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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Predictors of Safer Sex on the College Campus: A Social Cognitive Theory Analysis a
b
c
Ann O'leary PhDs , Fern Goodhart MS , Loretta Sweet Jemmott PhD & Daria Boccher-Lattimore MPH
d
a
Department of Psychology at Rutgers , State University of New Jersey , New Brunswick, USA
b
Department of Health Education , State University of New Jersey , New Brunswick, USA
c
Rutgers College of Nursing , Newark, USA
d
Princeton University, Department of Psychology , Princeton, NJ, USA Published online: 09 Jul 2010.
To cite this article: Ann O'leary PhDs , Fern Goodhart MS , Loretta Sweet Jemmott PhD & Daria Boccher-Lattimore MPH (1992) Predictors of Safer Sex on the College Campus: A Social Cognitive Theory Analysis, Journal of American College Health, 40:6, 254-263, DOI: 10.1080/07448481.1992.9936290 To link to this article: http://dx.doi.org/10.1080/07448481.1992.9936290
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Predictors of Safer Sex on the College Campus: A Social Cognitive Theory Analysis
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Ann O’Leary, PhD; Fern Goodhart, MS; Loretta Sweet Jemmott, PhD; and Daria Boccher-Lattimore, MPH
Abstract. In April and May 1989, the authors surveyed a sample of students enrolled on four college campuses in New Jersey (N = 923) concerning their HIV transmission-related behavior, knowledge, and a variety of conceptual variables taken primarily from social cognitive theory that were thought to be potentially predictive of safer sexual behavior. Analyses of sexually active, unmarried students’ responses indicated that men expected more negative outcomes of condom use and were more likely to have sexual intercourse while under the influence of alcohol or other drugs, whereas women reported higher perceived self-efficacy to practice safer sex. Regression analyses indicated that, among the factors assessed, stronger perceptions of self-efficacy to engage in safer behavior, expecting fewer negative outcomes of condom use, and less frequency of sex in conjuction with alcohol or other drug use significantly predicted safer sexual behavior. Enhanced selfefficacy to discuss personal history with a new partner was associated with a greater number of risky encounters. Implications of these findings for intervention efforts with students are discussed. Key Words. condom use, education, safer sex, social cognitive theory
T
he need to develop and deploy effective programs to prevent human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) is now widely recognized. At our university, 5% of visits to the student health center last year were for STDs. That college students are at significant risk for HIV infection was recently highlighted by the results of a Centers for Disease Control (CDC) blind seroprevalence study conducted on 19 college campuses.’ Results indicated an overall seroprevalence rate of .2%, Ann O’Leary is an assistant professor in the Department of Psychology at Rutgers, the State University of New Jersey, in New Brunswick, where Fern Goodhart is director of the Department of Health Education. Loretta Sweet Jemmott is an assistant professor in the Rutgers College of Nursing in Newark, and Darh Boccher-Latthore is a research associate in the Princeton University Department of Psychology in Princeton, NJ. 254
with rates ranging from 0% to .9%. Five of the 19 schools had rates of .3% or higher. Richard P. Keeling, chair of the American College Health Association (ACHA) Task Force on AIDS, has c d e d for widespread focus on primary prevention.* College students in New Jersey may be at particularly high risk for HIV infection. As of April 30, 1991, 11,030 of the 174,893 cumulative cases of AIDS reported to the CDC (about 6.3%) were from New Jersey. Because the primary initial vector for infection in this state was IV drug use, AIDS is essentially a heterosexual disease here. An important first step toward intervening effectively to change risk-associated sexual behavior in this population is the assessment of the psychological factors influencing students’ sexual behavior. Bandura’s social cognitive thee$ provides a comprehensive analysis of the determinants of behavior change that has been usefully applied to AIDS p r e ~ e n t i o n .In ~ social cognitive theory, perceptions of self-efficacy to carry out desired behaviors successfully, as well as positive and negative outcome expectancies regarding safer behaviors, are the key determinants of effective behavior change. For example, strong perceptions of the ability to negotiate safer sexual behavior with a new partner, greater expectations of positive outcomes of condom use (eg, preventing HIV infection), and lower expectations of negative outcomes from condom use (eg, reduced pleasure or negative partner response) should all contribute to safer sexual behavior. Several of these and related theoretical variables have demonstrated predictive utility in studies of behavior related to HIV transmission. Knowledge, which may affect outcome expectancies by enhancing perceived vulnerability and providing information regarding behavioral alternatives, has been shown in some studies to predict safer sexual behavior.’ The positive expectation of reduction of risk through safer sexual behavior relies on the perception of potential risk accruing to unprotected intercourse. Indeed, perceptions of vulnerability JA CH
PREDICTORS OF SAFER SEX
to HIV infection have been shown to be associated with less reluctance of students .to change sexual behavior.”* At the same time, perceived vulnerability in this group has been reported to be low.9 Perceived self-efficacy to negotiate condom use with partners has emerged as a strong predictor of sexual behavior change among gay men’*’’ and adolescents.6Negative expected outcomes of condom use in students have been identified; these include fear of offending the partner and the belief that sex with condoms is not enjoyable.”.’* Perceptions of positive social norms for safer sex may promote safer behavior by influencing social outcome expectancies; these have been shown to influence HIV transmissionrelated behavior. The use of drugs and alcohol in connection with sex may also enhance the likelihood of risky behavior, perhaps through temporarily reducing perceived risk or reducing self-efficacy to negotiate safer sex at the time of use. Among gay men, alcohol and drug use, particularly in conjunction with sex, have been shown to have this
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’*’’
The present investigation was designed to explore the utility of variables from social cognitive theory in predicting safer sexual practices among college students in New Jersey. METHOD In April and May 1989, we mailed questionnaires to 2,400students whose names had been randomly selected from registration records of the four New Jersey colleges chosen for our study. Respondents were asked to respond anonymously, but were informed they would receive payment of $5 by returning a self-addressed postcard under separate cover from the completed questionnaire. Because responses were anonymous, this study was granted exemption from approval by the Rutgers University Internal Review Board for the Protection of Human Subjects. Of the 2,400 students sampled, 923 returned surveys. The survey contained items designed to assess the following factors. Demographic information. This portion of the questionnaire asked about age, sex, student status (fun- v part-time; undergraduate v graduate), race, religious orientation, and annual income. Conceptual factors. Items were designed to assess the following conceptual factors taken from the health behavior models outlined above: knowledge, perceived potential risk, negative outcome expectancies regarding condom use, perceived social norms, self-efficacyto discuss a partner’s sexual history, and self-efficacy to perform safer sexual behaviors. Items making up the conceptual factors, overall responses of the total sample, and their internal reliabilities (coefficient alpha statistics) are given in Table 1. Intercorrelations performed for these variables yielded only two larger than .20; these were between the two self-efficacy scales, r(395) = .32,p < .OO01,and between self-efficacy to perform VOL 40, MAY 1992
safer behavior and negative expected outcomes, r(395) = - .33,p < .OO01. Sexual behavior. Specific information regarding sexual practices within the previous 60 days was requested, namely, the frequency of a number of sexual behaviors with both a primary and nonprimary partner. Sexual orientation information was also asked for. Alcohol and drug use in conjunction with sex. This item read, “Please indicate the number of times you had sex while under the influence of alcohol or other drugs during the past 60 days.” The 7-point response scale ranged from never to every day.
