 0.298 3.498 0.001**

Condom use self-efficacy 0.183 2.382 0.018*

**significant at p<0.01, *significant at p<0.05

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Section II Summary of the Findings from Two-Open-Ended Questions

In this section, additional findings that are based on the participants’ responses

to two open-ended-questions about premarital sexual behavior among Thai

adolescents are presented.

Question 1: Tell me what you feel about premarital sexual behavior among Thai

adolescents.

1. A number (n=63) of Thai male respondents almost universally considered

that it is acceptable to participate in premarital sexual relationships if they would

accept the responsibilities that are associated with having intimate relationships with

their girlfriend. The responsibilities could include unexpected pregnancies and the

prevention of the transmission of diseases. Besides, they suggested that it is okay with

them if teenagers would agree to protect themselves by using condoms or having their

partners use contraceptive methods to prevent unintended pregnancies. The study

participants recommended using birth control pills and/or injection birth control

substances.

2. A majority of Thai male adolescents (n=60) stated that they approved of

premarital sexual activity because it was accepted among their peers as an okay and

acceptable behavior. Thus, from their perspectives, it is now a common practice

among young unmarried adolescents to engage in sexual relations. Furthermore, some

of them expressed their approval of unmarried Thai adolescents, especially students,

living together as a “trial period”. If, after a designated period of time, the couple felt

displeased with each other, they could agree to terminate their relationship. At this

point, each person would go their own ways without obligation or shame. In

generally, it is agreed that the trend is gaining in momentum and in popularity. The

study participants suggested that this practice is becoming more common in the rural
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areas of Ubonratchathani Province. Other study participants thought that this living

arrangement is considered to be “fashionable” among Thai adolescents. A number of

factors, including the mass media, the internet, and friends, undoubtedly influence the

perceived frequency of premarital cohabitation by these Thai adolescents. They also

stated that this “fashionable” type of living arrangement is occurring as a component

of the emulation of city lifestyles that are admired by suburban and rural adolescents.

In addition, it is also linked to their perceptions of the freedoms that adolescents in the

west (United States, England, etc.) experience (Isarabhakdi, 1999).

3. In addition, some young Thai males (n=29) and females (n=32) stated that

premarital sexual behavior among Thai adolescents was influenced by a number of

sources, including internet, television, and pornographic magazines. These media are

easily available to them, and do not cost much money.

4. Some respondents, both males (n=18) and females (n=25), stated that

premarital sexual relationship is considered to be against the Thai traditional rule as

embedded in its culture and its practices. In general, they agree that young Thai

adolescents should obey to the rules and the cultural beliefs and practices that their

ancestors practiced over the centuries. These adolescents indicated that they would

remain abstinent until they are married.

5. Some Thai male adolescents (n=12) made the point that they engaged in

premarital sexual behavior with their girlfriend because they were driven by strong

sexual desires. A common perception among Thai male adolescents is that male

sexuality involves a physically powerful and well defined natural sexual urge that

requires periodic release. Having a sexual partner was seen as essential for the natural

release of their sexual urges, and they therefore engaged in sexual intercourse with a

fitting partner. Additionally, they claimed that there would not/should not be any
 198

negative consequence such as contracting STDs/HIV/AIDS because of several

reasons. First, they trusted their partners. Second, they would have known their

partners for a long time. Third, they did not think that they were susceptible to the

threat of sexually transmitted diseases.

Question 2: Would you share with me your thoughts about young Thai men

having sex before marriage? Now, tell me what you think about the female.

1. Some young Thai males (n=59) considered that having sex before marriage

was an ordinary practice that was common among Thai men. The adolescents

indicated that they would have sexual experiences before marriage whether it was

with prostitutes and/or their girlfriends. That is to say, these males made it clear that

they would engage in sexual relationships with a partner regardless of the nature of

the relationship - prostitute or girlfriend - perhaps both. On the other hand, these same

males emphatically stated that they thought that it is unacceptable for young Thai

females to engage in sexual activity before marriage. Their double standard regarding

sexual activity before marriage was not of concern to them.

2. Many young Thai males (n=42) stated that it is not an unusual finding

among Thai males if one discovers that the males agree that sexual activity before

marriage is okay for them. In fact, if Thai males do not practice premarital sexual

activities before marriage, they are at risk for being ridiculed by peers. They indicated

that “peer influence” among their friends is a very strong determinant of sexual

behaviors among the males.

3. Although there is widespread agreement that it is common for young Thai

men to have sexual experiences before marriage, it is not universally approved.

Young Thai female adolescents do not condone this sexual double standard and the

males’ sexual behaviors. The Thai females were more concerned about the risk of
 199

infections from sexually transmitted diseases (STDs). This threat was frequently cited

by young Thai women (n=20), as a basic reason to take exception to young Thai men

be able to have sexual experiences with females before marriage. They were also

concerned about the multi partners that the male adolescents are likely to have had at

the time of marriage. In general, young Thai females were more than twice as likely

as young Thai men to mention STDs when responding to queries about whether

having sexual relationships before marriage was common or appropriate for young

Thai adolescents.

4. A number of Thai female adolescents (n=24) responded that Thai females

should remain virgins until marriage. On the other hand, some young Thai males

(n=36) verbalized their thoughts. First, they admitted that their plans were to continue

to engage in sexual experiences with females before marriage with their girlfriends,

ex-girlfriends and/or prostitutes. Second, they also verbalized a strong desire to marry

with a virgin Thai female. Third, their last choice of a mate would be a female who

has had sexual experiences with other males.

5. Some young Thai females (n=22) pointed out that they had plans to remain

virgins until they got married. These adolescents voiced concerns about their personal

dignity and reputation. These adolescents expressed a desire to keep their virginity for

their groom or future husband-to-be. They claimed that “a good Thai girl” should not

be promiscuous and some avoid having sex before marriage. Others (n=20)

emphasized that it is a “taboo among Thai adolescents” to become sexually active

before marriage.

6. A number of Thai female adolescents (n=25) responded that they did not

want to make their parents upset or “lose face” by participating in unacceptable

behaviors, especially premarital sexual activities. Therefore, they have committed

 200

themselves to remaining virgins until they are married. Still, others (n=28) pointed out

that their sexual decision making and having sex before marriage would demolish

their own reputation and their family’s reputation as well. To demolish their family’s

reputation would be a taboo thing to do, and it would create much pain and anguish

for the family members and the Thai adolescent.

 201

CHAPTER V

Discussion

The purpose of this cross-sectional descriptive correlational study was to

determine the relationships among personal information, attitudes toward condom

use, condom use self-efficacy, and condom use behavior, and to identify statistical

predictors of condom use behavior. The study utilized Bandura’s Self-Efficacy (SE)

model of safer sex behavior (Bandura, 1990). Thai vocational school students

between the ages of 18 to 21 years in Ubonratchathani Province, Thailand were

invited to participate in the study. This study was conducted on a multistage cluster-

based sample of 270 vocational school students from three randomly selected

vocational schools in Ubonratchathani Province, Thailand. Because this research

aimed to examine actual usage of condoms among heterosexual partners, individuals

who described themselves as heterosexual were invited to participate in the study. All

subjects identified their sexual orientation as heterosexual (174 males, 64.4%; 96

females, 35.6%). Of the 270 subjects, 180 participants (66.66%) had been sexually

active and 90 participants (33.34%) had never been sexually active. Data generated

from the 270 subjects were analysis in this study.

This chapter includes the interpretation of the study findings. In addition, it

also presents the limitations of the study. The chapter concludes with study

implications for nursing research, nursing practice, health policy, and

recommendations for future research that addresses self-efficacy in condom use

behavior among Thai adolescents.

Discussion of major research findings

The important findings of this current study suggest that three factors are

important in explaining condom use behavior among Thai adolescents. These three
 202

factors include the self-reported history of alcohol/drug use, attitudes toward condom

use, and condom use self-efficacy. A number of studies have attempted to identify

factors that might influence condom use behavior through the use of various theories,

including the Health Belief Model, the Theory of Reasoned Action, and the Theory of

Planned Behavior. This study, however, is unique in that it was conceptualized with

using Bandura’s Self-Efficacy (SE) model of safer sex behavior (Bandura, 1990) to

examine the influence of the independent variables (gender, age, self-reported history

of alcohol/drug use, duration of the current intimate relationship, perceived preventive

behavioral peer norms, knowledge of STDs/HIV/AIDS and pregnancy, attitudes

toward condom use, and condom use self-efficacy) on the dependent variable, actual

usage of condoms. That is to say, in this study, multiple regression analysis

incorporated the possible independent variables that could predict the outcome,

condom use behavior. The results outlined in the previous chapter provide support the

conceptual framework of this study, Bandura’s Self-Efficacy (SE) model of safer sex

behavior (Bandura, 1990). Each of the eight variables that were presented in Chapter

4 will be discussed.

Gender

The current study findings revealed that gender was neither significantly nor

linearly related to actual condom usage among the adolescents. These results are not

consistent with some of the previous research studies that indicate that male

adolescents were more likely than female adolescents to report actual usage of

condoms (Laraque et al., 1997; Bazargan et al., 2000; Baele et al., 2000).

Nevertheless, the findings of this current study were consistent with the research of

Thato and associates (2003), who reported that gender of the participants (n=391) in

their study was not significantly correlated with actual condom use. A possible
 203

explanation for the non-significant relationship between gender and actual condom

use is that in this study was related to the primary reason for condom use - the

prevention of pregnancy (30%). Instead of using condoms, the participants might

have elected to employ other contraceptive methods for the prevention of pregnancy.

In this study, participants stated several major reasons for not using condoms.

Included in their explanations were they are “not natural (10.4%)”; “used other

methods (5.6%)”; and “partners disliked condoms (3.7%)”. The findings from this

study both contradict and support the scientific literature. Hence, there is a need for

additional research studies to further delineate the associations between gender and

actual condom use among Thai adolescents. For emphasis, gender and actual condom

use among sexually active adolescent populations need to be carefully explored. To

date, little is known about how gender influences condom-use behavior among Thai

adolescents.

Age

Another cogent finding in this current study revealed a non-significant

relationship between age and actual condom use. The results from this study support

and contradict the scientific literature. First, the similarities of the study, findings in

this study were similar to those of Thato et al. (2003). Their study focused on

vocational school students (n=391); their findings revealed that age was not

significantly related to actual condom use. On the other hand, age was found to be

significantly associated with condom use behavior among adolescents (Ku et al.,

1994; Pleck et al., 1993; Davis, Duncan, Turner, & Young, 2001). From this current

study, a non-significant relationship between age and actual condom use might be due

to the narrow age range in this study. Only individuals in the late adolescent stage of

development (ages 18 to 21) were invited to participate in this study. The rationale for
 204

recruiting individuals in this stage of development was related to the tools and tasks

that are associated with late adolescents, including autonomy, wooing and winning a

mate, selecting a vocation and a career (Rew, 2005; Zarrett & Eccles, 2006). In

addition, they are advancing toward becoming independent thinkers and good citizens

(Zarrett & Eccles, 2006). Their next developmental stage is or soon will be early

adulthood where sexual expressions and commitments are a major component of life

(Brown & Brown, 2006). In this study, the narrow age range may penalize the

strength of the relationship between age and actual condom use. Perhaps, with a wider

age range of participants in the research, there might be a stronger association among

the variables.

Second, the non-significant findings that support the scientific literature

follow. A non-significant relationship between age and condom use behavior in this

current study is supported by several previous research studies (Walter et al., 1993;

Raj, 1996; Khaing, 1998). Nonetheless, the age range utilized in these reported studies

was wider than the age range used in this current study. Contrarily, some previous

studies revealed a significant relationship between age and actual condom use. Baele

and associates discovered that condom use increased with age (Baele et al., 2001).

