HEALTH PSYCHOLOGY, 1992,11(6), 363-370 Copyright © 1992, Lawrence Erlbaum Associates, Inc.
Health Beliefs and Promotion of HIV-Preventive Intentions Among Teenagers: A Scottish Perspective Charles Abraham University ofDundee, Scotland
Paschal Sheeran This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Polytechnic ofEast London, England
Russell Spears University of Amsterdam, The Netherlands
Dominic Abrams University ofKent, England Beliefs concerning the spread of the human immunodeficiency virus (HIV) and preventive behaviors were examined in a sample of 351 sexually active Scottish teenagers. A postal questionnaire, including measures of variables specified by the health belief model (HBM) and preventive intentions, was employed. The relation between HBM measures and reported endorsement of HI V-preventive intentions was investigated. Results indicated that, in general, respondents intended to use condoms with new sexual partners. The majority also intended to carry condoms if they thought they might have sex with a new partner and to ask potential partners about their previous sexual history. Multiple-regression analyses showed that measures of health beliefs, gender, age, sexual experience, and previous condom use accounted for 17.8% to 24.3% of the variance in reported preventive intentions. Perceived barriers to preventive behaviors were found to be important predictors. However, the overall pattern of results raised questions concerning the adequacy of the HBM as a model of the determinants of HI V-preventive intentions, and the need for an extended model is discussed. Separate analyses were conducted for men and women and for 16- and 18-year-olds, and the implications for modeling intention formation in these subgroups are considered. The relevance of these findings to HIV-preventive campaigns is also discussed. Key words: AIDS, health beliefs, behavioral intentions, prevention, teenagers
Government-sponsored campaigns to prevent the human immunodeficiency virus (HIV) in the United Kingdom have had little impact on the behavior of the general population (Campbell & Waters, 1987; Gallup, 1987; Orton & Samuels, 1988; Sherr, 1987; Wober, 1987). Studies of gay men have, however, demonstrated the power of group-specific determinants of HIV-preventive change (e.g., Bradbeer, 1987; Fitzpatrick, McLean, Boulton, Hart, & Dawson, 1990; Joseph et al., 1987; Schechter et al., 1988). An understanding of such determinants would enable educational campaigns to address psychological and behavioral influences on HIV-preventive practices within specified groups. Sexually active teenagers have been identified as an important target group (Bury, 1991; Kilbourne, Buehler, & Rogers, 1990), and a clearer picture of HI V-relevant cognitions in this group and an awareness of distinctive subgroups of sexually active teenagers would be a useful basis for enhancing the effectiveness of future campaigns. Several models of the cognitive prerequisites of behavior could be employed to explore influences on HIV-preventive practices. The health belief model (HBM), for example, specifies a series of beliefs that have been shown to predict preventive behavior in response to a range of health risks (Becker et al., 1977; Janz & Becker, 1984;
Requests for reprints should be sent to Charles Abraham, Department of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, Scotland.
Rosenstock, 1974). The HBM has an expectancy-value and costbenefit-analysis structure and shares many elements with protection motivation theory (Rogers, 1975) and the theory of planned behavior (Ajzen & Madden, 1986). Unlike these models, however, the HBM proposes that beliefs affect behavior directly rather than through their influence on behavioral intentions. Direct belief and attitudinal influence on behavior have been reported (Fisher, 1984; Manstead, Proffitt, & Smart, 1983), but behavioral intentions have been shown to be key behavioral predictors mediating the effects of other cognitions in several areas, including condom use (Ajzen & Fishbein, 1980; Davidson & Jaccard, 1979; Sheppard, Hartwick, & Warshaw, 1988). Davidson and Morrison (1983) and Fisher (1984), for example, found positive and significant correlations between intentions to use condoms and reported condom use (rs = .78 and .44, respectively). Moreover, central HBM variables have been shown to affect preventive heath behavior through their impact on behavioral intentions (Cummings, Jette, Brock, & Heafner, 1979). The utility of HBM in describing psychological precursors of HIV-preventive practices must therefore depend on a clarification of the relations between its specified elements, HIV-preventive intentions, and HIV-preventive behaviors. The present study investigated the degree to which HBM predicts the endorsement of HIV-preventive intentions promoted by U.K. health education campaigns in sexually active teenagers. It also considers whether relations between health beliefs and preventive intentions vary as a function of teenagers' age and gender.
