Heterosexually active men's beliefs about methods for preventing sexually transmitted diseases

Perspectives on Sexual and Reproductive Health, May-June, 2003 by Mary Rogers Gillmore, Sorrel Stielstra, Bu Huang, Sharon A. Baker, Blair Beadnell, Diane M. Morrison

Heterosexual transmission accounted for the largest proportionate increase in the number of reported AIDS cases in the United States between 1996 and 2000, (1) and AIDS is the leading cause of death among individuals aged 25-44. (2) Other sexually transmitted diseases (STDs) also account for considerable morbidity and mortality. (3) Most of the research on heterosexual STD transmission has focused on women, undoubtedly because transmission from men to women is more efficient than the reverse, (4) women tend to have more severe sequelae than men and women traditionally have had less control of the means of prevention. (5) However, heterosexual STD transmission cannot be prevented without better understanding of men's, as well as women's, sexual beliefs and behaviors. (6)

Three strategies are recommended to reduce the risk of STD transmission: abstinence, mutual monogamy between uninfected partners and condom use. Heterosexual risk behaviors and male condom use have been well documented, (7) but information about other prevention strategies is scant. The purpose of this article is to provide information about heterosexually active men's beliefs about methods of STD prevention so that interventions can be better informed.

Beliefs about condoms are an important determinant of condom use. (8) As is true for women, men are more likely to use condoms with casual partners than with steady part ners. (9) This may reflect the belief of some men that condoms are necessary only with nonmonogamous partners, to avoid "bringing anything home," (10) or that introducing condoms into a steady relationship might imply infidelity. (11) Despite a relatively high general level of AIDS awareness, men who use condoms during vaginal intercourse do so primarily for contraception rather than disease prevention. (12)

Although research on men's beliefs about the female condom is limited, preliminary findings suggest that despite a lack of familiarity with the method, many men would be willing to try it. (13) However, some men are apprehensive about its efficacy, the embarrassment in asking a partner to use one, the potential reduction in sexual pleasure (14) and the concern that women could "sabotage" it if they desired a pregnancy but their male partner did not. (15) In addition, the female condom suffers from some of the same negative beliefs that men have about male condoms, including being associated with infidelity and disease. (16)

Heterosexually active men's beliefs about abstinence and monogamy have received scant research attention. Preliminary evidence suggests that in general, men are not in favor of abstinence, (17) and some believe that it is an "unnatural" and "unrealistic" strategy for STD prevention. (18) Very little information is available about their beliefs about monogamy as a disease prevention strategy.

The theory of reasoned action suggests that beliefs are important determinants of decisions about using such methods. (19) According to the theory, behavior (e.g., using a condom) is a direct function of intention to perform the behavior. Intention, in turn, is predicted by both attitudes and perceived social norms about the behavior. Beliefs about the outcomes of engaging in the behavior (e.g., use of condoms reduces pleasure) underlie attitudes. These outcome beliefs have two components--how likely the outcome is perceived to be and how good or bad it is considered. Similarly, normative beliefs underlie social norms, and these beliefs have two components--what specific others think one should do and how motivated one is to comply with their wishes.

A meta-analysis of studies of male condom use supports the theory of reasoned action. (20) However, the few studies focusing on heterosexually active men have tended to be based on small convenience samples of clients at STD clinics, adolescents or minority groups. A few large studies, based on national probability samples, have provided important information about heterosexually active men's sexual behaviors, including use of male condoms, (21) but they have not ascertained the men's beliefs about STD prevention methods.

In this article, we describe beliefs heterosexually active men hold about use of STD prevention methods; examine the relationship of these beliefs to men's characteristics; and examine the relationship of these beliefs to behavior, using longitudinal data. We use a theory-guided approach in a large, random sample of heterosexually active men. Notably, we elicited the beliefs from the men themselves, rather than generating a priori beliefs. This approach lends greater validity to the findings and imparts greater value to the information for those involved in STD prevention.

METHODS

The data come from a longitudinal study examining decisions about four methods for protecting against STDs--abstinence, monogamy, use of male condoms and use of female condoms--among heterosexually active men living in a large urban county in the northwestern United States. Data were collected in two phases. First, we used qualitative research to elicit beliefs about the four methods. Using results of content analysis of this information, we developed individual items tapping this content. In the second, quantitative phase, computerized interviews were conducted to explore men's beliefs and behaviors at study enrollment and again four months later. Both phases of the study were approved by the institutional review board of the University of Washington.