Beliefs about AIDS, Use of Alcohol and Drugs, and Unprotected Sex among Massachusetts Adolescents RALPH W. HINGSON, ScD, LEE STRUNIN, PHD, BETH M. BERLIN, MS,
AND
TIMOTHY HEEREN, PHD
Abstract: In August 1988, 1,773 Massachusetts 16-19-year-olds were surveyed by telephone using anonymous random digit dialing; response rate 82 percent. Logistic regression tested whether alcohol and drug use, perceived susceptibility to human immunodeficiency virus (HIV), severity of HIV if infected, effectiveness of condoms in preventing infection, barriers to condom use, and behavioral cues such as exposure to media or personal communication about acquired immunodeficiency syndrome (AIDS) were independently related to condom use. Among sexually active respondents, (61 percent of those interviewed) 31 percent reported always using condoms. Respondents who believed condoms are effective in preventing HIV transmission and woried they can get AIDS were 3.1 and 1.8 times, respectively, more likely to use condoms all the
time. Respondents who carried condoms and who had discussed AIDS with a physician were 2.7 and 1.7 times, respectively, more likely to use them. Those who believed condoms do not reduce sexual pleasure and would not be embarrassed if asked to use them were 3.1 and 2.4 times, respectively, more likely to use condoms. Teens who averaged five or more drinks daily or used marijuana in the previous month were 2.8 and 1.9 times, respectively, less likely to use condoms. Among respondents who drink and use drugs, 16 percent used condoms less often after drinking and 25 percent after drug use. Those counseling adolescents about HIV should assess and discuss beliefs outlined in the Health Belief Model, as well as their alcohol and drug use. (Am J Public Health 1990; 80:295-299.)
Introduction One-fifth of reported AIDS (acquired immunodeficiency syndrome) cases in the United States have been in the 20-29 year age group.' Given the incubation period, many of those persons were infected during their high school years or shortly thereafter. Knowledge of behavioral risks for AIDS does not prompt all at risk to change their behavior.2 Most older teens in Massachusetts have learned the principle modes of human immunodeficiency virus (HIV) transmission, and adolescent condom use has increased since 1986.34' However, twothirds of sexually active 16-19 year olds surveyed there in the fall of 1988 reported sexual intercourse in the past year without the use of condoms.4 Nationally, teenagers account for one-fourth of sexually transmitted disease cases.5 Educators need to move beyond imparting knowledge about modes of HIV transmission to change adolescent behavior. A specific set of beliefs described in the Health Belief Model has been found to predict behaviors to avoid other health risks,6 and has been hypothesized to also predict whether someone will adopt behavior to avoid HIV transmission.7 Persons who believe they are personally susceptible to HIV exposure, the consequences of exposure are severe, protective measures such as condom use are effective in preventing transmission, and perceive few barriers to the adoption of condom use may be more likely to adopt such behavior to avoid HIV transmission. According to this model, people make a rational cost-benefit analysis when trying to decide whether to adopt preventive behavior. Actual changes in behavior may then be stimulated by cues to action such as educational messages or learning that someone they know has AIDS. However, among adolescents, sexual encounters may be
unplanned and also often occur after drinking or drug use. Exploratory studies in San Francisco indicate gay men are more likely to have unprotected intercourse after alcohol and drug use.8 Whether this applies to heterosexuals warrants exploration. Because these and other factors may mitigate against adolescents making a cost-benefit analysis about HIV and condom use before each sexual encounter, it is important to assess whether the beliefs described in the model do indeed predict which adolescents will use condoms and, if so, which beliefs are the strongest independent predictors of use. It is also important to assess whether alcohol and drug use are negatively related to condom use and, if so, why. This Massachusetts statewide study of adolescents assessed: * whether beliefs outlined in the Health Belief Model are significantly associated with condom use among sexually active adolescents; * which beliefs are the strongest independent predictors of condom use after controlling for social and demographic characteristics of respondents; * whether condom use is less likely after drinking and drug use; and * whether those who use condoms less often after drinking and drug use have different characteristics and beliefs about HIV transmission.