364
ABRAHAM, SHEERAN, SPEARS, ABRAMS
METHOD
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Design The HBM incorporates six main components. The first four are (a) perceived severity (beliefs concerning the consequences of an illness), (b) perceived vulnerability (beliefs concerning the likelihood that one will contract an illness), (c) perceived effectiveness of the proposed preventive behavior, and (d) anticipated costs of or barriers to performing the behavior. The HBM also proposes that (e) environmental cues, such as exposure to media campaigns, may alert people to health threats and thereby trigger preventive behavior after other cognitive prerequisites are in place. Last, several studies have suggested that the HBM should incorporate (f) a measure of health motivation (Becker et al., 1977; Becker & Maiman, 1975). Measures of these six HBM constructs were therefore included as independent variables. The HBM proposes that the influence of demographic variables such as age and gender is mediated by differences in these beliefs. This claim was examined by including age and gender as two additional independent variables and by using them to create subsamples for separate investigation. Two other independent variables were included due to their particular relevance to the behavioral intentions under consideration: previous experience in using condoms and number of previous sexual partners (McCusker, Stoddard, Zapka, M. Zorn, & Mayer, 1989). As dependent variables, three measures of preventive intention relating to behaviors promoted by U.K. educational campaigns were included: intention to inquire about partners' sexual histories, intention to carry condoms, and intention to use condoms during sexual intercourse. Intentions relating to new partners were specified because new contacts have been highlighted as especially risky by these campaigns. We investigated the relation between these 10 independent variables and the teenagers' endorsement of the three preventive intentions. Our aim was to evaluate the utility of the HBM framework in modeling such intention formation and thereby to explore teenagerspecific prerequisites of HIV-preventive intentions. Recognizing that sexually active teenagers may fall into distinctive groups (in relation to HIV-preventive practices), we considered men and women and younger and older teenagers separately.
generated an obtainable sample of 1,075 teenagers who received questionnaires and a cover letter explaining that all responses would be kept strictly confidential. A response rate of 64% produced 690 responses.2 Only those who reported having had one or more sexual partners were included in the present analysis, and 4 outliers (reporting between 30 and 54 partners) were removed. This resulted in a sample of 351 (194 women, 154 men, and 3 of unidentified sex) with a mean age of 17.09 years. Thirty-eight percent of this group reported only 1 previous sexual partner, 71% reported between 1 and 3, and fewer than 5% reported more than 10. Seventy percent reported having used a condom during sexual intercourse. Independent and Dependent Measures Three intention items were included as dependent measures: "In future, if I have sex with anyone new I will ask them about their past sexual partners," "In future, I intend to carry condoms if I think I might be going to have sex with someone new," and "In future, I intend to use a condom if I have sex with someone new.". Five-point Likert scales were used for these and other items for which alternative response scales are not specified: strongly agree (1), agree (2), uncertain (3) disagree (4), and strongly disagree (5). Perceived severity was measured by asking "How many people who get the AIDS virus develop AIDS?" and "How many people who get AIDS actually die of it?": none (1), a few (2), some (3), about half (A), most (5), almost all (6), and all (7). Perceived vulnerability was measured by asking "How likely do you think it is that you already have the AIDS virus?" and "How likely do you think it is that you will get the AIDS virus in the next five years?": extremely unlikely (1), very unlikely (2), unlikely (3), not sure (4), likely (5), very likely (6), and extremely likely (7). The impact of environmental cues was measured by asking respondents whether they could remember eight specified U.K. campaigns (e.g., the Don't Die of Ignorance leaflet). Health motivation was measured by the "I am unlikely to change my behavior because of AIDS" item. Respondents were also asked to record their age, gender, the number of people they had had sexual intercourse with during their lives, and whether or not they had used a condom during sexual intercourse. The perceived reliability of new partners' replies to inquiries concerning their sexual histories was assumed to be crucial to the perceived effectiveness of such questioning. Inquiry effectiveness
