AIDS and Behavior

, Volume 18, Issue 1, pp 135–145 | Cite as

Predicting Condom Use in South Africa: A Test of Two Integrative Models

  • Sander M. EggersEmail author
  • Leif E. Aarø
  • Arjan E. R. Bos
  • Catherine Mathews
  • Hein de Vries
Original Paper


This study tested two integrative socio-cognitive models, namely the information–motivation–behavioral skills model (IMB) and the I-Change model (ICM), to assess their hypothesized motivational pathways for the prediction of condom use during last sexual intercourse. Students (N = 1066) from Cape Town, South Africa, filled out questionnaires at three different time points. Structural equation modeling demonstrated that self-efficacy did not predict behavior directly but indirectly via intention. Knowledge of how to use a condom and how STIs are transmitted directly predicted behavior when modeled as hypothesized by the IMB model, but indirectly when the factors attitude, subjective norms and self-efficacy were included as mediators, as hypothesized by the ICM. It is concluded that the ICM and IMB are similar in terms of model fit and explained variance, but that the ICM had a higher proportion of significant pathways.


Information–motivation–behavioral skills model I-Change model Theory of planned behavior Condom use HIV 



We would like to thank all partners involved in the SATZ project. The full title of the project is:”Promoting sexual and reproductive health. School-based HIV/AIDS prevention in sub-Saharan Africa”. The SATZ study was funded by the EC-INCO research programme (Fifth Framework Programme-Contract number ICA4-CT-2002-10038). The partners and principal investigators included: University of Cape Town (Alan J. Flisher), Muhimbili University College of Health Sciences (Sylvia Kaaya), University of the North (Hans Onya), Karolinska institute (Minou Fuglesang), University of Maastricht (Herman Schaalma), University of Oslo (Knut-Inge Klepp), World Population Foundation & Youth Incentives (Jo Reinders) and the University of Bergen (Leif Edvard Aarø–coordinator).


