Factors Associated with AIDS Risk Behaviors among High School Students in an AIDS Epicenter
Heather J. Walter, MD, MPH, Roger D. Vaughan, MS, Madeline M. Gladis, PhD, Deborah Fish Ragin, PhD, Stephanie Kasen, PhD, and Alwyn T. Cohall, MD
Introduction Adolescents, particularly those residing in or near one of the nation's acquired immunodeficiency syndrome (AIDS) epicenters, are at increasing risk of acquiring infection with human immunodeficiency virus (HIV), the virus that causes AIDS. I Although the total number of reported AIDS cases among 13- to 19year-olds thus far is small, the caseload in this age group has increased by 40 percent in the past year alone.' Moreover, one fifth of all AIDS cases has been reported among 20- to 29-year-olds,l many of whom acquired HIV infection as teenagers. Accordingly, the development, implementation, and evaluation of AIDS prevention programs for inner-city adolescents has become a recent public health priority.2 A greater understanding of the determinants of risk-related and preventive behaviors in target populations is an important precursor to the development of successful AIDS prevention programs.3 In the past several decades, a number of theoretical models have been advanced to predict involvement in a variety of preventive actions.4-6 Recently, constructs derived from several of these models have been applied theoretically and empirically to risky and preventive behaviors specific to AIDS,7-"1 and therefore these models were selected for inclusion in this investigation. The health belief model4 posits that individuals who believe that they are personally susceptible to the target disease, that the consequences of having the disease would be severe, and that the benefits of engaging in preventive actions outweigh the barriers are more likely to
adopt preventive behaviors than are individuals not holding these beliefs. Social cognitive theory6 suggests that one's appraisal of one's self-competence (i.e., self-efficacy) pertaining to preventive behaviors generates the self-confidence necessary for the successful performance of these behaviors. Finally, a recently proposed model of reference groupbased social influence11 hypothesizes that behavioral norms (beliefs about how people typically act) and values (beliefs about how people ought to act) interact to generate a normative standard to which individuals aspire to conform, thereby influencing the adoption and maintenance of preventive behaviors. To investigate the associations between beliefs derived from the seven constructs outlined above (susceptibility, severity, benefits, barriers, self-efficacy, norms, and values) and involvement in AIDS risk and preventive behaviors, a survey was administered in the spring of 1990 to a sample of 10th-grade students residing in an AIDS epicenter. The purpose of the survey was to identify correlates of risky and preventive behaviors that could be targeted for modification or reinforcement, respectively, in prevenHeather J. Walter, Stephanie Kasen, and Alwyn T. Cohall are with the College of Physicians and Surgeons, Columbia University, New York, NY. Roger D. Vaughan, Madeline M. Gladis, and Deborah Fish Ragin are with the New York State Psychiatric Institute, New York, NY. Requests for reprints should be sent to Heather J. Walter, MD, MPH, New York State Psychiatric Institute, Box 29, 722 W 168th St, New York, NY 10032. This paper was submitted to the Journal April 12,1991, and accepted with revisions November 12, 1991.
April 1992, Vol. 82, No. 4
Facton Assodated with AIDS Risk Behaviors tion programs. The survey analyses had four goals: first, to ascertain the prevalence of AIDS risk and preventive behaviors; second, to determine whether these behaviors varied by age, gender, race/ ethnicity, school attended, or AIDS-related knowledge; third, to descnbe the cross-sectional associations of AIDS risk and preventive behaviors with beliefs derived from the constructs identified above; and fourth, to determine whether the observed belief-behavior associations varied according to the demographic and knowledge variables identified above.
Methods Subjects Tenth-grade students in 2 of the 14 public academic high schools in a New York city borough were selected as the eligible study population. The two schools were selected on the basis of their willingness to participate in the survey and their racial/ethnic similarity to the entire population of the 14 schools. Passive parental consent was required for students' participation in the survey; the nonconsent rate was 5.5% in one school and 6.5% in the other. The mean age of participants (n = 531) was 16.0 years (SD, 1.0; range, 13 to 21 years); 44.3% of the participants were male. The racial/ethnic distribution of the participants was 59.2% Black, 28.3% Hispanic, and 12.5% other (primarily non-Hispanic Whites); the participants were predominantly from worldng-class or welfare-recipient families. The demographic distribution of the survey participants was similar to that of the eligible study population.
