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INTRODUCTION
The human immunodeficiency virus (HIV) and the sexually transmitted diseases (STD) are considered serious public health problems due both to the high costs generated to the health systems, and to the physical and emotional discomfort of those who suffer from these diseases. In Latin-America, the problem associated to STD and HIV/ AIDS is still alarming, and for that reason it is important to generate scientific explanations from the diverse social and human sciences, particularly from Psychology, regar ding the factors associated to behaviors at risk of catching a STD, or from a different perspective, explain the factors that are linked to safe sexual practices specifically in the young population, considering that during youth, sexual practices tend to be frequent and, on many occasions, un protected or unsafe (Bahamón, Vianchá, & Tobos, 2014; García-Polanco, 2014; García-Vega, Menéndez, Fernández, & Cuesta, 2012).
According to the Ministry of Health and Social Protection (2010), in Colombia, during the 2009-2011 period, an average of 94,000 people attended a health appointment due to sexually transmitted diseases, being the group of people raging between 20 to 29 years old, mostly women, the one that showed the highest percentages of medical consultations. Also, the geographical location where the participants of this study come from, occupied the third place with the highest rate of this type of problematic in the country.
Considering that STD are the result of risky sexual behaviors, Teva, Bermúdez and Ramiro (2014) acknowledge the need to develop strategies and actions which set up and reinforce protective behaviors, such as the right use of condom in every sexual relation. Thus, it is especially significant to consider carrying out scientific studies to explain the factors that influence the right and consistent use of condom in sexual relations among youngsters, sin ce it is during youth when lifelong sexual behaviors are established. In fact, an indicator to evaluate condom use among sexually active youngsters is the use of this item in their first sexual relation.
Countries such as France and England have reported a 77% of youngsters using condom in their first sexual relation, unlike countries like Mexico and Brazil where figures drop to a 48% and 43% respectively (Kocic, Kostic & Cagulovic, 2013). Sexual behavior of young people and adolescents is a reflection of the socio-cultural context where they interact, as it is also the interpretation of their own psycho-affective well-being, and thus, it is important to know the way in which they solve the issues in that matter.
The latter is relevant in the context of youth sexuality, considering that each time the first sexual intercourse is experienced at a younger age, a matter that favors a poor handling of sexuality due to the scarce evolving maturity of young people, who apparently do not possess enough interpersonal communication skills to be able to handle the negotiation processes associated with sexual relations along with the use of contraceptive methods (Sanchez-Meneses, Davila-Mendoza & Ponce-Rosas, 2015). In addition to this, there are structural barriers such as gender norms and cultural roles (Uribe, Gonzalez, & Santos, 2012) or the social stigma linked to the sexual realm, and the lack of access to friendly health care services or prevention programs in sexual health for youngsters (Kocic, Kostic & Cagulovic, 2013).
Another aspect to consider is the one related to men's beliefs on the use of condom as a constraint to feel pleasure during sex, which reflects the dominant model of mascu linity demanding an active role from the man associated to an imaginary of physical pleasure. (De Jesús-Reyes & Menkes-Bancet, 2014). In this respect, there are different approaches to study the factors associated to the consistent use of condom that identify patterns towards the evaluation of beliefs and attitudes regarding condom use, among other aspects that focus on the socio-cognitive conceptions of the phenomenon, thus covering some interrelation elements between beliefs and aspects concerning self-efficacy and certain social skills.
The theory of planned behavior (Ajzen, 1991) suggests that people's intentions to perform a behavior have to do with motivations influencing the same conducts. These intentions are signs of how people are willing to make an effort in order to perform a desired action. Therefore, the greater is the intention to carry out an action, the higher the probability to undertake it. If people perceive themselves as efficient, it's highly probable to carry it out. This principle from the theory of planned behavior is useful to explain that if a young person perceives him or herself as self-efficient to use a condom in a sexual relation it would be more likely to use it, even more if the environment and his or her sexual partner favor the communication on condom use in sexual relations.
In relation to the socio-cognitive aspects associated with condom use, some studies have identified that a companionship atmosphere within the couple plays an important role for protective behaviors unlike atmospheres focused on sexual contact (Kordoutis, 2012). Another aspect is linked to the evaluation that young people make about male condom, since the higher the value they give to its contraceptive qualities, the higher the preference to use it (Lameiras, Rodríguez, Calado & Gonzalez 2003).