Address reprints requests to Ralph W. Hingson, ScD, Professor and Chief, Social and Behavioral Sciences Section, Boston University School of Public Health, 85 East Newton Street, Boston, MA 02118-2389. Dr. Strunin is Assistant Professor, Ms. Berlin is Research Data Analyst, and Dr. Heeren is Associate Professor, also at Boston Univeristy. This paper, submitted to the Journal March 28, 1989, was revised and accepted for publication June 26,
1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
AJPH March 1990, Vol. 80, No. 3
Methods In September 1988, a statewide anonymous random digit dial telephone survey of 16-to-19-year-olds was conducted in Massachusetts using methods developed by Waksberg.9 Within each household, one adolescent was randomly selected using methods developed by Kish."0 The survey of 1,773 adolescents (response rate 82 percent) was conducted in English and Spanish and explored respondent knowledge and beliefs about HIV transmission; alcohol, marijuana, and other illegal drug use; and behavior change in response to the AIDS epidemic. The study specifically asked respondents beliefs that are identified in the Health Belief Model (see
Appendix for details). In addition, respondents were asked their age, level of education, gender, whether their sexual activity was with males, females or .both, and the number of sexual partners 295
HINGSON, ET AL.
they had in the past year. Chi square analyses tested whether individual beliefs outlined in the Health Belief Model and alcohol and drug use were associated with condom use. Condom use was classified as: never used condoms, use condoms some of the time, always used condoms. Stepwise logistic regression analysis" tested which beliefs were the strongest independent predictors of condom use after considering demographic characteristics, alcohol and drug use, and numbers of sexual partners, and whether alcohol and drug use were independently related to condom use. Condom use was dichotomized as always used condoms versus sometimes or never used. Odds ratios and confidence intervals were calculated. The chi square test for symmetry'2 assessed whether individuals were less likely to use condoms after drinking and drug use. Finally, chi square analyses tested for differences in characteristics and beliefs of adolescents who used condoms less often after drinking or drug use.
TABLE 1-Condom Use Among Sexually Active Massachusetts Teenag ors According to Numbers of Sexual Partners
Number of % Never Sexual Partners Use Condoms N = 380 (pastyear) 1 (N = 549)
2-4 (N = 370) 5-9 (N = 85)
10+ (N -- 28)
Bivariate Analysis
Condom use according to respondent characteristicsAmong the 1,773 adolescents interviewed, 61 percent (n = 1,050) reported having had intercourse in the previous year. Two percent of males reported homosexual behavior. Among sexually active teens, 31 percent (n = 320) reported always using condoms, 32 percent (n = 345) sometimes, and 37 percent (n = 385) never used condoms. Males were more likely than females to report always using (34 percent vs 26 percent). Thirty-nine percent of 19-year-olds compared to 29 percent of 16-year-olds were more likely to always use condoms. Thirty-one percent of Whites, 28 percent of Blacks, and 39 percent of Hispanics, but only 7 percent of persons from other racial backgrounds, always used condoms. Condom use varied by previous numbers of sexual partners (Table 1). Respondents who reported only one partner in the last year were much more likely to never use
26 35 52 75
29 36 26 17
(p
AND
TIMOTHY HEEREN, PHD
Abstract: In August 1988, 1,773 Massachusetts 16-19-year-olds were surveyed by telephone using anonymous random digit dialing; response rate 82 percent. Logistic regression tested whether alcohol and drug use, perceived susceptibility to human immunodeficiency virus (HIV), severity of HIV if infected, effectiveness of condoms in preventing infection, barriers to condom use, and behavioral cues such as exposure to media or personal communication about acquired immunodeficiency syndrome (AIDS) were independently related to condom use. Among sexually active respondents, (61 percent of those interviewed) 31 percent reported always using condoms. Respondents who believed condoms are effective in preventing HIV transmission and woried they can get AIDS were 3.1 and 1.8 times, respectively, more likely to use condoms all the
time. Respondents who carried condoms and who had discussed AIDS with a physician were 2.7 and 1.7 times, respectively, more likely to use them. Those who believed condoms do not reduce sexual pleasure and would not be embarrassed if asked to use them were 3.1 and 2.4 times, respectively, more likely to use condoms. Teens who averaged five or more drinks daily or used marijuana in the previous month were 2.8 and 1.9 times, respectively, less likely to use condoms. Among respondents who drink and use drugs, 16 percent used condoms less often after drinking and 25 percent after drug use. Those counseling adolescents about HIV should assess and discuss beliefs outlined in the Health Belief Model, as well as their alcohol and drug use. (Am J Public Health 1990; 80:295-299.)
