In the present study, we studied the sequence of steps that adolescents need to take to attain the goal of using condoms and their action-specific cognitions. The steps examined were: deciding to use condoms, buying condoms, and carrying condoms. We attempted to demonstrate that there was a logical sequence of steps and that simply focusing on intended condom use as the most proximal antecedent of condom use is not necessarily sufficient. We showed that having a positive intention to use condoms did not necessarily lead to buying and carrying condoms, the behaviors that have been shown to be very important in achieving condom use (Bryan et al., 2002
; Sheeran, Orbell, & Abraham, 1999
; van Empelen & Kok, 2006
). In examining the sequence of steps, intended condom use did explain intended condom buying, but it did not predict actual buying. It could be argued that the relationship between intended condom use and buying was mediated by intended buying, but the zero-order correlations suggest that this was not the case. In turn, when we examined condom carrying, intended carrying largely depended on intended buying, and not on intended condom use. Moreover, in explaining actual condom carrying, it was shown that carrying condoms was dependent on whether adolescents actually had bought condoms and intended to carry them. In sum, the results suggest that it is necessary to take into account specific preparatory actions, but that it is also essential to examine their specific cognitions (see Fig. for a summarized model).
Fig. 2 Summarized model of condom preparatory actions. I = intention; Att = Attitude; In = injunctive norm; Se = self-efficacy; Dn = descriptive norm; Pn = Personal (more ...)
The results indicated that the TPB variables were important predictors of intended condom use. In addition, personal norms and anticipated affect appeared to be particularly important in the context of casual sex partners, which is clearly seen as a less desirable situation in which to engage in unprotected sex. Perceived social approval (i.e., injunctive and descriptive norms) seemed an important factor throughout all behavioral stages of condom use, especially with regard to (intended) preparatory behaviors. Injunctive norms were all indirectly affecting behaviors via intention, which is in line with the TPB. Similarly, descriptive norms affected behavior via intentions, except for condom buying, where descriptive norms were not related to intended buying, but instead predicted actual buying. In other words, descriptive norms can influence decision making, but may also lead directly to imitation, which is in line with SCT (Bandura, 1997
). Additionally, attitude was found to have a direct effect on condom carrying, beyond intention. This direct relationship is in line with the literature, which suggests attitudes can activate behavior automatically, without intentional elaboration, when attitudes are highly accessible (Bargh, 1997
; Fazio, 1986
). Finally, habit was found to be a direct predictor of the preparatory behaviors and seems to overrule the effect of the cognitive factors. This also suggests that it is desirable to establish safer sexual behaviors early in the sexual careers of adolescents and to ensure safer sex habits are created.
Our approach of subdividing the goal of condom use into specific underlying behaviors concurs with the principle of compatibility (i.e., ensuring correspondence in measurement between cognitions and behaviors), as condom use may be considered a behavioral category rather than a single behavior (cf. Fishbein, 1993
). By focusing on more specific behaviors, it is easier to examine important cognitions because it is more likely that those cognitions are also more salient when plans are formulated or executed, thereby providing important information for intervention development.
The study results also suggests that motivational issues may play a role in behaviors, beyond the decision to use condoms, which is in contrast with action-oriented models, such as the Health Action Process Approach model (Schwarzer, 1992
) and the Rubicon Model of Action Phases (Gollwitzer, 1996
), which suggest that once people are motivated to pursue a specific goal, the additional processes of goal attainment are volitional. Our study suggests that preparatory behaviors are not entirely volitional and adolescents need to be motivated to carry out the preparatory behaviors.
Intentional abstinence was largely mediated by other social-cognitive factors, except in regard to condom buying behavior. This seems logical, as people who are not open to sexual intercourse in the short term will not feel the need to buy condoms. However, six of the participants among those who reported to be inclined toward abstinence at baseline (n
= 116), reported having a sex partner at follow-up, suggesting that the delay of onset of sexual activity to prevent HIV may be an important AIDS prevention tool, particularly for adolescents, but it may not be sufficient. Moreover, the abstinence approach has not found cogent empirical support (Jemmott & Fry, 2002
; Silva, 2002
). Focusing solely on abstinence might not be appropriate for all adolescents, and it certainly does not prepare them for the sexual activity they most likely will experience eventually.
The impact of sexual experience seems limited with regard to differences in cognitions towards condom use with casual sex partners. In general, adolescents were favorable towards condom use with casual sex partners, regardless of their sexual experience. With respect to condom use in steady sexual relationships, sexually inexperienced adolescents were generally more favorable towards condom use than experienced adolescents (cf. Schaalma et al., 1993
), although the differences were small. Thus, in general, adolescents did not seem to differ with regard to their opinions and beliefs about condom use, although a positive evaluation of condom use may decline with experience. This may suggest that preparing adolescents for possible negative consequences of using condoms is important in order to train them to cope with those consequences and to encourage condom maintenance.
Differences did exist with regard to preparatory actions for condom use, with sexually experienced adolescents being more positive and self-efficacious towards condom carrying and buying. It is important among sexually inexperienced adolescents to emphasize their generally positive cognitions about the use of condoms, and to stress that not anticipating possible sexual encounters may eventually compromise their own ideas about condom use. Furthermore, skill building to purchase or carry condoms may reduce resistance against buying or carrying condoms. Finally, it seems important for both sexually experienced and inexperienced adolescents to establish a sense of social approval of others, like peers and family members, for condom buying and carrying because this study showed that this is likely to be indirectly or directly related to preparatory actions.
