ATTITUDES TOWARDS CONDOM USE AMONG FEMALE COMMERCIAL SEX WORKERS IN CEBU CITY

A Research Paper Presented to the Faculty of the College of Nursing Velez College Cebu City

In Partial Fulfillment of The Requirements for the Degree Bachelor of Science in Nursing

Edeline O. Cosicol Gifthy Marie G. Perez McRoe David P. Mendoza [Group 13, BSN 4 D]

October 2012

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APPROVAL SHEET

This research paper entitled, ATTITUDES TOWARDS CONDOM USE AMONG FEMALE COMMERCIAL SEX WORKERS IN CEBU CITY prepared and submitted by EDELINE O. COSICOL, GIFTHY MARIE G. PEREZ and MCROE DAVID P. MENDOZA in partial fulfillment of the requirements for the degree BACHELOR OF SCIENCE IN NURSING, has been examined and is recommended for acceptance and approval for oral examination THE TECHNICAL PANEL

GILBERT C. ENDRIGA, RN, MN Research Instructor

FHINEL CRISTYL N. TUMULAK, RN, MN Research Adviser

PANEL OF ORAL EXAMINERS

Approved by the Committee on Oral Examination _________________________________ on _____________

with

grade

of

____________________________________ Chairman

_________________________________ Member

_________________________________ Member

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Accepted and approved in partial fulfillment of the requirements for the degree of BACHELOR OF SCIENCE IN NURSING.

MA. CAROL R. KANGLEON, RN, MN, DScN Dean of College of Nursing Velez College

ACKNOWLEDGMENT With sincere and deepest gratitude to many people who generously extended their help, support and assistance, to the ultimate realization of this research study; the researchers would like to bequeath their heartfelt appreciation to: Mrs. Ma. Carol R. Kangleon, the Dean of the College, for believing in the researchers and the importance of this research study. Mr. Gilbert Endriga, research instructor and Ms. Fhinel Cristyl Tumulak, research adviser, who devoted their valuable time in reviewing , making revisions, giving suggestions and guidance which substantially contributed in the preparation of this research study. Mr. & Mrs. Edgardo Cosicol, Mr. & Mrs. Expedito Perez, Mrs. Elvie Mendoza, their parents for moral support, for the unending love and providing them the financial assistance and deep concern all the way through their study.

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Ms. Alyssa Pearl F. Villanueva, for her help, unending support all the way through their study and giving them her time to make this research output possible. Mr. Peter Paul Quibranza, their statistician, for his expertise, lessons, suggestions, and patience in helping them understand applied statistics concepts which helped them in preparation for this research study. And lastly, to God, for His gift of wisdom and understanding to the researchers and for answering their prayers in their times of need. Edeline O.Cosicol, Gifthy Marie G. Perez & McRoe David P. Mendoza TABLE OF CONTENTS

Page Title page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i Approval Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Chapter I. INTRODUCTION Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Theoretical Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Conceptual Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Statement of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Statement of the Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Scope and Delimitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Significance of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

II. REVIEW OF STUDIES AND LITERATURE Review of Related Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Review of Related Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 III. METHODOLOGY Research Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Research Locale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Research Respondents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Research Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Data Gathering Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
IV. RESULTS AND DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

V. SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS Summary of Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

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APPENDICES
A. B. C. D. E. F. G. H. I.

Cover Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Research Instrument: MCAS Multidimensional Condom Attitude Scale . . . 62 Research Timetable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Research Budget. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Pilot Test Computed Reliability Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Correspondence to Legal Consultant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Correspondence to the Author of MCAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 Pictorials of Proposal Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Pictorials of Final Research Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 CURRICULUM VITAE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

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LIST OF TABLES

Table

Page

1. Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 2. Attitudes towards Condom Use UCLA MCAS scores . . . . . . . . . . . . . . . . . . . . . . . .41 3. Spearman Rho Correlation for age and MCAS Dimensions. . . . . . . . . . . . . . . . . . . . 42 4. Marital Status and Attitudes towards Condom Use. . . . . . . . . . . . . . . . . . . . . . . . . . .43 5. Educational Attainment and Attitudes toward Condom Use. . . . . . . . . . . . . . . . . . . . 43 6. Monthly Income and Attitudes towards Condom Use . . . . . . . . . . . . . . . . . . . . . . . . .43 7. Condom Use Length and Attitudes towards Condom Use . . . . . . . . . . . . . . . . . . . . . 44 8. Condom use on most recent sexual intercourse and Attitudes towards Condom Use .44 9. Condom Use during the Past Year and Attitudes towards Condom Use. . . . . . . . . . . 45 10. Decision maker to Condom Use and Attitudes towards Condom Use . . . . . . . . . . . 45 11. Suggestion of Condom Use and Attitudes towards Condom Use . . . . . . . . . . . . . .46

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LIST OF FIGURES

Figure

Page

1. The Theory of Planned Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2. Attitudes towards Condom Use: Conceptual Framework of the Study . . . . . . . . . 7 3. Site Map of Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

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ABSTRACT TITLE: ATTITUDES TOWARDS CONDOM USE AMONG FEMALE COMMERCIAL SEX WORKERS IN CEBU CITY COSICOL, EDELINE O. PEREZ, GIFTHY MARIE G. MENDOZA, MCROE DAVID P. SCHOOL: DEGREE: ADVISER: YEAR COMPLETED: Introduction. VELEZ COLLEGE BACHELOR OF SCIENCE IN NURSING FHINEL CRISTYL N. TUMULAK, RN, MN 2012 Female commercial sex workers (FCSWs) are at high risk of transmitting HIV/STIs. With FCSWs, risk reduction typically means consistent and appropriate condom use. Consistent condom use is reinforced by

AUTHORS:

certain

perceptions,

attitudes,

socio-demographic

factors, and external influences and norms. Methodology. Through networking and quota sampling, 32

respondents were gathered and were made to answer the translated instrument UCLA Multidimensional Attitudes scale with queries regarding demographic data and condom use. Statistical methods such as Spearman correlation coefficient, Kruskal-Wallis test and MannWhitney test are utilized to determine the correlation between each of the five MCAS dimensions (reliability, pleasure, stigma, negotiation, and purchase) to their demographic variables and condom use. Results. Spearman rho values indicate that there is a significant but weak correlation between age and stigma (r=.400, p=.023). There is no significant relationship between the five MCAS dimensions and other demographic factors (i.e., marital status, monthly income, time length of condom use, and education attainment) and recent condom use, decision, and suggestion to condom use. Discussion Higher susceptibility to condom use-related stigma among younger population is attributed to the fact that

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existing conservative views refuse that more young people are having sex at an earlier age.