We predicted that more frequent use of condoms during intercourse would be associated with (1) more knowledge concerning AIDS, (2) greater perceived potential risk, (3) perceptions of more positive social norms for safer behavior, (4) fewer negative expected outcomes of condom use, ( 5 ) stronger perceived selfefficacy to discuss history and to perform safer behavior, and (6) less frequent use of alcohol and other drugs in combination with sex. RESULTS Demographic information for those who returned surveys compared with demographic composition of the sample selected revealed small differences with respect to sex (returns = 51% women v sample = 59.5% women; returns = 12.5% black, 7.1% Hispanic, 64% white, v sample = 9.6% black, 5.7% Hispanic, 71.7% white). Information about Asian ethnicity was not available from one of the schools. Demographic characteristics of the total sample and of the subsample of sexually active, unmarried students who were examined separately are presented in Table 2. Results for Unmarried, Sexually Active Students
Responses of unmarried, sexually active students, by demographic factors, to conceptual items and behavioral safety are given in Table 3, which shows that sex differences were found for some of the factors. Men expected more negative outcomes of condom use, t(395) = 3.73, p < .01. Women reported higher perceived self-efficacy both for history taking, t(385) = 2.05,p < .05, and for achieving safer behavior, t(389) = 2.02,p < .05. Men were more likely to have sex under the influence, t(392) = 2.31, p < .05. Three differences between students of different academic status were obtained. Undergraduate students had marginally less knowledge about AIDS than graduate students, t(389) = 1.83,p < .07; perceived themselves to be less vulnerable, t(387) = 2.11, p < .05; and reported stronger perceived social norms for safer sex, t(390) = 2.18,p < .05. We also obtained differences in responses based on racial group. Analysis of variance (ANOVA) indicated significant differences between racial groups for level of knowledge, F(3, 394) = 5.95,p < .01. Post hoc t tests 255
COLLEGE HEALTH
indicated that white students were significantly more knowledgeable than were students from the Asian/Pacific Islands, t = 2.83,p < .01, and black students, t = 2.82, p < .01. For the history-taking self-efficacy measure, a one-way ANOVA yielded a significant effect, 04, 356) = 3.08,p < .05, accounted for by lower perceived efficacy reports by Asian/Pacific Island students relative to blacks, t = 2.0,p < .05, and Asians relative to Hispanics, t = 2.10,p < .05. A racial group difference for the tendency to have sex while under the influence of alcohol or other drugs was also significant,
F(3, 364) = 3.07,p < .05, with white students reporting such events with significantly more frequency than did blacks. Safety of Sexual Behavior We obtained very low rates of reported homosexual or bisexual orientation. Only 14 men in the total sample of 923 reported they were gay, 13 reported they were bisexual; 4 women reported they were lesbian, and 14 were bisexual. This low reporting of nonheterosexual orientation, despite the fact that responses were anony-
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TABLE 1 Students’ Responses, in Percentages, to Questions Dealing With Concepts of Risk for Infection With HIVIAIDS; Scores Reflecting Higher Factor Levels Are Shown in Bold Type False Definitely Probably A. Knowledge (reliability = .67) 1. Anyone can get AIDS who has unsafe sex or shares needles with an infected person. 2. A person whose blood tested negative for the HIV antibody can still transmit the virus. 3. It can take more than a year for a person infected with HIV to develop antibodies. 4. It usually takes 2-6 weeks for symptoms of AIDS to occur once a person has been infected with HIV. 5 . If a pregnant woman is infected with HIV, there is about a 50% chance her baby will be infected with the virus at birth. 6. The AIDS virus has been transmitted through sweat, sneezing, saliva, coughing, and tears. 7. A person can be infected with the virus and not have symptoms of AIDS. 8. AIDS can be cured if treated early. 9. Most household detergents can kill the virus on contact. 10. If two people have already been infected with HIV, safer sex between them isn’t necessary. 11. You can get AIDS by donating blood. 12. An experienced person can look at someone and tell if he or she is infected with the virus that causes AIDS. 13. No vaccines are currently being tested to prevent AIDS. 14. AIDS presents little danger to heterosexuals in New Jersey. 15. How likely is it that AIDS can be spread by a. mosquitoes b. sexual intercourse c. sharing intravenous needles d. romantic kissing e. living with a person with AIDS 16. How likely is it that the virus that causes AIDS can be transmitted a. by an infected man having anal sex with another man without a condom? b. by an infected man having vaginal sex with a woman without a condom? c. by an infected man having anal sex with a woman without a condom?
Don’t know
True Definitely Probably
2
2
1
14
82
11
11
21
32
25
3
5
24
34
33
37
23
29
9
2
5
5
15
52
23
55
27
7
8
3
2
3
6
29
61
71 49
17 14
7 16
3 14
2 8
40
26
16
13
5
68 77
15 15
3 5
8 3
7 1
53
26
13
4
5
79
15
2
2
1
50 0 0 35 45
20 0 0 33 33
13 1 0 9 7
14 5 2 19 10
3 94 97 5 4
1
1
2
4
92
1
1
1
11
86
1
0
2
9
88 (Table continues)
256
JACH
PREDCTORS OF SAFER S M
TABLE 1 (Contlnued) Disagree Strong Weak
Agree Weak
Strong
B. Perceived potential risk (reliability = 38)
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1. Even if I don’t protect myself, there really is practically no chance I could get AIDS. 2. If I don’t protect myself, there really is a chance I could get AIDS.
C. Perceived social norms (reliability = .71) 1. Very few students on campus are doing anything differently because of AIDS. 2. Many students are trying to protect themselves these days by using condoms. 3. Many men on campus keep condoms available. 4. Many of the people I know have made changes in their lives to protect themselves against AIDS. 5. AIDS has made many students on campus a lot more careful about who they have sex with. 6. Many women on campus keep condoms available. D. Negative expected outcomes of condom use (reliability = .70) 1. Using a condom would take all the fun out of sex for me. 2. I would be afraid that my sex partner would be angry or upset if I asked him or her to use a condom. 3. I would feel silly asking my sex partner to use a condom. 4. I would be afraid that my sex partner would think I was infected with HIV if I asked him or her to use a condom.
E. Self-efficacy to discuss history/negotiate (reliability = .So) How hard would it be for you to do each of the following with a new sex partner? 1. Ask how many sex partners she or he has had. 2. Ask if she or he has ever had sex with another person of hidher own gender. 3. Ask if she or he has ever shared IV needles. 4. Ask if she or he has been exposed to HIV.
F. Self-efficacy to practice safer sex (reliability = .71) How hard would it be for you to do each of the following with a new sex partner? 1. Buy condoms. 2. Discuss using a condom before having sex. 3. Use a condom. 4. Refuse to have sex with the person if he or she won’t use a condom. 5. If no condom is available, find another pleasurable activity (such as mutual masturbation) where a condom isn’t needed. 6. If no condom is available, stop sexual activity while you or your partner go to get a condom.
69
17
9
6
9
9
25
57
16
44
31
10
3
17
55
25
2
10 25
50 48
38
7 4
20
53
23
8
30
49
12
40
29
28
4
55
30
13
2
66
23
8
3
70
21
7
2
Very hard
Fairly hard
Fairly easy
very easy
12 31
36
32
m
m
35
6 16
23 35
34 26
37 22
2 1 1 3
7 8 4 19
19 39 22
30
72 51 73 48
11
21
35
33
13
29
32
27
m
14
Note: Some percentages do not total an even 100 because of rounding.
VOL 40, MAY 1992
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COLLEGE HEALTH
TABLE 2 Demographics of All Students and Sexually Active Single Respondents
Demographics
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Mean age (years) Sex Male Female Race Asian/Pacific Islander Black/African American Hispanic/Latino White Other Class Undergraduate Graduate Other Status Full-time Part-time Marital status Single Married Living with partner Divorced/separated Widowed Other Religion Protestant Roman Catholic Jewish Other Christian Muslim Buddhist Hindu Other None Family income $049,999 $lO,OoO-$19,999 $2O,OoO-$29,999 $3O,OOO-$39,999 $40,OoO-$49,999 $5O,OOO-$59,999 $6O,OOO or above Total
Total Number
YO
Sexually active single Number 070
23.2
26.2 372 549
40.3 59.5
170 227
42.8 57.2
78 87 52 650 40
8.6 9.6 5.7 71.7 4.4
28 36 28 276 22
7.2 9.2 7.2 70.8 5.7
647
304 84
22
70.9 26.8 2.4
5
77.3 21.4 1.3
590 321
64.8 35.2
300 92
76.5 23.5
621 234 40 22 2 2
67.4 25.4 4.3 2.4 0.2 0.2
347 0 38 8 1 2
87.6 0.0 9.6 2.0 0.3 0.6
165 414 98 17 6 16 36 87
17.9 45.0 8.8 10.7 1.8 0.7 1.7 3.9 9.5
68 191 30 41 4 1 5 18 38
17.2 48.2 7.6 10.4 1 .o 0.3 1.3 4.5 9.6
42 80 115 132 154 109 257 923
4.7 9.0 12.9 14.8 17.3 12.3 28.9 100.0
21 47 53 54 65 38 106 397
5.5 12.2 13.8 14.1 16.9 9.9 27.6 100.0
245
81
Note: Totals do not add up to 923 or 397 in every case because students did not respond to every question.
mous, may be partly because identity formation is still occurring in people in this age group. The behavioral risk incurred by the sexually active, unmarried respondents was defined as the number of unprotected vaginal or anal intercourse events in which they had engaged within the previous 60 days. This variable is given in the last column of Table 3. 258
Few students (28) reported sexual activity both with a primary and a nonprimary partner. Those who were practicing safer sex were doing so through condom use during intercourse rather than exclusively through oral sex with condoms (no subjects reported this) or mutual masturbation alone ( 5 students reported this). This can be taken as justification of our designation of condom JA CH
PREDICTORS OF SAFER S M
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use during intercourse as the primary behavioral safety measure.
Determinants of Safer Sexual Behavior In an effort to identify associations between sexual risk status and the predictor variables, we performed a hierarchical regression analysis with number of risky encounters during the past 60 days as the dependent variable. The demographic factors of age, race (with whites as the reference group), and sex were entered on the first step, and the conceptual variables were entered on the second step (see Table 4). Interestingly, older students reported more risky encounters; we also found a marginally significant tendency for black students to follow safer practices. Among the conceptual variables, neither knowledge nor perceived potential risk was associated with unsafe behavior. Students practicing riskier behavior, however, reported more negative expected outcomes from condom use, lower perceived self-efficacy to perform safer sex, more frequent sex under the influence, and, surprisingly, higher perceived selfefficacy to discuss sexual history. Perceived social norms contributed with marginal significance to behavioral safety. DISCUSSION This present study provides a comprehensive assessment of HIV/AIDS-related beliefs, experiences, and behavior in a college student population. It provides provisional support for the operation of several psychoso~~
cial theoretical factors in the practice of safer sexual behavior by college students in a high-risk geographic area. Negative expected outcomes of condom use and self-efficacy to practice safer sex were, as predicted, significant factors influencing condom use. More frequent practice of sex while under the influence of drugs or alcohol was also associated with riskier behavior. Contrary to our expectation, we found that students who expressed greater confidence in their ability to interview prospective partners concerning their risk-related histories were exposing themselves to more unsafe encounters. This result is presumably the consequence of students’ belief that a partner’s self-report of safe history confers adequate protection against the possibility of HIV infection. It seems unlikely that a young person would necessarily disclose all relevant information to a new sex partner; in view of the notorious difficulty with which even those who believe themselves skilled at the ’ ~ results detection of deception can indeed do ~ 0 ,these are alarming. Further, the notion that some groups are at elevated risk is becoming increasingly untenable as the epidemic spreads within the general population. Perceived potential risk for HIV failed to predict safety of sexual behavior. The internal consistency for this scale was lower than would be optimal; thus, it would be unwise to accept the null hypothesis in this case. Levels of reported vulnerability were quite high, with 82% of respondents agreeing with the statement, “If I don’t protect myself, there really is a chance I could get AIDS.”