The lack of consensus in the literature suggests that more empirical studies are needed

to help unravel the impact that the variable age has on condom use among Thai

adolescents.

Self-reported history of alcohol/drug use

In this current study, the findings revealed a significant negative relationship

(p<0.05) between self-reported history of alcohol/drug use and actual condom use. As

expected, the sexually active adolescents who consumed alcohol/drugs were less

likely to use condoms when engaged in sexual activity. Hence, the findings of this
 205

current study corroborate the results from previous studies. The relationship between

alcohol/drug use and high-risk sexual activity in adolescents is well supported in the

literature (Ford & Norris, 1994; Graves & Leigh, 1995; Lowry et al., 1994; Millstein

& Moscicki, 1995; Kaiser & Hays, 2005; So, Wong, & DeLeon, 2005; van

Griensven et al., 2005). The findings of this study were also similar to those obtained

by van Griensven and colleagues (2001) who studied sexual behavior, drug use, and

HIV/STDs in northern Thai adolescents. Their results indicated that 92.5% of male

and 80.5% of female study participants reported using alcohol/drugs before engaging

in sexual activity during the past 3 months. Furthermore, 22% of male and 3.6% of

female participants reported having ever used marijuana (van Griensven et al., 2001).

Another study was conducted to assess the relationship between alcohol and condom

use among high risk adolescents (n=300) in Denver, Colorado (USA). The results

showed that there was a significant association (r=-0.41) between alcohol use and

condom use behavior. In fact, the relationship (r=-0.41, p<0.001) between alcohol and

condom use was negative and significant among adolescents (Bryan, Rocheleau,

Robbins, & Hutchinson, 2005). In addition, Stoner, George, Peters, and Norris (2007)

conducted a study with students (n=115) at a large public university in the

northwestern United States to assess the association between alcohol intoxication on

the likelihood of risky sexual behavior (condom non-use). The participants reported

that the higher the level of their intoxication, the less likely they were to practice safer

sexual behavior (condom use).

In a recent study, Tho and colleagues (2007) conducted a cross-sectional

quantitative survey to examine the association between alcohol use and sexual

behaviors in 880 youths (412 males and 468 females) who were between 16 to 24

years of age, and residing in Nha Trang city, Vietnam. The findings revealed that the
 206

majority of the respondents (65.9%) had consumed alcohol, 25.8% had participated in

sexual touching among boy/girl friends, and 10.1% of respondents had engaged in

sexual behaviors, including vaginal sex, anal sex, and/or oral sex. Alcohol use was

significantly associated with the engagement in unsafe sexual practices (p < 0.001).

Forty percent of the males who did not use condoms during their last sexual activity

were drinkers when compared to 4.8% of the non-drinkers

(Tho, Singhasivanon, Kaewkungwal, Kaljee, & Charoenkul, 2007). The findings

regarding alcohol use and sexual risk taking behavior were similar to those

of Dunn, Bartee, and Perko (2003). They examined a self-reported alcohol use and

sexual behavioral practices among adolescents in Tennessee, USA. Their results

demonstrated a significant relationship between alcohol use and engaging in high risk

sexual behaviors (condom non-use). Furthermore, So, Wong, and DeLeon (2005)

examined sexual practices, HIV risks, and alcohol/substance use among 248

heterosexual Asian American college students. They found a lifetime prevalence of

unprotected sex (37%), alcohol before sex (23.8%), and drug use before sex (6.0%).

Ninety percent of the college students who have ever had sex did not use condoms.

Collectively, the findings of previous research studies and this current study,

suggest that there is a significant relationship between alcohol/drug use and unsafe

sexual behavior among adolescents. The possible reasons for these risky behaviors

have been delineated: alcohol/drug use plays a major role in the creation and

maintenance of unsafe sexual behavior. A traditional explanation has been provided

through the discussion of a disinhibition model (Buffum, 1988). The model suggests

that by way of pharmacological action, alcohol/drug use causes the expression of

behaviors that are usually suppressed and under control until an altered state of

consciousness consumes the individual. At this point, decision making, self-control,

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and other self-regulating behaviors wane. When person is without his/her typical

protective factors and cognitive capacity, other less desirable behaviors are likely to

appear. Consuming alcohol/drugs may produce sexual risk behaviors, including the

refusal to use condoms. Using alcohol/drugs decrease the typical functions of the

nervous system. Even when consumed or used in a low amount, alcohol/drugs could

decrease the individual’s ability to make a decision, and psychomotor coordination is

compromised (Buffum, 1988). Consequently, adolescents may engage in sexual risk

behaviors while under the influence of these substances. Prior use of any type of

substance is related to the initiation of sexual risk behavior (Cooper, 2002). This

process is not bound by culture or geography. That is, the use of alcohol/drugs during

the sexual encounter increases the likely hood of risky sexual behaviors (Dunn et al.,

2003; Bryan, Ray, & Cooper, 2007).

Duration of the current intimate relationship

Another finding in this current study revealed a non-significant relationship

between duration of the current intimate relationship and actual usage of condoms.

Results from this study both support and contradict the literature. The findings of this

current study were consistent with those of Thato et al. (2003). In a study conducted

by Thato and colleagues (2003) in vocational school students (n=391), the findings

revealed that the duration of the current intimate relationship was not significantly

related to actual condom use. On the other hand, the duration of the current intimate

relationship was found to be significantly associated with condom use behavior

among adolescents (Civic, 1999; Polacsek et al., 1999; Civic, 2000).

Recently, Bralock and Koniak-Griffin (2007) examined risky sexual behaviors,

gender, and power issues affecting sexual risk taking, which were the factors that

were most likely to promote self-protection among 126 female African American
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adolescents (14 to 20 years of age). They found that with length of relationship

increasing, trust often developed, leading to assumptions about partner fidelity and

safe sex. The length of the sexual relationship was a statistically significant predictor

of risky sexual behaviors. In this same study, the researchers concluded that

adolescents involved in lengthier intimate partner relationships were more likely to

report lower relative frequencies of condom use. In a study performed at a university-

based adolescent medicine clinic in San Francisco, California (USA), Ellen and

associates (1996) studied the association between the type of sexual relationship and

the adolescents’ perceptions about the consistency with which other adolescents use

condoms. The results showed that sexually experienced adolescents reported that

condoms were used less frequently with steady partners and more frequently with

“one-night stands” (p<0.001). The results of this study further demonstrated that

length of time of sexual relationship were statistically significant predictors of

condom use among adolescents (Ellen, Cahn, Eyre, & Boyer, 1996).

Similarly, Civic (1999) examined the association between characteristics of

dating relationships and condom use among heterosexual undergraduate adolescents

(n=210) in a Pacific Northwest university, USA. The results revealed that in a

multiple logistic regression model controlling for HIV/sexually transmitted diseases

(STDs), risk perception and contraceptive method, and relationship length were the

only relationship factors that significantly predicted condom use (OR = 0.91; 95% CI

= 0.84-0.99). Furthermore, Polacsek and associates (1999) found similar results when

they conducted a study among 812 African American young women in Baltimore,

Maryland. Telephone surveys were utilized to collect data on the attitudes, beliefs,

and practices of condom use with regular (main) sexual partners. The findings

revealed that length of sexual relationship was significantly related to condom use
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(Polacsek, Celentano, O’Campo, & Santelli, 1999). That is, if the relationships had

been ongoing for a longer period of time, there was less condom use.

Although it is well established that length of sexual relationship is a

statistically significant predictor of failure to use condoms (Bralock & Koniak-

Griffin, 2007), the finding of this current study contradicts this statement and the

literature presented earlier (Polacsek et al., 1999; Civic, 1999; Ellen et al., 1996;

Civic, 2000). The possible explanation for these differences could be that at the

beginning of intimate relationships, asking partners to use condoms might jeopardize

a sense of trust and the potential for “love”. Not using a condom could illustrate a

high degree of trust among the partners (Thato et al, 2003). In addition, among young

Thai women, requiring condom during sexual contact might help them to be

perceived as promiscuous. Recall that Thai men would prefer to engage in sexual

intercourse with virgin females (Knodel et al., 1996). Currently, in Thailand, very

limited research has been conducted that examines the influence of length of sexual

relationship on condom use behavior. Thus, further culture-specific research is needed

to delineate the relationship between the duration of the current intimate relationship

and actual usage of condoms among adolescents.

Perceived preventive behavioral peer norms

The current study findings showed a non-significant relationship between

perceived preventive behavioral peer norms and actual usage of condoms. Again,

these findings support and refute scientific literature. The unexpected results of this

present study were similar to what Maxwell, Bastani, and Warda (2000) have

reported. They examined AIDS related knowledge, attitudes, peer norms, and

behaviors among 211 Filipino-American adolescents and young adults residing in Los

Angeles County. The results revealed that peer norms were not significantly related to
 210

condom use during last sexual intercourse. Researchers suggested that the variables

that are related to AIDS risk behaviors among non-Asian populations may not explain

condom use among Filipino adolescents (Maxwell, Bastani, & Warda, 2000).

Nevertheless, in several previous studies, researchers found a significant relationship

between perceived preventive behavioral peer norms and actual condom use (Murphy,

Rotheram-Borus, & Reid, 1998; Isarabhakdi, 2000; Watronachai, 2004).

Recently, Parkes and associates (2007), in a study with 1,322 students (14 to 16 years

of age) in Scotland, the United Kingdom, reported a significant positive relationship

between peer sexual norms and condom use (Parkes, Wight, Henderson, & Hart,

2007). In Baltimore, Maryland (USA), another study was conducted

by Latkin, Forman, Knowlton, and Sherman (2003) to examine how peer norms

influence sexual risk behaviors among 1,051 young participants (18 to 25 years of

age). The results showed that peer norms about condom use (friends talking about

condoms, encouraging condom use, and using condoms) were significantly associated

with condom use (p<0.001). Also, Murphy, Rotheram-Borus, and Reid (1998) studied

peer and partner social norms on safe sex behavior in 132 heterosexual, sexually

active, inner city adolescents in Los Angeles, California (USA). The results indicated

that peer and partner social norms regarding safer sex were positively and

significantly related to safer sexual behavior (p<0.01).

In a study performed at adolescent health department clinics, and health

classes in high schools, Crosby and associates (2003) conducted a study among high-

risk African American (n=179) female adolescents (14 to 18 years of age) in

Birmingham, Alabama (USA). They assessed condom promotion strategies that

would be prospectively associated with condom use. The results revealed that peer
 211

norms regarding condom use were positively and significantly associated with actual

condom use (Crosby et al., 2003).

Although a number of previous research studies showed a significant

relationship between perceived preventive behavioral peer norms and actual usage of

condoms (Isarabhakdi, 2000; Crosby et al., 2003; Latkin, et al., 2003; Watronachai,

2004; Parkes et al., 2007), the finding of this current study is inconsistent with those

previous findings. The possible explanation that might explain this non-significant

relationship is low internal consistency (Cronbach α=0.47, original Cronbach α =

0.79) of the instruments that were used in the study. Also, the reader must also

consider important variables such as age, gender, culture, and societal norms, among

numerous others. Recently, the perceived preventive behavioral peer norm scale was

utilized to assess the influence of peer norms on condom use among adolescents in

Bangkok, Thailand (Thato et al., 2003); its internal consistency was quite low

(α=0.46). This five-item self-administered questionnaire assessed what adolescents

believed their friends thought regarding engaging in particular sexual-related

behaviors. Close inspection at the item level of the responses to perceived peer norms

demonstrated that items have little in common. An item asking “Do your friends think

that it is okay for teens to get pregnant?”; Most of the responses (64%) scored as 4

(none of my friends). Contrarily, an item inquiring “Do your friends think it is best for

teens to wait to have sex until they are older?” Most of the responses (30%) scored as

2 (some of my friends). According to Nunnally and Bernstein (1994), internal

consistency describes the estimation of reliability based on the average correlation

among items within the test. If the Cronbach’s alpha coefficient is low, the test is

either too short or the items have very little in common (Nunnally & Bernstein, 1994).

