The use of the Multidimensional Condom Attitude Scale in Chinese young adults

Sexually transmitted infections (STIs) remain a severe global health issue. China, including Hong Kong, is experiencing a rapid increase in HIV/AIDS [1, 2]. A population-based study of 18–26 year olds in Hong Kong found that chlamydia is relatively common in sexually active women (5.8%) and men (4.8%) [3]. The increasing popularity of smartphone online dating and a growing openness towards premarital sex and homosexual relationships have resulted in an increased prevalence of STIs [4‐7]. It should also be noted that Hong Kong is an important global city with a population of 7.3 million people [3], and the number of visitors to the region continues to rise. A systematic meta-analysis recently reported that the prevalence of travel-associated casual sex (tourists having sex with local people) could be as high as 20%, with 49.4% of these cases involving unprotected intercourse [8]. This phenomenon could be a contributing factor to the increase in STIs in the local community. To diminish the negative impact of STIs, their primary prevention is very important, especially amongst high-risk groups such as men who have sex with men, young people and sex workers.

An essential method of reducing the spread of STIs is consistent condom use. Meta-analyses have reported that consistent condom use can reduce the risk of HIV infection by 80–95% [9, 10]. Condom use is likewise associated with statistically significant protection of men and women against several types of STIs, including chlamydia, gonorrhoea, herpes simplex virus type 2 and syphilis [11]. Although analyses have shown that different interventions, including behavioural [12] and technology-based [13] approaches, can increase condom usage, inconsistent condom use is still found in different Chinese populations [5, 14]. Moreover, findings from a series of behavioural surveillance surveys from 1998 to 2015 showed no evident improvement in consistent condom use in Hong Kong [15]. Hence, there is an urgent need to further understand the barriers and facilitators of condom use to diminish the spread of STIs.

Understanding the predictors of condom use is key to developing effective interventions and community programmes to increase condom use. Attitude is an important factor in nearly all health behaviour models [16]; specifically, existing evidence suggests that attitude towards using condoms is a strong predictor of their use [17, 18]. Moreover, interventions that do not address attitude often fail to improve safe sexual behaviours [19]. Accordingly, understanding and enhancing a positive attitude towards the use of condoms are of paramount importance to achieve consistent condom use. These will, in turn, help reduce the spread of STIs.

This study established the validity and reliability of using the UCLA MCAS with young Chinese adults. However, the initial exploratory factor analysis suggested that the data obtained from the current Chinese population did not fit the structure found in western populations. For example, a previous study on Colombian men and women [36] and low-acculturated Hispanic women [26] replicated the original five-factor structure. Thus, the results suggested that condom use attitude is culturally specific. Related to this, previous studies have found that differences in race and ethnicity influence perceptions about condom use amongst African Americans and Caucasians [37] and the level of unwanted condom use amongst African Americans, Latinos and Caucasians [38]. This result has implications for the findings of the present study. First, interventions to promote positive attitudes towards condom use should be culture-specific [39] because health promotion strategies that are effective in western contexts may not necessarily transfer to Chinese populations. Second, from a psychometric perspective, caution is required when comparing attitude measured by the MCAS across other cultures given the difference in factor structure. Further studies are warranted to investigate any measurement invariance of this particular instrument across different cultures to ensure that the comparison of instrument scores is valid and meaningful [18]. Nevertheless, similar to the validation study on Colombian men and women [36], the present study also found that men have more positive attitudes towards the reliability and effectiveness of condoms and are less embarrassed by condom negotiation and use. This finding implies that further education to enhance female’s attitude towards the effectiveness of condoms and improve their skills in condom use negotiation is needed.

On the basis of the EFA result, items 6 (‘The use of condoms can make sex more stimulating’) and 20 (‘I never know what to say when my partner and I need to talk about condoms or other protection’) were excluded in the current study. This outcome is consistent with that suggested by Starosta et al. [18], who found that these two items functioned differently between the genders and should be removed from the scale. Item 6 was recommended for removal from the scale because it cannot accurately represent female attitudes towards condom use, thus possibly biasing the result obtained from this subscale [18]. Regarding item 20, Starosta et al. [18] pointed out that sexually active heterosexual women must have considerably more favourable attitudes about discussing the use of condoms than do men. Thus, the inclusion of item 20 in the scale might inflate the score in females compared to that in males [18].

Purchasing condoms was found to be far more embarrassing than condom use negotiation in a Chinese population. Specifically, approximately 25% of the participants said they would feel uncomfortable buying condoms, and more than half expressed embarrassment at being seen buying them. By contrast, only 10% of the participants felt it would be difficult to discuss condom use with their partner. Individuals may feel embarrassed about purchasing condoms because it involves a social audience and public behaviour but not about using condoms where the interaction is with just one other person [40]. A study in North America found that purchasing condoms elicits the most embarrassment, whereas using condoms is the least embarrassing [40]. A further study conducted in China, Canada and South Korea similarly found that the embarrassment associated with purchasing condoms exceeds that of using condoms [41]. Note that embarrassment about purchasing condoms impact purchase intent, which in turn significantly reduces the frequency of condom use [41, 42].