~
~~~
~~
~
TABLE 3 Mean Scale Scores by Demographic Category of Unmarried Students Sexually Active in Past 60 Days
Perceived Number Knowledge risk Range Total Sex Male Female Status Full-time Part-time Level Undergraduate Graduate Race Asian/Pacific Islander Black/African American Hispanic/Latino White
Self-efficacy Safer History Negative Under the # of risky sex taking Norms outcome influence encounters
397 397
43-107 93.4
2-8 4.2
9-24 19.5
3-16 10.4
1-32 20.9
3-17 8.4
0-60 1.9
6.6
169 226
93.9 92.8
4.2 4.2
19.2* 19.8
10.1 10.7
20.8 21.0
8.9*** 8.0
2.4** 1.5
6.2 6.9
298 92
93.3 93.9
4.2 4.2
19.5 19.5
10.5 10.1
21.0 20.4
8.4 8.4
1.8 2.0
6.3* 7.6
306 89
93.P 94.7
4.1*** 4.5
19.5 19.5
10.5 10.1
21.2*** 8.4 8.4 19.8
1.9 1.9
6.5 7.0
28 36 28 275
88.6*** 91 .O 92.9 94.4
4.2 4.1 3.9 4.3
18.9 20.6 19.2 19.6
9.6** 11.3 11.6 10.3
19.9 21 .o 21.5 21 .o
0.9** 0.6 0.9 2.2
5.4 4.8 8.2 6.6
8.6 7.5 8.4 8.4
Note: All categories do not add up to 397 because students left some questions unanswered. *p < .10; * p < .05; ***p < .01.
VOL 40, MAY 1992
259
COLLEGE HEALTH
TABLE 4 Multiple Regression Analysis of Predictors of Number of Unsafe Encounters (Unprotected Vaginal and Anal Intercourse) in Past 60 Days
Variables Step 1 Sex Age
Hispanic/Latino Asian
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Black
Step 2 Knowledge Perceived risk Social norms Negative outcomes Self-efficacy history Self-efficacy behavior Sex under the influence
P
t
0.83 0.12 1.53 -1.56 -2.01
1.25 2.18** 1.20 -1.19 - 1.74*
-0.03 -0.01 -0.13 0.23 0.42 -0.35 0.39
-0.57 -0.06 -1.92* 1.97** 4.03* * * * - 3.24*** 4.98****
Adjusted R2
F
.038
2.38
.@I
.155
6.90
.OOO1
P
*p < .10; * p < .05; ***p< .01; ****p< .001.
The finding that sexual activity in conjunction with alcohol and other drug use were associated with less safe sexual behavior is not surprising, given similar findings in other populations. The interpretation of these results, however, may not be straightforward. For example, it may be that a third-party variable such as a personality trait or a biological factor is responsible for both the tendency to use drugs and the tendency to engage in impulsive sexual behavior. Martin,I3 in a longitudinal study, found evidence for both causal and noncausal influence of drug use on risky sexual behavior, as well as a diminution over time (and, presumably, with education) in the strength of their association. This finding, in conjunction with our own, does suggest the effectiveness in educational interventions of emphasizing the self-regulation of drug use or, at least, advance preparation in terms of condom availability. The absolute levels of behavioral safety obtained in this study should not be generalized to other college student populations. First, our response rate was low enough to be vulnerable to bias, possibly with students who practiced safer sex more likely to complete the survey. Second, our geographic location is one where HIV and AIDS have received much media attention during the past several years and where the incidence of AIDS is high enough so that the epidemic is salient to the resident population. Despite these possible sources of overreporting of condom use, a dismayingly high percentage of unmarried, sexually active students-76% -reported engaging in risky behavior. The need for effective intervention in this population is clearly evident. Such efforts must provide skill building to enhance selfefficacy and also address barriers to condom use and ways to manage sexual behavior in situations where alcohol or other drugs may be available. 260
Implications for Intervention
Negotiating safer sex requires anticipating a partner’s possible reactions and developing effective responses. For interventions to be effective, skills-and students’ confidence in their skills-must be developed. Self-efficacy beliefs can be influenced in any of four wa~s~.’~,’’: through persuasion, as when someone expresses confidence in one’s abilities; through vicarious performance, particularly by others who are perceived to be similar to the target; through actual mastery experiences; and by means of physiological arousal levels. Social cognitive theory describes performance mastery as the most powerful of the four, followed by vicarious mastery; the least effective is persuasion. Vicarious performance can be achieved through video- or audiotaped depicsims of other young people negotiating condom use, controlling sexual impulses successfully, and encountering the sorts of partner reactions that are, in fact, likely to occur. Role plays can also provide vicarious performance mastery for those students who observe them as well as actual mastery experiences for those who participate in them, and are thus likely to be highly effective. Other condom use skills can also be vicariously conferred; for example, through demonstrations in which students put condoms on penis models. Of course, actual performance mastery is only attained when students begin to use condoms themselves. Similarly, dramatic performances, including improvisational and interactive theater, may provide vicarious enactments of desired behavior. Recent examples include the University of California-Los Angeles’s Kaleidoscope Theater,” University of Massachusetts’s Not Ready for Bedtime Players,” Columbia University’s Dr. Whoopee’s Assistants,zo and the University of Iowa’s Sex, Drugs and Remote ControL2’ Group discussions in JACH
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PREDETORS OF SAFER SEX
which students share experiences and assist in mutual problem solving for condom-use negotiation also serve as effective efficacy enhancers. Creating convenient and confidential opportunities for students to obtain condoms may also promote practice for enhancing condom-use skills, particularly if students are encouraged to try the condoms out before dyadic sexual activity (ie, for men, during masturbation; for women, by practicing on inanimate models). Many colleges now provide condom vending machines, which may be located in dormitories, laundry areas, rest rooms, or student centers. Students will readily take condoms that are provided in quantity, free of charge, at educational events or health centers. Some educators have been successful in obtaining quantities of condoms from manufacturers at low or no cost or that have been underwritten by their institutions, alumni, or others. It is of utmost importance that students understand that mere discussion of sexual or drug use history with a partner does not confer safety. Pertinent information for educators to convey might include the following: 1. HIV and other STDs are no longer restricted to socalled risk groups. 2. Individuals who are infected with HIV do not develop symptoms for years; thus, most infected people look and feel healthy and are unaware that they are infected. 3. Many students report a willingness to lie in order to obtain sex.22 Furthermore, although students may trust their current sexual partners, they have no way of learning the histories of their partners’ past partners. 4. Students report a very high incidence of undisclosed multiple sexual partners.