Moreover, as mentioned previously, the perceived preventive behavioral peer norm

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scale was used in a condom use study with adolescents in Bangkok, Thailand (Thato

et al., 2003). There is still much diversity within the Thai population, including

various norms, beliefs, health practices, and a variety of folk laws. As a result, the

sensitivity of this instrument might not be enough to capture the adolescents’

behaviors in this current study. The Ubonratchathani Province, Thailand, is remains a

diverse and dynamically changing geographical area for research on HIV/AIDS.

However, other, more culturally relevant and sensitive instruments should be

developed with psychometric properties related to the Thai population. Also, there is a

need for additional research to further delineate the relationship between perceived

preventive behavioral peer norms and actual condom use among adolescents.

Knowledge of STDs/HIV/AIDS and pregnancy

Of importance, the findings in this current study revealed a non-significant

relationship between knowledge of STDs/HIV/AIDS and pregnancy, and actual

condom use. The findings of this study, much like the previously reported data,

support and refute the reported research. A number of research studies have

demonstrated the importance of knowledge in determining adolescents’ behaviors

related to risk and prevention of STDs/HIV/AIDS and pregnancy. These studies,

however, have not shown a consistent relationship between knowledge and safer

sexual behaviors. Knowledge of STDs/HIV/AIDS and pregnancy has been found to

be significantly related to high-risk sexual behaviors by many researchers (Smith,

Weinman, & Mumford, 1992; Shafer & Boyer, 1991; Johnson, Rozmus, & Edmisson

1999; Tapia-Aguirre et al., 2004; Snelling et al., 2007). In these samples, greater

knowledge of STDs and HIV was related to fewer high-risk sexual behaviors.

Contrarily, other researchers have reported no significant relationships between

knowledge, sexual behaviors and condom use (Cole & Slocumb, 1995; Jemmott &
 213

Jemmott, 1991; Koniak-Griffin & Brecht, 1995; Rozmus & Edgil, 1993; Wulfert

&Wan, 1993; Okonta & Oseji, 2006; Colon, Wiatrek, & Evans, 2000; Kaemingk &

Bootzin, 1990). The finding of this present study supports the latter results. The

outcomes in this study is also consistent with previous research findings indicating

that there is no significant relationship between knowledge of STDs/HIV/AIDS and

pregnancy, and actual condom use among Thai adolescents (Wageewatana, 1990).

In a study conducted in the public high schools in Mexico, Tapia-Aguirre and

associates (2004) assessed the associations between condom use in Mexican youth

(n=13,293) and HIV/AIDS knowledge. They found that among high school Mexican

students (11 to 24 years of age), young men with high levels of knowledge about

HIV/AIDS were more likely to repeatedly use (Tapia-Aguirre et al., 2004). Similarly,

Snelling and associates (2007) conducted a study with young women in 23 low- and

middle-income countries (i.e. Brazil, Cameroon, & Zimbabwe). The purpose of the

study was to assess HIV/AIDS knowledge, women’s education, epidemic severity and

protective sexual behavior, reported a significant association between increased

knowledge of HIV/AIDS and condom use that varied in strength and cross-

nationalities (Snelling et al., 2007). Moreover, on the same theme, Johnson, Rozmus,

and Edmisson (1999) examined adolescents’ attitudes, knowledge, and values with

regard to sexuality, STDs, and sexual behavior among 170 rural high school students

in USA (grades 9 to 12), between the ages of 13 and 18 years. The results revealed a

significant relationship between knowledge of STDs and safer sexual behavior. The

researcher concluded that as the participants’ knowledge increased, the more likely

they were to use condoms during sexual intercourse. On the other hand, Okonta

and Oseji (2006) assessed the relationship between knowledge of HIV/AIDS and

sexual behavior among in-school adolescents (n=437) in the Delta State, Nigeria
 214

(Africa). The findings showed that knowledge of HIV/AIDS by in-school adolescents

has no significant relationship to their sexual behavior. The researcher suggested that

program planners should explore and integrate other factors (i.e. condom use self-

efficacy and attitudes toward condom use) that could impact positively on adolescent

sexual behavior. Furthermore, Colon, Wiatrek, and Evans (2000), in a study with

African-American male adolescents (n=229) between 14 to 19 years of age, reported

that HIV knowledge was not significantly related to adolescents’ decisions to use

condoms. Similar results were noted by Wulfert and Wan (1993). In their study with

single heterosexual and currently sexually active undergraduate students (n=212),

they found that AIDS knowledge was not related to condom use among adolescents.

Moreover, Shrier, Goodman, and Emans (1999), in a study with 24 adolescent girls,

reported that knowledge about condoms and STD prevention was not associated with

condom use. A number of research studies have revealed that even when adolescents

possess HIV prevention knowledge, they do not always consistently use condoms

(Belgrave et al., 1993; Brown, DiClemente & Park, 1992; Kaemingk & Bootzin,

1990; Kasen et al., 1992). A possible explanation for a non-significant relationship

between knowledge of STDs/HIV/AIDS and pregnancy and actual condom use could

be the fact that knowledge of STDs/HIV/AIDS and pregnancy may be necessary, but

not sufficient, to change sexual behavior. That is to say, sexual knowledge alone is

not sufficient to change sexual behavior among adolescents (Taylor-Seehafer & Rew,

2000; Low, 2006). Some research studies indicated that there is little connection

between knowledge of HIV/AIDS and self- protective sexual behavior (Koniak-

Griffin & Brecht, 1995; Strunin & Hingson, 1987). Learning that unprotected sexual

intercourse is the major route of HIV transmission may result in only minimal change

among adolescents’ risk sexual behavior. Consequently, factors other than knowledge
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may be having a greater impact on adolescents’ sexual behaviors (Jemmot, 1996;

Damond, Breuer, & Pharr, 1993). The role of cognition in sexual decision making

may differ among the Thai adolescent population. Thus, the instruments developed in

accordance with cognition-focused models may lack the ability to assess the essential

of decision making among Thai adolescents. According to Catania and colleagues

(1990), knowledge is important at the first stage of behavior change among adolescent

populations. Thus, knowledge is necessary, but not sufficient, to alter sexual

behavioral change (Catania, Kegeles, & Coates, 1990). For instance, if adolescents

have the necessary knowledge related to the route of HIV/AIDS transmission, they

might be more conscious about their risky behaviors. Nevertheless, when the behavior

involves the practice of condom use, it may involve more complicated processes,

including negotiation skills, and interpersonal communications. Generally, though,

adolescents have much HIV/AIDS knowledge, but they have knowledge deficits in

certain crucial areas. According to the evaluation of HIV/AIDS education programs,

increased knowledge is a common result. Only a few studies, nonetheless, have

reported favorable changes in HIV/AIDS risk behaviors (Fisher & Fisher, 1992).

Importantly, there is a need for further research studies to better understand the

cognitive factors that influence Thai adolescents’ decisions to engage in sexual

activity and to consistently use condoms. Emanating from this fact, researchers and

clinicians agree that Thai adolescents are a high risk group for acquiring

STDs/HIV/AIDS and for experiencing unintended pregnancies.

Attitudes toward condom use

In this current study, the findings showed a positive significant relationship

(p<0.01) between attitudes toward condom use (relationship safety, perceived risk,

interpersonal impact, safety, effect on sexual experience, and promiscuity) and actual
 216

condom use. As anticipated, the sexually active adolescents who possessed positive

attitudes toward condom were more likely to use condoms. The findings of this

present study corroborate the results from previous research. The relationship between

attitudes toward condom use and condom use behavior among adolescents is well

supported in the literature (Basen-Engquist & Parcel, 1992; Sheppard, Hartwick, &

Warshaw, 1988; Strader & Beaman, 1991). The findings of this study were consistent

with those recently obtained by Stulhofer and associates (2007). They studied

attitudes toward condom use and sexual behavior among young adults in Croatia

(Southeastern Europe) (n=1,093) aged 18 to 24. Their results indicated that positive

attitudes toward condom use were significantly associated with condom use behavior

(Stulhofer, Graham, Bozicević, Kufrin, & Ajduković, 2007).

Furthermore, Lescano and associates (2006) conducted a study to examine

adolescents’ attitudes (n=1,316) (aged 15 to 21 years) about and behaviors toward

condom use with “casual” and “main” sexual partners. The study took place in three

major cities in the United States: Atlanta, Georgia; Providence, Rhode Island; and

Miami, Florida. The researchers reported that a moderately significant positive

relationship between adolescents’ attitudes toward condom and condom use behavior

was evident (Lescano et al, 2006). The findings were consistent with Gebhardt and

colleagues (2003). These researchers studied with male and female adolescents

(n=701; 424 males and 277 females) between 15 to 23 years of age; they reported that

consistent condom use with casual partners was related to attitudes toward condom

use (Gebhardt, Kuyper, & Greunsven, 2003). Moreover, Minoia and Rose (1996)

examined attitudes toward condom use, frequency of condom use, and the

relationship between attitudes and condom use among sexually active female college

students (n=47) attending an upstate New York rural county family planning clinic.
 217

The results showed a positive significant relationship between attitudes toward

condom use and frequency of condom usage. Also, students who reported always

using condoms scored significantly higher in their attitudes toward condoms than

those who sometimes or never used condoms (p<0.05). Similarly, Myers and Clement

(1994) conducted a study to assess condom use and attitudes among heterosexual

college students (n=707) at 4 college campuses in Toronto, Canada. The findings

showed a significant relationship between positive attitudes toward condoms and

condom use behavior among participants. Also, females reported more positive

attitudes toward condom use than did their male counterparts. Males rated sexual

enjoyment to be more important. A greater proportion of males than females gave

reasons for not using condoms. A greater proportion of males than females gave

reasons for not using condoms. The researchers concluded that differences between

male and female attitudes and behavior are important to address in AIDS prevention

programs.

In addition, Tyden and associates (1996) conducted a longitudinal study to

investigate the changes in sexual behavior and attitudes as an indication of the impact

of intensified information activities aiming at decreasing the risk of spread of sexually

transmitted diseases among female adolescents (n=275) at Uppsala University,

Sweden. The findings showed that compared with the results in 1989, in 1994 the

participants’ attitudes toward condom use had become more positive. The actual use

of a condom had also increased both at the time of first intercourse and when

changing partner, from 40% to 60%. The researchers concluded that attitudes about

using condoms play a significant role in the actual use of condoms over time (Tyden,

Bjorkelund, Odlind, & Olsson, 1996). In addition, on the same theme, Cole and

Slocumb (1995), in a study with male adolescents (n=227) in a state-supported

 218

university in southeastern New England, USA. They found that there is a significant

relationship between attitude towards condom use and the practice of safer sexual

behaviors among adolescents. Over the years, a number of research studies have

revealed that condom use behaviors is a function of attitudes, positive or negative,

toward condom use (Davis, Sloan, MacMaster, & Kilbourne, 2007).

Collectively, supported by the findings of previous research studies and this

current study, attitudes toward condom use influence condom use behavior among

adolescents (Myers & Clement, 1994; Tyden et al., 1996; Lescano et al, 2006). That

is, sexually active adolescents with positive attitudes toward condom use are more

likely to use condoms (Stulhofer et al., 2007; Gebhardt et al., 2003; Minoia & Rose,

1996).

