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.

iv 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

v 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

vi 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

vii 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

viii 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, selfreported 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

ix 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

x 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 selfconfidence, 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 selfefficacy. 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 20002001, 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 PIDrelated 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 selfefficacy 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 selfefficacy 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 selfefficacy 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 selfefficacy (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, selfreported 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 wellbeing. 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 selfefficacy 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 (Asymptomatic, acute infection, or

B (Symptomatic; no A

C (AIDS indicator*)

no A or C conditions)

persistent generalized Lymphadenopathy)

>500

A1

B1

C1

200-500

A2

B2

C2

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) (10 Major subtypes) -

A

-

B (most seen in the US and Europe)

-

C

-

D

-

E (most seen in Central Africa)

-

F

-

G

-

H

-

I

-

J

- Subtype 4 - Subtype 5

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 lowincome 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). Lowincome 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 threefourths 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 resourcepoor 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 (RerksNgarm, 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 schoolbased 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 19441949, 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 nonuse 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 crosssectional 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 crossroad 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 premarital 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 (RathnawardanaGuruge, 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 everchanging 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 nonvirgin 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

88 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 1324 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 (1544 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

90 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,

91 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

92 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

93 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).

94 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 (OPrasertsawat, 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-

96 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.

97 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

98 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.

99 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

100 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

101 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. Selfefficacy also refers to the amount of effort individuals will put into performing a

102 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 selfefficacy 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

103 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 selfregulatory 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

104 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. Selfregulation 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.,

105 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

106 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 selfregulatory 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

107 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.

108 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

109 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 postintervention. The intention to use condoms in possible future sexual encounters increased significantly for the intervention youth compared to control youth between

110 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

111 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 skillsbuilding 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

112 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

113 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

114 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 selfesteem, 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

115 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 45year-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 selfefficacy, 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).

116 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, selfefficacy, 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

117 self-efficacy, emotion control, assertiveness, image confidence, and sexual control were the significant predictors of intention to use condom. Gender, age, global selfefficacy, 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

118 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 selfefficacy 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. Selfefficacy, 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

119 primary and secondary schools in Haiti. The participants were asked to fill out a selfadministered 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

120 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

121 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.

122 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

123 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

124 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

125 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

126 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

127 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.

128 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 selfreported 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-

129 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. Thirtythree 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

131 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

132 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.

133 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

134 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

135 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