Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706
Volume 2 (2): e21. April-June. 2024.
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Original Article
Stages of change, knowledge and self-efficacy for
condom use in migrants.
Jesús Ramón Aranda-Ibarra
1
& Raquel Alicia Benavides-Torres
2*
.
1
Facultad de Ciencias de la Salud, Universidad Autónoma de Baja California, Tijuana, B.C.
México.
2
Facultad de Enfermería, Universidad Autónoma de Nuevo León, Monterrey, N.L.,
México.
*Corresponding author: Raquel Alicia Benavides-Torres, Av. Dr. José Eleuterio González
1500, Mitras Nte., 64460, Monterrey, Nuevo León. Tel: 8183481010. E-mail:
rabenavi@gmail.com. ORCID: 0000-0001-5113-4250.
Sent: 11/23/2023 Accepted: 03/21/2024 Published: 07/04/2024
Abstract: Introduction: Migrants experience different circumstances that define sexual behavior,
increasing their vulnerability to acquiring STIs and HIV. For the prevention of STIs, including HIV,
adopting condom use as a protective practice is essential, according to the National Health and
Nutrition Survey. The objective of this study is to describe the relationship between condom
knowledge and self-efficacy in condom use with the stages of change for condom use in migrants in
transit. Method: The design is correlational and cross-sectional in a sample of migrant men and
women in transit in the city of Tijuana, Baja California. Data were processed using the Statistical
Package for the Social Sciences (SPSS) 25. Descriptives were determined using means ± standard
deviation (SD) and frequencies. Spearman's correlation coefficient (Spearman's Rho) was used with a
95% error margin, p<0.05. Results: In the stages of change for condom use, 31.1% were in
precontemplation, meaning they had no intention of using condoms in their vaginal, oral, and/or anal
sexual relations within the next six months. On the other hand, 26.6% were in preparation, indicating
they intended to always use condoms during vaginal, anal, or oral sex within the next thirty days.
19.8% of the migrants had been using condoms for more than six months in every sexual encounter,
classifying them in the maintenance stage for condom use. Migrants in the initial stages like
precontemplation and contemplation had lower scores than those in the maintenance stage.
Conclusion: Knowledge of condoms and self-efficacy in condom use have a significant positive
relationship with the stages of change for condom use. It is suggested to replicate the study with a
larger sample and incorporate variables such as motivation, decisional balance, and processes of
change, as well as others indicated by the literature as important in condom use behavior among
migrants in transit.
Keywords: Transtheoretical Model; Condoms; Self-efficacy; Migrants.
Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706
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1. Introduction
Sexually Transmitted Infections (STIs),
including the Human Immunodeficiency
Virus (HIV), remain a public health issue due
to their high incidence, despite being
preventable through behaviors like condom
use1. Currently, more than 30 viruses,
bacteria, or parasites are known to be
sexually transmitted, eight of which are
linked to a high incidence of STIs. Among
these, four are curable: syphilis, gonorrhea,
chlamydia, and trichomoniasis. The other
four are incurable viral infections but can be
managed with treatments that mitigate their
symptoms or the disease: Hepatitis B, herpes
simplex, Human Papillomavirus (HPV), and
HIV
1
. According to the WHO, more than a
million people contract an STI daily. In 2020,
it was estimated that 374 million people
acquired chlamydia, gonorrhea, syphilis, and
trichomoniasis (129, 82, 7.1, and 156 million
respectively), and more than 500 million
people are estimated to be carriers of HPV
2
.
In the Americas, the situation regarding STIs
is similar, with around 64 million cases
annually, making it the second most affected
region after Africa with 23.2% of cases of
trichomoniasis, chlamydia, gonorrhea, and
active syphilis
3
. In Mexico, according to the
2021 epidemiological report by the Ministry
of Health, there was a 75.3% increase in STI
cases compared to 2020. Over the last 15
years, the incidence rate of STIs has
increased by 124%, from 2.1 cases per 100,000
inhabitants to the current 4.7
4
.