  1. 1.
    UNAIDS. Global Report: UNAIDS report on the global AIDS epidemic: Joint United Nations Programme on HIV/AIDS; 2010.Google Scholar
  2. 2.
    Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Pillay-van-Wyk V, et al. South African national HIV prevalence, incidence, behaviour and communication survey 2008: a turning tide among teenagers?. Cape Town: HSRC; 2009.Google Scholar
  3. 3.
    Reddy P, James S, Sewpaul S, Koopman F, Funani N, Sifunda S, et al. Umthente uhlaba usamila: the 2nd South African youth risk behaviour survey 2008. Cape Town: South African Medical Research Council; 2010.Google Scholar
  4. 4.
    Bryan A, Kagee A, Broaddus M. Condom use among South African adolescents: developing and testing theoretical models of intentions and behavior. AIDS Behav. 2006;10(4):387–97.PubMedCrossRefGoogle Scholar
  5. 5.
    Eaton L, Flisher AJ, Aarø LE. Unsafe sexual behaviour in South African youth. Soc Sci Med. 2003;56(1):149–65.PubMedCrossRefGoogle Scholar
  6. 6.
    Hendriksen ES, Pettifor A, Lee SJ, Coates TJ, Rees HV. Predictors of condom use among young adults in South Africa: the reproductive health and HIV research unit national HIV survey. Am J Public Health. 2007;97(7):1241–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Jewkes R, Levin JB, Penn-Kekana LA. Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Soc Sci Med. 2003;56:125–34.PubMedCrossRefGoogle Scholar
  8. 8.
    Kalichman SC, Simbayi LC, Cain D, Jooste S, Skinner D, Cherry C. Generalizing a model of health behaviour change and AIDS stigma for use with sexually transmitted infection clinic patients in Cape Town. S. Afr. AIDS Care. 2006;18(3):178–82.CrossRefGoogle Scholar
  9. 9.
    Kaufman MR, Shefer T, Crawford M, Simbayi LC, Kalichman SC. Gender attitudes, sexual power, HIV risk: a model for understanding HIV risk behavior of South African men. AIDS Care. 2008;20(4):434–41.PubMedCrossRefGoogle Scholar
  10. 10.
    MacPhail C, Campbell C. `I think condoms are good but, aai, i hate those things’: condom use among adolescents and young people in a Southern African township. Soc Sci Med. 2001;52(11):1613–27.PubMedCrossRefGoogle Scholar
  11. 11.
    Pettifor A, Measham D, Rees HV, Padian NS. Sexual power and HIV risk, South Africa. Emerg. Infect. Dis. 2004. Accessed on 25 Jul 2011.
  12. 12.
    Albarracin D, Johnson BT, Fishbein M, Muellerleile PA. Theories of reasoned action and planned behavior as models of condom use: a meta-analysis. Psychol Bull. 2001;127:142–61.PubMedCrossRefGoogle Scholar
  13. 13.
    Sheeran P, Abraham C, Orbell S. Psychosocial correlates of heterosexual condom use: a meta-analysis. Psychol Bull. 1999;125(1):90–132.PubMedCrossRefGoogle Scholar
  14. 14.
    Janz NK, Becker MH. The health belief model: a decade later. Health Educ Behav. 1984;11(1):1–47.CrossRefGoogle Scholar
  15. 15.
    Rosenstock IM. Why people use health services. Milbank Q. 1966;44(3):94–127.Google Scholar
  16. 16.
    Maddux JE, Rogers RW. Protection Motivation Theory and self-efficacy: A revised theory of fear appeals and attitude change. J Exp Soc Psychol. 1983;19:469–79.CrossRefGoogle Scholar
  17. 17.
    Prentice-Dunn S, Rogers RW. Protection motivation theory and preventive health: beyond the health belief model. Health Educ Res. 1986;1:153–61.CrossRefGoogle Scholar
  18. 18.
    Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs: Prentice-Hall; 1986.Google Scholar
  19. 19.
    Ajzen I. The theory of planned behavior. Organ Behav Hum Dec. 1991;50:179–211.CrossRefGoogle Scholar
  20. 20.
    Albarracin D, Gillette JC, Earl AN, Glasman LR, Durantini MR, Ho M. A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. Psychol Bull. 2005;31(6):856–97.CrossRefGoogle Scholar
  21. 21.
    Harrison A, Newell M-L, Imrie J, Hoddinott G. HIV Prevention for South-African youth: which interventions work? a systematic review of current evidence. BMC Public Health. 2010;10:102.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Ingram BL, Flannery D, Elkavich A, Rotheram-Borus MJ. Common processes in evidence-based adolescent HIV prevention programs. AIDS Behav. 2008;12:374–83.PubMedCrossRefGoogle Scholar
  23. 23.
    Fisher JD, Fisher WA, Williams SS, Malloy TE. Empirical tests of an information–motivation–behavioral skills model of AIDS-preventive behavior with gay men and heterosexual university students. Health Psychol. 1994;13(3):238–50.PubMedCrossRefGoogle Scholar
  24. 24.
    Fisher WA, Fisher JD, Harman J. The information–motivation–behavioral skills model: a general social psychological approach to understanding and promoting health behavior. In: Suls J, Wallston KA, editors. Social psychological foundations of health and illness. Malden: Blackwell; 2003.Google Scholar
  25. 25.
    De Vries H, Mesters I, van de Steeg H, Honing C. The general public’s information needs and perceptions regarding hereditary cancer: an application of the integrated change model. Patient Educ Couns. 2005;56:154–65.PubMedCrossRefGoogle Scholar