Measurements Survey forms were distributed by research staff to all consenting, present 10thgraders enrolled in required general education courses in the spring semester of 1990. Survey completion required one class period; responses to the surveywere anonymous. AIDS-risk behaviors. The students were asked to complete five items regarding past-year involvement in AIDS risk and preventive behaviors, including use of illicit intravenous drugs, involvement in sexual intercourse, number and risk status of sexual partners, and consistency of condom use during sexual intercourse. A high-risk sexual partner was defined as one who was believed by the respondent to have a history of male homosexual intercourse or illicit intravenous drug use.
April 1992, Vol. 82, No. 4
An AIDS behavior index, ranging from lower to higher risk of acquiring infection with HIV, was created from these items according to the epidemiological model of HIV transmission proposed by Hearst and Hulley.12 Index scores ranged from 0 to 6; the definition of each risk level is presented in Table 1. Belefs derivedfrom the health belief modeL The students were asked to complete two items pertaining to perceived susceptibility to AIDS and three items pertaining to perceived severity of AIDS; and 15 and 17 items, respectively, constituting additive scales of the perceived benefits of and barriers to engaging in AIDS-preventive behaviors (i.e., sexual abstinence, consistent condom use, sexual monogamy, and knowing the sexual and drug use histories of sex partners). The internal consistency (alpha coefficient) of the benefits scale was 0.81, and that of the barriers scale, 0.77.
Belies de,ivedfm social cognitive theory. The students were asked to complete 13 items constituting an additive scale of perceived self-efficacy pertaiing to the preventive actions identified above. The internal consistency (alpha coefficient) of the scale was 0.80. Beliefs derivedfrnom the model ofsocial influence. The students were asked to complete eight items assessing their beliefs about how many of their four closest friends and what proportion of the students in their grade were involved in the pastyear in the preventive behaviors identified above (i.e., beliefs about norms). They were also asked to complete four items assessing whether they personally believed that people their age should be involved in these behaviors (i.e., beliefs about values). AIDS-related knowledge. The students were asked to complete 12 items pertaining to the transmission and prevention of HIV infection. These items were selected on the basis of their measurement characteristics from an original 72-item scale; the internal consistency (alpha coefficient) of the original scale was 0.82.
StatisticalAnalysis The analytic strategy compnsed four steps. First, descriptive statisticswere calculated to provide prevalence data for the investigated behaviors and beliefs, and bivariate relations between the behaviors and beliefs were assessed by computing odds ratios (ORs) and associated 95%o confidence intervals (Cas). Second, multiple
logistic regression was employed to assess differences in the distnbution of AIDS be-
havior index scores across the five demographic and knowledgevariables. Logistic rather than linear regression was employed because of the multinomial nature of the distribution of the AIDS behavior index scores. Accordingly, the AIDS behavior index scores were dichotomized to reflect lower versus higher risk. Third, multiple logistic regression again was used to assess the unique associations between beliefs derived from the seven investigated theoretical constructs and the AIDS behavior index scores. Finally, interaction variables, created by multiplying each demographic term or terms by the significantly associated beliefs, were added to the regression model to assess interaction effects.
Result AIDS-Risk and Preventive Behaviors Nearly two thirds (64.6%: 76.7% of males and 55.6% of females) of this sample of 10th-grade students reported ever having had sexual intercourse. The modal age ofinitiation of intercoursewas 11 years for males and 15 years for females. Three fifths (59.3%: 59.5% ofmales and 59.2% of American Joumnal of Public Health 529
Walt et aL
effects of gender, racelethnicity, school attended, or AIDS-related knowledge on the index scores, nor was there evidence of in-
teraction between any of thesevariables and the belief-behavior associations. The great majority ofthe students believed that half or more of their peers and friends had had sexual intercourse in the past year; half of the students believed that half or more of their friends had never or inconsistently used condoms in the past year. Three fifths of the males, but only one quarter of the females, believed that people their age should have intercourse. Substantial proportions ofthe students (in general, more males than females) were not sure that they could perform certain behaviors essential for effective AIDS prevention (Table 3).
