Psychosocial predictors of consistent condom use among migrant road construction workers in the Southwest Region of Cameroon using the Health Belief Model

Introduction A significant proportion of road construction workers are migrants and prone to HIV infection. This study investigated the psychosocial predictors of consistent condom use among migrant road construction workers in the South-west region of Cameroon using the Health Belief Model (HBM) as the theoretical framework. Methods A cross-sectional survey of a stratified sample of 254 road construction workers was conducted at construction sites along the Kumba-Mamfe road in the South-west region of Cameroon in December 2015. Data were collected using a pretested structured questionnaire and binomial logistic regression was performed to test the strength of association between the independent and the dependent variables using SPSS version 20 at the level 0.05. Results Only 67 (43.5%) reported consistent condom use. Perception of risk of contracting HIV was also low, 109 (42.9%). None of the constructs of the HBM was significantly associated with consistent condom use. However, perception that road construction workers are prone to HIV (perceived susceptibility) was associated with an increased likelihood of using condom consistently, OR = 2.1 (95% CI 0.72-6.12, p = 0.17); perception that consistent condom use could prevent HIV transmission (perceived benefit) was associated with an increased likelihood of using it consistently, OR = 1.9 (95% CI 0.74-4.80, p = 0.18); perception by workers that they can refuse sex with their partners if they refuse to use condoms (perceived self-efficacy) was associated with an increased likelihood of using condoms consistently, OR = 1.5 (95% CI 0.62-3.53, p = 0.38). However, the perception that condom reduces sexual pleasure (perceived barriers) was associated with a reduced likelihood of using it consistently, OR = 0.84 (95% CI 0.35-2.01, p = 0.698) Conclusion There were no significant associations between the psycho-social constructs of the HBM and consistent condom use. Therefore, interventions to increase the perception of risk of contracting HIV, which is assumed to be the immediate antecedent of consistent condom use is highly recommended.

South-west region has an HIV/AIDS prevalence of 5.7%, which is above the Cameroon national prevalence of 4.3% [11]. The response options were "1 = others" (reference category)' and "2 = always".

Predictor (independent) variables: constructs of the HBM
Perceived susceptibility to HIV: This was measured based on the level of agreement with the following item: "Road construction workers are prone to HIV/AIDS". The response options were categorized into "2 = agree" and "1 = disagree". "Disagree" was coded as the index category.

Perceived severity of HIV/AIDS: This measure was based on
the degree of agreement with the following statement: "HIV/AIDS is a deadly disease". The response options were categorized into "2=agree" and "1 = disagree". "Disagree" was coded as the index category.
Perceived benefit of condom use: This was measured based on the level of agreement with the following item: "Consistent condom Page number not for citation purposes 4 use during sexual intercourse can prevent HIV transmission". The response options were categorized into "2 = agree" and "1 = disagree". "Disagree" was coded as the index category.
Perceived barriers to condom use: This measure was based on the degree of agreement with the following statement: "Condom use decreases sexual pleasure". The response options were categorized into "2 = agree" and "1=disagree". "Disagree" was coded as the index category.
Perceived self-efficacy for condom use: This measure was based on the degree of agreement with the following statement: "I feel confident to refuse sex with my partner(s) if they refuse to use condom". The response options were categorized into "2 = agree" and "1 = disagree". "Disagree" was coded as the index category. consistently, (OR = 0.84 (95% CI 0.35-2.01, p=0.698)); perception of being at risk of contracting HIV was associated with an increased likelihood of using condom consistently, (OR=1.30 (95% CI 0.55-2.95, p = 0.5770)); being a Muslim was associated with an increased likelihood of using condom consistently, (OR = 1.60 (95% CI 0.20-12.54, p = 0.66)) and being single was associated with an increased likelihood of using condom consistently, (OR=2.50 (95% CI 0.38-17.06, p=0.33)) ( Table 3). influence their readiness to take action (use condoms consistently during sex to prevent HIV/AIDS) [9,10]. This study used the HBM as the framework to investigate the psychosocial predictors of consistent condom use among migrant road construction workers in the South-west region of Cameroon. In this study, the perception of risk of contracting HIV was low, 42.9%. Therefore, the majority of the road construction workers, 57.1% did not perceive themselves to be at risk of contracting HIV/AIDS. This majority may therefore not see the need for consistent condom use during sexual intercourse to prevent HIV transmission. The reason for the low-risk perception could be that the workers see their sexual partners as safe since they are resident in villages around the road construction sites with limitation in their movements and might therefore not be exposed to urban lifestyles and risky practices that may expose them to the risk of contracting HIV/AIDS. According to the HBM, for sexually active road construction workers to use condoms consistently, they must perceive themselves to be susceptible to the disease. From the many interventions and sensitisation programmes that have been going on since the advent of HIV, one would expectant that almost everyone should see themselves susceptible to HIV. Since Cameroon is experiencing a generalised epidemic with a prevalence of 4.3%, one would expect that the perceived susceptibility of road construction workers to HIV should be near 100%. However, the over 20% of the construction workers who did not perceive themselves to be susceptible to HIV, might not be motivated to use condom consistently during sexual intercourse to prevent the disease because they see themselves as not being at risk of contracting HIV. According to the assumptions of the HBM, for sexually active road construction workers to use condom consistently during sexual intercourse to prevent HIV transmission, they must realise that contracting HIV would have serious physical and social implications. It is when they realise the magnitude of the negative consequences of HIV/AIDS, that they would use condom consistently during sexual intercourse to prevent HIV/AIDS and avoid these negative consequences [14]. In this study, the 35.8% of the workers who did not perceive that HIV/AIDS is a deadly disease  [15]. Perceived barriers refer to one's belief in the tangible and psychological costs of the advised behaviours against a condition or problem [16,17].