Keywords: contraception, intention, behaviors, negotiation, correlation, quantitative research

Chapter 1 Introduction

Rationale of the Study Asian culture is heavily male centered. In some cultures women rarely have the right or courage to voice their opinion on condom usage. Condom use is hard in a culture where women are raised to be accommodating, polite, and subordinate to their male counterparts (Landry & Turnball, 1997). The social and educational status of women in some cultures can also hinder their knowledge on how to adequately protect themselves from attaining STDs (Landry & Turnball, 1997). They may also believe popular urban myths in order to deal or prevent contraction of STDs/pregnancies. This just adds to their knowledge deficit and ignorance and can sometimes lead to unwanted permanent physiologic damage. Females are the ones that have to deal with higher consequences if they were to acquire STDs or become pregnant. Women and infants suffer more serious health damage than men from all STIs. Without medical attention, some STI can lead to blindness, cancer heart disease, sterility, ectopic pregnancy, miscarriage, and even death (Eng & Butler, 1997; Yarber, 2003). About 15% of women who become infertile do so because of tubal damage caused by PID resulting from untreated STI. Because it is women who get pregnant, men tend to be unaware of their responsibility or to downplay their role in conception, although the popularity of the condom, responsibility may become more balanced. (Strong, DeVault, Sayad, & Yarber , 2005).

Females have a higher possibility of acquiring diseases than their male counterparts than vice versa. Due to the receptive anatomy of women, women are more prone to acquiring such STDs (Landry, Turnball, 1997; Van, 2011). Female Commercial Sex Workers (FCSWs) are at high risk of transmitting HIV/STIs (World Health Organization [WHO], 2002). Because there is no vaccine or cure, HIV prevention depends on ones ability to modify risky behaviors. With FCSWs, risk reduction typically means consistent and appropriate condom use (Morisky, Stein, Chiao, Ksobiech, & Malow, 2005). The Philippines has the lowest documented rates of condom use in Asia (Aquino, D'Agnes, Castro, Borromeo, Schmidt, & Gill, 2003), at 20-30% among groups at highest risk of HIV (including sex workers) (Philippine national AIDS council [PNAC], 2005). There are various factors that may contribute to low condom use in the Philippines. A common perception is that condoms are only for birth control and not for protection against HIV and other STIs (Gacad et al., 1998). This perception is reinforced by the view that condoms are discouraged by the Roman Catholic Church. Government family planning programmes have policies against supplying condoms to unmarried people (Balk, Brown, Cruz, & Domingo, 1997). The cost of condoms is also relatively high (UNAIDS, 2009). The majority of the supply of condoms is from international aid agencies (e.g., USAID) (Gacad, et.al, 1998). Many female sex workers assert that "knowing" their client was reason enough to not use a condom. Filipino women also tend to believe that the decision to use a condom is up to the man (Gacad, et. al, 1998). Men tend to feel the need to maintain their machismo image to the extent that they refuse to practice safe sex (Lim-Quizon, Roces, Cuenco, Ghee, Poumerol, & Omi, 1998). Culturally-sensitive but influential promotion of condoms appears to be an

obvious gap in the Philippines HIV/AIDS response. Women in the Philippines are not largely empowered to protect themselves and negotiate for safe sex due to cultural, physiological and socio-economic factors (Farr & Wilson,2010). Women are particularly vulnerable to the debilitating effects of diseases that can be contracted from unprotected sex. Certain social and cultural norms such as gender biases abet exposure to sexual and reproductive health risks. Female commercial sex workers, in particular, have perceptively increased risks due to the nature of their occupations, as aside from increased exposure, they are notably more susceptible due to effects of the widelyaccepted notion of immorality of casual and commercialized sex, of the insufficient government sexual and reproductive health support, and other contributing

sociodemographic factors. Also, health promotion should not be limited to scare tactics of the prevalence and devastating effects of HIV/AIDS and STIs. Various other factors must be considered, such as attitude towards the utilization of protective barriers, as they are proven to be hugely influential to overt behavior.

Theoretical Background

This study is anchored on Ajzen and Fishbeins Theory of Planned Behavior (See Figure 1). The Theory of Planned Behavior is an extension of the Theory of Reasoned Action (Ajzen & Fishbein 1980, Fishbein & Ajzen, 1975) made necessary by the original model's limitations in dealing with behaviors over which people have incomplete volitional control (Ajzen,1991). Both have been developed and amply used in HIV/AIDS research (Hausmann-Muela, Ribera & Nyamongo, 2003).

Figure 1. The Theory of Planned Behavior (Ajzen & Fishbein, 1980).

Behavior is a function of intention to behave in a particular manner. Intention, in turn, is a function of an individual's attitude about the act and the perceived norm regarding the behavior. A central factor in the Theory of Planned Behavior is the individual's intention to perform a given behavior. Intentions are assumed to capture the motivational factors that influence a behavior; they are indications of how hard people are willing to try, of how much of an effort

they are planning to exert, in order to perform the behavior. As a general rule, the stronger the intention to engage in a behavior, the more likely should be its performance. It should be clear, however, that a behavioral intention can find expression in behavior only if the behavior in question is under volitional control if the person can decide at will to perform or not perform the behavior. Although some behaviors may in fact meet this requirement quite well, the performance of most depends at least to some degree on such non-motivational factors as availability of requisite opportunities and resources (e.g., time, money, skills, cooperation of other, etc.) The behaviour involved in this study, which is condom use, is a resultant of three determinations of intention, according to the Theory of Planned Behavior.
Attitudes towards behaviour, which is determined by the belief that a specific

behaviour will have a concrete consequence and the evaluation or valorisation of this consequence (Hausmann-Muela, Ribera & Nyamongo, 2003). The attitudinal component of TRA consists of the individuals perception about consequences of the act, as well as the evaluation of those consequences. For instance, if an individual believes that unprotected sex may result in contracting HIV (perceived consequence of unprotected sex) and that contracting HIV is a dreadful possibility (evaluation of the consequence), then that individual is likely to have an aversive attitude toward unprotected sex (DeHart & Birkimer, 1997).
Subjective norms, or the belief in whether other relevant persons will approve ones