Participants and Questionnaire The study was based in Dundee, a city on the east coast of Scotland with a population of approximately 174,000. Dundee, like its larger neighbor, Edinburgh, has a serious HIV infection problem based primarily on transmission through intravenous (IV) drug use (Communicable Diseases Scotland Unit, 1988; Lothian Health Board HIV-AIDS Team, 1989; Smith et al., 1990). High infection rates in IV drug users (currently approximately 40%) have led to concerns about spreading heterosexual infection, and young heterosexuals have become a primary target group for HIV-preventive education. Our investigation formed part of a postal survey investigating attitudes and beliefs about relationships and sexual behavior in the context of spreading HIV and relevant health education campaigns. The sample of teenagers from two cohorts (16- and 18-year-olds) was randomly drawn from current and past school lists of students below the youngest, legal school-leaving age. An opt-out permissions letter was sent to potential participants' home addresses. This
Potential participants were sent a letter describing the study and inviting them to take part. They were asked to return a provided refusal slip in a prepaid envelope if they did not wish to participate. Personal follow-ups of a sample of nonrespondents indicated no significant demographic differences from respondents. Additionally, comparisons between questionnaires returned before and after a reminder letter revealed no relevant differences. Such similarity is one reliable indicator of the representativeness of a sample (Oppenheim, 1966). 3 Pilot interviews and questionnaires suggested that the somewhat inaccurate lennAIDS virus would maximize question comprehension. 'Two additional items intended to measure perceived severity ("Getting the AIDS virus is one of the worst things I can imagine happening to me") and perceived vulnerability ("I do not think anyone I have a sexual relationship with is likely to have the AIDS virus") were included in the questionnaire. However, these items did not correlate with the other two measures of perceived severity and vulnerability and could not be combined with them in single factors or reliable scales (see results of data-reduction procedures). These two measures were therefore excluded from this analysis.
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HEALTH BELIEFS AND HIV-PREVENTIVE INTENTIONS
was therefore measured using an item referring to the trustworthiness of partners' replies: "Before deciding to sleep with someone, I would trust them to tell the truth about their past sex life." The main barrier to such inquiries was assumed to be perceived impoliteness. Thus, inquiry offensiveness was measured using the "It would seem rude to ask a new partner about their sex life" item. Several condom-effectiveness components and barriers to carrying and using condoms were considered. These were operationalized using the eight items shown in Table 1. Three effectiveness items explored beliefs concerning protection against HIV during heterosexual intercourse and contraceptive effectiveness. Barriers included perceived pleasure reduction, perceived consensus regarding awkwardness of use, anticipated partners' reactions, and anticipated implications for social reputation. TABLE 1 Factor Analysis of Perceived Condom Effectiveness and Barrier Items Item Using a condom is effective in preventing a man passing the AIDS virus to a woman. Using a condom is effective in preventing a woman passing the AIDS virus to a man. Using condoms is a good way to avoid unwanted pregnancy. Most people find condoms awkward to use. Condoms would not spoil the pleasure of having sex. A person thinking of having sex with me would probably be pleased if I suggested using a condom. I would be offended if someone who wanted to have sex with me suggested protecting themselves against the AIDS virus. People would think I wanted casual sex if I carried condoms. Factor means (ranges = 1 to 5) Factor standard deviations
Condom Condom Condom Effectiveness Attractiveness Offensiveness
0.93
0.93
0.45 -0.73