In sum, taking a sexual health history cannot replace the practice of safer sex because it is impossible to know that the information one has obtained about risks is full and accurate. With respect to perceived risk, it is unlikely that those students who do not believe themselves to be personally vulnerable to HIV and other STDs will be motivated to practice safer sex, which has few “secondary gain” properties (as does exercise, which improves appearance in addition to protecting cardiovascular health). Enhancement of perceptions of vulnerability can be achieved by conveying information-for example, statistics regarding the prevalence of HIV and other STDs and their invisibility in a student population-but other strategies that provide concrete evidence of vulnerability may be even more effective. Providing exposure to others who are similar to the students but are infected with HIV or other STDs, through invited guests or videotaped materials, can enhance the sense of vulnerability as well as clarifying the perception of the severity of illness. For example, the Laurie Vollen video entitled Imagine This contains interviews with HIV-infected students; the ACHA video People Like Us portrays, through draVOL 40, MAY 1992
matic enactments, students who have been infected with other STDs. An effective exercise to demonstrate the ease with which transmission of STDs might occur within a college community is the Don’t Pass It Along exercise.u In this exercise, students are given index cards and, following a brief conversation, sign their names on the cards of each of two or three other students. One card, the infection vector, has been premarked with a small I. The student who has received this card stands, following which each person whose card was signed by the student stands, following which each person whose card was signed by any of these students stands. By this time, most of the class members are on their feet. The exponential “transmission” rate provides compelling evidence that one really is “sleeping with everyone your partner has slept with.” Another exercise that promotes the realization that certain behaviors are risky and also educates people about the relative risks that are associated with them is the Continuum of Probabilities exercise.23This exercise requires students to estimate the relative probabilities of various behaviors, which are placed on a visual analog scale that has been drawn on a blackboard. Other indications of the magnitude of the AIDS epidemic can be provided by displays of the Names Project Memorial Quilt panels, photography exhibits depicting affected individuals, candlelight vigils for those who have died, and other media portrayals of people with AIDSIHIV. Organizers of film series can be encouraged to present commercial films that dramatize and personalize the epidemic, such as Longtime Companion and An Early Frost. Concerns that condoms reduce sexual pleasure are perhaps best countered by encouraging first use, that is, to “just give them a try.” Students who do use condoms will report that sexual pleasure is affected little or not at all, and this will often occur spontaneously during group discussions. One strong selling point for many students is that the male partner can “last longer” with a condom, thus increasing his partner’s pleasure as well as his own. It can also be pointed out that feeling anxious about disease (or pregnancy) is even more impairing of sexual pleasure and that the sexual experience is better when one is relaxed. An effective activity for the classroom or small group setting is to have students generate pros and cons of condom use, combined with discussion that focuses on the positive aspects of the “cons”; for example, “having to interrupt sex” provides an erotic opportunity for the partner to put the condom on the male. Examples can be found in the Condom Comfort and Choosing Condoms exercises.” Social norms regarding safer sex can be enhanced in several ways. Classroom discussions are an obvious avenue for students to learn about peer values, behavior, and expectations. The peer educator has the ability to convey a strong sense of positive norms for safer behavior. Other programs specific to a particular campus may 261
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also be effective. At our university, we have produced a series of posters showing photographs of prominent campus figures from the faculty and administration, as well as students, delivering messages encouraging safer sex. We have also produced a videotape entitled Sex Matters, in which Rutgers students discuss sex and condom use in positive terms, enhancing norms for safer sex in a way that students find credible and compelling. Walkathons, fund-raising concerts, safer sex petitions, call-in radio shows, Condom Week activities, candlelight vigils, and other large-scale programs can be helpful in establishing a safer sex norm. Furthermore, integrating education regarding HIV/AIDS and other STDs into first-year student orientation, preceptor training, health center displays, academic curricula, library holdings, and residence hall and student life programs may all wield indirect influence on social norms. Many students are unaware of the connection between their use of alcohol and other drugs and their subsequent sexual behavior, both in terms of likelihood and safety. These points can be illustrated through presentation and discussion of facts and statistics, fictitious (or real) scenarios, and values clarification. Skill building for the management of alcohol/drug use is an appropriate adjunct to sexual health intervention efforts. It is unrealistic, and not necessarily desirable, to expect success in promoting abstinence from alcohol and other drugs among college students. If students are encouraged to practice safer sex consistently when sober and to have condoms available at all times, they are more likely to use them when intoxicated. Prevention of AIDS and other STDs constitutes a tremendous challenge to college health officials. Although we have described several potentially important factors in promoting behavioral change and suggested ways to address them in prevention efforts, it is clear that none of these factors is trivial. Perceptions of risk will remain forever difficult to achieve among college students, who will rarely see symptoms of each others’ infection and, thus, may doubt even objective statistics. Skill building requires fairly time- and labor-intensive attention to individual students and may also be costly for schools to implement. One cost-effective strategy that we are employing at our university involves identifying students at particularly high risk, such as those who have been diagnosed with other condom-preventable, sexually transmitted diseases, for more intensive intervention. It is crucial that educators develop multifaceted approaches to AIDS prevention. Single strategies, such as enhancing condom availability, although important, will probably be insufficient to alter student behavior significantly. Skill and self-efficacy building, enhancing perceptions of risk, and promoting positive social norms are all important components of the process of changing behavior. In the years to come, we must persevere in our efforts to understand the behavior change process and the changes in its determinants over time. We must also evaluate interventions rigorously; 262
for a discussion of methodological issues in AIDS research, see Catania et al.” With the likelihood of a vaccine years away, prevention remains our best hope for reversing this epidemic. ACKNOWLEDGMENTS This work was supported by National Institute of Mental Health Grant 1 R 0 1 MH45238 to Ann O’Leary, PhD. The authors wish to thank Catherine Charlton for developing many of the intervention strategies described here and Albert Bandura, John B. Jemmott 111, Richard Keeling, Polly McLaughlin, and Geralyn Molinari for helpful discussion and comment. REFERENCES 1. Gayle HD, Keeling RP, Garcia-Tunon M, et al. Prevalence of HIV among college and university students. New Engl JMed. 1990;323:1538-1541. 2. Keeling RP, ed. AIDS on the College Campus. 2nd ed. Rockville, MD: American College Health Association; 1989. 3. Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall; 1986. 4. Bandura A. A social cognitive approach to the exericse of control over AIDS infection. In: DiClemente R, ed. Adolescents and AIDS: A Generation in Jeopardy. Beverly Hills: Sage. In press. 5 . Emmons CA, Joseph JG, Kessler RC, Wortman CB, Montgomery SB, Ostrow DG. Psychosocial predictors of reported behavior change in homosexual men at risk for AIDS. Health Educ Q. 1986;13:331-345. 6. Hingson RW, Strunin L, Berlin BM, Heeren T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. A m J Pub Health. 1990;80: 295-299. 7. Thurman QC, Franklin KM. AIDS and college health: Knowledge, threat, and prevention at a northeastern university. J A m CON Health. 1990;38:179-183. 8. DiClemente RJ, Forrest KA, Mickler S. College students’ knowledge and attitudes about AIDS and changes in HIV-preventive behaviors. AIDS Educ Prevent. 1990;2:201212. 9. Turner C, Anderson P, Fitzpatrick R, Fowler R, Mayon-White R. Sexual behavior, contraceptive use and knowledge of AIDS of Oxford University students. J Biosoc Sci. 1988;20:445-451. 10. McKusick L, Coates TJ, Morin SF, Pollack L, Hoff C. Longitudinal predictors of reductions in unprotected anal intercourse among gay men in San Francisco: The AIDS Behavioral Research Project. A m J Pub Health. 1990;80:978-983. 11. Manning D, Balson P, Barenberg N, Moore TM. Susceptibility to AIDS: What college students do and don’t believe. J A m Coll Health. 1989;38:67-73. 12. Manning D, Barenberg N, Gallese L, Rice JC. College students’ knowledge and health beliefs about AIDS: Implications for education and prevention. J A m Coll Health. 1989;37:254-259. 13. Martin JL. Drug use and unprotected anal intercourse among gay men. Health Psychol. 1990;9:450-465. 14. Stall R, McKusick L, Wiley J, Coates TJ, Ostrow DG. Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: The AIDS Behavioral Research Project. Health Educ Q. 1986;13:359-371. 15. Kraut R. Humans as lie detectors. J Communication. 1980;30:209-216. 16. O’Leary A. Self-efficacy and health. Behov Res Ther. 1985;23:437-451.
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17. O’Leary A. Self-efficacy and health. Behavioral and stress-physiological mediation. Cog Ther Res. In press. 18. Mininni D. Kaleidoscope theater. Presented at the 68th annual meeting of the American College Health Association; May 1990; San Antonio. 19. Krull G. Not ready for bedtime players. Presented at the 69th annual meeting of the American College Health Association; May 1991; Boston. 20. Sloan BC. Sex, drugs, and rock and roll: The AIDS connection. Presented at the 68th annual meeting of the American College Health Association; May 1990; San Antonio.
W W W W W W W
Depression Mononucleosis Hepatitis Stress Cold Nutrition HPV
Now available are accurate, updated, attractive brochures written specifically for students. Beating Back the Blues: Dealing with Depression Addresses depression ranging from mild “blues” to suicidal feelings. Suggests self-help techniques and lists signs that indicate professional help may be needed. Gives advice on helping a friend who is depressed or feeling suicidal.
21. Petroff B. Sex, drugs, and remote control. Presented at the 68th annual meeting of the American College Health Association; May 1990; San Antonio. 22. Cochran SD, Mays VM. Sex, lies, and HIV. New Engl J Med. 1990,332(11):775-776. 23. Brick P, Charlton C, Kunins H, Brown S. Teaching Sqfer Sex. Hackensack, NJ: The Center for Family Life Education-Planned Parenthood of Bergen County, Inc; 198%27. 24. Catania JA, Gibson DR, Chitwood DD, Coates TJ. Methodological problems in AIDS behavioral research: Influences on measurement error and participation bias in studies of sexual behavior. Psycho1 Bull. 1990;108:339-362.
and C, with an emphasis on prevention. Includes valuable immunization information on hepatitis B - one of the fastest spreading sexually transmitted diseases.
Stress in College: Stretching the Rubber Band? Reviews short- and long-term stress management techniques, including a practical plan to beat procrastination. Warns students about alcohol abuse and other possible danger signs of stress overload. Lists common signs of rising stress levels.
Managing the Common Cold Gives practical advice about treatment and prevention techniques.
Eating 101: The Basics of Good Nutrition Provides realistic advice on how to improve eating habits without radical lifestyle changes. Emphasizes slow, practical diet changes. Covers healthful snacks, smart choices at fastfood restaurants, and eating better on a budget.
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Offers the latest information about human papillomavirus, genital warts, and precancerous cell changes. Covers treatment and prevention. Features a case study about an infected couple, exploring the impact of an HPV diagnosis on their relationship.
So You’ve Got Mono Covers symptoms, causes, and treatment of infectious mononucleosis. Relates complications that can develop and precautions that should be taken.