behavior, plus the personal motivation to fulfill with the expectations of others. Subjective norms regarding condom use is determined by the appraisals salient others would wish the individual to engage (or not) in the behavior under

consideration, and their motivation to comply with these expectations. Salient others typically includes people such as parents, friends and health professionals whose opinions are important to the individual. The normative component of TRA consists of the perceived behavioral norm and motivation to comply with the norm. For example, if the individual believes that only promiscuous people use condoms (perceived norm) and wishes to abstain from condom use to avoid seeming promiscuous (motivation to comply), he or she will likely have a positive normative conception of unprotected sex (DeHart & Birkimer, 1997).
Perceived behavioural control, determined by the belief about access to the resources

needed in order to act successfully, plus the perceived success of these resources (information, abilities, skills, dependence or independence from others, barriers, opportunities etc.) (Hausmann-Muela, Ribera & Nyamongo, 2003). Perceived behavioral control is the individuals perception of his/her ability to perform the behavior. This factor reflects past experience as well as external factors, such as anticipated impediments, obstacles, resources and opportunities that may influence the performance of the behavior. It has two factors: the perceived likelihood of encountering factors that will facilitate or inhibit the successful performance of behavior, weighted by their perceived power to facilitate or inhibit performance (Ajzen, 1991). Perceived behavioral control is a factor which may explain why an individual may not express the overt behavior despite positive attitudes.

Conceptual Framework

Figure 2. Attitudes towards condom use: Conceptual framework of the study Figure 2 illustrates the conceptual framework of the study, which is adapted from Ajzen and Fishbeins Theory of Planned Behavior. Attitudes towards condom use, subjective norms, and perceived behavioral control are deemed correlated to demographic variables, such as age, educational status, employment, and monthly income. In turn, these attitudes, subjective norms, and perceived behavioral control influence the intention to use condoms which influence overt behavior of condom use. Attitudes towards condom use include personal cognitive and affective aspects regarding condom reliability and effectiveness, pleasure, stigma, negotiation, and purchase. Subjective norms are represented as perceived pressures from outside or social influences such as religion, formal policies, government campaigns, and health professionals statements. Attitudes, subjective norms, and perceived behavioral control are interrelated and may influence each other. Subjective norms and perceived behavioral control may be very closely linked to each other, as such in the case of formal policies instituted by managers in some establishment-based sex work, and government campaigns and legislations on sexual and reproductive health.

Statement of the Problem This study aimed to describe the attitudes towards condom use among female commercial sex workers in Cebu City. Specifically, this study sought to answer the following: 1. What is the demographic profile of the respondents in terms of: 1.1.Age; 1.2.Marital Status; 1.3.Educational attainment; 1.4.Religion; 1.5.Occupation / Employment; 1.6.Average Monthly Income? 2. What are the attitudes towards condom use of the respondents in terms of:
2.1. 2.2.

Reliability and effectiveness; Pleasure associated with condoms;

2.3.Stigma associated with condoms; 2.4.Embarrassment about negotiation and use of condoms; and 2.5.Embarrassment about purchasing condoms? 3. What are the respondents intentions on the usage of condoms in terms of: 3.1.Who primarily decides on the use of condoms; and 3.2.Suggesting condom use to partner?

4. Is there significant relationship between the respondents demographic variables and their attitudes towards condom use? 5. Is there a significant relationship between the respondents attitude and intention towards condom use?

Statement of the Hypothesis Attitudes towards condom use among female commercial sex workers are significantly related to their intentions of the condom use. Demographic variables are significantly related to their attitudes towards condom use.

Scope and Delimitation This study was executed in Cebu City, Philippines, where the selected respondents are locals of. The respondents of this study were selected from the Cebu city population of commercial sex workers through non-probability sampling methods and which as the main prerequisite to be included in the study is a self-declaration of being a sex worker. At least thirty respondents will be made to answer a questionnaire comprising the Likert-type instrument tool UCLA Multidimensional Condom Attitudes Scale (see Appendix C) along with demographic data queries and multiple choice questions regarding actual condom use. This study will aim to obtain statistical data regarding the attitudes of female commercial sex workers in Cebu city towards condom use through utilization of the aforementioned tool to be correlated with their demographic variables and past condom use to obtain degrees of relationships. The timeframe of this research study ranges from November of 2011 towards July 2012. The data-collection can be executed at anytime of the year.

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This study on attitudes is limited to the aforementioned scales scope which is broad and may be generalized or insufficient due to its innate universality and multidimensionality. Due to the nature of this study (descriptive correlative) and also due to the nature of the datacollecting tool to be used, data collected may be vague and constrained, though the researchers are going to conduct supplemental interviews after data analysis to validate or to make comparisons with the quantitative results. Though interviews are employed, they are strictly limited to the focus of the study, which are the attitudes, and quantitative research is not exploratory. Correlative research also doesnt express causality.

Significance of the Study The results of the study will be of great benefit to the following: Female Commercial Sex Workers. The results of this study will contribute to the further promotion of womens reproductive health, especially to the population of female commercial sex workers who are often stigmatized and marginalized but are in dire need of these services. The results of this study, together with other studies and community efforts, will hopefully pave way to the implementation of universal access to HIV prevention, reproductive health promotion, and care in an evidenced-based and supportive manner. Nurses and Nursing students. The results of this study will be especially beneficial to the nurses role as client advocates and health educators. The data of the study would holistically yield aspects influencing health behaviour of the client through exploration of the cognitive, affective, and conative (behavioral) features. Holistic knowledge of the aspects influencing behaviour would lead to a more appropriate, modernistic, and culturallycompetent teaching and care.

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Government and non-government health organizations. Through the results of the study, health organizations will be able to pinpoint problem areas concerning the information dissemination and/or lack thereof regarding reproductive health, sexually transmitted infections and health-promoting methods such as condom use. The health organizations will be able to create programs addressing current issues concerning reproductive health. When these programs sufficiently succeed, millennium goals towards the control of spread of HIVAIDS and STIs will be met. The Philippine society in general. Even though the study is aimed towards a specific subculture which is that of the female commercial sex workers, the results would also be reflective of the particular socially-related and influenced health attitudes as data yielded can be suggestive of contemporary cultural and Philippines-specific reproductive health issues. The data will provide information to be loosely interpreted by an individual of the society as deemed fit to societal issues and personal beliefs and may affect individual attitudes and perspectives and influence health decisions and even informed and backed-up opinions regarding contentious government legislations and programs aimed on reproductive health. Future researchers. The results of the study can be used by other researchers as a building block or basis towards related studies which could be more focused and specific for instance focusing on a single factor measured by the scale to get more in-depth results.