RESULTS General Response Pattern Respondents were convinced of the severity of HIV infection (80% thought between one half and all of those infected developed AIDS, and 70% thought most, almost all, or all those with AIDS died due to the disease). However, they did not feel personally vulnerable. Eighty-seven percent thought it was very unlikely or extremely unlikely that they had been infected. Fewer than 3% thought they were likely to be infected in the next 5 years, and 60% estimated that this was very unlikely or extremely unlikely. Although this may be based on a realistic risk appraisal, such perceived invulnerability may adversely affect health motivation (cf. Abrams, Abraham, Spears, & Marks, 1990). Fifteen percent of respondents reported remembering between 0 and 3 educational campaigns, and 41% reported remembering between 6 and 8 campaigns (M = 5.03, SD = 1.51). Fifty-eight percent did not regard questioning partners about previous sexual history as rude (16% were uncertain), and 58% also felt they could trust the answers they received (27% were uncertain). Eighty-six percent regarded condoms as effective, but 42% thought most people find them awkward to use, and 32% thought they would spoil sexual pleasure. Only 17% felt they would be offended by a suggestion of condom use (14% were uncertain), but 37% thought others would think they wanted casual sex if they carried them (25% were uncertain). Seventy-seven percent of respondents reported that they intended to use a condom with new sexual partners—with 23% remaining uncertain (M = 4.11, SD = 0.88). Fifty-seven percent reported intending to question new partners about their previous sexual history—with 29% remaining uncertain (M = 3.56, SD = 1.00). Similarly, 51% reported intending to carry condoms when anticipating sex with a new partner—with 29% remaining uncertain (M = 3.35, SD = 0.98). Data Reduction on Independent Variables
0.69
0.55
0.81
0.68 4.08
3.09
2.63
0.63
0.60
0.80
The four items measuring perceived vulnerability and severity were reduced to two measures by calculating respondents' mean response across the two items corresponding to each construct. This simplification was supported by principal-components analysis with varimax rotation. The two emergent factors corresponded to the two HBM constructs explaining 39.9% and 34.6% of the variance with loadings ranging from .83 to .88. The same procedures were used to reduce the eight condomeffectiveness and condom-barrier items to three measures. The results of the factor analysis are shown in Table 1. The three factors group the three perceived effectiveness items and divide the five barrier items. The factors and corresponding measures were labeled Condom Effectiveness, Condom Attractiveness, and Condom Offensiveness and accounted for 26.1%, 18.1%, and 13.5% of the variance, respectively. Statistical Analyses Standard stepwise multiple regressions were performed (Tabachnick & Fidell, 1989). Measures of age, gender, experience in using condoms, number of previous sexual partners, health motivation, environmental cues, perceived vulnerability, perceived severity,
-0.11* 0.11* 0.08 0.10* 0.29** 0.09*
0.14* 0.06 0.11* 0.00 0.14** 0.30** 0.27**
0.10
0.13**
0.01 -0.27** 0.02 0.02 0.06 -0.01
-0.11*
0.18** 0.12* 0.27** -0.05 -0.10* -0.01
0.04
-0.20**
-0.05 -0.00
0.07
-0.36**
-0.02
0.05
-0.02
0.11*
0.09
0.17*
0.08
0.35**
-0.02
0.07
0.03
-0.05
0.04
0.23**
0.05
0.14*
0.37**
0.25**
0.02
1.00
1.00
1.00
0.10*
1.00
*p < .05. **p < .01.
Age
Gender
use
Intention to ask Intention to carry Intention to use Perceived severity Perceived vulnerability Health motivation Environmental cues Condom effectiveness Condom attractiveness Condom offensiveness Inquiry effectiveness Inquiry offensiveness Number of partners Condom
Variable
Intention to Carry
-0.01 0.04 0.06
0.16*
0.01
-0.07
-0.13**
-0.08
-0.08 -0.04 0.03
-0.07
-0.05
0.11*
-0.02
-0.01
0.03
0.06
-0.05 -0.07
1.00
0.02
1.00
0.08 -0.03 0.10*
-0.18**
-0.09
0.09*
-0.06
-0.04
0.11*
1.00
Perceived EnvironIntention Perceived VulnerHealth ability Motivation mental Cues Severity to Use
0.02 0.05 -0.05
0.01
0.03
0.02
-0.12*
0.15**
1.00
Condom Effectiveness
Variable
1.00
Inquiry Effectiveness
0.01
0.13**
1.00
Inquiry Offensiveness
-0.09* 0.01 0.25** 0.14** -0.13** -0.01
-0.28**
0.13** -0.15**
0.04
1.00
Condom Offensiveness
0.14** -0.12* -0.02 0.03 -0.14** -0.01
-0.13**
-0.01
0.13**
-0.15**
1.00
Condom Attractiveness
TABLE 2 Correlation Matrix of Variables Used in Regression Analyses
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Intention to Ask
6
366
0.06 0.28** 0.11*
1.00 1.00 0.04 0.08
Number Condom of Partners Use
1.00 -0.01 1.00
Gender Age
367