Discussion
According to the HBM, for workers to use condoms consistently to prevent HIV transmission they must perceive few barriers to condom use and be able to overcome these barriers. The majority of the respondents in this study, 63.8% perceived that condom decreases sexual pleasure. Therefore because of this barrier, these respondents may not use condoms consistently to prevent HIV transmission. This finding calls for concerted efforts and interventions among road construction workers to enable them to understand that the benefit of condom in preventing HIV/AIDS, outweighs any barrier they might experience in using condom since the consequences of contracting HIV are serious. Going by the tenets of the HBM, It is only when a worker realises that he has the capacity to deal with any barrier to condom use, that he would be Page number not for citation purposes 6 able to use it consistently during sexual intercourse. Perceived selfefficacy for condom use is the strength of a worker's belief in his own ability to refuse sex with his partners if they refuse to use condom [17]. A worker should feel that he is capable of using condom correctly because it is that confidence that would motivate him to initiate condom use and use it consistently. In this study, up to 46.1% of the road construction workers did not have the confidence in their ability to refuse sex with their partners if they refuse to use condom. This calls for programmes and interventions  [19]. Also, the majority of them, 68.1%, had up to only primary level education. Their young age, coupled with their low level of education makes them more vulnerable to HIV transmission because most of them may lack sufficient knowledge regarding transmission and prevention of HIV, and also skills to negotiate condom use with their sexual partners. Since most of the migrant road construction workers are paid on the daily or weekly basis, they always have money at hand to buy sex regularly, which might put them at risk of contracting HIV because most of them do not use condom consistently. There is, therefore, the need to organize HIV/AIDS awareness programmes on a regular basis at the construction sites so that workers can be imparted with knowledge and skills to protect themselves against HIV transmission.
In this study, none of the constructs of the HBM was a significant predictor of consistent condom use. These findings are contrary to other findings among migrant workers in Benin [20] where perceived barrier was a significant predictor of consistent condom use; in Myanmar [21] and Thailand [22], where perceived susceptibility was found to be a significant predictor of consistent condom use; and in Ethiopia [20], South Africa [23] and Tanzania [24] where perceived self-efficacy was found to be significant predictor of consistent condom use. However, the results of this study are consistent with those from Myanmar [21] where perceived benefit of condom use and perceived severity were not found to be perceived self-efficacy for condom use was associated with an increased likelihood of using it consistently; perceived barrier to condom use was associated with a reduced likelihood of using it Page number not for citation purposes 7 consistently; perception of being at risk of contracting HIV was associated with an increased risk of using condom consistently; being a Muslim was associated with an increased likelihood of using condom consistently and being single was associated with an increased likelihood of using condom consistently (Table 3)

Authors' contributions
Elvis Enowbeyang Tarkang conceptualised the study, designed the research instrument, analysed and interpreted the data, wrote the first draft of the manuscript and revised the manuscript. Lilian Belole Pencille assisted in writing the first draft of the manuscript and in revising the manuscript. All authors approved the final manuscript. Table 1: Socio-demographic characteristics of the study population Table 2: Psychosocial predictors of consistent condom use Table 3: Odds Ratios (OR) of using condom consistently from the logistic regression models