Condom use self-efficacy

In this current study, the findings showed a positive significant relationship

(p<0.01) between condom use self-efficacy (consistent condom use self-efficacy,

correct condom use self-efficacy, and communication self-efficacy with partner) and

actual condom use. Overall, the results of this study were consistent with previous

studies. As anticipated, individuals with strong confidences regarding condom use

with partners were more likely to consistently use condoms. This finding was

supported by other studies (Kasen et al., 1992; Joffe & Radius, 1993; Polacsek et al.,

1999; Posner et al., 2001; Holschneider & Alexander, 2003; Fernandez-Esquer et al.,

2004; Godin et al., 2005; Meekers et al., 2006).

Another important finding is related to the theoretical bases of Bandura’s Self-

Efficacy (SE) model about safer sex behavior (Bandura, 1990). Several researchers

(Hingson et al., 1990; Taylor-Seehafer & Rew, 2000) noted that sexual knowledge,

exclusively, did not cause behavior modification and that knowledge of HIV/AIDS
 219

was not always related to self-protective behavior. This information, nonetheless,

supports the notion that self-efficacy may be a link to condom use; it could also be

one of the key elements that is associated with knowledge and required to modify

sexual risk taking behaviors (Jemmot, 1996). Congruent with Bandura (1992a, 1977),

self-efficacy influences behavior. In particular, condom self-efficacy is proposed to

influence condom use (Bandura, 1992b; Wulfert & Wan, 1993). The scientific

literature suggests that a high self-efficacy is a significant variable that influences

condom use (Diiorio et al., 2000; Dilorio, Dudley, Soet, Watkins, & Maibach, 2000).

Specifically, adolescents who demonstrate high self-efficacy during sexual activities

are more likely to use condoms in a consistent manner when compared with their less-

assertive peers (DiClemente et al., 1996). Furthermore, the role of self-efficacy in

condom use behavior was documented among high school students in USA (Basen-

Engquist & Parcel, 1992; Kasen et al., 1992; Park et al., 2002) and college students

(Joffe & Radius, 1993; Wulfert & Wan, 1993).

A study done by Soler and colleagues (2000) revealed that low-income

American women with high scores on condom related self-efficacy and strong

confidence in their ability to negotiate condom use were more likely to be consistent

condom users (Soler, Quadagno, & Sly, 2000). Similarly, Kasen, Vaughan,

and Walter (1992), in a study with tenth grade students (n=181) in 3 high schools in

New York City, reported a significant positive relationship between self-efficacy in

condom use and condom use behavior. Furthermore, those students with lower self-

efficacy for correct and consistent condom use were five times less likely to use

condoms in a constant fashion. This finding was similar with Delamater and

associates (2000), who reported that among African American male adolescents in

their study, there was an association between self-efficacy to use condoms and the
 220

frequency of using a condom. That is, when self-efficacy in condom use was high, the

percentage of condom use increased (DeLamater, Wagstaff, & Havens, 2000).

Moreover, Polacsek and associates (1999) reported that individuals who had greater

condom use self-efficacy with partners were more likely to use condoms every time

during sexual contacts (Polacsek et al., 1999). Comparable findings were reported by

Maxwell and colleagues (1999). They reported that condom users were more likely to

report high self-efficacy in condom use and more sexual communication with partners

than respondents who did not use condoms at last sexual intercourse (Maxwell,

Bastani, & Warda, 1999). In addition, Kaneko (2007), in a study with Japanese

teenage women (n=456) who reported having had sex in the past, reported that a

significant association existed between self-efficacy of practicing safe sex and

condom-use behavior. The percentage of participants showing higher self-efficacy

was greater among those who reported always using condoms than those who

reported not always using condoms. This finding was consistent with the results in the

recent study conducted by Davis and associates (2007). They reported that current

condom use is significantly associated with condom use self-efficacy and positive

attitudes toward safer sexual practices among 156 sexually active students (Davis et

al., 2007). Similarly, Abbey and associates (2007), in a study with heterosexual

college students (n=298) at a large urban university, reported that self-efficacy

regarding condom use when intoxicated was a significant predictor of frequency of

condom (Abbey, Parkhill, Buck, & Saenz, 2007).

Over a decade, a number of research studies have shown a positive significant

relationship between condom use self-efficacy and condom use (Kasen et al., 1992;

Polacsek et al., 1999; Diiorio et al., 2000; Dilorio et al., 2000; Park et al., 2002; Davis

et al., 2007). Taken together, the findings in the literature (Kaneko, 2007; Maxwell et
 221

al., 1999; DiClemente et al., 1996) and this present study suggested that condom use

self-efficacy plays a major role in condom use behavior among adolescents

(DeLamater et al., 2000; Abbey et al., 2007; Kaneko, 2007). For emphasis, sexually

active adolescents with high self-efficacy condom use were more likely to

consistently use condoms.

Actual Usage of Condoms

In the current study, the model predicting actual usage of condoms fits the data

moderately well. Personal information (gender, age, self-reported history of

alcohol/drug use, duration of the current intimate relationship, and perceived

preventive behavioral peer norms), knowledge of STDs/HIV/AIDS and pregnancy,

attitudes toward condom use, and condom use self-efficacy together explained a

moderate amount of the variance in actual condom use (11.3%). Nonetheless, only

self-reported history of alcohol/drug use, attitudes toward condom use, and condom

use self-efficacy were significant predictors of actual condom use. Gender, age,

duration of the current intimate relationship, perceived preventive behavioral peer

norms, and knowledge of STDs/HIV/AIDS and pregnancy were not significant

predictors of actual condom use. Thus, the results of this study provide partial support

for the model employed in the study. In this study, Bandura’s Self-Efficacy (SE)

model of safer sex behavior (Bandura, 1990) was utilized and self-efficacy was

proposed to influence safer sexual behaviors (Bandura, 1977). Specifically, condom

self-efficacy was proposed to influence actual condom use (Bandura, 1992b).

The concept of condom use self-efficacy is receiving increasing recognition as

an important predictor of condom use behavior. Self-efficacy, or a person’s belief in

his or her capacity to execute a given skill, determines the degree of the extent and the

amount of the investment that that a person will commit to a given task (Bandura,
 222

1986). The study conducted by Sieving and colleagues (1997) revealed that self-

efficacy in condom use was the strongest predictor in sexual risk behavior among

adolescent women. Adolescent women with elevated self-efficacy levels performed

the highest levels of condom use behaviors (Sieving et al., 1997). Similarly, youth

with low self-efficacy and negative attitudes about condoms were more likely to

engage in casual sexual experiences, have more non-monogamous partners, and report

higher frequencies of coercive sexual experiences (St. Lawrence, Brasfield, Jefferson,

Allyene, & Shirley, 1994). Furthermore, the findings of this current study is congruent

with those of Taffa and associates (2002), who found that condom use behaviors

among adolescents were influenced by self-efficacy in condom use, attitudes toward

condom use, and alcohol use/substance consumption (Taffa, Klepp, Sundby, & Bjune,

2002). These results are similar to findings obtained in another study (Gebhardt et al.,

2003), where overall results showed that consistent condom use behaviors among

adolescents were influenced by condom use self-efficacy, and attitude towards

condom. Further evidence that self-reported history of alcohol/drug use, attitudes

toward condom use, and condom use self-efficacy influenced the actual condom use

among heterosexual adolescents is evident in other research studies (Joffe & Radius,

1993; Soet et al., 1998; Diiorio et al., 2000; Meekers & Klein, 2002; Holschneider &

Alexander, 2003; Godin et al., 2005; Meekers et al., 2006).

Additionally, knowledge of STDs/HIV/AIDS and pregnancy was not a

significant predictor of actual condom use. This finding contradicts, and at the same

time, supports previous research studies. Anderson and colleagues (1990) found that

students who were more knowledgeable about HIV/AIDS were less likely to engage

in unsafe sexual behaviors (Anderson et al., 1990). On the other hand, DiClemente

and associates found that rural students who were knowledgeable about AIDS
 223

reported higher rates of HIV-related sexual risk behaviors (DiClemente, Brown,

Beausoleil, & Lodico, 1993). On the other hand, Singhasut (1991) did not find a

relationship between HIV/AIDS knowledge and sexual risk behaviors among Thai

adolescents. Explanations of the differences in these findings may be related to that

fact that knowledge may be essential, but it is not sufficient, to change risky sexual

behaviors.

Furthermore, perceived preventive behavioral peer norms were not a

significant predictor of actual usage of condoms. These finding both corroborate and

contradict the previous studies. This finding was consistent with the previous study

conducted by Maxwell and colleagues (2000). On the other hand, it contradicts the

study completed by Watronachai (2004). As discussed in the previous section, one

explanation is about the psychometric properties of the instrument utilized in the

study, and the diversity among Thai adolescent populations.

Overall, the findings regarding the predictors of condom use in this study are

consistent with a number of previous research outcomes that posited that adolescents’

self-reported history of alcohol/drug use, attitudes toward condom use, and condom

use self-efficacy could explain actual condom use among adolescents. That is to say,

the Bandura’s Self-Efficacy (SE) model of safer sexual behavior is useful for

understanding Thai adolescents’ condom use behavior. However, as mentioned

previously, the findings of this current study partially supported Bandura’s Self-

Efficacy (SE) model of safer sexual behavior. This phenomenon will be described in

the next section, implications for nursing research. According to the findings of this

study, there is the need for additional research to explore factors influencing condom

use among Thai adolescents. This program of research will help to promote consistent
 224

and effective condom use behavior, including HIV/STD-related prevention strategies,

for the high-risk Thai adolescent populations.

Discussion of the Findings from Two-Open-Ended Questions

In this section, two major themes emerged from the participants’ responses to

the two open-ended-questions that specifically addressed premarital sexual behavior

among Thai adolescents. Both of the themes will be discussed.

Young Thai people themselves appear to condone premarital sexual activity for

males, but not for females

A number of respondents (n=59) in this study, both males and females,

highlight continuing, widespread, gender-specific attitudes toward premarital sexual

activity. In general, males were more likely to consider premarital sexual activity as

acceptable to themselves and among the community dwellers. The young Thai males

tended to focus on and highlight their sexual activity. It is as if they felt proud of

being male and sexually active (Knodel et al., 1996). This finding is similar to the

data in scientific literature that suggest that Thai males become sexually active, in

part, as a method of fulfilling their perceptions about Thai culture and the roles of

men (see the writing of VanLandingham, Knodel, Pramualratana, & Saengtienchai,

1995). On the other hand, Thai females were reluctant to report their sexual

involvement and verbalized their concerns about the double standard that exists

among male and female Thai adolescents and sexual activity. In addition, the Thai

females were not able to articulate an option for females in the society regarding

sexual values and behaviors. The double standard regarding sexual activity before

marriage is deeply embedded in Thai culture. It is learned at a very early age, and

could be a barrier to sexual disease prevention and early detection among individuals

in the country (Knodel et al., 1996).

 225

Females, on the other hand, had some reluctance about premarital sexual

activity. They did not think that premarital sexual activity was approved by members

of the Thai society. Moreover, young male and female Thai people, in general,

considered premarital sexual activity to be more acceptable for males than for

females. These double standards are particularly evident in research studies not only

in Asia (i.e. Thailand and Vietnam) but in the other countries in Latin America (i.e.

Peru and Argentina) as well. In a study conducted in the north and northeastern

regions of Thailand, Isarabhakdi (1995) investigated the factors associated with

sexual behavior and attitudes of never-married males (n=577) and never married

females (n=517) aged 15 to 24 years. The results showed that 46% of females and

32% of males hold the belief that men should be virgins at marriage. However, in the

case of female virginity at marriage, 71% of females and 63% of males stated that

women should not engage in sexual activity until after marriage. In a study conducted

among college students (17 to 24 years of age) in Hanoi and Ho Chi Minh City, Viet

Nam, 8% of females agreed that casual sex can be fun, and almost two in five males

(37%) shared the females’ opinions about sex for fun (Vu Quy Nhan, 1996).