The ABCs of Viral Hepatitis Describes behaviors that put people at risk for hepatitis A, B,
VOL 40, MAY 1992
For more information or to order brochures, contact:
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American College Health Association P.O. Box 28937 Baltimore, MD 21240-8937 (410) 859-1500
263
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Predictors of Safer Sex on the College Campus: A Social Cognitive Theory Analysis a
b
c
Ann O'leary PhDs , Fern Goodhart MS , Loretta Sweet Jemmott PhD & Daria Boccher-Lattimore MPH
d
a
Department of Psychology at Rutgers , State University of New Jersey , New Brunswick, USA
b
Department of Health Education , State University of New Jersey , New Brunswick, USA
c
Rutgers College of Nursing , Newark, USA
d
Princeton University, Department of Psychology , Princeton, NJ, USA Published online: 09 Jul 2010.
To cite this article: Ann O'leary PhDs , Fern Goodhart MS , Loretta Sweet Jemmott PhD & Daria Boccher-Lattimore MPH (1992) Predictors of Safer Sex on the College Campus: A Social Cognitive Theory Analysis, Journal of American College Health, 40:6, 254-263, DOI: 10.1080/07448481.1992.9936290 To link to this article: http://dx.doi.org/10.1080/07448481.1992.9936290
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Predictors of Safer Sex on the College Campus: A Social Cognitive Theory Analysis
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Ann O’Leary, PhD; Fern Goodhart, MS; Loretta Sweet Jemmott, PhD; and Daria Boccher-Lattimore, MPH
Abstract. In April and May 1989, the authors surveyed a sample of students enrolled on four college campuses in New Jersey (N = 923) concerning their HIV transmission-related behavior, knowledge, and a variety of conceptual variables taken primarily from social cognitive theory that were thought to be potentially predictive of safer sexual behavior. Analyses of sexually active, unmarried students’ responses indicated that men expected more negative outcomes of condom use and were more likely to have sexual intercourse while under the influence of alcohol or other drugs, whereas women reported higher perceived self-efficacy to practice safer sex. Regression analyses indicated that, among the factors assessed, stronger perceptions of self-efficacy to engage in safer behavior, expecting fewer negative outcomes of condom use, and less frequency of sex in conjuction with alcohol or other drug use significantly predicted safer sexual behavior. Enhanced selfefficacy to discuss personal history with a new partner was associated with a greater number of risky encounters. Implications of these findings for intervention efforts with students are discussed. Key Words. condom use, education, safer sex, social cognitive theory
T
he need to develop and deploy effective programs to prevent human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) is now widely recognized. At our university, 5% of visits to the student health center last year were for STDs. That college students are at significant risk for HIV infection was recently highlighted by the results of a Centers for Disease Control (CDC) blind seroprevalence study conducted on 19 college campuses.’ Results indicated an overall seroprevalence rate of .2%, Ann O’Leary is an assistant professor in the Department of Psychology at Rutgers, the State University of New Jersey, in New Brunswick, where Fern Goodhart is director of the Department of Health Education. Loretta Sweet Jemmott is an assistant professor in the Rutgers College of Nursing in Newark, and Darh Boccher-Latthore is a research associate in the Princeton University Department of Psychology in Princeton, NJ. 254
with rates ranging from 0% to .9%. Five of the 19 schools had rates of .3% or higher. Richard P. Keeling, chair of the American College Health Association (ACHA) Task Force on AIDS, has c d e d for widespread focus on primary prevention.* College students in New Jersey may be at particularly high risk for HIV infection. As of April 30, 1991, 11,030 of the 174,893 cumulative cases of AIDS reported to the CDC (about 6.3%) were from New Jersey. Because the primary initial vector for infection in this state was IV drug use, AIDS is essentially a heterosexual disease here. An important first step toward intervening effectively to change risk-associated sexual behavior in this population is the assessment of the psychological factors influencing students’ sexual behavior. Bandura’s social cognitive thee$ provides a comprehensive analysis of the determinants of behavior change that has been usefully applied to AIDS p r e ~ e n t i o n .In ~ social cognitive theory, perceptions of self-efficacy to carry out desired behaviors successfully, as well as positive and negative outcome expectancies regarding safer behaviors, are the key determinants of effective behavior change. For example, strong perceptions of the ability to negotiate safer sexual behavior with a new partner, greater expectations of positive outcomes of condom use (eg, preventing HIV infection), and lower expectations of negative outcomes from condom use (eg, reduced pleasure or negative partner response) should all contribute to safer sexual behavior. Several of these and related theoretical variables have demonstrated predictive utility in studies of behavior related to HIV transmission. Knowledge, which may affect outcome expectancies by enhancing perceived vulnerability and providing information regarding behavioral alternatives, has been shown in some studies to predict safer sexual behavior.’ The positive expectation of reduction of risk through safer sexual behavior relies on the perception of potential risk accruing to unprotected intercourse. Indeed, perceptions of vulnerability JA CH
PREDICTORS OF SAFER SEX
to HIV infection have been shown to be associated with less reluctance of students .to change sexual behavior.”* At the same time, perceived vulnerability in this group has been reported to be low.9 Perceived self-efficacy to negotiate condom use with partners has emerged as a strong predictor of sexual behavior change among gay men’*’’ and adolescents.6Negative expected outcomes of condom use in students have been identified; these include fear of offending the partner and the belief that sex with condoms is not enjoyable.”.’* Perceptions of positive social norms for safer sex may promote safer behavior by influencing social outcome expectancies; these have been shown to influence HIV transmissionrelated behavior. The use of drugs and alcohol in connection with sex may also enhance the likelihood of risky behavior, perhaps through temporarily reducing perceived risk or reducing self-efficacy to negotiate safer sex at the time of use. Among gay men, alcohol and drug use, particularly in conjunction with sex, have been shown to have this
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’*’’
The present investigation was designed to explore the utility of variables from social cognitive theory in predicting safer sexual practices among college students in New Jersey. METHOD In April and May 1989, we mailed questionnaires to 2,400students whose names had been randomly selected from registration records of the four New Jersey colleges chosen for our study. Respondents were asked to respond anonymously, but were informed they would receive payment of $5 by returning a self-addressed postcard under separate cover from the completed questionnaire. Because responses were anonymous, this study was granted exemption from approval by the Rutgers University Internal Review Board for the Protection of Human Subjects. Of the 2,400 students sampled, 923 returned surveys. The survey contained items designed to assess the following factors. Demographic information. This portion of the questionnaire asked about age, sex, student status (fun- v part-time; undergraduate v graduate), race, religious orientation, and annual income. Conceptual factors. Items were designed to assess the following conceptual factors taken from the health behavior models outlined above: knowledge, perceived potential risk, negative outcome expectancies regarding condom use, perceived social norms, self-efficacyto discuss a partner’s sexual history, and self-efficacy to perform safer sexual behaviors. Items making up the conceptual factors, overall responses of the total sample, and their internal reliabilities (coefficient alpha statistics) are given in Table 1. Intercorrelations performed for these variables yielded only two larger than .20; these were between the two self-efficacy scales, r(395) = .32,p < .OO01,and between self-efficacy to perform VOL 40, MAY 1992
safer behavior and negative expected outcomes, r(395) = - .33,p < .OO01. Sexual behavior. Specific information regarding sexual practices within the previous 60 days was requested, namely, the frequency of a number of sexual behaviors with both a primary and nonprimary partner. Sexual orientation information was also asked for. Alcohol and drug use in conjunction with sex. This item read, “Please indicate the number of times you had sex while under the influence of alcohol or other drugs during the past 60 days.” The 7-point response scale ranged from never to every day.