Diwiusion Our principal finding is that a substantial proportion of a sample of 10th-grade
females) reported ever having used (or having had their partner use) a condom during intercourse. Table 1 presents the proportions of students reporting past-year involvement in each category of AIDS-related behaviors. No students reported use of illicit intravenous drugs; less than half reported sexual abstinence. Only one fifth of sexually active students reported protected intercourse with one low-risk partner.
Beif-Behavior Correlations Significant bivariate associations were observed between beliefs derived from all seven investigated theoretical constructs (i.e., susceptibility, severity, benefits, barriers, self-efficacy, norms, and values) and the AIDS risk behavior scores. However, in a multivariate analysis in which beliefs derived from all seven constructs were entered into the model
530 American Journal of Public Health
along with age, gender, race/ethnicity, school attended, and AIDS-related knowledge, beliefs derived from only three (i.e., norms, values, and self-efficacy) of the seven constructs were significantly associated with involvement in higher-risk behaviors (Table 2). In the presence of beliefs derived from these three constructs, beliefs derived from the four health belief model constructs (i.e., perceived susceptbility to and severity of AIDS, and perceived benefits of and barriers to engaging in preventive actions) were not significantly associated with higher-risk behaviors. The analyses revealed a significant main effect of age on AIDS behavior index scores: older students were slightly more likely to be in the higher categories of risk than were younger students (OR = 1.2 per year, 95% C1, 1.1 to2.1). The analysesfailed to provide any evidence of si nt main
students residing in an AIDS epicenter reported involvement in behaviors that place them at risk for acquiring infection with HIV. Beliefs derived from three theoretical constructs (i.e., norms, values, and selfefficacy) were cross-sectionally associated with riskier behaviors. In the presence of beliefs derived from these three constucts, beliefs derived from health belief model constructs were not significantly associated with higher AIDS risk. Before we consider the implications of these results, some methodological issues should be addressed. First, because of the self-report nature of the survey, the veracity of students' responses may be questioned. However, responses to the survey were anonymous to maximize accurate self-disclosure. In addition, there was high agreement (above 98%) of responses to similarly worded items assessing the same behavioral domains that were dispersed throughout the survey. The validity of responses also is strengthened by the similarity of the behavior prevalence rates reported in this study to those reported in other studies.13-18 Finally, there is evidence suggesting that questionnaire data are as accurate as interview data in assessing sexual-behavior prevalence rates among groups of subjects.19 Second, although the high survey participation rates obtained in this study suggest that the findings may be generalizable to similar populations of students, the findings may not be applicable to students attending schools unwfling to participate in such surveys, to students with a different demographic profile, or to teenApril 1992, Vol. 82, No. 4
Factors Assodated with AIDS Risk Behaviors
agers who are habitually absent or have withdrawn from school. A number of recent studies13-'8 conducted among various populations of adolescents have suggested that substantial proportions of teenagers and young adults engage in behaviors that increase their risk for acquiring infection with HIV. The most common behavioral profile among sexually active adolescents in this sample was a teenager who had unprotected sexual intercourse with partners believed to be at low risk for carying HIV. Because in the absence of HIV antibody testing one cannot be certain that one's partner indeed is uninfected,20 and because seropositivity rates in AIDS epicenters are estimated to be high,21 this behavioral profile (which is applicable to over two thirds of the sexually active students in this sample) conveys nontrivial risk to these teenagers. Of particular concern because of their greatly increased risk of HIV infection'2 are the 1.3% of the sexually active students in this sample who reported unprotected intercourse with high-risk partners, and the 6.6% who reported a history of sexually transmitted disease (similar percentages also have been reported