Chapter 2 Review of Studies and Literature

Review of Related Literature The Theory of Planned Behavior posits that the intention to perform or not to perform a behavior is determined by three factors, one of which is the attitudes toward the behavior (Ajzen & Fishbein). An attitude differs from an opinion, a belief, or simply a point of view. An attitude implies a feeling about something as well as knowledge of it. Attitudes have dynamic, motivational impact that the other concepts lack. When beliefs or opinions are emotionally tinged, when they involve existing situations, and when they cause us to respond in a consistent way toward people or events, they become attitudes. Thus attitudes have three parts: (1) beliefs, ideas, or knowledge about the way things are, or ought to be; (2) emotions or feelings associated with the beliefs; and (3) actiona readiness to respond to specific ways (Lagland & Saxon, 1985). Behaviors such as condom use are determined by intentions which are determined by attitudes towards it, among subjective norms and perceived behavioral control. A study by Helweg-Larsen and Collins in 1994 with the purpose of developing a multidimensional, multiple-indicator condom attitudes scale has led to the formulation of five domains of independent determinants of condom use behavior: (1) reliability and effectiveness of condoms; (2) the sexual pleasure associated with condom use; (3) the stigma associated with people proposing or using condoms; (4) the embarrassment about negotiating and using condoms; and (5) the embarrassment about purchasing condoms.

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Reliability and effectiveness Compelling international evidence has been gathered by the US Department of Health and Human Services and the United Nations Population Fund which shows that consistent use of latex male condoms is a highly effective method for preventing HIV transmission. Scientific research by the US National Institutes of Health and World Health Organization (WHO) found intact condomsare essentially impermeable to particles the size of sexually transmitted disease pathogens, including the smallest sexually transmitted virus (UNAIDS, 2004). Latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV, the virus that causes AIDS. In addition, correct and consistent use of latex condoms can reduce the risk of other sexually transmitted infections (STIs), including discharge and genital ulcer diseases. While the effect of condoms in preventing human papillomavirus (HPV) infection is unknown, condom use has been associated with a lower rate of cervical cancer, an HPV-associated disease (Centers for Disease Control and Prevention, 2001). The dissemination of evidence regarding the efficacy of condoms can be used to promote the use of condoms both as a contraceptive method and as a barrier against the transmission of STDs, including HIV (WHO, n.d.). Common misperceptions and fears related to condom use are that (a) condoms have holes that allow the virus to pass through; (b) condoms are not reliable and leak; and (c) condoms break off or slip easily. To address these fears and misconceptions, the World Health Organization in an undated publication has emphasized the following facts: Condoms are made of latex, polyurethane, synthetic material, or animal tissue and new male and female condoms are being developed by Research and Development

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teams around the world. The less common animal tissue condom is not suited for HIV/STI prevention because it is permeable to small viruses such as hepatitis B and possibly HIV. Condom effectiveness also depends on user behaviour in opening the package, putting on the condom, sexual activity, lubrication, and number of times an individual condom is used. Quality assured condoms (male and female) are the most effective available technology to reduce the sexual transmission of HIV and other STIs. Only condoms that meet all of the specifications established by WHO or other qualified authority are packaged for distribution.

Condoms are effective against most STIs, including gonorrhoea and HIV. They are protective as long as they prevent bodily fluids of one partner touching the genitals or any mucous membrane of the other person

Condoms do not protect against infections, such as genital ulcers, which often occur in areas not covered by the condom. Sexual activity should be avoided with individuals having open lesions around their genitals until the individuals have been treated and the lesions have healed.

Condoms stay firmly in place on a mature erect penis when applied according to instructions included in its packaging.

Condom breakage rate increases with insufficient lubrication or with the use of non water-based lubricants.

Consistent and correct use of condoms remains the most effective means of HIV prevention for people who have sexual intercourse.

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Pleasure In relation to pleasure, common concerns and perceptions regarding condom use are that (a) Condoms reduce spontaneity; (b) Condoms cause premature ejaculation, and can reduce sensation and pleasure; (c) Condoms cause impotence, penile weakness, and loss of erection; and (d) Condoms cause vaginal dryness (WHO, n.d.). The limited effect, so far, of public-health campaigns to promote effective use of barrier methods might be attributable, in part, to scare tactics that emphasise adverse consequences of sexual acts. Promotion of pleasure in use of male and female condomsalongside safer sex messagescan facilitate consistent use of condoms and boost their effectiveness to protect against STI and pregnancy (Philpott, Knerr, & Maher, 2006). Pleasureand even sex itselfhas been noticeably absent from much of the dialogue surrounding STI and the spread of HIV/AIDS (Philpott, 2005). Increasingly, sexual pleasure is being recognised as a determinant of sexual health in the areas of reproductive health and human rights. For example, WHO (2006) offers this working definition of sexual health: Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence... Stigma Condoms are sometimes thought to be associated with illicit or casual sex. Some people also believe that providing information to young people on condom use for prevention of

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pregnancies and STIs, including HIV, will promote earlier first time sexual experiences and/or increased sexual activity. Other related perceptions are that using condoms means you dont trust your partner and that the condoms are for use with sex workers and for casual sex; married and long-term partners dont need protection against infection (WHO, n.d.) Sex work is often regarded as a social ill and a symbol of a society's moral degeneration; sex workers are expediently ignored in public consciousness or alternatively focused as vendors of vice and even as vectors and sources of disease and being a core reservoir of STDs and HIV (Richter, n.d.). The following is a statement from an interview from a staff of NGO supporting migrant workers and network supporting sex workers: In the past, women in sex work (and gay men) were singled out in our local programmes, not really with the sole agenda of protecting them, but because they were thought of as the culprits. Studies have proven this wrong - because it is the customer, usually the men, who go back to their spouse or have other sexual relationships where they increase the risk of transmission. Recent data shows many of those testing positive are monogamous women. Purchase and Use Health educators who believe that rational people make rational choices once they have all the information might create interventions in which they teach individuals to use disease information to persuade their partners to use condoms. However, this approach may be problematic for several related reasons. First, the failure to use condoms is more often related to concerns regarding how one appears to other people than to lack of information about the benefits of using condoms (Leary, Tchividjian, & Kraxberger, 1994). That is, people are embarrassed to buy condoms, are embarrassed about introducing the issue to their