We predicted that more frequent use of condoms during intercourse would be associated with (1) more knowledge concerning AIDS, (2) greater perceived potential risk, (3) perceptions of more positive social norms for safer behavior, (4) fewer negative expected outcomes of condom use, ( 5 ) stronger perceived selfefficacy to discuss history and to perform safer behavior, and (6) less frequent use of alcohol and other drugs in combination with sex. RESULTS Demographic information for those who returned surveys compared with demographic composition of the sample selected revealed small differences with respect to sex (returns = 51% women v sample = 59.5% women; returns = 12.5% black, 7.1% Hispanic, 64% white, v sample = 9.6% black, 5.7% Hispanic, 71.7% white). Information about Asian ethnicity was not available from one of the schools. Demographic characteristics of the total sample and of the subsample of sexually active, unmarried students who were examined separately are presented in Table 2. Results for Unmarried, Sexually Active Students
Responses of unmarried, sexually active students, by demographic factors, to conceptual items and behavioral safety are given in Table 3, which shows that sex differences were found for some of the factors. Men expected more negative outcomes of condom use, t(395) = 3.73, p < .01. Women reported higher perceived self-efficacy both for history taking, t(385) = 2.05,p < .05, and for achieving safer behavior, t(389) = 2.02,p < .05. Men were more likely to have sex under the influence, t(392) = 2.31, p < .05. Three differences between students of different academic status were obtained. Undergraduate students had marginally less knowledge about AIDS than graduate students, t(389) = 1.83,p < .07; perceived themselves to be less vulnerable, t(387) = 2.11, p < .05; and reported stronger perceived social norms for safer sex, t(390) = 2.18,p < .05. We also obtained differences in responses based on racial group. Analysis of variance (ANOVA) indicated significant differences between racial groups for level of knowledge, F(3, 394) = 5.95,p < .01. Post hoc t tests 255
COLLEGE HEALTH
indicated that white students were significantly more knowledgeable than were students from the Asian/Pacific Islands, t = 2.83,p < .01, and black students, t = 2.82, p < .01. For the history-taking self-efficacy measure, a one-way ANOVA yielded a significant effect, 04, 356) = 3.08,p < .05, accounted for by lower perceived efficacy reports by Asian/Pacific Island students relative to blacks, t = 2.0,p < .05, and Asians relative to Hispanics, t = 2.10,p < .05. A racial group difference for the tendency to have sex while under the influence of alcohol or other drugs was also significant,
F(3, 364) = 3.07,p < .05, with white students reporting such events with significantly more frequency than did blacks. Safety of Sexual Behavior We obtained very low rates of reported homosexual or bisexual orientation. Only 14 men in the total sample of 923 reported they were gay, 13 reported they were bisexual; 4 women reported they were lesbian, and 14 were bisexual. This low reporting of nonheterosexual orientation, despite the fact that responses were anony-
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TABLE 1 Students’ Responses, in Percentages, to Questions Dealing With Concepts of Risk for Infection With HIVIAIDS; Scores Reflecting Higher Factor Levels Are Shown in Bold Type False Definitely Probably A. Knowledge (reliability = .67) 1. Anyone can get AIDS who has unsafe sex or shares needles with an infected person. 2. A person whose blood tested negative for the HIV antibody can still transmit the virus. 3. It can take more than a year for a person infected with HIV to develop antibodies. 4. It usually takes 2-6 weeks for symptoms of AIDS to occur once a person has been infected with HIV. 5 . If a pregnant woman is infected with HIV, there is about a 50% chance her baby will be infected with the virus at birth. 6. The AIDS virus has been transmitted through sweat, sneezing, saliva, coughing, and tears. 7. A person can be infected with the virus and not have symptoms of AIDS. 8. AIDS can be cured if treated early. 9. Most household detergents can kill the virus on contact. 10. If two people have already been infected with HIV, safer sex between them isn’t necessary. 11. You can get AIDS by donating blood. 12. An experienced person can look at someone and tell if he or she is infected with the virus that causes AIDS. 13. No vaccines are currently being tested to prevent AIDS. 14. AIDS presents little danger to heterosexuals in New Jersey. 15. How likely is it that AIDS can be spread by a. mosquitoes b. sexual intercourse c. sharing intravenous needles d. romantic kissing e. living with a person with AIDS 16. How likely is it that the virus that causes AIDS can be transmitted a. by an infected man having anal sex with another man without a condom? b. by an infected man having vaginal sex with a woman without a condom? c. by an infected man having anal sex with a woman without a condom?
Don’t know
True Definitely Probably
2
2
1
14
82
11
11
21
32
25
3
5
24
34
33
37
23
29
9
2
5
5
15
52
23
55
27
7
8
3
2
3
6
29
61
71 49
17 14
7 16
3 14
2 8
40
26
16
13
5
68 77
15 15
3 5
8 3
7 1
53
26
13
4
5
79
15
2
2
1
50 0 0 35 45
20 0 0 33 33
13 1 0 9 7
14 5 2 19 10
3 94 97 5 4
1
1
2
4
92
1
1
1
11
86
1
0
2
9
88 (Table continues)
256
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PREDCTORS OF SAFER S M
TABLE 1 (Contlnued) Disagree Strong Weak
Agree Weak
Strong
B. Perceived potential risk (reliability = 38)
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1. Even if I don’t protect myself, there really is practically no chance I could get AIDS. 2. If I don’t protect myself, there really is a chance I could get AIDS.
C. Perceived social norms (reliability = .71) 1. Very few students on campus are doing anything differently because of AIDS. 2. Many students are trying to protect themselves these days by using condoms. 3. Many men on campus keep condoms available. 4. Many of the people I know have made changes in their lives to protect themselves against AIDS. 5. AIDS has made many students on campus a lot more careful about who they have sex with. 6. Many women on campus keep condoms available. D. Negative expected outcomes of condom use (reliability = .70) 1. Using a condom would take all the fun out of sex for me. 2. I would be afraid that my sex partner would be angry or upset if I asked him or her to use a condom. 3. I would feel silly asking my sex partner to use a condom. 4. I would be afraid that my sex partner would think I was infected with HIV if I asked him or her to use a condom.
E. Self-efficacy to discuss history/negotiate (reliability = .So) How hard would it be for you to do each of the following with a new sex partner? 1. Ask how many sex partners she or he has had. 2. Ask if she or he has ever had sex with another person of hidher own gender. 3. Ask if she or he has ever shared IV needles. 4. Ask if she or he has been exposed to HIV.
F. Self-efficacy to practice safer sex (reliability = .71) How hard would it be for you to do each of the following with a new sex partner? 1. Buy condoms. 2. Discuss using a condom before having sex. 3. Use a condom. 4. Refuse to have sex with the person if he or she won’t use a condom. 5. If no condom is available, find another pleasurable activity (such as mutual masturbation) where a condom isn’t needed. 6. If no condom is available, stop sexual activity while you or your partner go to get a condom.
69
17
9
6
9
9
25
57
16
44
31
10
3
17
55
25
2
10 25
50 48
38
7 4
20
53
23
8
30
49
12
40
29
28
4
55
30
13
2
66
23
8
3
70
21
7
2
Very hard
Fairly hard
Fairly easy
very easy
12 31
36
32
m
m
35
6 16
23 35
34 26
37 22
2 1 1 3
7 8 4 19
19 39 22
30
72 51 73 48
11
21
35
33
13
29
32
27
m
14
Note: Some percentages do not total an even 100 because of rounding.
VOL 40, MAY 1992
257
COLLEGE HEALTH
TABLE 2 Demographics of All Students and Sexually Active Single Respondents
Demographics
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Mean age (years) Sex Male Female Race Asian/Pacific Islander Black/African American Hispanic/Latino White Other Class Undergraduate Graduate Other Status Full-time Part-time Marital status Single Married Living with partner Divorced/separated Widowed Other Religion Protestant Roman Catholic Jewish Other Christian Muslim Buddhist Hindu Other None Family income $049,999 $lO,OoO-$19,999 $2O,OoO-$29,999 $3O,OOO-$39,999 $40,OoO-$49,999 $5O,OOO-$59,999 $6O,OOO or above Total
Total Number
YO
Sexually active single Number 070
23.2
26.2 372 549
40.3 59.5
170 227
42.8 57.2
78 87 52 650 40
8.6 9.6 5.7 71.7 4.4
28 36 28 276 22
7.2 9.2 7.2 70.8 5.7
647
304 84
22
70.9 26.8 2.4
5
77.3 21.4 1.3
590 321
64.8 35.2
300 92
76.5 23.5
621 234 40 22 2 2
67.4 25.4 4.3 2.4 0.2 0.2
347 0 38 8 1 2
87.6 0.0 9.6 2.0 0.3 0.6
165 414 98 17 6 16 36 87
17.9 45.0 8.8 10.7 1.8 0.7 1.7 3.9 9.5
68 191 30 41 4 1 5 18 38
17.2 48.2 7.6 10.4 1 .o 0.3 1.3 4.5 9.6
42 80 115 132 154 109 257 923
4.7 9.0 12.9 14.8 17.3 12.3 28.9 100.0
21 47 53 54 65 38 106 397
5.5 12.2 13.8 14.1 16.9 9.9 27.6 100.0
245
81
Note: Totals do not add up to 923 or 397 in every case because students did not respond to every question.
mous, may be partly because identity formation is still occurring in people in this age group. The behavioral risk incurred by the sexually active, unmarried respondents was defined as the number of unprotected vaginal or anal intercourse events in which they had engaged within the previous 60 days. This variable is given in the last column of Table 3. 258
Few students (28) reported sexual activity both with a primary and a nonprimary partner. Those who were practicing safer sex were doing so through condom use during intercourse rather than exclusively through oral sex with condoms (no subjects reported this) or mutual masturbation alone ( 5 students reported this). This can be taken as justification of our designation of condom JA CH
PREDICTORS OF SAFER S M
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use during intercourse as the primary behavioral safety measure.
Determinants of Safer Sexual Behavior In an effort to identify associations between sexual risk status and the predictor variables, we performed a hierarchical regression analysis with number of risky encounters during the past 60 days as the dependent variable. The demographic factors of age, race (with whites as the reference group), and sex were entered on the first step, and the conceptual variables were entered on the second step (see Table 4). Interestingly, older students reported more risky encounters; we also found a marginally significant tendency for black students to follow safer practices. Among the conceptual variables, neither knowledge nor perceived potential risk was associated with unsafe behavior. Students practicing riskier behavior, however, reported more negative expected outcomes from condom use, lower perceived self-efficacy to perform safer sex, more frequent sex under the influence, and, surprisingly, higher perceived selfefficacy to discuss sexual history. Perceived social norms contributed with marginal significance to behavioral safety. DISCUSSION This present study provides a comprehensive assessment of HIV/AIDS-related beliefs, experiences, and behavior in a college student population. It provides provisional support for the operation of several psychoso~~
cial theoretical factors in the practice of safer sexual behavior by college students in a high-risk geographic area. Negative expected outcomes of condom use and self-efficacy to practice safer sex were, as predicted, significant factors influencing condom use. More frequent practice of sex while under the influence of drugs or alcohol was also associated with riskier behavior. Contrary to our expectation, we found that students who expressed greater confidence in their ability to interview prospective partners concerning their risk-related histories were exposing themselves to more unsafe encounters. This result is presumably the consequence of students’ belief that a partner’s self-report of safe history confers adequate protection against the possibility of HIV infection. It seems unlikely that a young person would necessarily disclose all relevant information to a new sex partner; in view of the notorious difficulty with which even those who believe themselves skilled at the ’ ~ results detection of deception can indeed do ~ 0 ,these are alarming. Further, the notion that some groups are at elevated risk is becoming increasingly untenable as the epidemic spreads within the general population. Perceived potential risk for HIV failed to predict safety of sexual behavior. The internal consistency for this scale was lower than would be optimal; thus, it would be unwise to accept the null hypothesis in this case. Levels of reported vulnerability were quite high, with 82% of respondents agreeing with the statement, “If I don’t protect myself, there really is a chance I could get AIDS.”