For the prevention of STIs, including HIV,
adopting condom use as a protective practice
is essential. According to the National Health
and Nutrition Survey, condom use is more
common among adolescents during their
first sexual encounter, reaching 82.7% among
males and 69.2% among females. However,
this decreases in subsequent encounters to
79.2% among males and 54.9% among
females. As age increases, condom use
becomes less common: among people aged
20 to 29 years, 72.1% of males and 59.3% of
females use condoms, while in the 30 to 39
age group, only 53.4% of males and 41.5% of
females do. For the 40 to 49 age group,
condom use drops to 38.5% among males and
21.4% among females
5
.
Migrants are a vulnerable population with a
higher sexual risk due to their displacement
experiences
6
. According to Guerra, this
group has been associated with a high
prevalence of STIs/HIV since the beginning
of the pandemic
7
. Migrants are three times
more likely to get infected than non-
migrants
8
. Mobile populations, such as
migrants, accounted for 3.6% of the global
population in 2020
9
. The International
Organization for Migration (IOM) estimated
that approximately 281 million people lived in
a country other than their birth country, with
21% residing in North American countries
10
.
Migrants suffer from a range of
communicable and non-communicable
diseases requiring urgent recognition and
attention
11
.
In recent years, Mexico has seen a significant
increase in the number of irregular migrants
due to migratory flows from Central America
heading to the USA. According to the
Migration Policy Unit, Registration, and
Identity of Persons, the first quarter of 2022
saw a 148.7% increase in the arrival of both
national and foreign migrants, increasing the
number of people in this situation at the
Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706
Volume 2 (2): e21. April-June. 2024.
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country's borders
12,13
. By 2019, Baja California
had 10,000 Central American migrants from
Honduras, El Salvador, Guatemala, and
Belize, with 70% in Tijuana. Most of them are
in 32 migrant shelters, with 25% in hotels and
apartments
14
.
Migrants experience various circumstances
that shape sexual behavior, increasing their
vulnerability to acquiring STIs and HIV. The
risk is heightened due to Risky Sexual
Behaviors (RSB)
7
. Several factors influence
migrants' RSB, such as their knowledge of
condom use. Public health studies have
shown that poor knowledge about condom
use hinders the adoption of preventive
measures
7,8
. Another crucial predictor of
condom use is self-efficacy, which is defined
as the confidence individuals have in their
ability to handle different situations, thus
reducing sexual risk among migrants
15
.
Prochaska and Di Clemente explain these
relationships in their Transtheoretical Model
of Change, which describes how, when, and
why people change
16
. To understand the
phenomenon of change, the model describes
stages that individuals go through to achieve
change and the relationship between
knowledge and self-efficacy with progress in
these stages. Therefore, the objective of this
study is to describe the relationship between
condom knowledge and self-efficacy in
condom use with the stages of change for
condom use among migrants in transit.
2. Method
A baseline study was conducted on a pilot
feasibility trial of an intervention using
Motivational Interviewing with migrants in
transit located in shelters, approved by the
research, ethics, and biosafety committees
with authorization number FAEN-D-1915.17
The data presented in this document are
from the cross-sectional correlational
analysis done with the sample of migrant
men and women in transit in the city of
Tijuana, Baja California. The sample size was
calculated using the nQuery Advisor
statistical package, through a test for
multiple linear regression considering a
sample size of 177 participants. A proportion
of variance explained for two covariables of
0.06, considered between small and medium,
with a power of 80 and a significance level of
0.05, was established. The 177 data collected
in the baseline tests of the study were used.
2.1 Stages of Change for Condom Use
To collect the data, a personal data form was
used to understand the characteristics of the
participants. To measure the stages of
change, an algorithm for the stages of change
in condom use was used, which classifies
participants based on questions about the
frequency of condom use and/or the
intention each time they have vaginal, oral, or
anal sex. This is a translation of the proposal
by Grimley et al.
18
.
2.2 Condom Knowledge
The validated scale by Robles et al.
