Locus of control and contraceptive knowledge , attitude and practice among university students

OBJECTIVE: To assess the relationship between locus of control and knowledge, attitude and practice regarding pill and condom use among university students. METHODS: The inquiry was developed in Campinas, a city in Southeastern Brazil, in 2006. A total of 295 adolescent newcomers to a public university answered a structured questionnaire and Levenson’s multidimensional locus of control scale. The scores of the dimensions of locus of control were calculated and Spearman’s correlation coeffi cient was used to assess their correlation with knowledge and practice concerning pill and condom use. In order to assess the relationship between the dimensions of locus of control and sociodemographic variables and variables related to the individuals’ sex life, Kruskal-Wallis and Mann-Whitney tests were used. RESULTS: Male adolescents had higher scores of powerful others externality when compared to female adolescents (p=0.01). Students living alone had lower internality (p=0.01). When locus of control was compared to condom use in the fi rst intercourse, considering only the 102 students who informed the age of the beginning of sexual activity, greater internality was found among male adolescents who did not use condoms (p<0.05). When the locus of control scores were correlated with contraceptive knowledge and practice, it was found that the higher the powerful others externality locus, the lower the adequate use of contraceptive methods (r = -0.22, p=0.03). CONCLUSIONS: The powerful others externality locus infl uences the practice of contraceptive use in this group of adolescents. DESCRIPTORS: Adolescent. Condoms, utilization. Contraceptive Agents. Internal-External Control. Health Knowledge, Attitudes, Practice. 40 Locus of control and contraception Alves AS & Lopes MHBM Contraception decisions made in adolescence, with little or no previous experience, may bring lifelong consequences. Studies designed to understand the decision-making process concerning contraception in adolescents remain inconclusive. However, multiple factors are known to infl uence the decision-making process, resulting in attitudes and practices.3 Data show that there is a gap between knowledge and adequate practice regarding contraception.10 Personal characteristics and personality are also known to infl uence behavior, contributing to the use or nonuse of contraception in adolescence.1,3 The locus of control scale is used for this type of assessment. Locus of control refers to an individual’s generalized expectations concerning where control over subsequent events resides. In other words, who RESUMO OBJETIVO: Avaliar a relação do lócus de controle com conhecimento, atitude e prática relacionados à pílula e ao preservativo entre adolescentes estudantes universitários. MÉTODOS: Estudo tipo inquérito desenvolvido em Campinas, SP, em 2006. O total de 295 adolescentes ingressantes de uma universidade pública respondeu a um questionário estruturado e à escala multidimensional de lócus de controle de Levenson. Foram calculados os escores das dimensões do lócus de controle e o coefi ciente de correlação de Spearman para avaliar a correlação com o conhecimento e a prática do uso de pílula e preservativo. Para avaliar a relação entre as dimensões do lócus de controle e as variáveis sociodemográfi cas e variáveis relacionadas à vida sexual foram usados os testes de Kruskal-Wallis e Mann-Whitney. RESULTADOS: Os adolescentes do sexo masculino apresentaram maior externalidade-outros poderosos quando comparados com as do sexo feminino (p=0,01). Estudantes que viviam sozinhos tinham uma internalidade mais baixa (p=0,01). Quando o lócus de controle foi comparado com o uso de preservativo na primeira relação sexual, considerando-se apenas os 102 estudantes que informaram a idade de início da atividade sexual, foi encontrada maior internalidade entre os adolescentes do sexo masculino que não usaram preservativo (p<0,05). Ao correlacionar os escores do lócus de controle com o conhecimento contraceptivo e prática, observou-se que quanto mais elevado o escore do lócus de controle externalidade outros-poderosos, menor o uso adequado de métodos contraceptivos (r = -0,22, p=0.03). CONCLUSÕES: O lócus externalidade outros-poderosos infl uencia a prática de uso de método contraceptivo nesse grupo de adolescentes. DESCRITORES: Adolescente. Preservativos, utilização. Anticoncepcionais. Controle Interno-Externo. Conhecimentos, Atitudes e Prática em Saúde.

Contraception decisions made in adolescence, with little or no previous experience, may bring lifelong consequences.
Studies designed to understand the decision-making process concerning contraception in adolescents remain inconclusive.However, multiple factors are known to infl uence the decision-making process, resulting in attitudes and practices. 3ta show that there is a gap between knowledge and adequate practice regarding contraception. 10rsonal characteristics and personality are also known to infl uence behavior, contributing to the use or nonuse of contraception in adolescence. 1,3e locus of control scale is used for this type of assessment.Locus of control refers to an individual's generalized expectations concerning where control over subsequent events resides.In other words, who RESUMO OBJETIVO: Avaliar a relação do lócus de controle com conhecimento, atitude e prática relacionados à pílula e ao preservativo entre adolescentes estudantes universitários.