  26. 26.
    De Vries H, van Osch L, Eijmael K, Smerecnik C, Candel M. The role of risk perception in explaining parental sunscreen use. Psychol Health. 2012;27(11):1342–58.PubMedCrossRefGoogle Scholar
  27. 27.
    Fisher JD, Fisher WA. Changing AIDS-Risk behavior. Psychol Bull. 1992;111(3):455–74.PubMedCrossRefGoogle Scholar
  28. 28.
    Fisher WA, Williams SS, Fisher JD, Malloy TE. understanding AIDS risk behavior among sexually active urban adolescents: an empirical test of the information–motivation–behavioral skills model. AIDS Behav. 1999;3(1):13–23.CrossRefGoogle Scholar
  29. 29.
    Robertson AA, Stein JA, Baird-Thomas C. gender differences in the prediction of condom use among incarcerated juvenile offenders: testing the information–motivation–behavioral skills (IMB) model. J Adolescent Health. 2006;38:18–25.CrossRefGoogle Scholar
  30. 30.
    Ybarra M, Korchmaros J, Kiwanuka J, Bangsberg D, Bull S. Examining the Applicability of the IMB Model in Predicting Condom Use Among Sexually Active Secondary School Students in Mbarara, Uganda. AIDS Behav. 2012:1–13.Google Scholar
  31. 31.
    Molla M, Astr NA, Brehane Y. Applicability of the theory of planned behavior to intended and self-reported condom use in a rural Ethiopian population. AIDS Care. 2007;19(3):425–31.PubMedCrossRefGoogle Scholar
  32. 32.
    Muñoz-Silva A, Sánchez-García M, Nunes C, Martins A. Gender differences in condom use prediction with theory of reasoned action and planned behaviour: the role of self-efficacy and control. AIDS Care. 2007;19(9):1177–81.PubMedCrossRefGoogle Scholar
  33. 33.
    Mustanski B, Donenberg G, Emerson E. I can use a condom, i just don’t: the importance of motivation to prevent HIV in adolescent seeking psychiatric care. AIDS Behav. 2006;10:753–62.PubMedCrossRefGoogle Scholar
  34. 34.
    Anderson ES, Wagstaff DA, Heckman TG, Winett RA, Roffman RA, Solomon LJ, et al. Information–motivation–behavioral skill (IMB) model: treatment effects on condom use among women in low-income housing. Ann Behav Med. 2006;31(1):70–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Kalichman SC, Malow R, Devieux J, Stein JA, Piedman F. HIV risk reduction for substance using seriously mentally ill adults: tests of the information–motivation–behavioral skills (IMB) model. Community Ment Health J. 2005;41(3):277–90.PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Kalichman SC, Stein JA, Malow R, Averhart C, Devieux J, Jennings T, et al. Predicting protected sexual behaviour using the information-motivation-behaviour skills model among adolescent substance abusers in court-ordered treatment. Psychol Health Med. 2002;7(3):327–38.PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    De Vries H, Mudde A, Leijs I, Charlton A, Vartiainen E, Buijs G, et al. The european smoking prevention framework approach (EFSA): an example of integral prevention. Health Educ Res. 2003;18(5):611–26.PubMedCrossRefGoogle Scholar
  38. 38.
    Dijk F, Reubsaet A, De Nooijer J, De Vries H. Smoking status and peer support as the main predictors of smoking cessation in adolescents from six European countries. Nicotine Tob Res. 2007;9:S495–504.PubMedCrossRefGoogle Scholar
  39. 39.
    De Vries H, Kremers SPJ, Smeets T, Brug J, Eijmael K. The effectiveness of tailored feedback and action plans in an intervention addressing multiple health behaviors. Am J Health Promot. 2008;22(6):417–25.PubMedCrossRefGoogle Scholar
  40. 40.
    Schneider F, van Osch L, Kremers SPJ, Schulz DN, van Adrichem M, De Vries H. Optimizing diffusion of an online computer tailored lifestyle program: a study protocol. BMC Public Health. 2011;11:480.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    De Vries H, Lezwijn J, Hol M, Honing C. Skin cancer prevention: behaviour and motives of Dutch adolescents. Eur J Cancer Prev. 2005;14:39–50.PubMedCrossRefGoogle Scholar
  42. 42.
    Knops-Dullens T, De Vries N, De Vries H. Reasons for non-attendance in cervical cancer screening programmes: an application of the integrated model for behavioural change. Eur J Cancer Prev. 2007;16:436–45.PubMedCrossRefGoogle Scholar
  43. 43.
    Nierkens V, Stronks K, Van Oel CJ, De Vries H. Beliefs of Turkish and Moroccan immigrants in the Netherlands about smoking cessation: implications for prevention. Health Educ Res. 2005;20(6):622–34.PubMedCrossRefGoogle Scholar
  44. 44.
    Panday S, Reddy SP, Ruiter RAC, Bergstrom E, De Vries H. Determinants of smoking among adolescents in the Southern Cape-Karoo region. S Afr Health Promot Int. 2007;22(3):207–17.CrossRefGoogle Scholar
  45. 45.
    Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, et al. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ. 2008;337:a506.PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Kirby DB. The impact of abstinence and comprehensive sex and STI education programs on adolescent sexual behavior. Sex Res Soc Policy. 2008;5(3):18–27.CrossRefGoogle Scholar