17

partners, and worry about the impression they give to their partners (Helweg-Larsen & Collins, 1994). Knowing the rational reasons for using a condom may not overcome these interpersonal concerns. Second, given the powerful images associated with AIDS (e.g., being gay, promiscuous, or "unclean"), AIDS might be exactly the reason one should not use to convince one's partner to use a condom. Research on attitudes and classical conditioning suggests that one should avoid linking a desired behavior (e.g., using condoms) with an image or word (AIDS) that, rightly or wrongly, carries negative connotations. Misperceptions about condom use with regard to reliability such as those aforementioned can be highly contributory to the repeated neglect of use, especially in commercial sex workers which are among high risk groups. Though pleasure in condom use may be deemed inapplicable to certain situations such as that in the context of sex work, pleasure can and does have an effect on attitude due to its affective nature. Condom use stigma, which receives its impact from social norms and desirability, can elicit aversion towards its use on a personal level and hamper government efforts of its promotion which, if well enacted, can greatly support national reproductive health, specifically to sex workers. The Philippines on Sex Work, Reproductive Health, and Condom Use Sex work in the Philippines is illegal, but common in many locations. There is, however, a government-run system of social hygiene clinics which test for sexually transmitted infections and issue 'pink cards' that permit girls and women to work in bars, on the streets, etc. These Social hygiene clinics for sex workers are available in some areas, but not all. They tend to focus on regulating the women involved in sex work and do not always ensure privacy. Also, services for sex workers at social hygiene clinics were free in the past, but some locations have introduced charges.

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In terms of reproductive health care availability, sexual and reproductive health services are not available at all primary health facilities. For example, the city of Manila has banned the provision of contraceptives in its clinics. Regarding male condoms, they are available; but supplies have decreased dramatically, partly because they are the subject of intense social and religious controversy, are not widely used and tend to only be promoted among specific groups, such as sex workers. Meanwhile, female condoms are not easily available (International Planned Parenthood Federation [IPPF], n.d.). According to IPPF, there exist multiple social, political and financial barriers to girls and young women accessing sexual and reproductive health and HIV prevention services. These include: Lack of relevant services, especially ones that are youth-friendly. Conservative attitudes of staff, such as that young people, especially unmarried females, have no right to seek services relating to sex.

Norms that allow males to control females access to condoms, testing, etc. Religious and cultural pressures, such as to be passive in sexual relations. Costs (for condoms, HIV testing, etc.) Stigma linked to HIV and AIDS Access to sexual and reproductive health services tends to be based on marital status, rather than age. Married youth are treated as adults (for whom services are acceptable), while those who are unmarried can be isolated.

In particular, judgemental attitudes by health workers are a powerful barrier to both young people and people living with HIV. This is prevalent despite commitments in

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the Fourth AIDS Medium Term Plan to providing guidelines and training for staff to provide youth-friendly services and combat stigma.

There are particularly significant barriers to accessing condoms. Alongside poor supplies, these include religious views that condoms encourage promiscuity and are a sign of sex work. Such factors contribute to some 68% of young women having sex without using any form of protection (IPPF, n.d.)

Socio-structural factors and influences Social-structural factors such as extreme poverty, which characterizes Filipino FCSWs, and a lack of support by employers as well as customers may impede safe sex practices; satisfying the customers desire for sex without a condom may have become almost mandatory in maintaining ones livelihood and reducing conflicts with employers, despite the FCSWs personal perception of risk. Peers may also exert an influence on safe sex behaviors when FCSWs are based within establishments. Therefore, economic, peer influences, and employment/employer-related factors may have become a major barrier against consistent condom use (Morisky et al., 1998; Outwater et al., 2000). Attitudes are deemed to modify and modulate behaviors; personal attitudes consist of cognitive, affective, and conative factors. Consistent and correct condom use has been proven as a highly effective method of contraception and prevention of STIs. As such, misperceptions towards reliability and effectiveness of condom use yield negative attitudes towards the behavior. Dialogues and campaigns directed towards sexual health have been noticeably devoid regarding the topic, pleasure, which may significantly affect attitudes towards condom use thus promoting its use. Social stigma which influences subjective

20

norms, inaccessibility, and certain cultural factors further hamper the procurement and use of condoms. Review of Related Studies On Sexually Transmitted Infections and HIV. In a study on the prevalence of STI among Filipino sex workers, carefully collected specimens obtained from 936 female and 421 male sex workers revealed STDs in 51.7% and 10% of females and males respectively. The two most common pathogens demonstrated were N. gonorrhea and C. trachomatis. Other organisms/infection demonstrated included candida, trichomonas, herpes infection, G. vaginalis, syphilis and genital warts. HIV infection was detected in 1 female. Commercial sex workers have long been a priority for prevention efforts due to the common belief that this group is in part responsible for the spread of HIV among heterosexuals. A high number of sex partners and sex without condoms make this group particularly vulnerable to infection by HIV and other STIs (Morisky, Pena, Tiglao & Liu, 2002). On Gender Differences on Attitudes Towards Condom Use. In Helweg-Larsen & Collins 1994 study, mean differences between men and women were discovered on two of the five MCAS factors, and correlations between a given condom attitude scale and criterion variables consistently differed for men and women. Overall, men were less embarrassed about purchasing condoms than women, whereas women were more positive on issues related to identity stigma. These results are consistent with those by Campbell, Peplau, and DeBro (1992), who found that women were more positive than men on two dimensions (sexual sensation and interpersonal issues) whereas men were more positive on issues of comfort and convenience