elsewhere).'3-'8 Although a number of studies have documented the prevalence of AIDS risk behaviors among adolescents, fewer have investigated theoretically or empirically suggested determinants of these behaviors. The findings of two studies recently conducted among teenagers have been informative in this regard. Hingson et al.8 showed that beliefs about the benefits and barriers of condom use and beliefs about susceptlbility to getting AIDS were associated cross-sectionally with condom use, as is predicted by the health belief model. Kasen et al.10 demonstrated that intercourse refusal and condom use self-efficacy were correlated with involvement in sexual intercourse and condom use among adolescents, net of the influence of beliefs derived from health belief model constructs, as is predicted by social cognitive
theory. The findings from this study demonstrate that although bivariate associations between beliefs derived from health belief model constructs and AIDS risk behaviors were observed, these associations were attenuated in the presence of certain socioenvironmental factors (i.e., beliefs about norms, values, and self-efficacy). The results are similar to those reported frm a number of studies examiining factors influencing drug use among teenagers,2- 24 and suggest that individual/cognitive interven-
April 1992, Vol. 82, No. 4
tions (e.g., those based upon the health beliefmodel) emphasizing the disease-related knowledge and beliefs of individuals as they exist apart from the social world may have only small effects on teenagers' motivations to initiate preventive actions. Instead, a more productive strategy may be to address salient socioenvironmental influences on preventive behaviors. For example, the data from this study suggest that teenagers could be helped to clarify their personal values relating to involvement in preventive actions, and an understanding of the effects of outside influences (e.g., peer pressure) on those values could be facilitated. Adolescents' misconceptions about the prevalence of risky and preventive behaviors among their peers could be corrected. Preventive action self-efficacy could be enhanced by empowering youths with the skills necessary to successfully perform risk-reducing behaviors. Skills in which teenagers may be particularly deficient include questioning sexual partners about sex and drug-use histories, using condoms correctly and consistently, and refusing offers to engage in sexual intercourse in certain high-pressure social situations. In summary, teenagers (particularly those residing in or near AIDS endemic areas) are at risk for acquiring infection with HIV. Because certain socioenvironmental factors (i.e., beliefs about norms, values, and self-efficacy) may strongly influence involvement in AIDS risk behaviors, further elucidation of the social influence process among adolescents should become a prevention research priority. For the present, it may prove to be beneficial for practitioners to reinforce values incompatible with involvement in AIDS risk behaviors, correct misconceptions about the normative status of such behaviors, and teach skills enabling effective, sustained preventive action. 0
Acknowledgments This research was supported by NIMHNVDA grant 5-P50-MH43520 to Heather J. Walter, MD, MPH, Principal Investigator, AIDS Prevention for Adolescents in School, and Anke A. Ehrhardt, PhD, Principal Investigator, HIV Center for Clinical and Behavioral Studies. The authors wish to thank Richard Neugebauer, PhD, and Judith Rabkin, PhD, for reviewing the manuscript.
References 1. HIVt4IDS Surveillance Repo.1 Atlanta,
Ga: Centers for Disease Control; December 1990.
2. Flora JA, Thoresen CE. Reducing the risk of AIDS in adolescents. Am Psychol. 1988;43:965-970. 3. Kirscht JP. Preventive health behavior: a review of research and issues. Health PsychoL 1983;2:277-301. 4. Becker M. The health beliefmodel and personal health behavior. Health Educ Monog. 1974;2(special issue). 5. Ajzen I, Fishbein M. UnderstandingAttitudes and Predicitng Social Behavior. Englewood Clis, NJ: Prentice-Hall; 1980. 6. BanduraA.SocialFoundions ofThought and Action: A Social Cognitive 7heory. Englewood Cliffs, NJ: Prentice-Hall; 1986. 7. Becker M, Joseph J. AIDS and behavioral change to avoid risk: a review.AmlJPublic Health. 1988;78:384-410. 8. Hingson RW, Strunin L, Berlin BM, Heeren T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J Public Health. 1990;80:295-299. 9. Bandura A. Perceived self-efficacy in the exercise of control over AIDS infection. Presented at the Conference on Women and AIDS: Promoting Health Behaviors; National Institutes of Mental Health and Drug Abuse research conference; 1987; Bethesda, Md. 10. Kasen SK, Vaughan RD, Walter HJ. Self efficacy for AIDS preventive behaviors among tenth grade students. Health Educ Q. In press. 11. Fisher JD. Possible effects of reference group-based social influence on AIDS-risk behavior and AIDS prevention. Am Psy-
choL 1988;43:914-920. 12. Hearst N, Hulley SB. Preventing the heterosexual spread of AIDS: are we gIving our patients the best advice? JAMA.