INTRODUCTION
or what is responsible for what happens.It may be internal, when the individual perceives him/herself as the author of the event source in which he/she is involved; or external, when the individual attributes control of his/her own life to other persons, entities or even to luck or destiny.
The term "locus of control" was created by Rotter, in 1960, and classifi ed as internal and external control. 13t was later modifi ed by Levenson, who created three dimensions of control: internality (subscale I), powerful others externality (subscale P) and chance externality (subscale C).These last two, control of one's life by powerful people and chance (destiny or luck as reference to occurrences in life), are assigned according to the subject's perception. 4 is expected that adolescent university students are worried about contraception because they are initiating their preparation for professional life.Therefore, the objective of the present study was to evaluate the association of locus of control with contraceptive knowledge and practice among adolescents.

METHODS
A knowledge, attitude and practice (KAP) survey was carried out among adolescent university students enrolled at a public university in Campinas, Southeastern Brazil, in 2006.This university enrolls 2,830 new students annually.a Only students aged 19 years or less at the time of the interview were included in the study.
Aiming to obtain a more homogeneous sample, students enrolled in evening courses and those studying in other campi were excluded.Students enrolled in courses in which it was not possible to obtain authorization from the course coordinator to collect the data were also not included.
The sample size was calculated based on the gender percentages of students enrolled in 2006 (60% males, 40% females) and on the variables of interest.A correlation coeffi cient (r) of 0.20, with α equal to 0.05 and β equal to 0.10 (90% power) was considered, resulting in a sample size of 259 students. 6thorization for data collection was obtained from 19 course coordinators.
At the beginning or the end of the class, and after the professor had granted authorization, the students were invited to participate in the study.Students willing to participate signed an informed consent form before answering the questionnaire.Questionnaire fi lling was supervised by the main investigator.
A questionnaire to collect data on sociodemographic characteristics and sex life was used (age, gender, color, religion, paid employment, existence of a partner, family income, age at initiation of sexual activity, current use of contraception, moment of fi rst use of contraception -before or after initiating sexual activity), as well as questions regarding knowledge, attitude and practice with respect to pill and condoms.
The questionnaire was submitted to prior evaluation by three reviewers, who were investigators with experience in women's healthcare research and in the KAP survey methodology.The questionnaire was pre-tested in a group of 13 adolescent students in another campus at the same university.In order to assure anonymity of the respondents, each course was identifi ed by an alphabetic code.Respondents were identifi ed in the questionnaires by numbers.
Questions referring to practice were separated into two groups of six questions: one for oral contraceptive pill users and the other for condom users.Scores for correct answers were added, each question being worth one point.Total scores varied from 0 to 12 for practice and 0 to 20 for knowledge.Attitude was evaluated as positive or negative for each related question.
Levenson's multidimensional locus of control scale adapted for use in Brazil was employed. 4This scale assesses how different dimensions of locus of control in university students are expressed, and the relationship between these dimensions and contraceptive knowledge, attitude and practice, specifi cally with respect to contraceptive pill and condoms, since these are the most common contraceptive methods used by adolescents. 8evenson's multidimensional locus of control scale is composed of 24 items and has three subscales, each of which contains eight items: internality -subscale I (internal locus of control); powerful others externality -subscale P (powerful others locus of control); chance externality -subscale C (chance locus of control).The 24 items form a single, Likert-type scale with fi ve levels of response: I completely agree (5); I agree (4); undecided (3); I disagree (2); and I completely disagree (1). 4 In order to obtain the total score, the points achieved in each item of the subscale were added.For subscale I, items 1, 4, 5, 9, 18, 19, 21 and 23 were added.For subscale P: 3, 8, 11, 13, 15, 17, 20 and 22. Subscale C: 2, 6, 7, 10, 12, 14, 16 and 24.Scores varied from 8 to 40 points.
For data analysis, we considered that the higher the locus of control score, the greater the tendency to believe in that controlling source.However, when the values in a control source are low, this does not mean that the individuals perceive control as coming from another source.Both sources can be considered, because the dimensions are independent. 4database was created using the Epi Info software, version 3.3.2.Data was checked for accuracy prior to analysis.
The descriptive statistics of the scores of the locus of control dimensions were calculated using Spearman's correlation coeffi cient to assess their correlation with knowledge and practice concerning pill and condom use.
In order to evaluate the relationship between the dimensions of locus of control and the sociodemographic