We included other background factors (e.g., demographics) in the analyses, but most factors did not have a direct influence on any of the behaviors under examination. As such, it seems that possible differences are largely mediated by more proximal psychosocial factors, although it may well be that some factors may also moderate certain relationships between psychosocial factors and intended or actual behaviors (Van der Straten et al., 1998
). One exception was the direct effect of gender on the buying of condoms, with girls less likely to buy condoms than boys.
In conclusion, it may be important to focus on the sequence of steps that need to be followed, and the underlying social-cognitive factors, in order to attain and even maintain a complex behavior such as condom use. Studies have shown that it is important to plan and prepare for certain behavior, such as condom use, and this may be especially important for adolescents, because of their sexual inexperience. Without specific planning and preparation, adolescents may engage in risky behavior simply because they find themselves in situations they had not anticipated (Gibbons et al., 2003
; van Empelen & Kok, 2006
Before discussing the implications of the present study, it should be mentioned that the findings may be limited due to the fact that a large number of adolescents in the sample were sexually inexperienced. It is worth noting that the inclusion of inexperienced adolescents was done intentionally, given that most HIV prevention programs targeting adolescents, focus on ages at which the majority of adolescents is still inexperienced. Nevertheless, one may wonder to what extent a hypothetical condom use situation is related to real-life experience; more specifically, to what extent intentions are predictive of behavior, when the decision is hypothetical (e.g., Ajzen, Brown, & Carvajal, 2004
). Studies have shown that intentions were predictive in hypothetical situations of complex health behaviors and other behaviors (e.g., voting: Flynn et al., 1997
). Moreover, intentions represent an individual’s motivation and readiness for a specific goal behavior and as such are a very important prerequisite for behavior. Finally, the decision to engage in preparatory actions is not a hypothetical one. As such, such decisions may well explain the goal of condom use, over and above the behavioral intentions.
An additional limitation is related to the design of the study. Within the present study, we have suggested a chain of behaviors. Despite the two time measurements within the present study, some of the relationships examined were cross-sectional. Therefore, one could question the direction of the relationships. For instance, one may wonder to what extent the decision to use condoms leads to the decision to carry condoms or vice versa. Indeed, it is likely that both decisions have a bidirectional relationship. It is important that future studies further examine the causal chain of cognitions and behaviors, preferably by using cross-lagged panel designs, longitudinal or experimental designs in order to examine directionality and change.
School-based educational approaches can serve as important tools in disseminating information about HIV/AIDS and preventive practices to adolescents, but also in teaching the behavioral skills needed for HIV preventive behavior (Kalichman & Hospers, 1997
). Moreover, they may be very effective in reaching those adolescents who are not yet sexually active. Kirby and DiClemente (1994
) showed that the most effective school education programs had common characteristics: (1) a theoretical grounding in social learning or influence theories (e.g., Bandura, 1997
); (2) a narrow focus on reducing specific sexual risk-taking behaviors; (3) experiential activities to convey information on the risks of unprotected sex, ways of avoiding those risks, and personalizing that information; (4) instruction on social influences and pressures; (5) reinforcement of individual values and group norms against unprotected sex that are age- and experience-appropriate; (6) activities aimed at increasing relevant skills and confidence (self-efficacy); and (7) special training for teachers and staff.
We contend that prevention programs should take into account the considerations of Kirby and DiClemente (1994
), but should go beyond motivation-only approaches, by aiming at all planning and preparatory stages of goal achievement. Implementation plans (Gollwitzer, 1996
) could be used as a means of reinforcing the initiation and frequency of engaging in preparatory behaviors among adolescents. Implementation intentions (that is, specifying when, where, and how the behavior is performed) may increase the frequency of preparatory behaviors because the contextual cues will elicit performance of the intended behavior. It should be noted, however, that this method requires that people possess a positive intention to perform a specific behavior. Thus, interventions should ensure that adolescents are motivated not only to use condoms, but also to buy and carry them. Additionally, peer education (e.g., Turner & Shepherd, 1999
) could be used as method to establish social approval with regard to preparatory behaviors, given that: (1) peers who prepare themselves (e.g., have condoms available) may function as positive role models, (2) peers are credible sources, (3) peers are reinforcing and empowering, and (4) peer models themselves may benefit from being a model. Furthermore, stimulating parent-child communication and parental control may create a sense of social approval, and both have shown to be related to a reduction in sexual risk taking, in terms of inconsistent condom use and inconsistent contraceptive use (e.g., Hutchinson, 2002
; Wight, Williamson, & Henderson, 2006
). Finally, safer sexual behavior could be encouraged by ensuring that condoms are routinely available. Condom availability programs might enable adolescents to buy condoms, and may reinforce condom carrying, without necessarily increasing sexual activity (Kirby, 2002
). Parents could also provide their children with condoms, to set a safe sex and condom availability norm, and to ensure that their children are well-prepared for safer sex.