1988;259:2428-2432. 13. Goodman E, Cohall AT. Acquired immunodeficiency syndrome and adolescents: knowledge, attitudes, beliefs, and behaviors in a New York City adolescent minority population. Pediatrics. 1989;84:36-42. 14. Anderson JE, Kann L, Holtzman D, Arday S, Truman B, Kolbe L. HIV/AIDS knowledge and sexual behavior among high school students. Fam Plann Perspec. 1990;22:252-255. 15. Hingson R, Strunin L, Berlin B. Acquired immunodeficiency syndrome transmission: changes in knowledge and behaviors among teenagers, Massachusetts statewide surveys, 1986 to 1988. Pediat,ics. 1990;85: 24-29. 16. Keller SE, Bartlett JA, Schleifer SJ, Johnson RL, Pinner E, Delaney B. HIVrelevant sexual behavior among a healthy inner-city heterosexual adolescent population in an endemic area of HIV. JAdolesc Health Care. 1991;12:44 48. 17. MacDonald NE, Wells GA, Fisher WA, et al. High-risk STD/HIV behavior among college students. JAMA. 1990;263:31553159. 18. Kotloff KL, Tacket CO, Clemens JD, et al. Assessment of the prevalence and risk factors for human immunodeficiency virus type 1 (H[V-1) infection among college students using three survey methods. Am J
EidiL 1991;133:2-8. 19.
DeLImater J, MacCorquodale P. The efAmerican Joumal of Public Health 531
Walter et al.
fects of interview schedule variations on reported sexual behavior. SociolMeth Res. 1975;4:215-236. 20. Cochran SD, Mays VM. Sex, lies and HIV. NEngIJMeL 1990;322:774. Letter. 21. Drucker E, Vermund ST. Estimating population prevalence of human immunodeficiency virus infection in urban areas with
high rates of intravenous drug use: a model of the Bronx in 1988. Am J EpidemioL 1989;130:133-142. 22. Jessor JR, Chase JA, Donovan JE. Psychosocial correlates of marijuana use and problem dfinking in a national sample of adolescents. AmJPublic Health. 1980;70: 604-613.
23. Kandel DB. Epidemiological and psychosocial perspectives on adolescent drug use. JAmAcad Child Psychiatry. 1982;21:328347. 24. Robinson TN, Killen JD, Taylor CB, et al. Perspectives on adolescent substance use. A defined population study. JAMA. 1987;258:2072-2076.
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532 American Journal of Public Health
April 1992, Vol. 82, No. 4
Heather J. Walter, MD, MPH, Roger D. Vaughan, MS, Madeline M. Gladis, PhD, Deborah Fish Ragin, PhD, Stephanie Kasen, PhD, and Alwyn T. Cohall, MD
Introduction Adolescents, particularly those residing in or near one of the nation's acquired immunodeficiency syndrome (AIDS) epicenters, are at increasing risk of acquiring infection with human immunodeficiency virus (HIV), the virus that causes AIDS. I Although the total number of reported AIDS cases among 13- to 19year-olds thus far is small, the caseload in this age group has increased by 40 percent in the past year alone.' Moreover, one fifth of all AIDS cases has been reported among 20- to 29-year-olds,l many of whom acquired HIV infection as teenagers. Accordingly, the development, implementation, and evaluation of AIDS prevention programs for inner-city adolescents has become a recent public health priority.2 A greater understanding of the determinants of risk-related and preventive behaviors in target populations is an important precursor to the development of successful AIDS prevention programs.3 In the past several decades, a number of theoretical models have been advanced to predict involvement in a variety of preventive actions.4-6 Recently, constructs derived from several of these models have been applied theoretically and empirically to risky and preventive behaviors specific to AIDS,7-"1 and therefore these models were selected for inclusion in this investigation. The health belief model4 posits that individuals who believe that they are personally susceptible to the target disease, that the consequences of having the disease would be severe, and that the benefits of engaging in preventive actions outweigh the barriers are more likely to
adopt preventive behaviors than are individuals not holding these beliefs. Social cognitive theory6 suggests that one's appraisal of one's self-competence (i.e., self-efficacy) pertaining to preventive behaviors generates the self-confidence necessary for the successful performance of these behaviors. Finally, a recently proposed model of reference groupbased social influence11 hypothesizes that behavioral norms (beliefs about how people typically act) and values (beliefs about how people ought to act) interact to generate a normative standard to which individuals aspire to conform, thereby influencing the adoption and maintenance of preventive behaviors. To investigate the associations between beliefs derived from the seven constructs outlined above (susceptibility, severity, benefits, barriers, self-efficacy, norms, and values) and involvement in AIDS risk and preventive behaviors, a survey was administered in the spring of 1990 to a sample of 10th-grade students residing in an AIDS epicenter. The purpose of the survey was to identify correlates of risky and preventive behaviors that could be targeted for modification or reinforcement, respectively, in prevenHeather J. Walter, Stephanie Kasen, and Alwyn T. Cohall are with the College of Physicians and Surgeons, Columbia University, New York, NY. Roger D. Vaughan, Madeline M. Gladis, and Deborah Fish Ragin are with the New York State Psychiatric Institute, New York, NY. Requests for reprints should be sent to Heather J. Walter, MD, MPH, New York State Psychiatric Institute, Box 29, 722 W 168th St, New York, NY 10032. This paper was submitted to the Journal April 12,1991, and accepted with revisions November 12, 1991.