Interestingly, on the other side of the global community, among youth attending high

school in Lima, Peru (South America), 49% of females and 68% of males agreed that

males should gain sexual experience prior to marriage. Furthermore, within this same

population, 73% of females and 59% of males held the view that females must be

virgins at marriage (Villanueva, 1992). Collectively, all of these findings suggest that

there are double standards for males and females regarding premarital sexual activity.

Furthermore, Kornblit (1993) examined the sexual models among secondary high

school students in Buenos Aires, Argentina (South America). The results showed that

large majorities of young students (85%) agreed that premarital sexual activity was
 226

“normal” for both females and males. Clearly, approval of premarital sexual activity

was evident among both males and females in this society. Therefore, there is a need

for further research studies to better understand how young Thais and young people in

other parts of the world view premarital sexual activity, and how male sexual

expressions has become such an acceptable behavior among cultures. The condoning

of premarital sexual activity could, in the long term, mitigate against safer sexual

practices among adolescents in Thailand.

Gender double standards about premarital sexual activity among Thai people

are often considered socially justifiable

The responses from the participants (n=36) in this study suggest that young

Thai females and males accept the double standards regarding premarital activities in

Thailand. In addition, the constraints that are imposed on the sexual behavior of

women are seldom considered. Young Thai females are expected to be “nice girls”

and protect their virginity until marriage. On the other hand, Thai males are widely

perceived by the Thai society to need sexual experiences with a variety of partners

before marriage. That is to say, males were expected to be sexually active; there was

no blemish to their reputation or character if they engaged in sexual activity

frequently, and with a variety of partners. Engaging the services of prostitutes was a

frequent and anticipated custom. Young Thai males in particular and, the Thai society

in general, held females to a different standard: they were expected to remain virgins,

which also implies that they are “decent” females who are worthy of being a wife and

mother.

In a study conducted in manufacturing factories in Bangkok and surrounding

suburban areas, Ford and Kiittisuksathit (1994) examined the sexual awareness,

lifestyles and related health service needs of young single Thai factory workers (15 to
 227

24 years of age). The findings from 18 focus group discussions were outlined with

principal reference to the Thai gender construction of sexuality. They found that a

gender double-standard was evident. For example, almost all of the young Thai men

reported that their first sexual contact was with a prostitute. Visiting brothels

remained an important peer group activity among the males. Yet, at that same time,

most male participants indicated that they would not marry a non-virgin female.

Within this reality, female participants stated that it was difficult for them to

acknowledge sexual feelings or experiences. The cultural context within which they

lived made it difficult to exercise any decision-making action within the male-female

partnership. Most of the Thai females indicated that they would not insist on

contraceptive use with their partners for fear of being stigmatized as sexually

experienced, and perhaps a “loose girl”. Furthermore, females were very concerned

about the impact of premarital sexual activity on their dignity and their

family/parents’ reputation. These findings were consistent with Soonthorndhada

(1996), who conducted a qualitative study with 96 young unmarried female factory

workers and students in Bangkok, Thailand. The female participants in this study

recognized that: “We cannot do whatever we want, roaming, smoking, drinking, etc.”;

“We are brought up this way”; “It is social expectations, they will look down on you

if you go loose”; “Men can go anywhere, do whatever they like, even trying sex”; and

“No-one wants a woman who has had sexual experience” (Soonthorndhada, 1996,

p.39).

Furthermore, on the other side of the world, in Argentina, the findings from

the study conducted among adolescents attending reproductive health services in two

hospitals revealed a similar belief and practice trend. The study posited that the

widespread belief among the adolescents was that male “sexual urges” are
 228

uncontrollable, and that a physical relief mechanism, sexual activity, is in their best

interest. Hence, the society condones casual sexual relations for men, but not for

females (Pantelides, 1991). Consistent with Soonthorndhada’s study (1996), female

adolescents in schools and young female factory workers in Bangkok, Thailand,

concurred that “All men are just like that. I think they have a lot of sex urge”

(Soonthorndhada, 1996, p.39). In addition, college students in a study in Dumaguete

City, Philippines, argued that “Men should have sexual experience…women do not

need this experience”. This belief helps to justify the males’ sexual behavior; it also

aids in helping to maintain the gender double standards about premarital sexual

activity. Furthermore, “If a man does not get quite a lot of experience before

marriage, he will want even more after”…“Women are more idealistic than men”

(Cadelina & Cadelina, 1996, p. 39). They would prefer to remain virgins until

marriage but many of them become objects for male pleasure much too soon.

Likewise, low-income young women in Buenos Aires, Argentina, expressed that “The

man can go with many women and not lose his reputation, but if the woman does the

same thing with men, they will always say bad things about her” (Gogna, Pantelides,

Ramos, & Silvina, 1996, p. 40). Again, the gender double standards are blatant.

There is a need for additional research to further describe the gender double

standards, especially sexual double standards, among young Thai people.

Collectively, the findings of the current study and the extant literature raise many

important social, cultural, political, and economic issues that influence the health

beliefs and practices among young Thai people. It also highlights many similarities

about gender inequality regarding sexuality – premarital sex and gender – in the world

community.
 229

Limitations of the study

The first limitation of this study is related to the nature of cross-sectional study

designs. The direction of any causation is problematical in cross-sectional

associations. The cross-sectional design did not allow for any conclusions to be drawn

regarding causal relationships because exposure and event were measured at the same

time. Because data were collected at one point in time, the direction of causation is

not implicated in this study.

Second, all the data reported in this present study were based on the

adolescents’ self-reporting of their sexual behaviors. With self-reported data, the

shortcomings are related to self-selection, recall bias, and social desirability effect.

These elements are always present when assessing the behaviors and attitudes

associated with sensitive topics, including sexual risk behaviors. In this study, because

data were self-reported by Thai students, the results could be an underestimation of

sexual risky behaviors and other related characteristics of the adolescents.

Third, the study population included only vocational school students (18 to 21

years-of-age). It did not consider adolescents/young adults in high school or college in

the Ubonratchathani Province. Thus, results of the study can only be generalized to

heterosexual vocational school students aged 18 to 21 years in this province. Neither

high school nor college students can be included in the interpretations of these

research results.

Fourth, in this study, a multistage cluster sampling method was employed to

recruit the participants. Given that few studies about adolescents’ sexual risk behavior

are available about Thai adolescents, it is appropriate that Thai researchers begin to

develop statistical characteristics of the adolescent population. This study is the first

study that has been conducted on vocational school adolescents on sexual risk
 230

behavior in the Ubonratchathani Province. The interpretations of the findings of this

study are relevant for that population (Burns & Grove, 2001). The findings can be

used to guide future research, including intervention study. However, because of the

sample selection and the random selection process those were used to identify schools

involved in this study present the limitation.

Fifth, the Thai version of attitudes toward condom use questionnaire was

utilized in this study. It was translated from English to Thai. Translation from the

source language to the target language may encounter problems with interpretation,

although the measurement revealed that acceptable translation reliability was evident.

Moreover, the western orientated research measure might not be culturally

appropriate for Thai adolescent populations. Also, it is not yet known if vocational

students have different perceptions, attitudes, and beliefs about condom use when

compared to high school and/or young college students.

Sixth, in this study, the Bandura’s Self-Efficacy (SE) model of safer sexual

behavior explained 11% (R2=11.3%) of the variance of the actual condom use. Even

though this model was limited in the explanation of the variance of the actual condom

use, it does provide a guide for future study. A larger sample size would probably

have increased the R2 (Osborne, 2000).

There is always a concern about findings in study where the theoretical model

have been utilized or adapted to another culture (Burns & Grove, 2001).

Seventh, some of the measures used in this study had low internal consistency,

including the perceived preventive behavioral peer norm scale (Cronbach’s alpha

coefficient=0.47). The measures that were chosen for this study were adapted from a

different culture and administered to a group of adolescents in a specific province in

Thailand. One remedy to this concern could be that in future research, these measures
 231

would be pilot tested to attain psychometric properties (Burns & Grove, 2001) for

Thai adolescents in the Ubonratchathani Province. Again, at this time, this finding

point out basic concern that should be considered for future research.

Despite these limitations, the results of this study are significant as they

provide evidence about current sexual behaviors that occur among the participants in

this sample. Besides, this study lays the groundwork for further investigations around

significant variables (gender, age, self-reported history of alcohol/drug use, duration

of the current intimate relationship, perceived preventive behavioral peer norms,

knowledge of STDs/HIV/AIDS and pregnancy, attitudes toward condom use, condom

use self-efficacy, and actual usage of condoms).

In addition, the strengths of this study included a theory-based study. It also

maximized external validity by using a random sampling approach, and through

having adequate power to detect a significant difference in the findings. Therefore,

this study could guide further investigations for the examination of the sexual risk

taking behaviors and condom use among Thai adolescents.

Study Implications

Nursing Research

The results of this study have helped to advance the knowledge base for

nursing research in a couple of areas: factors influencing condom use; and

contributions of the Bandura’s Self-Efficacy (SE) model of safer sexual behavior

among Thai adolescents. The significant findings in this study suggest that sexually

active adolescents who possessed positive attitudes toward condom use and possessed

high self-efficacy in condom use were more likely to consistently use condoms during

sexual intercourse. Furthermore, those sexually active adolescents who consumed

larger amounts of alcohol/drugs were less likely to use condoms. Based on the
 232

significant findings in this study, the interventions aim at enhancing actual condom

use should be implemented. The attitudes toward condom use, condom use self-

efficacy, and the effect of alcohol/drug use on usage of condoms should be

emphasized in interventions that are designed to address safer sexual behaviors

among Thai adolescents. Besides, focus groups among Thai adolescents could be

conducted to further explore the various perspectives regarding premarital sexual

behavior and condom use in Thai adolescents. This approach will also help to assure

that culturally sensitive intervention programs will be developed for this vulnerable

population.

To help prevent the multiple negative consequences of unprotected premarital

sexual behaviors among Thai adolescents, health care profession, particularly nurse

researchers and educators, should cooperate with each other and create evidence-

based interventions to address this malady. The interventions to delay the initiation of

premarital sexual behavior among non-sexually active adolescents should also be a

primary structured program that is well developed and culturally sensitive.

Furthermore, the high rates of condom non-use as evident from this investigation

support the need for nurse researchers to examine the relationships among the

STDs/HIV infection rates, unintended pregnancy rates, and condom non-use. These

types of data will help to confirm the urgent need to reduce sexual risk behaviors

among Thai adolescents.

In addition to providing knowledge about factors influencing condom use, the

findings from this study have generated partial support for the use of Bandura’s Self-

Efficacy (SE) model of safer sexual behavior (Bandura, 1990) as a viable conceptual

framework. Four components in the model were investigated in this study. They were

included knowledge of STDs/HIV/AIDS and pregnancy, attitudes toward condom

 233

use, condom use self-efficacy, and perceived preventive behavioral peer norms.

According to this model, an effective risk behavioral change must involve these four

components. Self-efficacy is one of these key components (Bandura, 1990). In this

current study, only two out of four components (attitudes toward condom use and

condom use self-efficacy) were significant predictors of condom use. Therefore,

results of this study partially supported the theorized relationships of the model. This

finding suggests that either a flaw in an underlying theory proposition or the

psychometric properties of the instruments utilized in this study was at hand. Finally,

in this study, unexpected findings about knowledge of STDs/HIV/AIDS and

pregnancy, and perceived preventive behavioral peer norms variables indicated a need

for further research to re-examine the model. Such studies could occur in other

provinces at vocational and high schools. This phenomenon should also be explored

among college students.

Nursing Practice

Health care providers, especially school nurses, should be aware of the low

rates of condom use among sexually active adolescents in vocational schools in

Thailand. Also, health care providers and school nurses will need to be

knowledgeable, capable, and have positive attitudes when assessing adolescent sexual

behavior. Sexual history taking is an important and sensitive topic for adolescents.