21

(similar to our Embarrassment of Buying factor) and efficacy. Similarly, Hingson, Strunin, and Berlin (1990) found that compared with women, men were more likely to believe that condoms reduce pleasure. Sacco, Levine, Reed, and Thompson (1991) found that women were more positive toward condoms than men on five out of eight subscales but were more inhibited than men about buying and keeping condoms. These authors suggested that women's positive attitudes failed to result in increased condom use because the women felt they had to rely on a male partner to buy, keep, and supply the condoms. In the present study, women's past condom use did not correlate significantly with any of the MCAS factors. This may indicate the same underlying dynamic: Women may not be in control of the decision to use condoms, and their attitudes are therefore not related to past use. On Condom use errors and problems. In Crosby, Sanders, Yarber, Graham, and Dodges (2001) study on condom use errors and problems among college men, results showed that a sizable proportion of college men reported a variety of errors and problems that could contribute to condom failure or decreased condom efficacy. Moreover, some of the reported errors occurred frequently. For example, among the 30% who reported that they put the condom on with the wrong side up, this error occurred more than one-third of the times they used a condom. Three widely understudied errors that could compromise the protective value of condoms were reported by a substantial proportion of men: (1) putting condoms on after sex started, (2) using the same condom while switching between vaginal, anal, or oral sex, and (3) having erection problems associated with condom use. In addition, a large proportion of respondents reported lack of communication about condoms before sex began and lack of condom availability. Previous studies have established that

22

communication about condom use and lack of condom availability are strong predictors of subsequent condom use. On Affective attitudes. In a study conducted by Olapegba and Chovmen in 2008 on condom use among students, the findings revealed further that there was a significant influence of affective attitude towards condom on condom use. This suggests that students with positive affective attitude towards condom reported using condom more than students with negative affective attitude towards condom. This affective attitude could have been influenced by existing knowledge about condom which could be either religious sentiments or cultural beliefs. On Cost, availability, and acceptability. According to Morisky and colleagues study in 2005 about the impact of a social influence intervention on condom use and sexually transmitted infections among establishment-based female sex workers in the Philippines, for condom use to become commonplace among Filipino FCSWs, the financial penalty for their use must be minimized and that will require educational programs targeted toward acceptance of condoms by clients, civic organizations and governmental agencies. Female commercial sex workers are particularly susceptible to acquiring STIs, thus consistent and correct condom use is crucial. Attitudes derived from perceived reliability and effectiveness may be affected by former experiences in which condoms have failed to sufficiently serve its function which may be attributable to its incorrect usage. Gender differences in attitudes towards condom use are determined to MCAS UCLA suggest that attitude formation may significantly vary among the genders thus requiring furthers study. Much of condom use promotion have been directed towards knowledge expansion, though beneficial, may be ineffective without consideration of affective factors towards its use.

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Condom availability and acceptability which are composed of social influences and government efforts have bearings on subjective norms and perceived behavioral control.

Definition of Terms For a better understanding of the different terms that are used in the study; they are defined conceptually and/or operationally below: Attitude. It is a learned tendency to respond in a certain way because of beliefs, feelings, and readiness to act (Ragland & Saxon, 1985). In this study, attitudes of respondents towards condom use is measured through the Multidimensional Condom Attitude Scale instrument. Commercial Sex workers. It is the occupation where there is an exchange of money or goods for sexual services, either regularly or occasionally, involving female, male, and transgender adults, young people and children where the sex worker may or may not consciously define such activity as income-generating. Operationally, this refers to the subjects nature of occupation which will serves as the basis of their attitude to condom use (Swanson, 2009). Conative. It refers to the connection of knowledge and affect to behavior and is associated with the issue of "why." It is the personal, intentional, planful, deliberate, goaloriented, or striving component of motivation, the proactive (as opposed to reactive or habitual) aspect of behavior (Baumeister, Bratslavsky, Muraven & Tice, 1998; Emmons, 1986).

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Condom. It is temporary cover for an erect penis and is usually made out of latex (rubber). The purpose of this is to collect ejaculated sperm so that they dont go to the vagina and potentially start pregnancy (Fitch & Cox, 2005) Gatekeeper. These are the people who metaphorically, have the ability to open or close the gate to the researcher seeking access into the setting (Lewis-Beck, Bryman & Liao, 2004). It is a researchers access to a potential subject, to a site or to information (Tilley & Watson, 2004) Intention. It is a behavioral intention measures a person's relative strength of intention to perform a behavior. Attitude consists of beliefs about the consequences of performing the behavior multiplied by his or her valuation of these consequences (Ajzen & Fishbein, 1975). Respondents. This is the individual that provides data to be collected during the research process. Also referred to as a unit, unit of analysis, participant, experimental unit, or subject (Ostrow & Kessler, 1993). In this study, this refers to the female commercial sex workers ages 16 years old and above and are self-declared sex workers. Sexually Transmitted Infections (STI). A group of aquired infections through any kind of intimate contact. Intimate contact may include rubbing against one another, kissing, and vaginal and oral penetration (Tellier & Fariello, 2010)

Chapter 3 Methodology Research Design The researchers in this study have adapted the positivist paradigm wherein there is a fixed, prespecified design, objectivity and generalizations are sought, and information and data are measured and quantitative and are analyzed statistically (Polit & Beck, 2008). This research made use of the cross-sectional, descriptive-correlational design. In a crosssectional design, data are collected at one point in time. Descriptive research has its main objective the accurate portrayal of the characteristics of persons, situations, or groups, and/or the frequency in which certain phenomena occur (Polit & Beck, 2008). The purpose of correlational research is to discover relationships between two or more variables, to make predictions of how one variable might affect another, and to examine possible existence of causations. The researchers correlated attitudes of the respondents which are measured through a standardized tool to demographical variables such as age, marital status, educational attainment, religion, employment, average monthly income, use and intentions towards condom use through statistical methods. Research Locale The primary setting for this study was within the vicinity of Cebu City. The city is politically subdivided into 80 barangays and is divided into North and south district. Specific data collection sites will not be disclosed to protect the identity of the respondents and to uphold their freedom from exploitation. The selected research locale is an advantage to the researchers due to convenient proximity to the researchers areas of residence. This allowed easier access to exclusive areas where potential respondents can be found owing to

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the researchers familiarity and knowledge of the constituents of the locale. Also, Cebu city is one of the most highly industrialized cities in the Philippines so it can be surmised that there would be a relative high prevalence of commercial sex workers. According to Cebu City Health department 2010 statistics, there is a fast increase of female commercial sex workers from 2,360 recorded on 2009.