April 1992, Vol. 82, No. 4
Facton Assodated with AIDS Risk Behaviors tion programs. The survey analyses had four goals: first, to ascertain the prevalence of AIDS risk and preventive behaviors; second, to determine whether these behaviors varied by age, gender, race/ ethnicity, school attended, or AIDS-related knowledge; third, to descnbe the cross-sectional associations of AIDS risk and preventive behaviors with beliefs derived from the constructs identified above; and fourth, to determine whether the observed belief-behavior associations varied according to the demographic and knowledge variables identified above.
Methods Subjects Tenth-grade students in 2 of the 14 public academic high schools in a New York city borough were selected as the eligible study population. The two schools were selected on the basis of their willingness to participate in the survey and their racial/ethnic similarity to the entire population of the 14 schools. Passive parental consent was required for students' participation in the survey; the nonconsent rate was 5.5% in one school and 6.5% in the other. The mean age of participants (n = 531) was 16.0 years (SD, 1.0; range, 13 to 21 years); 44.3% of the participants were male. The racial/ethnic distribution of the participants was 59.2% Black, 28.3% Hispanic, and 12.5% other (primarily non-Hispanic Whites); the participants were predominantly from worldng-class or welfare-recipient families. The demographic distribution of the survey participants was similar to that of the eligible study population.
Measurements Survey forms were distributed by research staff to all consenting, present 10thgraders enrolled in required general education courses in the spring semester of 1990. Survey completion required one class period; responses to the surveywere anonymous. AIDS-risk behaviors. The students were asked to complete five items regarding past-year involvement in AIDS risk and preventive behaviors, including use of illicit intravenous drugs, involvement in sexual intercourse, number and risk status of sexual partners, and consistency of condom use during sexual intercourse. A high-risk sexual partner was defined as one who was believed by the respondent to have a history of male homosexual intercourse or illicit intravenous drug use.
April 1992, Vol. 82, No. 4
An AIDS behavior index, ranging from lower to higher risk of acquiring infection with HIV, was created from these items according to the epidemiological model of HIV transmission proposed by Hearst and Hulley.12 Index scores ranged from 0 to 6; the definition of each risk level is presented in Table 1. Belefs derivedfrom the health belief modeL The students were asked to complete two items pertaining to perceived susceptibility to AIDS and three items pertaining to perceived severity of AIDS; and 15 and 17 items, respectively, constituting additive scales of the perceived benefits of and barriers to engaging in AIDS-preventive behaviors (i.e., sexual abstinence, consistent condom use, sexual monogamy, and knowing the sexual and drug use histories of sex partners). The internal consistency (alpha coefficient) of the benefits scale was 0.81, and that of the barriers scale, 0.77.
Belies de,ivedfm social cognitive theory. The students were asked to complete 13 items constituting an additive scale of perceived self-efficacy pertaiing to the preventive actions identified above. The internal consistency (alpha coefficient) of the scale was 0.80. Beliefs derivedfrnom the model ofsocial influence. The students were asked to complete eight items assessing their beliefs about how many of their four closest friends and what proportion of the students in their grade were involved in the pastyear in the preventive behaviors identified above (i.e., beliefs about norms). They were also asked to complete four items assessing whether they personally believed that people their age should be involved in these behaviors (i.e., beliefs about values). AIDS-related knowledge. The students were asked to complete 12 items pertaining to the transmission and prevention of HIV infection. These items were selected on the basis of their measurement characteristics from an original 72-item scale; the internal consistency (alpha coefficient) of the original scale was 0.82.