Nurses’ special HIV/AIDS knowledge and skill sets will be essential for the

identification of antecedent factors that influence HIV/AIDS related sexual risk

behaviors, including condom non-use. The assessment of adolescent sexual behavior

should be included in regular health assessment procedures in every health care

setting in Thailand. The benefits of condom use should be emphasized among this

population. Moreover, the negative consequences of unprotected premarital sexual

 234

practice, namely, the potential for contracting STDs/HIV/AIDS and other maladies

should be highlighted and discussed in a variety of forums.

In addition, the significant findings in this study could be used as baseline data

for integrating and adapting HIV/AIDS intervention programs for Thai adolescents.

Clearly, factors influencing condom use among Thai adolescents need to be carefully

considered when designing interventions. The findings of this study support the

position that nurses should implement research-based HIV preventive interventions,

including school-based programs, to reduce and change sexual risky behaviors among

adolescents.

Health Policy

The results of this study support the importance of targeting students in

vocational schools for prevention of HIV/AIDS infections. The high rate of vocational

school students who are engaging in premarital sexual behavior without using

condoms is an area of extreme concern for Thai health policy officials. Participating

in sexual intercourse without condom use could result into several negative

consequences. Such consequences include contracting STDs/HIV/AIDS, and

experiencing unintended pregnancies. These negatives outcomes are health related

problem. Importantly, they are also of huge social concern in Thai communities.

Corroboration and corporation among a variety of governmental, private, and

community-based organizations are mandatory to prevent the continuous occurrences

of these preventable diseases. The two major ministries under the Thai government,

the Thai Ministry of Public Health and the Thai Ministry of Education, are two

potential resources within the nation that could take the leadership in developing new

and novel approaches to the prevention of HIV/AIDS among Thai adolescents. Close

corroboration among these two key ministries and other relevant organizations could
 235

perhaps help to increase the awareness within the nation about the current and long-

term impact of HIV/AIDS on Thai adolescents and their communities. For starters,

the Thai Ministry of Public Health should provide funding to develop the programs

that address adolescent sexual risk taking behaviors. Efforts to also be make to assist

those adolescents who are HIV positive or who might be HIV infection. Next, the

Thai Ministry of Education should consider re-examining the available data about

adolescent risky sexual behavior and the implications of these behaviors. When the

economic costs, coupled with the potential for disabilities and the excessive loss of

lives, it becomes even clearer who immediate action is necessary to curtail the waves

of HIV/AIDS. The education and the health systems in Thailand are two of the

bedrock organizations that are at the center of all activities in Thailand. These two

organizations have a unique opportunity to assist Thai youth. Discussions regarding

policies that highlight sexual education programs that emphasize the delay of the

initiation of premarital sexual behavior among non-sexually active students are

another essential approach for the Thai governmental and private organizations. Such

programs could be integrated into school curricula; they will need to be age specific

and culturally relevant. In addition to supporting prevention efforts with all

adolescents, the consistent use of condoms needs to be stressed in the media, the

schools, and the communities. These discussions and program initiatives about sexual

delay and condom use need to be promoted as an integral component of a healthy

national imperative, with specific goals and objectives.

Recommendations for Future Research

As a cross-sectional descriptive correlational study, this research examined the

relationships among personal information, attitudes toward condom use, condom use

self-efficacy, and actual usage of condoms among Thai adolescents. Results from this
 236

study can guide further research. Recommendations for future research studies are

delineated.

1. The study should be replicated with a more heterogeneous sample of

adolescents in the Ubonratchathani Province, and in the other provinces to achieve a

more representative sample of Thai adolescents. Such studies will also help to

validate the predictive nature of the independent variables on the outcome variable,

condom use among Thai adolescents. Studies in other populations, including high

school, college, and younger age vocational school students, should be conducted to

compare to predictive models.

2. More influencing factors on condom use should be included to increase the

potential for explaining the variations in condom use among the sample. These

possible potential variables include parental norms toward premarital sexual behavior,

social support or partner support for condom use, communications between parents

and adolescents about condom use, and condom use barriers as perceived and

experienced by the adolescent groups.

3. The research measures should be revised to better identify the variables that

are associated with or predict condom use.

4. Focus groups with sexually active Thai adolescents should be conducted to

gain a more in-depth understanding of the adolescents’ premarital sexual beliefs and

behavior. Special emphasis should be placed on the factors that include and mitigate

against condom use.

5. Of equal importance is the need to assure that all interventions and other

research related activities are culturally-sensitive and reflect Thai culture and

folkways. Intervention programs should focus on increasing actual condom use by

promoting positive attitudes towards self-efficacy and condom use. Importantly,

 237

programs must also stress the negative and sometimes deleterious effect that

alcohol/drugs have on condom use.

6. The further studies should utilize a longitudinal design and incorporate

more variables into the study to investigate the significance and the stability of the

predictors of actual condom use. Again, Bandura’s Self-Efficacy (SE) model for safer

sexual behavior (Bandura, 1990) could be used in such future studies. Also, condom

use behavioral changes, overtime, and their consequences should be further examined

as well.

7. In order to delay the early initiation of premarital sexual activity among

Thai adolescents, intervention programs need to incorporate and address the benefits,

the pride, and the value of being sexual abstinent. This approach could be embedded

within the Thai culture and taught in the public and private schools, in health clinics,

and at other relevant settings. Focus group discussions could be integrated into this

initiative and the outcomes should be used to design culturally specific and relevant

programs for the reduction and elimination of HIV/AIDS in Thailand.

Summary

This is a cross-sectional descriptive correlational study. This study aimed to

examine the relationships among personal information, attitudes toward condom use,

condom use self-efficacy, and condom use behavior, and identified statistical

predictors of condom use behavior. This study was conceptualized by the Bandura’s

Self-Efficacy (SE) model of safer sexual behaviors (Bandura, 1990) among Thai

vocational school students between the ages of 18-21 years in the Ubonratchathani

Province, Thailand. A sample of vocational school students (n=270) were invited to

participate in the study. The research employed a multistage cluster sampling

procedure. Data were analyzed by using descriptive statistics, correlation, and

 238

multiple regressions analyses. The results of the study demonstrated that self-reported

history of alcohol/drug use, attitudes toward condom use, and condom use self-

efficacy were significant predictors of actual use/non use of condoms. In addition, the

independent variables, namely gender, age, duration of the current intimate

relationship, perceived preventive behavioral peer norms, and knowledge of

STDs/HIV/AIDS and pregnancy were not significant predictors of actual condom use.

Among the studies conducted with Thai adolescent populations, this current

study was the first one to investigate the relationships among the selected variables

and actual condom use in Thai adolescents. It employed Bandura’s Self-Efficacy (SE)

model of safer sexual behaviors (Bandura, 1990). The significant findings were

explicated, and the Bandura’s Self-Efficacy (SE) model of safer sex behavior was

empirical tested and confirmed by a moderate amount (11.3%) of variance in the

dependent variable, actual condom use. The dependent variable was explained by the

independent variables as identified in the study. The findings of this study may lead to

a better understanding of factors that influence condom use among Thai adolescents.

Nursing research, practice, and those in health policy promulgation should benefit

from the results of this study. Collectively, the findings of this study may help to

further the research efforts about new knowledge generation, the ultimate goal for

nursing science. Importantly, adolescent’s morbidity and mortality rates related to

unprotected premarital sexual activity could be reduced, and their well-being

enhanced through the reduction and elimination of this global malady (WHO, 2002;

Mensch, Clark, & Anh, 2003; Kilian et al., 2007).

 239

APPENDICES
 240

Appendix A

List of 15 vocational schools in Ubonratchathani Province

1. Ubonratchathani Technical College

2. Detudom Technical College

3. Ubonratchathani Vocational College

4. Ubonratchathani Polytechnic College

5. Ubonratchathani College of Agriculture and Technology

6. Warin Shamrap Industrial and Community Education College

7. Trakan Phutphon Industrial and Community Education College

8. Khemarat Industrial and Community Education College

9. Technologyratchathani School

10. The North Eastern Polytechnic School

11. Khemarat Technology and Business Administration School

12. Ratchaphruek Technology School

13. Namyeun Technology and Business Administration School

14. Buntarik Technology and Business Administration School

15. Sirindhorn Technology and Business Administration School

 241

Appendix B

Figure 1. Bandura’s self-efficacy (SE) model of safer sex behavior (Bandura, 1990)

Information
(AIDS knowledge)

Development of
individual’s self-regulatory
skills Safer Sex Behavior
(Attitudes) (Condom Use)

Enhancement of
individual’s sense of self-
efficacy
(Self-Efficacy)

Peer group support

(Peer group comparison)

According to Bandura’s self-efficacy (SE) model of safer sex, an

effective risk behavior change must involve four components, one of
which is self-efficacy. The four components include: (1) an informational
component to increase awareness and knowledge of health risks; (2) a
component to develop the self-regulatory and risk reduction skills needed
to translate risk knowledge into preventive behavior; (3) a component to
increase the level of these skills and individual’s level self-efficacy with
respect to them; and (4) a component that develops or engages social
supports for the individual who is making the change, in order to
facilitate the change process and promote maintenance. All four
components relate to safer sex behavior (Bandura, 1990).
 242

Appendix C

Figure 2. Adaptive model of Bandura Self-Efficacy (SE) study of sexual risk behavior

among Thai adolescents in Ubonratchathani Province (Bandura, 1990)

Personal information
- Gender
- Age
- Self-reported history of
alcohol/drug use
- Duration of the current
intimate relationship

Perceived preventive
behavioral peer norms

Knowledge of STDs/HIV/AIDS
& Pregnancy
Condom use
behavior
Actual usage of
Attitudes toward condom use condoms at time
- Relationship safety of intercourse
- Perceived risk
- Interpersonal impact
- Safety
- Effect on sexual experience
- Promiscuity

Self-efficacy in condom use

- Consistent condom use self-efficacy
- Correct condom use self-efficacy
- Communication self-efficacy with partner
 Appendix D 243
Figure 3. Substruction diagram based on Bandura’s Self-Efficacy (SE) model of safer sex

Theoretical Person Sex Behavior

System Constructs

Gender Sexual Attitudes/Sexual Self-Efficacy

Concepts
Risk Behavior

- relationship
Operational Variables Thai adolescents safety -consistent condom
System - perceived risk use SE
- interpersonal -correct condom
Personal information impact use SE
- safety -communication SE
- effect on sexual with partner
Characteristics Knowledge of Perceived experience -outcome of condom
age, gender, self- STDs/ HIV/ preventive - promiscuity use
reported history of AIDS & behavioral -use of condom -peer-pressure to use
alcohol/drug use, pregnancy peer norms -freq. of sex or not use condom
duration of current
intimate relationship

CAS-A
Empirical Demo Q. Knowledge Q. PPBPN S. CSES-T
SRCU
indicators

Ratio/nominal/ Scale Scale Scale Scale

Scores / Values ordinal
 244

Key:
CAS-A - Condom Attitude Scale-Adolescent version (23 items)
CSES-T - Condom Self-Efficacy Scale-Thai version (14 items)
SRCU - Self-Reported Condoms Use (3 items)
PPBPN S. - Perceived Preventive Behavioral Peer Norm Scale (5 items)
Knowledge Q. - Knowledge of STDs/HIV/AIDS & Pregnancy Questionnaire (39 items)
Demo Q. - Demographic Questionnaire
 245

Appendix E

Figure 4. Ubonratchathani Province located in the northeastern region of Thailand

 246

Appendix F

List of 14 provinces in the first national HIV sentinel surveillance of

Thailand

1. Payao

2. Chiang Rai

3. Chiang Mai

4. Nakhon sawan

5. Lumpoon

6. Chonburi

7. Saraburi

8. Ratchaburi

9. Samuthprakarn

10. Phuket

11. Songkhla

12. KhonKaen

13. Nakhon Ratchasima

14. Ubonratchathani

Source: Ministry of Public Health, Thailand (1996). National HIV Serosurveillance,

Thailand, 1989-1996. Bangkok, Thailand: Ministry of Public Health Press.