19
was used
for the test of knowledge on the correct use
of condoms. This instrument includes six
statements about aspects related to the
packaging and the correct way to put on and
remove a condom, with response options of
true, false, and don't know. Correct answers
are coded with one (1) and incorrect answers
(including don't know) with a value of zero
(0), where a higher score indicates a higher
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level of knowledge. An example item is "It is
necessary to place the condom to the base of
the penis because if not, it will slip during
sexual intercourse." The scale was subjected
to an analysis to obtain the discriminative
power of each item through factor analysis,
including those items with a factor load
greater than 0.40. The test reports a difficulty
index of 0.37 and a Cronbach's alpha of 0.75.
2.3 Condom Use Self-Efficacy
The subscale related to condom use from the
self-efficacy scale to prevent AIDS validated
by López & Moral
20
was used. This is a 27-item
self-efficacy scale to prevent AIDS (SEA-27)
with Likert-type and dichotomous questions.
The subscale comprises only the second
factor, composed of eight items related to
condom use, with Likert-type responses
where 1 = not at all sure, 2 = somewhat sure,
3 = moderately sure, 4 = very sure, and 5 =
completely sure. Higher scores indicate
greater self-efficacy for condom use. An
example question is, "How sure are you that
you can use a condom every time you have
sex?" The complete scale presents an internal
consistency of α = 0.89, and the subscale of
self-efficacy for condom use reports an alpha
of 0.75.
2.4 Statistical Analysis
The data were processed using IBM Social
Package for the Social Sciences (SPSS) 25.
Descriptives were determined using means ±
standard deviation (SD) and frequencies. To
initiate the analysis, the Kolmogorov-
Smirnov test was performed to determine
the distribution of the data, and Spearman's
correlation coefficient (Spearman's Rho) was
used with a 95% error margin, p < 0.05.
3. Results and discussion
The initial characteristics of the 177 migrants
indicate that 61% are men, with the
predominant educational level being high
school (similar across different countries) at
45.2%. Regarding marital status, 60%
reported being single. Foreign migrants make
up 68.4% of the sample, with Venezuela being
the most common country of origin at 39%.
Only 15.3% have temporary migration status,
with the majority (48%) being in an irregular
situation. At the time of the study, 55.4% had
been away from their place of origin for less
than three months.
The characteristics of the 177 migrants
further indicate that 5.6% engaged in
transactional sex during their journey, only
11.9% consumed alcoholic beverages, 96%
reported not using drugs during the journey,
and none of the participants were diagnosed
with HIV (Table 1). The average age is 32.09
years (SD = 8.99), the number of times they
crossed into the USA is 0.42 (SD = 0.94), and
the age at which they first crossed is 28.82
(SD = 8.54). In relation to sexual behavior, the
average number of sexual partners during the
journey is 2.01 (SD = 4.71) (Table 2).
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Table 1. Sociodemographic characteristics of the sample (Frequencies)
Sociodemographic data
Total (n=177)
f
%
Gender
Female
Male
69
39
108
61
Education
None
8
4.5
Elementary
24
13.6
Middle School
48
27.1
High School
80
45.2
Bachelor's Degree
16
9
Postgraduate
1
.6
Marital status
Single
79
44.6
Married
53
29.9
Divorced
6
3.4
Widower
4
2.3
Cohabiting
35
19.8
Nationality
Mexican
56
31.6
Foreign
121
68.4
Place of origin
Mexico
56
31.6
Cuba
6
3.4
Nicaragua
3
1.7
Honduras
18
10.2
Venezuela
69
39.0
El Salvador
11
6.2
Haiti
4
2.3
Guatemala
8
4.5
Peru
2
1.1
Migratory status
Regular
65
36.7
Irregular
85
48
Temporary
27
15.3
Time elapsed since leaving place of origin
Less than 3 months
98
55.4
Over three months
47
26.6
Over 6 months
20
11.3
Over 12 months
12
6.8
Living in the USA
Yes
24
13.6
No
153
86.4
Transactional sex
Yes
10
5.6
No
157
88.7
Rather not answer
10
5.6
Alcohol consumption
Yes
21
11.9
No
154
87
Rather not answer
2
1.1
Drug use
Yes
4
2.3
No
170
96
Rather not answer
3
1.7
HIV diagnosis
Yes
0
0
No
177
100
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Nota: n= 177 f = frecuencia %= Porcentaje
Table 2. Sample sociodemographic characteristics
Sociodemographic data
Total
(n=177)
M
SD
Min
Max
Age
32.09
8.99
18
54
Number of sexual partners during transit
2.01
4.71
0
50
Number of times you have crossed to USA
0.42
0.94
0
6
Age of first time crossing to the U.S.