In addition to this, other studies show that a positive or favorable attitude towards condom use predicts its utilization to a higher rate (Teva, Bermúdez & Ramiro, 2014; Díaz Loving, Rivera & Saldivar, 2015; Uribe, Amador, Zacarías & Villarreal, 2012). Also, the studies that highlight the interrelation between cognitive aspects like beliefs and some variables of social nature with the use of condom have found that the communication with the sexual partner and the perception of self-efficacy are associated to condom use in young people (Charnigo, Crosby & Trootman, 2010; Espada, Morales, Guillén, Ballester & Orgiles, 2015).
Self-efficacy perception is understood as those opinions and beliefs people have about their abilities to produce certain performance levels. These opinions about somebody's own abilities influence the events affecting their lives and such beliefs will determine how the person feels, thinks, self-motivates and develops behaviors. Similarly, sexual assertiveness can be considered as the ability to express or communicate one's own needs in a clear, straight forward manner without going against the right of the other person. In the sexual context, it can be defined as the ability to manifest openly and respectfully to the partner the needs, wishes and feelings about the sexual act and everything involved in it, including the protective methods, personal desires, and any particular feeling, among others.
Studies conducted in this way have shown that the most common factors associated to condom use are: partner's communication, self-efficacy, the ability to use it as well as assertiveness (Farmer & Meston, 2006; Grossman, Hadley, Brown, Houck, Peters & Tolou-Shams, 2008; Heeren, Jemmott, Mandeya & Tyler, 2009; Zhang, Zhang & Chock, 2014; Parent & Moradi, 2015; Schmid, Leonard, Ritchie & Gwads, 2015). Research in this area concludes that in order to counteract the hegemonic male norms that promote sexual risk-taking among men and women's subordination, sexual communication and self-efficacy are a key foothold for the increase in condom use. (Leddy, Chakravarty, Dladla, de Bruyn, & Darbes, 2015).
In Latin-America, some studies agree with what was said before when reporting that the intention to use condom, high self-efficacy and communication with the sexual partner are interrelated and predict condom use in young people (Valencia & Canaval, 2012; Uribe, Andrade, Zacarías & Betancourt, 2013; Giménez-García, Ballester-Arnal, Gil-Llario, Cárdenas-López, & Duran-Baca, 2013; Matera, 2014; Álvarez, Bauermeister & Villarruel, 2014). These data show that youngsters who are assertive with their partners and who speak openly about their sexuality, have higher possibilities to deal with condom use and carry out protective behaviors (Uribe, Aguilar, Zacarías & Aguilar, 2015; Villegas, Cianelli, Santisteban, Lara & Vargas, 2016).
Taking as a reference the results of the investigations previously cited, and considering that youth sexual behavior is the result of cognitive and socio-cultural factors and of the interrelation among youngsters, which raises an appropriate scenario for the psychological research applied to a complex health problems, such as STD and unwanted pregnancy among youth groups, the aim of this study was to determine to what extent assertive communication and the perception of self-efficacy in the use of condom are related and predict safe, sexual practices in a sample of male and female students from two cities in Colombia.
METHOD
Type of research
A descriptive, correlational and predictive design study was carried out with the purpose to explain the co-variations between assertive communication and self-efficacy in the use of condom and determine to what extent these variables predict condom use in men and women.
Participants
A non-probability convenience sample was used, consisting of 645 youngsters aged between19 and 26 years old, of which 372 (59%) were women and 259 (41%) were men. The males' average age was 20.6 years old (DE=1.589) while the females' was 21.3 years old (DE=2.042). All of them were university students from a higher education institution in the cities of Barranquilla and Cúcuta, Colombia, who participated voluntarily in this study. The selection criterion was to answer affirmatively to the question: "have you had sexual relations?"
Instrument
A questionnaire validated with young Mexican population was used for the present study. Such instrument was adapted and validated with a Colombian sample of 1455 university youngsters from four cities, two from the north of the country and two from the center. Some statistical, confirmatory factorial tests and reliability analysis were carried out for each factor through the Cronbach alpha model. As a result, the instrument was formed by two sections: the first one contains background information (sex, age, family they live with) as well as questions about sexual patterns and frequency of condom use in sexual relations. The second section has 36 items with five multiple choice answers of ordinal type where 1 represents totally disagree and 5 totally agree, the questions are grouped in five factors that altogether have an Alpha value of, 806. The first factor is called Submission-infatuation and contains 9 items with an Alpha value of, 844 and a variance of 34%; the second factor is Sexual Assertiveness, it has 8 items, an Alpha value of, 728 and a variance of 17.6%; the third factor was called Self-efficacy perception (in condom's use), which has 7 items, an Alpha value of ,773 and a variance of 16.5%. A fourth factor is called Low-risk perception, (regarding the inconsistent use of condom), it has 6 items, an Alpha value of ,70 and a variance of 15.4%; and the fifth factor is called Condom's use rejection, it has 6 items, an Alpha value of ,75 and a variance of 15.4%.