 247

Appendix G

The Instruments

1. Demographic Questionnaire

2. Perceived Preventive Behavioral Peer Norms

3. Knowledge on STDs/HIV/AIDS and Pregnancy

4. Attitudes toward condom use

5. Self-efficacy in condom use

6. Actual usage of condoms (Three questions (Q. 21, 24, & 26) were asked

and they were included in the demographic questionnaire)

 248

ID…………..

Case Western Reserve University

Frances Payne Bolton School of Nursing

Factors influencing condom use among Thai adolescents

We are interested in learning more about young people’s beliefs and knowledge of

sexually transmitted diseases (STDs, such as Gonorrhea, Syphilis, Herpes Simplex,

etc.), acquired immunodeficiency virus syndrome (AIDS), and pregnancy. The

information you provide will be very helpful in developing better STDs/HIV/AIDS

and pregnancy prevention programs for all adolescents in Thailand.

PLEASE DO NOT WRITE YOUR NAME ON THE QUESTIONNAIRE AND ANSWER

SHEET.

The ID number provided at the top of the questionnaire will be used as your personal

code, so no one knows that this questionnaire is yours.

The answers you give on this questionnaire are voluntary. Whether or not you choose

to participate in this study will not affect your grade in any classes. The answer you

give will be kept privately. No one will know what you write, so please answer all

questions as honestly as you can. There is no right or wrong answers. We are only

interested in what you know, feel, and do.

Thank You for Your Cooperation

 249

Demographic Questionnaire

Direction: We would like to know about your background information, please fill in

the blank box and/or X that best describes yourself.

Demographic Data

1. How old are you?

(A). 18 (B). 19 (C). 20 (D). 21

2. What is your gender?

(A). Female (B). Male

3. Where do you live?

(A). Apartment/Dormitory (B). Parents’ house (C). Relatives’ house

(D). School (E). Temple

4. Who do you live with?

(A). By myself (B). With my parents (C). With my friends (same sex)

(D). With my girl/boyfriend (E). With my relatives

5. What is your parents’ income per month?

(A). < 5,000 ฿ (B). 5,000-10,000 ฿ (C). 10,001-15,000 ฿

(D). 15,001-20,000 ฿ (E). > 20,000 ฿

6. How much money do you have a month?

(A). <1,000 ฿ (B). 1,001-2,000 ฿ (C). 2,001-3,000 ฿

(D). 3,001-4,000 ฿ (E). > 4,000 ฿

7. Who do you get money from?

(A). Parents (B). Girl/boyfriend (C). Parents & I work

(D). Parents & Girl/boyfriend (E). Girl/boyfriend & I work (F). Work &

Girl/boyfriend
 250

The following questions are about sexual experiences. We realize this information
is very personal, but we really appreciate your honesty in answering theses
questions. Remember your answers are completely confidential.

8. Have you ever had voluntary sexual intercourse?

(A). Yes (B). No Go to question # 41

9. If yes, how old were you the first time you had sexual intercourse?

(A).11 (B).12 (C).13 (D).14 (E).15 (F).16 (G).17 (H).18 (I).19 (J).20 (K).21

10. For the first time you had sex, who did you have sex with?

(A). My girl/boyfriend (B). Sex worker

(C). Friend (D). Brother/sister (E). Others…………………..

11. What type(s) of sex have you had?

(A). Vaginal intercourse (B). Anal intercourse (C). Oral intercourse

(D). Vaginal & Anal (E). Vaginal & Oral

(F). Anal & Oral (G). Vaginal, Anal, & Oral

12. Have you ever been pregnant or have you ever gotten a girl pregnant?

(A). Yes (B). No Go to question # 15

13. Have you/your partner ever had an abortion?

(A). Yes, once (B). Yes, twice (C). Yes, 3 times (D). Yes, > 3 times

14. Where did you/your partner have the abortion done?

(A). Private hospital (B). Federal hospital (C). Clinic by physician

(D). Clinic by illegal person (E). Done at clinic by physician first, then went to

hospital (F). Done at clinic by illegal person first, then went to hospital
 251

15. How many different people have you ever had sexual intercourse with in the last

6 months?

(A).1 (B).2 (C).3 (D).4 (E).5 (F).6 (G).7 (H).8 (I).9 (J).10

16. Currently, do you have a girl/boyfriend?

(A). Yes (B). No

17. If yes, how many girl/boyfriends do you have?

(A).1 (B).2 (C).3 (D).4 (E). >4

18. How long have you been sexually active with your current (most recent) partner?

(A). 7-15 days (B). 16-30 days (C). 31-45 days (D). 46-60 days

(E). 60-90 days (F). > 90 days

19. In the last three months, how often did you have sexual intercourse?

(A). None (B). One or two times (C). Once a month

(D). Once a week (E). More than two times a week

20. When having sexual intercourse, do you or your partner use:

(A). Condoms (B). Birth control pills (C). Injection birth control

(D). Withdrawal or “pulling out” (E). No method (don’t use any type of birth

control)

21. At the beginning of a relationship with your current partner, how often did you or

your partner use a condom when having sexual intercourse?

(A). Never (B). Sometimes (C). Often time (D). Most of the time (E). Every time

22. For the condom user only, why do you use condoms? (select all that use)

(A). To prevent pregnancy (B). To prevent STDs

(C). To prevent AIDS (D). Partner’s need

23. For the non-condom user only, why don’t you use condoms? (select all that use)

(A). Not natural (B). Partner dislike (C). Not convenient

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(D). Don’t have condoms when needed (E). No risk for pregnancy (F). No risk for

STDs (G). No risk for AIDS (H). Use of other contraceptives

24. The last few times when having sex with your current partner, how often do you

or your partner use condoms?

(A). Never (B). Sometimes (C). Often time (D). Most of the time (E). Every time

25. Who decides when to use condoms?

(A). We never use condoms (B). I decide (C). My partner decides

(D). We both decide

26. In general, when you had sex with your current partner, did you or your partner
use condoms?
(A). Never (B). Sometimes (C). Often time (D). Most of the time (E). Every time

27. Have you ever had sexual intercourse after drinking alcohol (e.g., beer, wine, wine

coolers, and hard liquor)?

(A). Yes (B). No Go to question # 29

28. If yes, about how often do you have sexual intercourse after drinking alcohol?

(A). Never (B). once in a while (C) Half of the time (D). Most of the time

(E). All of the time

29. Have you ever had sexual intercourse after using drugs (e.g., amphetamine,

ecstasy, cocaine, heroine, and inhalants)?

(A). Yes (B). No Go to question # 32

30. If yes, about how often do you have sexual intercourse after using drugs?

(A). Never (B). once in a while (C) Half of the time (D). Most of the time

(E). All of the time

 253

31. When you have a sexual intercourse after drinking alcohol or using drugs, about

how often do you/have your partner use condoms?

(A). Never (B). Sometimes (C). Often time (D). Most of the time (E). Every time

The following questions are about sexually transmitted diseases.

32. Have you ever been told by a doctor or a nurse that you had any sexually

transmitted disease?

(A). Yes (B). No

Have you ever had any of the following? (Please do not ignore these questions)

33. Syphilis (A). Yes (B). No (C). Don’t know

34. Gonorrhea (A). Yes (B). No (C). Don’t know

35. Venereal Warts (A). Yes (B). No (C). Don’t know

36. Chlamydia (A). Yes (B). No (C). Don’t know

37. Herpes around mouth (A). Yes (B). No (C). Don’t know

38. For boy, Herpes on or around the penis or rectum

(A). Yes (B). No (C). Don’t know

For girl, Herpes on or around the vagina or rectum

(A). Yes(B). No (C). Don’t know

39. For boy, Urethritis (infection in the penis)

(A). Yes (B). No (C). Don’t know

For girl, Pelvic inflammatory diseases

(A). Yes (B). No (C). Don’t know

40. Any other sexually transmitted disease, such as yeast

(A). Yes (B). No (C). Don’t know

 254

In the next section, we would like you to provide your information to help us
develop appropriate sex education program, please answer honestly.

Do you think you have enough and accurate knowledge of

41. Reproductive systems (A). Yes (B). No

42. Sexually transmitted diseases (A). Yes (B). No

43. AIDS (A). Yes (B). No

44. Contraceptives (A). Yes (B). No

What types of presentations about STDs/HIV/AIDS you like to have in your

school?

45. Lecture (A). Yes (B). No

46. Class discussions (A). Yes (B). No

47. Individual discussion (A). Yes (B). No

48. Film/VDO (A). Yes (B). No

What types of presentations about contraceptives you like to have in your

school?

49. Lecture (A). Yes (B). No

50. Class discussions (A). Yes (B). No

51. Individual discussion (A). Yes (B). No

52. Film/VDO (A). Yes (B). No

53. Where do you get most of your information about sexually transmitted diseases

and AIDS? (Please choose only one response)

(A). Friends (B). Parents (C). School (D). Magazines/books

(E). TV (F). Newspaper (G). Internet

 255

The Perceived Preventive Behavioral Peer Norms Scale

In this section, we would like to ask you how you feel about your friends’ thought.

Please X that best describes your feeling about your friends.

A = None of my friends

B = A few of my friends

C = Some of my friends

D = Most of my friends

E = All of my friends

1. Do your friends think it is best for teens to wait to have sex until they are older?

A B C D E

None of my friends A few of my friends Some of my friends Most of my friends All of my friends

2. Do your friends think that teens should use condoms when they have sex?

A B C D E

None of my friends A few of my friends Some of my friends Most of my friends All of my friends

3. Do your friends think that it is okay for teens to get pregnant?

A B C D E

None of my friends A few of my friends Some of my friends Most of my friends All of my friends

4. Do your friends think that it is okay for teens to drink alcohol?

A B C D E

None of my friends A few of my friends Some of my friends Most of my friends All of my friends

5. Do your friends think that it is okay for teens to use drug?

A B C D E

None of my friends A few of my friends Some of my friends Most of my friends All of my friends
 256

The Knowledge of STDs/HIV/AIDS & Pregnancy Scale

We would like to ask you about the knowledge of STDs/HIV/AIDS and pregnancy,

please X the response of each following question.

A = True

B = False

C = I don’t know
True False Don’t
Items
know

HIV/AIDS Knowledge

1. Some people can be “carriers” of the AIDS virus, which means they can A B C

pass it to someone else even though they are not sick.

2. AIDS can be cured. A B C

3. AIDS attacks the body’s immune system so that it cannot fight off A B C

infections.

4. A person has to be a homosexual or bisexual man to get AIDS. A B C

5. People can get AIDS by kissing someone with AIDS. A B C

6. A person can get AIDS by using the same drinking glass as someone who A B C

has AIDS.

7. A person can get AIDS by being sneezed on or coughed on by someone A B C

who has AIDS.

8. Using condoms (rubbers) can reduce your chances of getting AIDS. A B C

9. People can get AIDS by giving blood. A B C

10. A person can have the AIDS virus in his/her body and not look or feel A B C

sick.

11. AIDS is sexually transmitted, like herpes and gonorrhea. A B C

12. People can get AIDS by swimming in a public pool. A B C

13. People can get AIDS by sharing needles. A B C

 257

True False Don’t

Items
know

14. A person can get AIDS from having sex with someone who have A B C

AIDS virus.

15. A pregnant woman with AIDS can pass it on to her baby during A B C

pregnancy or while giving birth.

16. People can get AIDS by getting infected blood transfusion. A B C

17. Having sex with many different people increases the chances of A B C

getting AIDS.