Figure 3. Site map of study. Retrieved from http://cebuonwheels.tripod.com

Research Respondents

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The target population for this study was female commercial sex workers located in the metropolitan Cebu city area. The researchers utilized snowball sampling technique with a minimum quota of 30 respondents. A quota method was implemented because there is no basis on the actual population size of FCSWs in the metropolitan area. Thus, a quota of a minimum of 30 respondents was chosen in order to give a brief insight into the attitudes of individuals of that specific sub culture. The respondents of this study were over 16 years old and were self-declared female commercial sex workers, which were the only inclusion criteria set to be eligible for the study. The respondents originated from referrals from acquaintances of the researchers, also known as data collectors, and other commercial sex workers. From the data collectors the researchers were referred to a FCSW; be she their acquaintance, friend, neighbor, and so forth. Then from that FCSW the data collector and researchers inquired for other contacts of other FCSWs that they may know, thus implementing a network sampling technique wherein early sample members were asked to refer other people who would meet the eligibility criteria. When attaining the data from the questionnaire, the FCSWs were oriented about the premise of the study, its purpose, confidentiality and anonymity policy through the use of the data collectors who have been trained regarding the administration of the questionnaires.

Research Instrument

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Attitude towards condom use were measured using the University of California Los Angeles Multidimensional Condom Attitudes Scale (UCLA MCAS) by Helweg-Larsen and Collins (1994) (see Appendix B). The purpose of the UCLA Multidimensional Condom Attitudes Scale (MCAS) is to measure condom attitudes in five independent areas: (a) the reliability and effectiveness of condoms, (b) the sexual pleasure associated with condom use, (c) the stigma associated with people proposing or using condoms, (d) the embarrassment about negotiating and using condoms, and (e) the embarrassment about purchasing condoms. The scale can be used with individuals who do and do not have personal experience with condoms. The 25-item MCAS assesses five independent factors associated with condom use. The MCAS was found to be reliable and valid in three studies using ethnically diverse samples of UCLA undergraduates (Fisher, Davis, Yarber & Davis, 2010). As of August 2008 it had been cited 97 times; the scale has been used in 31 of these articles. The scale has been used with a range of populations, such as HIV-positive individuals from urban clinics in California (Milam, Richardson, Espinoza, & Stoyanoff, 2006), Chinese and Filipina American college women (Lam & Barnhart, 2006), sexually active adult cocaine or heroin users (Rosengard, Anderson, & Stein, 2006), cocaine abusing, opioid-dependent HIV-positive adults entering a methadone program (Avants, Warburton, Hawkins, & Margolin, 2000), individuals in a large public psychiatric hospital diagnosed primarily with schizophrenia and mood disorders (Weinhardt, Carey, & Carey, 1997), American Indian men in New York City who identified as gay/bisexual/two-spirit and heterosexual (Simoni, Walters, Balsam, & Meyers, 2006), and HIV-positive Zambian women (Jones, Ross, Weiss, Bhat, & Chitalu, 2005). Furthermore, the MCAS has been

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translated to Spanish (DeSouza, Madrigal, & Millan, 1999; Unger & Molina, 1999), Japanese (Kaneko, 2007), and various Zambian languages such as Bemba, Nyanja, and Nsenga (Jones et al., 2005), as cited by Fisher, Davis, Yarber and Davis (2010). Overall, the body of research using the MCAS shows that it has been a reliable and valid measure of condom attitudes in a wide range of participants. Reported reliability for each of the MCAS factors in Helweg-Larsen and Collins 1994 study are as follows: reliability and effectiveness (.86); pleasure (.74); stigma (.62); embarrassment about negotiation and use (.92); embarrassment about purchase (.88). The five dimensions of the MCAS cannot meaningfully be summed to generate a single global score because the factors are independent. The statistical independence of the five factors was established via factor analyses and confirmatory factor analysis in structural equation modeling which showed that a model with five independent factors was superior in fitting the data compared to a unidimensional model (all 25 questions averaged). Thus, it is important that the five factors are scored separately (Fisher, Davis, Yarber & Davis, 2010). Some of the MCAS items are worded negatively (i.e., indicate a negative attitude toward condoms), and the score must therefore be reversed before adding or averaging the scores (higher scores will then indicate more positive condom attitudes) (Helweg-Larsen, 1994). The scoring for these items is as follows: 1. Reliability and Effectiveness of Condoms: Reverse score Questions 6 and 14; then

add Questions 4, 6, 9, 14, and 20. 2. Pleasure Associated With Condoms: Reverse score Questions 2, 8, and 25; then add

Questions 2, 8, 15, 19, and 25.

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3.

Stigma Associated With Condoms: Reverse score Questions 3, 13, 18, 22, and 24;

then add Questions 3, 13, 18, 22, and 24. 4. Embarrassment About Negotiation and Use of Condoms: Reverse score Questions 1,

7, and 16; then add Questions 1, 7, 12, 16, and 21. 5. Embarrassment About Purchasing Condoms: Reverse score Questions 5, 11, 17, and

23; then add Questions 5, 10, 11, 17, and 23. It is inherent and must be acknowledged that when researchers measure an attribute, they may also be inadvertently measuring attributes that are not of interest. These errors of measurement can be also expected from the instruments being a self-administered questionnaire. The true score component is what is hoped to be isolated; the error component is composite of other factors that are also being measured, contrary to the researchers wishes. Many factors contribute to errors of measurement. Some biases that may be present and must be considered include: 1. situational contaminants, which is a composite of the external undesirable influences to the respondents which may include the presence of an observer and environmental factors; 2. Transitory personal factors, which are temporary personal states and moods, 3. Response-set biases, which may include social desirability, acquiescence, and extreme responses (especially that the instrument utilizes Likert scale); and 5. Instrument clarity (Polit & Beck, 2008). Considering that most of the respondents do not comprehend English well and that the original language of the instrument scale is English, the researchers translated the instrument to the local language, which is Cebuano. Semantic equivalence was secured through repeated consultations, translations, and revisions from at least 10 local language regular users whose native tongue is the local dialect. Back translation to English was then employed with the