Procedure
An authorization was requested to school officials of the universities mentioned before, and after the acceptance, teachers and students from the research incubators were trained in the questionnaire application, which was applied during class time in each institution under the supervision and collaboration of teachers. For the analysis of the descriptive data, correlations and regression testing, a SPSS software version 20 for Windows was used.
Data Analysis
Percentages and descriptive statistics were used to analyze the general characteristics of the participants, in addition to the t Student test in order to analyze sex differences with respect to onset of sexual activity and sexual partners; the Mann-Whitney U test to analyze the differences between groups in condom use and sexual practices, and Spearman correlation for continuous variables along with lineal regression testing for the analysis of predictive models in condom use both in men and women.
RESULTS
In the first place, the general characteristics, sexual pattern and use of condom in male and female participants are presented below. Later, in second place, the compara tive analyses by gender of the variables under study and the analysis of correlations are indicated; and finally, the models of variables that predict condom use in men and women are shown.
Concerning sexual preferences, in the men's group, a 91.4% reported having heterosexual preference, 3.6% declared having homosexual preference and 2% reported a bisexual preference. In the women's group, 94.2% had a heterosexual preference, 3.5% declared having homosexual preference and 2.3% a bisexual one.
Regarding the question about condom use in sexual relations, 76.4% of men's group responded they use it before penetration; a 7.2% declared using it only to ejaculate and a 16.5% said they did not use it. In the women's group, 59.7% declared using it before penetration, a 13.1% reported to use it previous to their partner's ejaculation, a 25.6% did not use it and a 1.6% did not answer the question.
Concerning the age of the first sexual relation -sexual debut- and the number of sexual partners, and taking into account that the curves distribution was normal, the t Student test was used, in which men reported an average in sexual debut at 15.7 years of age (DE=1.699) while the women's group reported an average of 17.2 years old (DE=1.744). Therefore, men have their first sexual relation at a younger age than women (p<.000). With regard to the number of sexual partners, the men's group reported having had 5.8 partners on average (DE=5.158) while women reported an average of 2.8 (DE=2.142, p<.000).
Condom use in sexual relations
In relation to the question "did you use condom in your first sexual relation?" the group of men responded positively in a 55.5% whereas the women's group did it in a 53.8%. On average, a 44% of women and men did not use condom in their first sexual intercourse.
As normal distribution curves were not obtained and the data corresponded to ordinal variables, a Mann-Whitney U test was performed to account for the differences with respect to the frequency of condom use among women's and men's groups, and in order to analyze whether there are significant differences regarding condom use.
Table 1 presents the results showing significant differences between groups regarding sexual relations with occasional partners in the last 30 days, together with condom use. The men's group has a higher frequency of condom use in sexual relations with occasional partners and in the sexual life in general in comparison to the women's group.
After doing a comparative analysis between the average of condom use in the men and women groups, and for the purpose of analyzing the relationship between the frequency of condom use in sexual relations with stable partners and occasional ones, an analysis of Spearman correlations with the variables perception of self-efficacy, sexual assertiveness, condom use rejection and low-risk perception was carried out. Table 2 shows these correlations for men and women.
In the men's group, a significant, negative correlation is shown between condom use in the last 30 days and rejection of it (r=237); the frequency of use during their sexual life with the variables perception of self-efficacy (r=462) and with sexual assertiveness (r=331) and negative correlations with the variable condom use rejection (r=-317) and low-risk perception (r=337).
For the women's group, significant correlations were obtained between the condom use frequency in the last 30 days along with the variables sexual assertiveness (r=141), as well as condom use during their sexual life with the variables self-efficacy (r=372) and sexual assertiveness (r=275). A significant negative correlation between condom use and rejection to use it was found (r= -168).
It is important to mention that in the majority of significant correlations, the scores were below .40, a condition that can be attributed to the size of both samples.
Taking into account that the variables of condom use both in the last 30 days and in sexual life in general correlate significantly with the perception of self-efficacy and sexual assertiveness in women and in men, it was determined to perform a linear regression test with the method of successive steps to determine the extent to which assertiveness and self-efficacy in condom use predict protected sexual behavior, and thus analyze the proposed models in men and women (see Table 3).
The results point out that the assertiveness variable predicts the use of condom in the last 30 days in the men's group; the model proposed for women indicates that the perception of self-efficacy in the use of condom along with sexual assertiveness predicts almost a double percentage of condom use than in the model proposed for men.