18. A person can get AIDS by shaking hands with someone who has A B C

AIDS.

STDs Knowledge

19. All sexually transmitted diseases can be cured. A B C

20. A person can get a sexually transmitted disease by sitting on a A B C

public toilet.

21. If a person has a sexually transmitted disease and doesn’t get A B C

treated, it always goes away with no problems left.

22. Birth control pills can protect a girl from getting a sexually A B C

transmitted disease.

23. A person can get a sexually transmitted disease from swimming in A B C

a public pool.

24. People with sexually transmitted disease look dirty. A B C

25. A pregnant woman with a sexually transmitted disease can pass it A B C

on to her baby during pregnancy or while giving birth.

26. A person can get cancer from having a sexually transmitted disease. A B C

27. Using condoms can reduce the chances of getting a sexually A B C

transmitted disease.

28. I can always tell if someone has a sexually transmitted disease. A B C

 258

True False Don’t

Items
know

Pregnancy Knowledge

29. A sexually active girl can become pregnant if she forgets to take A B C

her birth control pill for several days in a row.

30. A condom can be used more than once. A B C

31. A young man should put on a condom just before he ejaculates A B C

(comes).

32. If a condom is used, a young man should be careful how he pulls A B C

out.

33. If the male pulls out before he comes, he cannot make the girl A B C

pregnant.

34. A young man cannot make a girl pregnant the first few times he A B C

has sex.

35. A girl is most likely to become pregnant if she has sex about two A B C

weeks after her period begins its cycle.

36. Condom is the most effective for preventing STDs/HIV. A B C

37. Condom and pills are more effective for preventing pregnancy than A B C

withdrawal.

38. Withdrawal and rhythm are the least effective for preventing A B C

pregnancy.

39. If a young couple has had unprotected sex a few times and a A B C

pregnancy did not happen, then they do not have to worry about her

getting pregnant.
 259

The Condom Attitude Scale – Adolescent Version (CAS-A)

We would like to ask you about your attitudes toward condom. Please X that best

describes your attitudes about condom.

A = Strongly disagree

B = Mostly disagree

C = Somewhat disagree

D = Neither agree nor disagree

E = Somewhat agree

F = Mostly agree

G = Strongly agree
A B C D E F G
Items
1. Using a condom takes the “wonder” out of sex.
2. I am concerned about catching AIDS or some other
sexually transmitted disease.
3. A condom is not necessary when you and your
partner agree not to have sex with anyone else.
4. Condoms are messy.
5. A condom is not necessary if you know your partner.
6. Using condoms shows my partner I care about
him/her.
7. A condom is not necessary if you’re pretty sure the
other person doesn’t have a sexually transmitted disease.
8. If I’m not careful, I could catch a sexually transmitted
disease.
9. I wouldn’t use a condom if my partner refused.
10. People who carry condoms would have sex with
anyone.
11. I wouldn’t mind if my partner brought up the idea of
using a condom.
12 Condoms create a sense of safety.
 260

A B C D E F G
Items

13. People who use condoms sleep around a lot.

14. If I’m not careful, I could catch AIDS.
15. Condoms take away the pleasure of sex.
16. If my partner suggested using a condom, I would
respect him or her.
17. Other people should respect my desire to use a
condom.
18. I worry that I could catch a sexually transmitted
disease.
19. If my partner suggested using a condom, I would
feel relieved.
20. People who carry condoms are just looking for sex.
21. A condom is not necessary when you are with the
same partner for a long time.
22. If my partner suggested a condom, I would think
he/she was only being cautious.
23. Condoms protect against sexually transmitted
diseases.
 261

The Condom Self-Efficacy Scale (CSE)

We would like to ask you about your beliefs in how well you can do the following

behavior, so please X that best describes how sure you are.

Very Unsure Somewhat Sure Very

Unsure Sure Sure

I feel sure that:

1. I could carry a condom with me in case I needed one. 0 1 2 3 4

2. I could use a condom each time I and my partner had sex. 0 1 2 3 4

3. I could use a new condom each time I and my partner 0 1 2 3 4

had sex.

4. I could stop to put a condom on myself or my partner. 0 1 2 3 4

5. I or my partner could unroll a condom all the way to 0 1 2 3 4

the base of the penis.

6. I could use a condom without it slipping. 0 1 2 3 4

7. I or my partner could get rid of a condom in the 0 1 2 3 4

garbage after sex.

8. I or my partner could hold the condom at the base of 0 1 2 3 4

the penis while withdrawing after sex

9. I could use a condom if drinking beer, wine or other liquor. 0 1 2 3 4

10. I could talk about using condoms with any sexual partner. 0 1 2 3 4

11. I could talk about using a condom if I were unsure 0 1 2 3 4

of my partner’s feelings about condoms.

12. I could talk about using condoms with a potential 0 1 2 3 4

sexual partner before we started to hug and kiss.

13. I could talk a partner into using a condom when 0 1 2 3 4

we have sexual intercourse.

14. I could say no to sex if my partner refused to use a 0 1 2 3 4

condom.
 262

The Actual Usage of Condom Questionnaire

This instrument consists of three questions and they were asked in the

demographic questionnaire (Q. 21, 24, & 26).

(1). “At the beginning of a relationship with your current partner, how often did you

or your partner use a condom when having sexual intercourse?”

A. Never use B. Sometimes use C. Often time use D. most of the time E. every time use

(2). “The last few times when you had sex with your current partner, did you or your
partner use condoms?”
A. Never use B. Sometimes use C. Often time use D. most of the time E. every time use

(3). “In general, when you had sex with your current partner, did you or your partner

use condoms?”

A. Never use B. Sometimes use C. Often time use D. most of the time E. every time use

In the following section, we would like to know your opinion about premarital
sexual activity among Thai adolescents.

1. Tell me what you feel about premarital sexual behavior among Thai adolescents.

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

2. Would you share with me your thoughts about young Thai men having sex before

marriage? Now, tell me what you think about the female.

…………………………………………………………………………………………

…………………………………………………………………………………………

…….……………………………………………………………………………………
 263

Appendix H

Diagram of Data Collection Procedure

Step 1 Meeting with the superintendent of 15 vocational

schools and explain the study to that person

Step 2
The approval letters will be attained from all of the schools that will
potentially be involved in the study

Step 3 Three schools will be randomly selected

Step 4 Propose the study to the IRB of CASE to get approval

Step 5 After getting approval from the IRB of CWRU, the researcher
will again contact the directors of 3 randomly selected schools to
explain description of the study

Step 6
For each randomly selected school, two out of four
programs of the study will be randomly selected.

Step 7 One classroom will be randomly selected

from each of the academic programs
 264

Diagram of Data Collection Procedure (cont’d)

Step 8
Cooperate with the teacher and students in each classroom to
schedule a convenient period for data collection

Step 9 A brief explanation and the purpose of the study will be provided to
students. Also, the researcher will give some time for questions and
answers to assure that the students understand what is being asked of them.

In each classroom, 20 subjects who meet the inclusion criteria and agree to
Step 10 participate in the study will be recruited. To get the information about the students
and to determine if the students meet the inclusion criteria, the teacher will be
asked to help with the elimination process that will occur before the data
collection process begins. Those students who do not meet the criteria will be
escorted to a designated classroom area in the school where they will be provided
with educational materials in Thai and at their developmental levels that address
the topic of HIV/AIDS prevention. A school employee (teacher or counselor) will
be in the classroom with the students during this time. The researcher will obtain
these materials from the district public health department. After the data have been
collected, the researcher will provide opportunities for the students who do not
meet the criteria to discuss HIV/AIDS prevention and ask questions about ways to
prevent HIV/AIDS. Those students will be excluded from the study. The informed
consent will be asked for from the participants. Confidentiality and anonymity of
the questionnaires will be emphasized.
 265

Diagram of Data Collection Procedure (cont’d)

Questionnaires will be distributed to the subjects. The

Step 11
distance of seating will be emphasized to assure participants
cannot see responses of others in the classroom setting.

Step 12 Subjects complete the questionnaires

(50-60 minutes)

Step 13 The questionnaires will be handed back to the researcher.

The researcher will check the questionnaires to minimize
the incidence of missing data. The envelopes contained
the questionnaires and the answer will be sealed tightly
before the researcher leave the classroom. The students
will be thanked and given an additional opportunity to
discuss the research.
 266

Appendix I

A sample of the letter to the Thai vocational school director

April 17, 2007

Ubonratchathani Technical College

Amphur Muang Ubonratchathani

Thailand 34000

Dear the Director of Ubonratchathani Technical College:

My name is Natawan Khumsaen. I am a doctoral student at Frances Payne Bolton

School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA. My doctoral

dissertation advisor is Professor Dr. Faye A. Gary. I am writing to you to ask for your

assistance in my doctoral dissertation research about factors influencing condom use among

Thai adolescents. This descriptive study will identify statistical predictors of condom use

behavior among Thai students. The information obtained from this study will guide the

development of sex education in the future aimed at delaying the initiation of engaging in

premarital sexual behavior, and promoting safer sex behavior among sexually active students.

Regarding confidentiality, this study will use anonymous questionnaire, and the results will

be reported as group data. Moreover, students have the right to withdraw from the study at

any time if they feel uncomfortable.

Therefore, I, as the researcher, ask for a permission to collect data in your school

setting. Please feel free to contact me if you have any questions or concerns. I can be reached

by email at natawan.khumsaen@case.edu or phone: 001-1-216-229-1517. Thank you for

your consideration. I am looking forward to hearing from you.

Sincerely,

Natawan Khumsaen, RN, MSN, PhD Candidate

Frances Payne Bolton School of Nursing
Case Western Reserve University
Cleveland, OH, USA 44106-4904
 267

Appendix J

A sample of the letter of permission from the Thai vocational school

director
 268

Appendix K
Case Western Reserve University IRB Approval Letter
Case Western Reserve University
Institutional Review Board
NOTICE OF APPROVAL
Responsible Investigator: Faye Gary
Department: Nursing - General
IRB Protocol #: 20070702
Title: Factors Influencing Condom Use in Thai Adolescents
Co-Investigator: Natawan Khumsaen
Approval Date: August 21, 2007
Continuing Review Deadline: August 6, 2008
Expiration Date: August 20, 2008
The Institutional Review Board (IRB) has APPROVED the above new protocol
through the expedited review process.
It has been determined that this study involves minimal risk, and that no vulnerable
populations will be involved.
As an investigator of human subjects, your responsibilities include the following (see
full description of responsibilities at our website):
1. Report all adverse events and unanticipated problems involving human
subjects to the IRB Office, located in the Office of Research Compliance
(ORC), within three (3) business days of your knowledge of the occurrence.
2. Provide the IRB with a complete Continuing Review form (available at the
CWRU IRB Web Pages, or from the ORC) by the continuing review deadline
noted above, and when the study is terminated.
3. Discontinue all work pertaining to this protocol if a continuing review
approval is not finalized by the expiration date noted above.
4. Submit all proposed changes to the protocol to the IRB, and receive approval
from the IRB, before implementation of the change.
5. Keep all research data and original consent documents in your possession for
at least three (3) years after the study is terminated.
Please use the attached consent forms for your study.
If you wish to amend it, please submit an addendum – wait for IRB approval –
prior to implementation.
If you have to place your consent on letterhead AND/OR online, please make
certain that you use only the text on the stamped document.

Questions? Please visit our

website: http://ora.ra.cwru.edu/orc_humansubjects_CWRU_IRB.asp
OR
contact our administrative office…
Isabel Sanchez, IRB Director
216.368.6993
Maureen Dore-Arshenovitz, IRB Assistant
216.368.6925; Fax: 216.368.3737
CASE Institutional Review Board
Office of Research Compliance
Sears Building 657
Cleveland, OH 44106-7230
 269

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