~
~~~
~~
~
TABLE 3 Mean Scale Scores by Demographic Category of Unmarried Students Sexually Active in Past 60 Days
Perceived Number Knowledge risk Range Total Sex Male Female Status Full-time Part-time Level Undergraduate Graduate Race Asian/Pacific Islander Black/African American Hispanic/Latino White
Self-efficacy Safer History Negative Under the # of risky sex taking Norms outcome influence encounters
397 397
43-107 93.4
2-8 4.2
9-24 19.5
3-16 10.4
1-32 20.9
3-17 8.4
0-60 1.9
6.6
169 226
93.9 92.8
4.2 4.2
19.2* 19.8
10.1 10.7
20.8 21.0
8.9*** 8.0
2.4** 1.5
6.2 6.9
298 92
93.3 93.9
4.2 4.2
19.5 19.5
10.5 10.1
21.0 20.4
8.4 8.4
1.8 2.0
6.3* 7.6
306 89
93.P 94.7
4.1*** 4.5
19.5 19.5
10.5 10.1
21.2*** 8.4 8.4 19.8
1.9 1.9
6.5 7.0
28 36 28 275
88.6*** 91 .O 92.9 94.4
4.2 4.1 3.9 4.3
18.9 20.6 19.2 19.6
9.6** 11.3 11.6 10.3
19.9 21 .o 21.5 21 .o
0.9** 0.6 0.9 2.2
5.4 4.8 8.2 6.6
8.6 7.5 8.4 8.4
Note: All categories do not add up to 397 because students left some questions unanswered. *p < .10; * p < .05; ***p < .01.
VOL 40, MAY 1992
259
COLLEGE HEALTH
TABLE 4 Multiple Regression Analysis of Predictors of Number of Unsafe Encounters (Unprotected Vaginal and Anal Intercourse) in Past 60 Days
Variables Step 1 Sex Age
Hispanic/Latino Asian
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Black
Step 2 Knowledge Perceived risk Social norms Negative outcomes Self-efficacy history Self-efficacy behavior Sex under the influence
P
t
0.83 0.12 1.53 -1.56 -2.01
1.25 2.18** 1.20 -1.19 - 1.74*
-0.03 -0.01 -0.13 0.23 0.42 -0.35 0.39
-0.57 -0.06 -1.92* 1.97** 4.03* * * * - 3.24*** 4.98****
Adjusted R2
F
.038
2.38
.@I
.155
6.90
.OOO1
P
*p < .10; * p < .05; ***p< .01; ****p< .001.
The finding that sexual activity in conjunction with alcohol and other drug use were associated with less safe sexual behavior is not surprising, given similar findings in other populations. The interpretation of these results, however, may not be straightforward. For example, it may be that a third-party variable such as a personality trait or a biological factor is responsible for both the tendency to use drugs and the tendency to engage in impulsive sexual behavior. Martin,I3 in a longitudinal study, found evidence for both causal and noncausal influence of drug use on risky sexual behavior, as well as a diminution over time (and, presumably, with education) in the strength of their association. This finding, in conjunction with our own, does suggest the effectiveness in educational interventions of emphasizing the self-regulation of drug use or, at least, advance preparation in terms of condom availability. The absolute levels of behavioral safety obtained in this study should not be generalized to other college student populations. First, our response rate was low enough to be vulnerable to bias, possibly with students who practiced safer sex more likely to complete the survey. Second, our geographic location is one where HIV and AIDS have received much media attention during the past several years and where the incidence of AIDS is high enough so that the epidemic is salient to the resident population. Despite these possible sources of overreporting of condom use, a dismayingly high percentage of unmarried, sexually active students-76% -reported engaging in risky behavior. The need for effective intervention in this population is clearly evident. Such efforts must provide skill building to enhance selfefficacy and also address barriers to condom use and ways to manage sexual behavior in situations where alcohol or other drugs may be available. 260
Implications for Intervention
Negotiating safer sex requires anticipating a partner’s possible reactions and developing effective responses. For interventions to be effective, skills-and students’ confidence in their skills-must be developed. Self-efficacy beliefs can be influenced in any of four wa~s~.’~,’’: through persuasion, as when someone expresses confidence in one’s abilities; through vicarious performance, particularly by others who are perceived to be similar to the target; through actual mastery experiences; and by means of physiological arousal levels. Social cognitive theory describes performance mastery as the most powerful of the four, followed by vicarious mastery; the least effective is persuasion. Vicarious performance can be achieved through video- or audiotaped depicsims of other young people negotiating condom use, controlling sexual impulses successfully, and encountering the sorts of partner reactions that are, in fact, likely to occur. Role plays can also provide vicarious performance mastery for those students who observe them as well as actual mastery experiences for those who participate in them, and are thus likely to be highly effective. Other condom use skills can also be vicariously conferred; for example, through demonstrations in which students put condoms on penis models. Of course, actual performance mastery is only attained when students begin to use condoms themselves. Similarly, dramatic performances, including improvisational and interactive theater, may provide vicarious enactments of desired behavior. Recent examples include the University of California-Los Angeles’s Kaleidoscope Theater,” University of Massachusetts’s Not Ready for Bedtime Players,” Columbia University’s Dr. Whoopee’s Assistants,zo and the University of Iowa’s Sex, Drugs and Remote ControL2’ Group discussions in JACH
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PREDETORS OF SAFER SEX
which students share experiences and assist in mutual problem solving for condom-use negotiation also serve as effective efficacy enhancers. Creating convenient and confidential opportunities for students to obtain condoms may also promote practice for enhancing condom-use skills, particularly if students are encouraged to try the condoms out before dyadic sexual activity (ie, for men, during masturbation; for women, by practicing on inanimate models). Many colleges now provide condom vending machines, which may be located in dormitories, laundry areas, rest rooms, or student centers. Students will readily take condoms that are provided in quantity, free of charge, at educational events or health centers. Some educators have been successful in obtaining quantities of condoms from manufacturers at low or no cost or that have been underwritten by their institutions, alumni, or others. It is of utmost importance that students understand that mere discussion of sexual or drug use history with a partner does not confer safety. Pertinent information for educators to convey might include the following: 1. HIV and other STDs are no longer restricted to socalled risk groups. 2. Individuals who are infected with HIV do not develop symptoms for years; thus, most infected people look and feel healthy and are unaware that they are infected. 3. Many students report a willingness to lie in order to obtain sex.22 Furthermore, although students may trust their current sexual partners, they have no way of learning the histories of their partners’ past partners. 4. Students report a very high incidence of undisclosed multiple sexual partners.