This finding has several implications. First, further discussions about this embarrassment and suggestions about how to cope with it are required in sexual health education [41]. Current sexual health education in Hong Kong and initiatives relating to condom use largely focus on the importance of using condoms, the right way to use them and their effectiveness. However, topics related to embarrassment and purchasing behaviours are neglected. Therefore, purchase-related embarrassment and the strategies to cope with it must be considered in sexual health education in order to promote consistent condom use and improve sexual and reproductive health worldwide [41]. Second, the process of obtaining condoms should be improved and made less embarrassing [42]. Undoubtedly, purchasing condoms online is less embarrassing. However, individuals cannot obtain them immediately, and this is particularly relevant to the context of casual sex in which people need condoms instantly. In Hong Kong, condoms are mainly available in convenience stores, supermarkets and pharmacies, but those who are worried about being seen may not wish to buy condoms from such shops. Vending machines for condoms are available but not very common, and so a possible solution is to place more of these machines in public—but relatively private—places, such as public toilets. Fundamentally, more public health campaigns and sexual health education to help cope with embarrassment about purchasing condoms are required [41].

Perhaps surprisingly, the concept of condom reliability and effectiveness was suboptimal in the present study. Only approximately half of the participants agreed that condoms were an effective and satisfactory method of birth control while more than 40% expressed concerns over their reliability. A related research from Singapore found that 42.1% of the adolescents studied had experienced condom slippage and 32.1% had experienced breakage [43]. A negative attitude towards reliability and effectiveness and a fear of upsetting consequences are probable reasons for the high prevalence of inconsistent condom use in the Hong Kong community [5, 44, 45], and these have implications for the findings. First, qualitative studies are required to explore why people think condoms are unreliable and/or ineffective. Second, individuals should be taught how to choose the correct condom size as well as how to use condoms properly to enhance their reliability and effectiveness in birth control and STI prevention.

A moderate gender difference in embarrassment about condom purchase was found. In line with previous studies in China [41] and the United States [46], female participants were more embarrassed about purchasing condoms than do their male counterparts. A potential reason for this greater degree of embarrassment is because ‘a female is purchasing a male method of contraception’ [47]. Other possible reasons in this population are that sex is still largely taboo in Chinese culture and the existence of gender inequality. For example, Chinese people tend to highlight the importance of premarital sexual abstinence for girls rather than for boys [48], a propensity that is likely to make females more embarrassed about buying condoms than do males. In addition to these gender differences, variance in embarrassment about negotiating condom use across sexual orientations was found, with non-heterosexual respondents more embarrassed than their heterosexual counterparts. An explanation for this may be related to psychological and social factors, such as anxiety, loneliness or distress associated with sexual identity [49]. Disparity in the rates of intimate partner violence (IPV) may also lead to this difference. IPV has been shown to be more prevalent in some non-heterosexual groups than in heterosexual populations [50, 51] and suggested to be capable of lowering the efficacy of condom negotiation [52]. Future interventions aimed at enhancing attitude towards condom use should account for the differences in gender and sexual orientation.

Different levels of embarrassment about negotiating condom use were found between participants who had sexual experience and those who did not. Sexually inexperienced people felt more embarrassed about discussing condom use with their partner and buying condoms in the first place. A possible explanation here is that embarrassment about negotiation and purchase is a barrier to initiating sexual activities amongst young adults. However, these associations should be interpreted with caution because causality cannot be inferred from this limited cross-sectional analysis. Thus, further longitudinal studies are needed to explore the temporal relationship between embarrassment and experience.

The present study has some limitations. First, given its cross-sectional nature, the test–retest reliability and responsiveness of the instrument could not be assessed, and further studies are required to establish the psychometric properties. Second, all participants were aged between 18 and 29 years old. Therefore, the findings may not be generalisable to a wider population. That said, the intention of the current study was to study this subgroup specifically because it was previously found that inconsistent condom use is common within it [5]. For example, young adults are more sexually adventurous than older adults [53]. Furthermore, STIs, including chlamydia, are reported to be highly prevalent in this subgroup of the Hong Kong community [3]. Third, given that only attitude towards condom use was measured, other aspects, such as knowledge, self-efficacy and sexual behaviour, should be included in future studies to investigate their relationships with this attitude.

The validity and reliability of the MCAS were evaluated in young Chinese adults. Instead of the five-factor structure developed in previous studies, a six-factor scale was found, suggesting that condom attitudes are culturally specific. High levels of embarrassment about purchasing condoms and negative attitudes towards their reliability and effectiveness were reported, implying that future health interventions regarding condom use must focus on these inadequately promoted areas.