An analysis of condom use in sexual life was done for men and women; the proposed model in Table 4 for the men's group indicates that self-efficacy perception predicts a 27.1% of condom use, whereas in the women's group this same variable predicts a 35% of condom use and a 37.3% in the perception model of self-efficacy and sexual assertiveness.
DISCUSSION
According to the results obtained in the young university sample, the sexual preference of the majority is heterosexual, which indicates that sexual practices are related to the socio-cultural hegemonic norms. However, it is important to consider the need to carry out studies focused on non-heterosexual preferences and analyze the inter-subjective variables that have an impact on the safe sexual practices of this group of young people.
Social and cultural norms tend to generate an influence on sexual behavior. In this study, the percentages reported by men and women on the correct use of condom are high. It's important to mention that women allow their sexual partners to use condom only to ejaculate, which is associated with "avoiding pregnancy" and responds to socio-cultural norms assigned to men and women. This sexual practice where condom use is incorrectly performed puts at risk the sexual health of this group of people.
The age of the first sexual relation -sexual debut- is reported as being lower in men than in women and the number of sexual partners is higher in men than in women, which can be seen as a response to gender stereotypes or sexual roles that are more tolerant with respect to male sexuality compared to that of women.
Something noticeable is that women have their first sexual experience with men who are older than them, and in this way, they are exposed to having sexual relations without any protection, which makes them vulnerable to acquire any STD, due to the probability that the partner has already had diverse sexual partners.
With regard to the use of condom in the first sexual experience, a little less of fifty percent of women and men did not use it. According to Kocic, Kostic & Cagulovic (2013). not using condom in the first sexual experience predisposes its inconsistent use in future sexual practices. Something to notice about this study is that men, unlike women, tend to use condom more frequently, which responds to gender mandates or established sexual roles for women and men (Uribe, Gonzalez & Santos, 2011).
According to Bandura (1994), self-efficacy perceptions and beliefs generate an influence on people's behaviors. Besides, it is noticeable that self-efficacy perception variables and sexual assertiveness do not only predict condom use in sexual relations. Self-efficacy perception and assertiveness are linked to one another, correlated, that is to say, they are the result of a series of cognitive processes of interrelation and emotional expression. Such psychological processes may turn into an intention or particular conduct that explains, in an important way, the possibility and intention to use condom in a sexual relation.
In this study, and taking as a reference the correlation data analysis and the linear regression analysis, self-efficacy perception and sexual assertiveness are related in a very significant way to safe sexual practices, which coincides with some other previous studies in non-Latin-American contexts. (Heeren, Jemmott, Mandeya & Tyler, 2009; Farmer & Meston, 2006; Grossman, Hadley, Brown, Houck, Peters & Tolou-Shams, 2008; Zhang, Zhang & Chock, 2014; Parent & Moradi 2015; Leddy, Chakravarty, Dladla, de Bruyn, & Darbes, 2015; Schmid, Leonard, Ritchie & Gwadz, 2015) as well as in Latin-American contexts (Valencia & Canaval, 2012; Uribe, Andrade, Zacarias & Betancourt, 2013; Matera, 2014; Alvarez, Bauermeister & Villarruel, 2014; Uribe, Aguilar, Zacarias & Aguilar, 2015).
Nevertheless, is it essential to mention that when condom use is reported, this one is not always used properly; therefore, it is important to consider this variable in subsequent studies. In this sense, it's worth to take into account the use of qualitative methods that explore intersubjective aspects related to the knowledge and use of condom among youngs ters, and thus search for other elements not considered in this study that might help to understand this phenomenon in a better way.
As a conclusion, it can be said that the strategies headed to promote the use of condom in men and women, must be focused on other aspects, such as the development of sexual assertiveness or assertive communication with the sexual partner as well as on the empowerment in the correct and systematic use of condom during any type of sexual relation among young people, as pointed out by Teva, Bermudez & Ramiro (2014) and Uribe, Aguilar, Zacarias & Aguilar (2015).
Regarding this aspect, it has been reported that the socio-cognitive models about condom use and other safe sexual behaviors explain in a better way its use or resistance on the part of young people, because despite having a wide range of information about the consequences of risky sexual behaviors, they still maintain those behaviors.
In addition,, it is advisable that the campaigns that promote the correct and consistent use of condom, take into account differentiating elements according to gender that might efficiently sensitize the two genders having as a point of reference the attributed stereotypes.
Finally, the limitations of this study are focused on the need to widen the understanding about cultural factors involved in the use or non-use of condom, as well as the qualitative approach to beliefs, knowledge and particular aspects related to couples, the use of condoms, the role of gender and any other social influences that have not been explored yet.