In sum, taking a sexual health history cannot replace the practice of safer sex because it is impossible to know that the information one has obtained about risks is full and accurate. With respect to perceived risk, it is unlikely that those students who do not believe themselves to be personally vulnerable to HIV and other STDs will be motivated to practice safer sex, which has few “secondary gain” properties (as does exercise, which improves appearance in addition to protecting cardiovascular health). Enhancement of perceptions of vulnerability can be achieved by conveying information-for example, statistics regarding the prevalence of HIV and other STDs and their invisibility in a student population-but other strategies that provide concrete evidence of vulnerability may be even more effective. Providing exposure to others who are similar to the students but are infected with HIV or other STDs, through invited guests or videotaped materials, can enhance the sense of vulnerability as well as clarifying the perception of the severity of illness. For example, the Laurie Vollen video entitled Imagine This contains interviews with HIV-infected students; the ACHA video People Like Us portrays, through draVOL 40, MAY 1992
matic enactments, students who have been infected with other STDs. An effective exercise to demonstrate the ease with which transmission of STDs might occur within a college community is the Don’t Pass It Along exercise.u In this exercise, students are given index cards and, following a brief conversation, sign their names on the cards of each of two or three other students. One card, the infection vector, has been premarked with a small I. The student who has received this card stands, following which each person whose card was signed by the student stands, following which each person whose card was signed by any of these students stands. By this time, most of the class members are on their feet. The exponential “transmission” rate provides compelling evidence that one really is “sleeping with everyone your partner has slept with.” Another exercise that promotes the realization that certain behaviors are risky and also educates people about the relative risks that are associated with them is the Continuum of Probabilities exercise.23This exercise requires students to estimate the relative probabilities of various behaviors, which are placed on a visual analog scale that has been drawn on a blackboard. Other indications of the magnitude of the AIDS epidemic can be provided by displays of the Names Project Memorial Quilt panels, photography exhibits depicting affected individuals, candlelight vigils for those who have died, and other media portrayals of people with AIDSIHIV. Organizers of film series can be encouraged to present commercial films that dramatize and personalize the epidemic, such as Longtime Companion and An Early Frost. Concerns that condoms reduce sexual pleasure are perhaps best countered by encouraging first use, that is, to “just give them a try.” Students who do use condoms will report that sexual pleasure is affected little or not at all, and this will often occur spontaneously during group discussions. One strong selling point for many students is that the male partner can “last longer” with a condom, thus increasing his partner’s pleasure as well as his own. It can also be pointed out that feeling anxious about disease (or pregnancy) is even more impairing of sexual pleasure and that the sexual experience is better when one is relaxed. An effective activity for the classroom or small group setting is to have students generate pros and cons of condom use, combined with discussion that focuses on the positive aspects of the “cons”; for example, “having to interrupt sex” provides an erotic opportunity for the partner to put the condom on the male. Examples can be found in the Condom Comfort and Choosing Condoms exercises.” Social norms regarding safer sex can be enhanced in several ways. Classroom discussions are an obvious avenue for students to learn about peer values, behavior, and expectations. The peer educator has the ability to convey a strong sense of positive norms for safer behavior. Other programs specific to a particular campus may 261
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COLLEGE HEALTH
also be effective. At our university, we have produced a series of posters showing photographs of prominent campus figures from the faculty and administration, as well as students, delivering messages encouraging safer sex. We have also produced a videotape entitled Sex Matters, in which Rutgers students discuss sex and condom use in positive terms, enhancing norms for safer sex in a way that students find credible and compelling. Walkathons, fund-raising concerts, safer sex petitions, call-in radio shows, Condom Week activities, candlelight vigils, and other large-scale programs can be helpful in establishing a safer sex norm. Furthermore, integrating education regarding HIV/AIDS and other STDs into first-year student orientation, preceptor training, health center displays, academic curricula, library holdings, and residence hall and student life programs may all wield indirect influence on social norms. Many students are unaware of the connection between their use of alcohol and other drugs and their subsequent sexual behavior, both in terms of likelihood and safety. These points can be illustrated through presentation and discussion of facts and statistics, fictitious (or real) scenarios, and values clarification. Skill building for the management of alcohol/drug use is an appropriate adjunct to sexual health intervention efforts. It is unrealistic, and not necessarily desirable, to expect success in promoting abstinence from alcohol and other drugs among college students. If students are encouraged to practice safer sex consistently when sober and to have condoms available at all times, they are more likely to use them when intoxicated. Prevention of AIDS and other STDs constitutes a tremendous challenge to college health officials. Although we have described several potentially important factors in promoting behavioral change and suggested ways to address them in prevention efforts, it is clear that none of these factors is trivial. Perceptions of risk will remain forever difficult to achieve among college students, who will rarely see symptoms of each others’ infection and, thus, may doubt even objective statistics. Skill building requires fairly time- and labor-intensive attention to individual students and may also be costly for schools to implement. One cost-effective strategy that we are employing at our university involves identifying students at particularly high risk, such as those who have been diagnosed with other condom-preventable, sexually transmitted diseases, for more intensive intervention. It is crucial that educators develop multifaceted approaches to AIDS prevention. Single strategies, such as enhancing condom availability, although important, will probably be insufficient to alter student behavior significantly. Skill and self-efficacy building, enhancing perceptions of risk, and promoting positive social norms are all important components of the process of changing behavior. In the years to come, we must persevere in our efforts to understand the behavior change process and the changes in its determinants over time. We must also evaluate interventions rigorously; 262
for a discussion of methodological issues in AIDS research, see Catania et al.” With the likelihood of a vaccine years away, prevention remains our best hope for reversing this epidemic. ACKNOWLEDGMENTS This work was supported by National Institute of Mental Health Grant 1 R 0 1 MH45238 to Ann O’Leary, PhD. The authors wish to thank Catherine Charlton for developing many of the intervention strategies described here and Albert Bandura, John B. Jemmott 111, Richard Keeling, Polly McLaughlin, and Geralyn Molinari for helpful discussion and comment. REFERENCES 1. Gayle HD, Keeling RP, Garcia-Tunon M, et al. Prevalence of HIV among college and university students. New Engl JMed. 1990;323:1538-1541. 2. Keeling RP, ed. AIDS on the College Campus. 2nd ed. Rockville, MD: American College Health Association; 1989. 3. Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall; 1986. 4. Bandura A. A social cognitive approach to the exericse of control over AIDS infection. In: DiClemente R, ed. Adolescents and AIDS: A Generation in Jeopardy. Beverly Hills: Sage. In press. 5 . Emmons CA, Joseph JG, Kessler RC, Wortman CB, Montgomery SB, Ostrow DG. Psychosocial predictors of reported behavior change in homosexual men at risk for AIDS. Health Educ Q. 1986;13:331-345. 6. Hingson RW, Strunin L, Berlin BM, Heeren T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. A m J Pub Health. 1990;80: 295-299. 7. Thurman QC, Franklin KM. AIDS and college health: Knowledge, threat, and prevention at a northeastern university. J A m CON Health. 1990;38:179-183. 8. DiClemente RJ, Forrest KA, Mickler S. College students’ knowledge and attitudes about AIDS and changes in HIV-preventive behaviors. AIDS Educ Prevent. 1990;2:201212. 9. Turner C, Anderson P, Fitzpatrick R, Fowler R, Mayon-White R. Sexual behavior, contraceptive use and knowledge of AIDS of Oxford University students. J Biosoc Sci. 1988;20:445-451. 10. McKusick L, Coates TJ, Morin SF, Pollack L, Hoff C. Longitudinal predictors of reductions in unprotected anal intercourse among gay men in San Francisco: The AIDS Behavioral Research Project. A m J Pub Health. 1990;80:978-983. 11. Manning D, Balson P, Barenberg N, Moore TM. Susceptibility to AIDS: What college students do and don’t believe. J A m Coll Health. 1989;38:67-73. 12. Manning D, Barenberg N, Gallese L, Rice JC. College students’ knowledge and health beliefs about AIDS: Implications for education and prevention. J A m Coll Health. 1989;37:254-259. 13. Martin JL. Drug use and unprotected anal intercourse among gay men. Health Psychol. 1990;9:450-465. 14. Stall R, McKusick L, Wiley J, Coates TJ, Ostrow DG. Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: The AIDS Behavioral Research Project. Health Educ Q. 1986;13:359-371. 15. Kraut R. Humans as lie detectors. J Communication. 1980;30:209-216. 16. O’Leary A. Self-efficacy and health. Behov Res Ther. 1985;23:437-451.
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17. O’Leary A. Self-efficacy and health. Behavioral and stress-physiological mediation. Cog Ther Res. In press. 18. Mininni D. Kaleidoscope theater. Presented at the 68th annual meeting of the American College Health Association; May 1990; San Antonio. 19. Krull G. Not ready for bedtime players. Presented at the 69th annual meeting of the American College Health Association; May 1991; Boston. 20. Sloan BC. Sex, drugs, and rock and roll: The AIDS connection. Presented at the 68th annual meeting of the American College Health Association; May 1990; San Antonio.
W W W W W W W
Depression Mononucleosis Hepatitis Stress Cold Nutrition HPV
Now available are accurate, updated, attractive brochures written specifically for students. Beating Back the Blues: Dealing with Depression Addresses depression ranging from mild “blues” to suicidal feelings. Suggests self-help techniques and lists signs that indicate professional help may be needed. Gives advice on helping a friend who is depressed or feeling suicidal.
21. Petroff B. Sex, drugs, and remote control. Presented at the 68th annual meeting of the American College Health Association; May 1990; San Antonio. 22. Cochran SD, Mays VM. Sex, lies, and HIV. New Engl J Med. 1990,332(11):775-776. 23. Brick P, Charlton C, Kunins H, Brown S. Teaching Sqfer Sex. Hackensack, NJ: The Center for Family Life Education-Planned Parenthood of Bergen County, Inc; 198%27. 24. Catania JA, Gibson DR, Chitwood DD, Coates TJ. Methodological problems in AIDS behavioral research: Influences on measurement error and participation bias in studies of sexual behavior. Psycho1 Bull. 1990;108:339-362.
and C, with an emphasis on prevention. Includes valuable immunization information on hepatitis B - one of the fastest spreading sexually transmitted diseases.
Stress in College: Stretching the Rubber Band? Reviews short- and long-term stress management techniques, including a practical plan to beat procrastination. Warns students about alcohol abuse and other possible danger signs of stress overload. Lists common signs of rising stress levels.
Managing the Common Cold Gives practical advice about treatment and prevention techniques.
Eating 101: The Basics of Good Nutrition Provides realistic advice on how to improve eating habits without radical lifestyle changes. Emphasizes slow, practical diet changes. Covers healthful snacks, smart choices at fastfood restaurants, and eating better on a budget.
HPV
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Offers the latest information about human papillomavirus, genital warts, and precancerous cell changes. Covers treatment and prevention. Features a case study about an infected couple, exploring the impact of an HPV diagnosis on their relationship.
So You’ve Got Mono Covers symptoms, causes, and treatment of infectious mononucleosis. Relates complications that can develop and precautions that should be taken.
The ABCs of Viral Hepatitis Describes behaviors that put people at risk for hepatitis A, B,
VOL 40, MAY 1992
For more information or to order brochures, contact:
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American College Health Association P.O. Box 28937 Baltimore, MD 21240-8937 (410) 859-1500
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