28.82
8.54
9
54
Note: n=Sample; M=Mean; SD=Standard deviation; Min=Minimum; Max=Maximum
In the stages of change for condom use,
31.1% were in precontemplation, meaning
they had no intention of using condoms in
their vaginal, oral, and/or anal sexual
relations within the next six months. On the
other hand, 26.6% were in preparation,
indicating they intended to always use
condoms during vaginal, anal, or oral sex
within the next thirty days. 19.8% of the
migrants had been using condoms for more
than six months in every sexual encounter,
classifying them in the maintenance stage
for condom use (Figure 1).
Migrants in the initial stages, such as
precontemplation and contemplation, had
lower scores than those in the maintenance
stage (Table 3).
Figure 1. Classification of stages of change for condom use among migrants in transit.
31.1%
19.8
16.9%
24.9
26.6%
23.7
5.6%
14.7
19.8%
16.9
0
5
10
15
20
25
30
35
Condom use HIV Testing
Stages of change for condom use
Pre-contemplation Contemplation Preparation Action Keep up
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Table 3. Knowledge and self-efficacy scores for condom use according to each stage of change.
Stage of change
Variable
M
Min
Max
SD
Pre-contemplation (n = 55)
Knowledge
40.90
0.00
100.00
29.71
Self-efficacy
56.25
0.00
100.00
26.98
Contemplation (n= 30)
Knowledge
51.66
0.00
100.00
22.88
Self-efficacy
59.68
15.63
100.00
25.20
Preparation (n= 47)
Knowledge
60.63
0.00
100.00
28.32
Self-efficacy
67.81
12.50
100.00
22.62
Action (n= 10)
Knowledge
53.33
16.67
83.33
21.94
Self-efficacy
69.06
50.00
93.75
14.98
Keep up (n=35)
Knowledge
64.28
0.00
100.00
23.27
Self-efficacy
79.82
25.00
100.00
23.04
Note: n=Sample; M=Mean; SD=Standard deviation; Min=Minimum; Max=Maximum
The increase in knowledge and self-
efficacy along with the progression in the
stages of change is to be expected, since
according to Prochaska and DiClemente's
transtheoretical model of change, the
greater the knowledge of the
phenomenon and the greater the self-
efficacy, the more advanced in the stages
of change the person is in adopting the
behavior
21
. On the other hand, there are
studies that agree with these results such
as Tung et al.
22
where they evaluated the
association between gender and TTM
constructs, and knowledge of HIV/AIDS,
it was found that participants in the
contemplation stage were 4.10 times
more likely to have high self-efficacy
(CI=95%: 2.10-8.04, p<0.001) than those in
precontemplation. Tung et al.
23
in a study
developed with the aim of assessing
sexual and condom use behaviors, shows
that action-placed participants
presented significantly higher self-
efficacy scores than precontemplation
participants in specific situations such as:
when receiving peer pressure (M=3. 55
SD=1.20 vs. M=2.88, SD=1.06, p=0.008;
when there is not much risk (M=3.91,
SD=1.10 vs. M=3.16, SD=1.06, p=0.004); and
when the risk seems low (M=4.02,
SD=0.97 vs. M=3.04, SD=1.14, p=0.0001).
As can be seen, both variables showed
higher scores in the more advanced
stages of change, this is due to the fact
that according to Ramirez et al.