Introduction One-fifth of reported AIDS (acquired immunodeficiency syndrome) cases in the United States have been in the 20-29 year age group.' Given the incubation period, many of those persons were infected during their high school years or shortly thereafter. Knowledge of behavioral risks for AIDS does not prompt all at risk to change their behavior.2 Most older teens in Massachusetts have learned the principle modes of human immunodeficiency virus (HIV) transmission, and adolescent condom use has increased since 1986.34' However, twothirds of sexually active 16-19 year olds surveyed there in the fall of 1988 reported sexual intercourse in the past year without the use of condoms.4 Nationally, teenagers account for one-fourth of sexually transmitted disease cases.5 Educators need to move beyond imparting knowledge about modes of HIV transmission to change adolescent behavior. A specific set of beliefs described in the Health Belief Model has been found to predict behaviors to avoid other health risks,6 and has been hypothesized to also predict whether someone will adopt behavior to avoid HIV transmission.7 Persons who believe they are personally susceptible to HIV exposure, the consequences of exposure are severe, protective measures such as condom use are effective in preventing transmission, and perceive few barriers to the adoption of condom use may be more likely to adopt such behavior to avoid HIV transmission. According to this model, people make a rational cost-benefit analysis when trying to decide whether to adopt preventive behavior. Actual changes in behavior may then be stimulated by cues to action such as educational messages or learning that someone they know has AIDS. However, among adolescents, sexual encounters may be
unplanned and also often occur after drinking or drug use. Exploratory studies in San Francisco indicate gay men are more likely to have unprotected intercourse after alcohol and drug use.8 Whether this applies to heterosexuals warrants exploration. Because these and other factors may mitigate against adolescents making a cost-benefit analysis about HIV and condom use before each sexual encounter, it is important to assess whether the beliefs described in the model do indeed predict which adolescents will use condoms and, if so, which beliefs are the strongest independent predictors of use. It is also important to assess whether alcohol and drug use are negatively related to condom use and, if so, why. This Massachusetts statewide study of adolescents assessed: * whether beliefs outlined in the Health Belief Model are significantly associated with condom use among sexually active adolescents; * which beliefs are the strongest independent predictors of condom use after controlling for social and demographic characteristics of respondents; * whether condom use is less likely after drinking and drug use; and * whether those who use condoms less often after drinking and drug use have different characteristics and beliefs about HIV transmission.
Address reprints requests to Ralph W. Hingson, ScD, Professor and Chief, Social and Behavioral Sciences Section, Boston University School of Public Health, 85 East Newton Street, Boston, MA 02118-2389. Dr. Strunin is Assistant Professor, Ms. Berlin is Research Data Analyst, and Dr. Heeren is Associate Professor, also at Boston Univeristy. This paper, submitted to the Journal March 28, 1989, was revised and accepted for publication June 26,
1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
AJPH March 1990, Vol. 80, No. 3
Methods In September 1988, a statewide anonymous random digit dial telephone survey of 16-to-19-year-olds was conducted in Massachusetts using methods developed by Waksberg.9 Within each household, one adolescent was randomly selected using methods developed by Kish."0 The survey of 1,773 adolescents (response rate 82 percent) was conducted in English and Spanish and explored respondent knowledge and beliefs about HIV transmission; alcohol, marijuana, and other illegal drug use; and behavior change in response to the AIDS epidemic. The study specifically asked respondents beliefs that are identified in the Health Belief Model (see
Appendix for details). In addition, respondents were asked their age, level of education, gender, whether their sexual activity was with males, females or .both, and the number of sexual partners 295
HINGSON, ET AL.
they had in the past year. Chi square analyses tested whether individual beliefs outlined in the Health Belief Model and alcohol and drug use were associated with condom use. Condom use was classified as: never used condoms, use condoms some of the time, always used condoms. Stepwise logistic regression analysis" tested which beliefs were the strongest independent predictors of condom use after considering demographic characteristics, alcohol and drug use, and numbers of sexual partners, and whether alcohol and drug use were independently related to condom use. Condom use was dichotomized as always used condoms versus sometimes or never used. Odds ratios and confidence intervals were calculated. The chi square test for symmetry'2 assessed whether individuals were less likely to use condoms after drinking and drug use. Finally, chi square analyses tested for differences in characteristics and beliefs of adolescents who used condoms less often after drinking or drug use.
TABLE 1-Condom Use Among Sexually Active Massachusetts Teenag ors According to Numbers of Sexual Partners
Number of % Never Sexual Partners Use Condoms N = 380 (pastyear) 1 (N = 549)
2-4 (N = 370) 5-9 (N = 85)
10+ (N -- 28)
Bivariate Analysis
Condom use according to respondent characteristicsAmong the 1,773 adolescents interviewed, 61 percent (n = 1,050) reported having had intercourse in the previous year. Two percent of males reported homosexual behavior. Among sexually active teens, 31 percent (n = 320) reported always using condoms, 32 percent (n = 345) sometimes, and 37 percent (n = 385) never used condoms. Males were more likely than females to report always using (34 percent vs 26 percent). Thirty-nine percent of 19-year-olds compared to 29 percent of 16-year-olds were more likely to always use condoms. Thirty-one percent of Whites, 28 percent of Blacks, and 39 percent of Hispanics, but only 7 percent of persons from other racial backgrounds, always used condoms. Condom use varied by previous numbers of sexual partners (Table 1). Respondents who reported only one partner in the last year were much more likely to never use
26 35 52 75
29 36 26 17
(p