  47. 47.
    Noar SM, Zimmerman RS. Health behavior theory and cumulative knowledge regarding health behaviors: are we moving in the right direction? Health Educ Res. 2005;20(3):275–90.PubMedCrossRefGoogle Scholar
  48. 48.
    Weinstein ND. Testing four competing theories of health-protective behavior. Health Psychol. 1993;12(4):324–33.PubMedCrossRefGoogle Scholar
  49. 49.
    Mathews C, Aarø LE, Grimsrud A, Flisher AJ, Kaaya S, Onya H, et al. Effects of the SATZ teacher-led school HIV-prevention programmes on adolescent sexual behaviour: cluster randomised controlled trials in three sub-Saharan African sites. Int Health. 2012;4:111–22.PubMedCrossRefGoogle Scholar
  50. 50.
    Seebregts CJ, Zwarenstein M, Mathews C, Fairall L, Flisher AJ, Seebregts C, et al. Handheld computers for survey data and trial data collection in resource-poor settings: development and evaluation of PDACT, a palm pilot interviewing system. Int J Med Inform. 2009;78:721–31.PubMedCrossRefGoogle Scholar
  51. 51.
    Mukoma W, Flisher AJ, Helleve A, Aarø LE, Mathews C, Kaaya S, et al. Development and test-retest reliability of a research instrument designed to evaluate school-based HIV/AIDS interventions in South Africa and Tanzania. Scand J Public Health. 2009;37:7–15.PubMedCrossRefGoogle Scholar
  52. 52.
    Aarø LE, Flisher AJ, Kaaya S, Onya H, Fuglesang M, Klepp K-I, et al. Promoting sexual and reproductive health in early adolescence in South Africa and Tanzania: development of a theory and evidence-based intervention programme. Scand J Public Health. 2006;34(2):150–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Muthén LK, Muthén BO. Mplus user’s guide: sixth edition. Los Angeles, CA: Muthén & Muthén; 2010.Google Scholar
  54. 54.
    Taylor AB, MacKinnon DP, Tein J-Y. Tests of the three-path mediated effect. ORM. 2008;11:241–69.Google Scholar
  55. 55.
    Cole DA, Maxwell SE. Testing mediational models with longitudinal data. J Abnorm Psychol. 2003;112:558–77.PubMedCrossRefGoogle Scholar
  56. 56.
    MacKinnon DP. Introduction to statistical mediation analysis. New York: Erlbaum and Taylor Francis Group; 2008.Google Scholar
  57. 57.
    Hu L, Bentler PM. Cut off criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model. 1999;6(1):1–55.CrossRefGoogle Scholar
  58. 58.
    Flora DB, Curran PJ. An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data. Psychol Methods. 2004;9(4):466–91.PubMedCentralPubMedCrossRefGoogle Scholar
  59. 59.
    Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51(6):1173–82.PubMedCrossRefGoogle Scholar
  60. 60.
    Bryan A, Fisher JD, Fisher WA. Tests of the mediational role of preparatory safer sexual behavior in the context of the theory of planned behavior. Health Psychol. 2002;21(1):71–80.PubMedCrossRefGoogle Scholar
  61. 61.
    Fishbein M. The role of theory in HIV prevention. AIDS Care. 2000;12(3):273–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Rhodes F, Stein JA, Fishbein M, Goldstein RB, Rotheram-Borus MJ. Using theory to understand how interventions work: project respect, condom use, and the integrative model. AIDS Behav. 2007;11:393–407.PubMedCrossRefGoogle Scholar
  63. 63.
    Mittal M, Senn TE, Carey MP. Intimate partner violence and condom use among women: does the information–motivation–behavioral skills model explain sexual risk behavior? AIDS Behav. 2012;16(4):1011–9.PubMedCentralPubMedCrossRefGoogle Scholar
  64. 64.
    Vermeer W, Bos AE, Mbwambo J, Kaaya S, Schaalma HP. Social and cognitive variables predicting voluntary HIV counceling and testing among Tanzanian medical students. Patient Educ Couns. 2009;75(1):135–40.PubMedCrossRefGoogle Scholar
  65. 65.
    Sheeran P, Abraham C. Measurement of condom use in 72 studies of HIV-preventive behaviour: a critical review. Patient Educ Couns. 1994;24:199–216.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Sander M. Eggers
    • 1
    Email author
  • Leif E. Aarø
    • 2
    • 3
  • Arjan E. R. Bos
    • 4
  • Catherine Mathews
    • 5
    • 6
    • 7
  • Hein de Vries
    • 1
  1. 1.Department of Health PromotionSchool for Public Health and Primary Care (CAPHRI), Maastricht UniversityMaastrichtThe Netherlands
  2. 2.Division of Mental HealthNorwegian Institute of Public HealthOsloNorway
  3. 3.Department of Health Promotion and DevelopmentUniversity of BergenBergenNorway
  4. 4.School of Psychology, Open UniversityHeerlenThe Netherlands
  5. 5.Health System Research UnitSouth African Medical Research CouncilCape TownSouth Africa
  6. 6.School of Public Health and Family Medicine, University of Cape TownCape TownSouth Africa
  7. 7.Adolescent Health Research Unit, Department of Psychology and Mental HealthUniversity of Cape TownCape TownSouth Africa

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