24
in a
study with 232 immigrant Latina
farmworkers with the purpose of
knowing the egalitarian attitudes
towards women in relation to knowledge
of HIV, self-efficacy for HIV and
intentions to negotiate safe sex. The
results show that the greater the
knowledge of HIV (β=0.197, p<0.005), the
greater the self-efficacy for HIV (β=0.210,
p=0.004), and the greater the intentions
for safe sex (β=0.172, p=0.022), which
suggests a relationship between the
variables with an impact on behavior to
reduce sexual risk, including condom use.
The results show that there is a low
significant correlation between the
stages of change for condom use with
condom knowledge (Rho(175)=0.304,
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p<0.001) and condom use self-efficacy
(Rho(175)=0.317, p<0.001) (Table 4).
Table 4. Correlations of stages of change for condom use with condom use knowledge and self-
efficacy.
Variables
Knowledge about the
Condom
Condom use self-efficacy
Stages of Change for
Condom Use
0.304**
0.317**
Note: * p <0.05; ** p <0.001
Additionally, a multiple linear regression
model was calculated to predict the
effect of condom knowledge (β=0.205,
SE=0.004, p<0.05) and condom use self-
efficacy (β=0.260, SE=0.004, p=0.001) on
the stages of change for condom use. The
regression equation was statistically
significant (F(2-174)=15.27, p<0.001).
R2=0.149, indicating that the predictor
variables only explain 14.9% of the stages
of change for condom use (Figure 2).
This model allows predicting a low
percentage of the stages of change;
however, there are other studies such as
the one by Gullette & Turner, which was
carried out with the objective of
describing the relationship between the
stages of change and condom use,
showing that individuals who were in a
higher stage of change were more
confident in the efficacy of condom use
(β=0.31, p<0.05)
25
.
Figure 2. Schematic of the stages of change model for condom use in migrants.
4. Conclusions
In the present study, it was possible to
respond to the objective of describing the
relationship between knowledge of
condom use and self-efficacy of condom
use with the stages of change for condom
use in migrants in transit. Knowledge of
condoms and self-efficacy for condom
use have a significant positive
Stages of change
for condom use in
migrants
(β= 0.205, p<0.05)
(β= -0.260, p<0.001)
- Condom knowledge
- Self-efficacy of condom use
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relationship with the stages of change for
condom use; this could indicate that the
greater the knowledge and self-efficacy
of the migrant about condoms, the better
positioned he/she is in the stages of
change; this statement can be confirmed
by the model that shows the predictive
effect of the variable.
The study demonstrates the relationship
between the variables. It is worth
mentioning that, although the correlation
between the variables is low, it is an
important finding that encourages us to
increase the sample size to confirm the
results. Additionally, the further analysis
of the regression model calculation
shows that the study variables
significantly predict the stages of change
for condom use among migrants.
However, it also highlights the need to
explore other variables that might
enhance the model's explanatory power,
such as processes of change, decisional
balance, and motivation, which are
factors influencing the stages of change
for adopting a behavior, as indicated by
Prochaska and DiClemente's
Transtheoretical Model of Change.
Therefore, it is suggested to replicate the
study with a larger sample and
incorporate variables such as motivation,
decisional balance, and processes of
change, as well as other factors indicated
by the literature as important in condom
use behavior among migrants in transit.
5. Declarations
5.1 Author Contributions
Conceptualization: JRAI; Methodology:
JRAI; Validation: JRAI, RABT; Formal
Analysis: JRAI, RABT; Investigation: JRAI;
Resources: JRAI; Data Curation: JRAI,
RABT; Writing - Original Draft: JRAI;
Writing - Review & Editing: JRAI, RABT;
Visualization: JRAI; Supervision: JRAI,
RABT; Project Administration: JRAI, RABT.
5.2 Conflict of Interest
The authors declare that there is no
conflict of interest regarding the
development of this study.
5.3 Funding
This study was conducted during the
doctoral studies of the first author, who
is recognized with a scholarship for
postgraduate studies from the National
Council of Humanities, Sciences, and
Technologies (CONAHCYT) of Mexico.
5.4 Acknowledgements
We thank the people in transit who gave
some of their time to participate in the
study.
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