StatisticalAnalysis The analytic strategy compnsed four steps. First, descriptive statisticswere calculated to provide prevalence data for the investigated behaviors and beliefs, and bivariate relations between the behaviors and beliefs were assessed by computing odds ratios (ORs) and associated 95%o confidence intervals (Cas). Second, multiple
logistic regression was employed to assess differences in the distnbution of AIDS be-
havior index scores across the five demographic and knowledgevariables. Logistic rather than linear regression was employed because of the multinomial nature of the distribution of the AIDS behavior index scores. Accordingly, the AIDS behavior index scores were dichotomized to reflect lower versus higher risk. Third, multiple logistic regression again was used to assess the unique associations between beliefs derived from the seven investigated theoretical constructs and the AIDS behavior index scores. Finally, interaction variables, created by multiplying each demographic term or terms by the significantly associated beliefs, were added to the regression model to assess interaction effects.
Result AIDS-Risk and Preventive Behaviors Nearly two thirds (64.6%: 76.7% of males and 55.6% of females) of this sample of 10th-grade students reported ever having had sexual intercourse. The modal age ofinitiation of intercoursewas 11 years for males and 15 years for females. Three fifths (59.3%: 59.5% ofmales and 59.2% of American Joumnal of Public Health 529
Walt et aL
effects of gender, racelethnicity, school attended, or AIDS-related knowledge on the index scores, nor was there evidence of in-
teraction between any of thesevariables and the belief-behavior associations. The great majority ofthe students believed that half or more of their peers and friends had had sexual intercourse in the past year; half of the students believed that half or more of their friends had never or inconsistently used condoms in the past year. Three fifths of the males, but only one quarter of the females, believed that people their age should have intercourse. Substantial proportions ofthe students (in general, more males than females) were not sure that they could perform certain behaviors essential for effective AIDS prevention (Table 3).
Diwiusion Our principal finding is that a substantial proportion of a sample of 10th-grade
females) reported ever having used (or having had their partner use) a condom during intercourse. Table 1 presents the proportions of students reporting past-year involvement in each category of AIDS-related behaviors. No students reported use of illicit intravenous drugs; less than half reported sexual abstinence. Only one fifth of sexually active students reported protected intercourse with one low-risk partner.
Beif-Behavior Correlations Significant bivariate associations were observed between beliefs derived from all seven investigated theoretical constructs (i.e., susceptibility, severity, benefits, barriers, self-efficacy, norms, and values) and the AIDS risk behavior scores. However, in a multivariate analysis in which beliefs derived from all seven constructs were entered into the model
530 American Journal of Public Health
along with age, gender, race/ethnicity, school attended, and AIDS-related knowledge, beliefs derived from only three (i.e., norms, values, and self-efficacy) of the seven constructs were significantly associated with involvement in higher-risk behaviors (Table 2). In the presence of beliefs derived from these three constructs, beliefs derived from the four health belief model constructs (i.e., perceived susceptbility to and severity of AIDS, and perceived benefits of and barriers to engaging in preventive actions) were not significantly associated with higher-risk behaviors. The analyses revealed a significant main effect of age on AIDS behavior index scores: older students were slightly more likely to be in the higher categories of risk than were younger students (OR = 1.2 per year, 95% C1, 1.1 to2.1). The analysesfailed to provide any evidence of si nt main
students residing in an AIDS epicenter reported involvement in behaviors that place them at risk for acquiring infection with HIV. Beliefs derived from three theoretical constructs (i.e., norms, values, and selfefficacy) were cross-sectionally associated with riskier behaviors. In the presence of beliefs derived from these three constucts, beliefs derived from health belief model constructs were not significantly associated with higher AIDS risk. Before we consider the implications of these results, some methodological issues should be addressed. First, because of the self-report nature of the survey, the veracity of students' responses may be questioned. However, responses to the survey were anonymous to maximize accurate self-disclosure. In addition, there was high agreement (above 98%) of responses to similarly worded items assessing the same behavioral domains that were dispersed throughout the survey. The validity of responses also is strengthened by the similarity of the behavior prevalence rates reported in this study to those reported in other studies.13-18 Finally, there is evidence suggesting that questionnaire data are as accurate as interview data in assessing sexual-behavior prevalence rates among groups of subjects.19 Second, although the high survey participation rates obtained in this study suggest that the findings may be generalizable to similar populations of students, the findings may not be applicable to students attending schools unwfling to participate in such surveys, to students with a different demographic profile, or to teenApril 1992, Vol. 82, No. 4