RESULTS
Most students (82.7%) were aged 18-19 years old; 51.9% were male; 79.7% considered themselves white; 50.2% referred to themselves as Catholics; 92.2% did not work; 49.5% lived with their family and 32.5%, with friends; and the family income of 59.3% of the students was 6-10 times higher than the current Brazilian minimum wage or more.
In Table 1, locus of control is evaluated according to gender.Male adolescents were found to have greater powerful others externality when compared to female adolescents.
In the correlation of locus of control with age, color, religion, paid employment, with whom they lived, existence of a partner, family income, age at initiation of sexual activity and current contraceptive use, no signifi cant differences were found between these variables, except for students living alone, who had lower internality (p=0.01).
Table 2 compares the dimensions of locus of control with the moment of initiation of contraceptive use.No statistically signifi cant difference was found.
Tables 3 and 4 refer to the 102 adolescents who had already initiated sexual activity, stratifi ed by gender and compared regarding their locus of control.Except for condom use in the fi rst sexual intercourse, results were not signifi cant.Male adolescents who did not use condoms had greater internality.
For these 102 adolescents, the locus of control scores, correlated with the percentage of correct answers to the questions on knowledge and practice, showed that the higher the powerful others externality, the lower the adequate practice of contraceptive methods (r = -0.221,p=0.03).
Concerning attitude, both males and females had positive attitudes towards the two contraceptive methods.Since the groups were very homogenous, it was impossible to carry out any further analyses.

DISCUSSION
In the present study, male adolescents had higher scores of powerful others externality when compared to female adolescents.Nevertheless, this result should be viewed with caution, since there was little difference between sexes.This fi nding differs from results reported by most studies carried out using locus of control, since greater internality tends to be associated with males. 4However, more recent studies report no difference in locus of control between males and females.The results of the present study would appear to refl ect changes that are in agreement with the current posture of greater assertiveness adopted by women in society.However, male adolescents, even university students, seem to be more infl uenced by others, which may also refl ect these same changes.
Studies suggest that certain personality characteristics contribute to the use or nonuse of contraception by adolescents.Regarding locus of control, individuals who consider that the cause of what happens to them is external and out of their own control have lower likelihood of using contraceptives. 1,3e present study found that the higher the powerful others externality, the lower the adequate practice of contraception.Therefore, it is fundamental to identify the infl uences (friends, health professionals and family members) and offer greater support to those individuals with higher externality (through adequate follow-up provided by specialized health professionals and the involvement of signifi cant individuals), since this age group is strongly affected by external factors.
When the locus of control was compared with use of condoms in the fi rst intercourse, higher internality was found among male adolescents who did not use condoms, a method that also prevents sexually transmitted diseases.Perhaps their feelings of invulnerability, very common among adolescents, could explain this result, which should be viewed with caution, considering the small number of male adolescents that did not use condoms (only fi ve).Therefore, further investigations are necessary.
A study in the United Kingdom, involving 150 undergraduate nurses, 9 using Rotter's internality-externality scale, found that students with high internality scores in locus of control were better motivated to achieve objectives and showed greater satisfaction when compared to those who had higher externality scores.Also, men had higher internality scores than women (52.9% and 47.4%, respectively).Individuals with higher internality scores were also found to perform better academically and to deal better with stressful situations and environment changes. 9study in the United States used Nowicki & Strickland locus of control scale on use of contraceptive methods in 66 female adolescents (mean age 17 years) and reported 47% of individuals with higher externality and 53% with higher internality scores.The study was based on the hypothesis that adolescents with higher internality scores in locus of control would be more effective users of contraceptive methods than those with higher externality scores, and this hypothesis was confi rmed. 11other study in the United States, involving 1,851 women, used the Rotter scale to compare two groups of adolescents.Results showed that the group of adolescents who had become pregnant had higher externality scores in locus of control compared with the group of adolescents who did not become pregnant. 12 study involving 508 female graduate students also of the internals as opposed to 63% of the externals. 7evertheless, a Canadian study comprising 191 female university students, using the same scale, emphasized that there are controversies with respect to the relationship between internality in locus of control and the use of contraceptive methods. 5 the present study, no association was found between age and locus of control, probably due to the small age range (17-19 years).However, a study carried out over four consecutive years, involving 236 high school students in the United States, using the Nowicki & Strickland locus of control scale, found a gradual reduction in externality with the passage of time, and the authors considered that this decline may be a result of the freedom acquired with the increase in age and with the feeling of empowerment. 2e of the limitations of the present study is the use of Levenson's multidimensional locus of control scale.This does not allow comparisons, as Levenson's scale has three independent dimensions whereas other studies used scales with only two dimensions.
If externality is a factor that truly predisposes individuals to unsafe contraceptive practices, this characteristic should be considered in interventions regarding contraception in order to increase the adolescents' sexual and reproductive empowerment.These individuals need to be stimulated to believe that the prevention of sexually transmitted infections, AIDS (acquired immunodefi ciency syndrome) and undesired pregnancy are within their own control.
variables and variables related to the individuals' sex life, Kruskal-Wallis and Mann-Whitney tests were used.The signifi cance level was established at 5%.The study was approved by the Research Ethics Committee of the Faculdade de Ciências Médicas, Universidade Estadual de Campinas (authorization 516/2005).
Information on

Table 2 .
Dimensions of locus of control according to the moment of initiation of use of contraceptive methods among adolescents.

Table 3 .
Dimensions of locus of control of adolescents who had initiated sexual activity according to gender.Campinas,

Table 4 .
Dimensions of locus of control of use of preservative on the fi rst intercourse, according to the gender.Campinas,