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help of 3 individuals whose native language is English but also understands the Cebuano dialect, and had no prior knowledge about the questionnaire. The translators are all bilingual, have first-hand familiarity with both cultures, and are capable of understanding the conceptual underpinnings of the constructs. The individuals translated the questionnaire from Cebuano back into English and the back translations were compared with the original English form. The translation and back-translation process was a cyclical and repetitive process with multiple discussions and reviews until semantic equivalence was achieved, which was when the original and back-translated items are identical and equivalent and meaning. Once the translation of the tool has been deemed accurate (See Appendix C for final test instrument), a pilot test was done in order to determine reliability and semantic equivalence of the translated tool (See Appendix E for derived reliability values). Ten bilingual individuals were recruited to answer both the Cebuano and the English-Cebuano versions of the instrument; their scores were then correlated with each other with the correlation coefficient and Cronbach alpha obtained. Since the instrument tool has five independent components, five reliability values were derived. Computed internal consistency reliability were as follows: reliability and effectiveness (.83); pleasure (.72); stigma (.81); negotiation and use (.91); and purchase (.87). Along with the instrument tool are queries regarding demographic data, such as age, marital status, educational attainment, religion, occupation, and average monthly income. There are also queries regarding past condom use, negotiation and intention towards condom use. Data Gathering Procedures

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Fieldwork To spearhead the study, the researchers deemed it valuable and informative to conduct a fieldwork just to have an incipient understanding of the study at hand. Background information was gathered so that the researchers will have an understanding of the importance of condom use among sex workers and to help the researchers formulate a hypothesis. The researchers interviewed several FCSWs to gain insight to their livelihood and lifestyle. The researchers conducted a spontaneous interview with several FCSWs in the house of the data collector because it is a neutral setting in which the FCSWs would not feel anxious or threatened. The FCSWs were asked several questions regarding to topics such as: contraception as affected by religion, condom usage, condom association, condom use level of comfort, and condom effectiveness. Of the five FCSWs interviewed, three of them demonstrated a positive attitude towards condom usage as evident through their praise of condom effectiveness and condom reliability. But they also verbalized that they felt a negative stigma when it came to them personally having to buy condoms. One informant stated that she was uncomfortable with the thought of having to buy condoms because of the fact that she is female and she feels that it is more socially acceptable for the male partner is to buy the condoms, but she will buy the condoms if necessary. In general, the informants gave valuable information and tips on how to approach other FCSWs and what to expect from them in terms of responses. They gave a general insight onto the level of knowledge that FCSWs have towards condom reliability and effectiveness as well as general demographic information such as educational background and age.

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Through networking, the researchers were able to achieve the set quota of respondents with little close and personal contact thus creating a fitting distance: proximal enough to be able to efficiently accomplish the study while at the same time reducing the associated risks of being directly involved and physically present in the field. Training the Data Collector Criteria for selection of data collectors included having a considerable level of interaction and relationship with certain FCSWs. They must be well acquainted with FCSWs that they have established trust and concord. The data collectors have undergone preliminary training about the tasks and technicalities involved. The data collectors were oriented about the premise of the study and the proper administration of the research instrument. The data collectors were also taught on how to attain verbal consent from the respondents. Verbal consent was specially utilized in this study since the FCSWs may view a written and tangible consent form as intimidating or precarious, viewing it as something that can be possibly used against them judicially, thus making them more disinclined to provide consent. In addition, the data collectors were trained by the researchers so that they would know exactly how to explain the various statements on the questionnaire should any problems and confusions arise. After answering the questionnaires, the respondents were given a small stipend in exchange for their time.

Data Collection The UCLA Multidimensional Condom Attitudes Scale by Helweg-Larsen and Collins (1994) was primarily utilized for data collection of pertinent data. The researchers have

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obtained permission from the authors to use the instrument. The researchers translated the instrument to the respondents preferred dialect for consistency and comprehension. Interview schedule was performed for a few of the respondents who had difficulty reading the questionnaire. The instrument measures attitude on the basis of five independent key areas. The respondents were briefed about the significance of the study and their rights (see Appendix B).They were told that they have the right to refuse participation in the study, and that they may turn in a blank questionnaire or may not answer certain items they dont want to. They were also told that their identities and locations will not be disclosed. They were also not required to inscribe their names and the questionnaires are devoid of queries on names; instead, the questionnaires were assigned with numbers. The respondents were also told to answer the questionnaire as honestly as possible, that there are no right or wrong answers, and that they could take their time in answering. The respondents were given cash incentives which was negotiable between the two parties (data collectors and FCSWs) as a form of disbursement for the time they have imparted to participate in the study. Since concealing the identity of the respondents was imperative to keep them safe and earn their trust, the researchers will thoroughly explain how all written material will be kept in padlocked drawers, all soft copy data will be kept in password protected folders, aliases will be used, and that after 5 years all information pertinent to the FCSW will be burned and deleted ensuring safety of their identity.

Data Analysis To answer each of the sub-problems, the following statistical methods will be employed:

35 1. The Spearman's rank correlation coefficient or Spearman rho is a non-

parametric measure of statistical dependence between two variables. It is equivalent to the Pearson's r correlation, computed on the variables, after they have been transformed into rank-orders. Because age is not normally distributed and the scatterplot reveals that it doesn't follow a line, Pearson r cannot be used to find its correlation with the 5 MCAS dimensions. The Spearman rho is used instead, the nonparametric equivalent of Pearson r. The correlation coefficient is a number between +1 and -1. This number implies the magnitude and direction of the association between two variables. The closer the correlation is to either +1 or -1, the stronger the correlation. If the correlation is 0 or very close to 0, there is no association between the two variables. If the correlation is positive, the two variables have a positive relationship (as one increases, the other also increases). If the correlation is negative, the two variables have a negative relationship (as one increases, the other decreases).
2. The KruskalWallis test is most commonly used when there is one nominal

variable and one measurement variable, and the measurement variable does not meet the normality assumption of an anova. It is the non-parametric analogue of a one-way anova. A one-way anova may yield inaccurate estimates of the P-value when the data are very far from normally distributed. The KruskalWallis test does not make assumptions about normality. Like most non-parametric tests, it is

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performed on ranked data, so the measurement observations are converted to their ranks in the overall data set (McDonald, 2009). Because the researchers had nonnormal data and a small sample size, the researchers decided to perform the Kruskal-Wallis Test (the nonparametric equivalent of the ANOVA) to determine if there is a significant difference in the demographic profiles with respect to each of the 5 MCAS dimensions.
3. The MannWhitney U-test (also known as the MannWhitneyWilcoxon test,

the Wilcoxon rank-sum test, or the Wilcoxon two-sample test) is utilized by the researchers to find out if condom use in the most recent sexual encounter is significantly related to the MCAS dimensions. It is limited to nominal variables with only two values; it is the non-parametric analogue to the independent t-test (McDonald, 2009). SPSS, a statistical software program for personal computers was used to perform the aforementioned statistical methods.