The study aimed to explore the factors that influence adolescent’s condom use decision-making in the Western Cape, South Africa. The results suggest sexual debut was central to conversations about condom use decision-making among adolescents. Conversations about sexual debut might have emerged among the adolescents so that they are not seen as already having sex – so that conversations about sex and condom use are more euphemistic. The role of fear, however, was also seen as driving the decision-making process of rationally examining the alternatives when a decision needed to be taken about using a condom or not.
Scholars have called attention to the importance of understanding and exploring adolescent sexual decision-making , particularly related to condom use, to inform HIV and pregnancy prevention interventions. Through exploring the data, it became clear that social expectancies, parental influence and the fear of undesirable future outcomes were integral to adolescent condom use decision-making.
Using the affective decision-making perspective, values, expectancies and emotions are key when examining adolescent risk behaviour . Evaluating positive and negative outcomes of behaviour during the decision-making process, called expectancies, is important to explore as adolescents exhibit agency in their choices around health-related decision-making . Findings in this study confirm what has been written in the literature about the assumption that negative expectancies, such as becoming pregnant, becoming a parent or contracting HIV or other related sexual transmitted infections  are often shaped by the values held by adolescents.
In addition to the values and expectancies, the findings suggest that emotions and affective states (the emotions and affective states which emerged in the decision-making process from the findings included: hope, love, anticipated regret, and fear) were important factors in adolescent decision-making. Affective states are often ignored in health-related decision-making and thus are not always incorporated into the theoretical frameworks that underpin many health-related interventions . Affective states such as motivation, emotion, and stress, to name but a few are important when making decisions about health . Adolescents are making decisions about emotionally laden issues . They talk about things in relation to how they think or expect they may feel. We tend to ignore emotions in interventions/research because of social constructions of emotions and the self as being vulnerable which is disempowering and perpetuates stigma . Instead, we focus on risk perception, knowledge and attitudes , which are important too. We could reshape our interventions/research by understanding the role of emotion and affective states in health-related decision-making and behavioural outcomes.
The themes suggest the important role of an evaluation of the alternatives but also the role of affective states in driving the outcomes of such evaluations, that are often ignored in health promotion and prevention interventions. The themes related to condom use decision-making also highlighted the role of fear in the decision-making process. Fear has often been cited as influencing the process of making sense of available information which is important to making a decision. Diminished attention is paid to the risk-related information in the presence of fear. However, others have believed that the presence of fear is associated with the awareness of risk related to the potential alternatives to be chosen in the health-related decision-making process .
Guilamo-Ramos and colleagues [26, 27] found that adolescents were concerned about the implications and consequences that engaging in risky sexual behaviour would have on those they interact with socially, like peers, parents and neighbours. These concerns about the implications and consequences of sexual behaviour were also seen among adolescents in the current study where there were concerns about pregnancy, parenthood and disease infection. Anticipation of regret as an affective state which pointed to concerns about the social implications and consequences of sexual behaviour, was a common underlying factor that influenced how adolescents thought about sexual debut. These findings highlight not only the importance that adolescents may place on values as part of their sexual debut and condom use decision-making processes, but also how these values inform some of the expectancies or outcomes regarding condom use or non-use.
Public health interventions aimed at promoting sexual and reproductive health of adolescents should not only consider adolescents as being rational young people who evaluate the available alternatives based on the knowledge shared in many sexual and reproductive health interventions. It is evident that when faced with a situation in which a choice needs to be taken around condom use or non-use, decisions are also guided by various emotions and affective states. Whether condom use decision-making is informed by knowledge related to rational decision-making or emotions as part of affective decision-making only is not possible to answer. The result suggests that these two forms of decision-making (rational and affective) are not mutually exclusive and could be happening simultaneous during the condom use decision-making process. Many sexual and reproductive health interventions that have focused on cognitive and behavioural models have seen an increase in knowledge related to sexual risk , but have not seen a change in behavioural outcomes. Perhaps by taking into account affect and how it might work in tandem with knowledge when thinking about adolescent sexual decision-making could be the shift in behavioural outcomes. There is a need for interventions that are based on both rational and affective decision-making processes which are central to the decision-making styles used by adolescents when making decisions around condom use and risky sexual behaviour [18, 23, 27, 29]. Interventions which consider both rational and affective decision-making processes would be categorised as behavioural change interventions stemming from motivation .
Behaviour change interventions aimed at improving condom use decision-making should, therefore, be multi-faceted with a combination of education (information to facilitate behaviour change), persuasive (apply communication strategies to prompt emotions or spark action), incentivisation (provide an anticipated reward), coercion (bringing about anticipated punishment or cost for actions against targeted behaviour change), environmental restructuring (foster change within the social or physical environment), modelling (have individuals to emulate or aspire to be) and enablement (provide support to increase the targeted behaviour change) components as adapted from S Michie, MM van Stralen and R West  Behaviour Change Wheel. Emotions and affective states have been shown to play an important role in the condom use decision-making process, addressing the gap, as highlighted by RA Ferrer and WB Mendes , for better understanding of emotions and affective states in health decision-making to inform intervention development and implementation .
In addition, interventions should consider the social ecology of adolescents, as the influence of parents and social expectations emerged as important factors in the decision making process regarding sexual debut in our study. RJ DiClemente, LF Salazar and RA Crosby  have supported the notion of interventions that are ecological – considering the various levels of causation or influence in sexual debut and condom use choices – suggesting that these are effective and promote the adoption of less risky outcomes. Therefore, complex interventions that consider adolescents, relationships with others, peers, family and the community are needed which inform decision-making processes around condom use decision-making. These complex interventions would also address the different levels of causation or influence in the decision-making process which is furthermore shaped by society, culture, values, economic and other social factors . Interventions might also consider role-playing situations or behavioural rehearsal in which sex and condom use negotiations take place which might inform adolescent decision-making but also decision-making competence and self-efficacy. Decision-making competence and self-efficacy have been associated with better decisional outcomes [32–34].
Understanding how adolescents make decisions about health-related behavioural outcomes should be further examined to identify and understand whether values, expectancies, anticipated future outcomes and emotions are central to the decision-making process engaged. Being able to understand and identify whether these rational and affective appraisals are part of the decision-making processes across all health-related decisions, could inform future public health interventions which are aimed at primary and secondary prevention.
One of the limitations of the study related to the limitations inherent in the vignettes used to elicit information from the participants about their condom use decision-making: (i) the characters in the vignettes had heterosexual relationships and thus did not portray condom use among adolescents in same-sex relationships, (ii) the vignettes also failed to consider the use of other contraceptives which might have played a role in the perceptions towards condom use and thus impacted on the adolescent’s decision-making around condom use, (iii) the estimated control associated with understanding the hypothetical versus the real experience of adolescent agency in making condom use decisions might be difficult to ascertain through the use of vignettes.