Factors Assodated with AIDS Risk Behaviors
agers who are habitually absent or have withdrawn from school. A number of recent studies13-'8 conducted among various populations of adolescents have suggested that substantial proportions of teenagers and young adults engage in behaviors that increase their risk for acquiring infection with HIV. The most common behavioral profile among sexually active adolescents in this sample was a teenager who had unprotected sexual intercourse with partners believed to be at low risk for carying HIV. Because in the absence of HIV antibody testing one cannot be certain that one's partner indeed is uninfected,20 and because seropositivity rates in AIDS epicenters are estimated to be high,21 this behavioral profile (which is applicable to over two thirds of the sexually active students in this sample) conveys nontrivial risk to these teenagers. Of particular concern because of their greatly increased risk of HIV infection'2 are the 1.3% of the sexually active students in this sample who reported unprotected intercourse with high-risk partners, and the 6.6% who reported a history of sexually transmitted disease (similar percentages also have been reported
elsewhere).'3-'8 Although a number of studies have documented the prevalence of AIDS risk behaviors among adolescents, fewer have investigated theoretically or empirically suggested determinants of these behaviors. The findings of two studies recently conducted among teenagers have been informative in this regard. Hingson et al.8 showed that beliefs about the benefits and barriers of condom use and beliefs about susceptlbility to getting AIDS were associated cross-sectionally with condom use, as is predicted by the health belief model. Kasen et al.10 demonstrated that intercourse refusal and condom use self-efficacy were correlated with involvement in sexual intercourse and condom use among adolescents, net of the influence of beliefs derived from health belief model constructs, as is predicted by social cognitive
theory. The findings from this study demonstrate that although bivariate associations between beliefs derived from health belief model constructs and AIDS risk behaviors were observed, these associations were attenuated in the presence of certain socioenvironmental factors (i.e., beliefs about norms, values, and self-efficacy). The results are similar to those reported frm a number of studies examiining factors influencing drug use among teenagers,2- 24 and suggest that individual/cognitive interven-
April 1992, Vol. 82, No. 4
tions (e.g., those based upon the health beliefmodel) emphasizing the disease-related knowledge and beliefs of individuals as they exist apart from the social world may have only small effects on teenagers' motivations to initiate preventive actions. Instead, a more productive strategy may be to address salient socioenvironmental influences on preventive behaviors. For example, the data from this study suggest that teenagers could be helped to clarify their personal values relating to involvement in preventive actions, and an understanding of the effects of outside influences (e.g., peer pressure) on those values could be facilitated. Adolescents' misconceptions about the prevalence of risky and preventive behaviors among their peers could be corrected. Preventive action self-efficacy could be enhanced by empowering youths with the skills necessary to successfully perform risk-reducing behaviors. Skills in which teenagers may be particularly deficient include questioning sexual partners about sex and drug-use histories, using condoms correctly and consistently, and refusing offers to engage in sexual intercourse in certain high-pressure social situations. In summary, teenagers (particularly those residing in or near AIDS endemic areas) are at risk for acquiring infection with HIV. Because certain socioenvironmental factors (i.e., beliefs about norms, values, and self-efficacy) may strongly influence involvement in AIDS risk behaviors, further elucidation of the social influence process among adolescents should become a prevention research priority. For the present, it may prove to be beneficial for practitioners to reinforce values incompatible with involvement in AIDS risk behaviors, correct misconceptions about the normative status of such behaviors, and teach skills enabling effective, sustained preventive action. 0
Acknowledgments This research was supported by NIMHNVDA grant 5-P50-MH43520 to Heather J. Walter, MD, MPH, Principal Investigator, AIDS Prevention for Adolescents in School, and Anke A. Ehrhardt, PhD, Principal Investigator, HIV Center for Clinical and Behavioral Studies. The authors wish to thank Richard Neugebauer, PhD, and Judith Rabkin, PhD, for reviewing the manuscript.
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