perceived effectiveness, and perceived barriers were entered as the independent variables. When reported intention to ask about previous partners constituted the dependent variable, measures of perceived inquiry, effectiveness, and offensiveness were included. However, in the case of intentions to carry and to use condoms, perceived condom effectiveness and the two condom-barrier measures (condom attractiveness and offensiveness) were included. The correlation matrix for the variables entered into the regressions is presented in Table 2. The three preventive intentions were positively correlated. Perceived condom effectiveness and attractiveness were also positively correlated, and both were negatively correlated with perceived condom offensiveness. Similarly, inquiry offensiveness was negatively correlated with inquiry effectiveness, and the two offensiveness measures were positively correlated. However, it should be noted that none of the correlations approached levels at which multicollinearity between independent variables became problematic (e.g., r = .70; Tabachnick & Fidell, 1989). The results of these multiple regressions are shown in Tables 3 through 5. The tables list the independent variables that were significant predictors of each of the three reported intentions (hereafter abbreviated to "ask," "carry," and "use"). It is worth noting here that the measures are self-reports and that predictor or predictors is used with reference to the regression analyses rather than in a causal sense. All Fs were significant (p < .001). Dashes in the tables represent independent variables that were not significant predictors for a particular subsample. The tables show the standardized regression coefficients (f$s), the proportion of the squared multiple correlation predictable from each significant independent variable (R2 change), and the total percentage of variation explained. Predictors of Preventive Intentions
the variance. Thirteen percent of the variance in intention to carry condoms is accounted for by condom attractiveness and offensiveness, whereas condom attractiveness accounted for 8.8% of the variance in intentions to use condoms. Thus, perceived barriers (inquiry offensiveness, condom attractiveness, condom offensiveness) and, in the case of intention to ask, perceived effectiveness, were shown to be important predictors. Women were less likely to report intending to carry condoms but more likely to report intending to ask. Indeed, gender appears as an important predictor of the intention to carry. Perhaps surprisingly, respondents reporting larger numbers of previous sexual partners were less likely to intend to use condoms. Thus, those with the most "risky" life styles seem least intent on taking precautions. Previous condom use is a significant but weak predictor of intentions to use condoms, suggesting that such intentions are not strongly tied to established habit and may therefore be modifiable. These findings emphasize the importance of perceived costs and benefits of the specified preventive behaviors but do not support the overall HBM framework. Perceived severity and motivation were weak predictors, and perceived condom effectiveness, perceived vulnerability, and environmental cues were not significant predictors of behavioral intention. Moreover, individual characteristics such as gender and sexual experience appeared to have direct effects on intention formation. Table 4 shows the results of multiple regressions conducted separately for men and women. Inquiry offensiveness and effectiveness were important predictors for both men and women. Inquiry offensiveness was a better predictor of men's intentions to ask, but inquiry effectiveness was a better predictor of women's intentions. Condom attractiveness was an important predictor of men's and women's reported intentions to use and to carry condoms. However, although condom offensiveness was an important predictor of
Table 3 shows the results of the three multiple regressions applied to the total sample. Between 17.8% and 24.3% of the variance is accounted for by the independent variables. In the case of intention to ask, inquiry offensiveness and effectiveness account for 22.1% of TABLE 3 Significant Predictors of Reported Intentions: Total Sample Intention and Predictor Variables
0
R2 Change
-0.37 0.29 -0.16
0.139 0.082 0.022
Ask
Inquiry offensiveness Inquiry effectiveness Gender Variance explained Carry Condom attractiveness Gender Condom offensiveness Perceived severity Motivation Variance explained
24.3% 0.29 0.27 -0.22 0.14 0.11
23.1%
0.083 0.071 0.047 0.018 0.012
Use
Condom attractiveness Number of partners Perceived severity Condom use Variance explained Note. N = 351.
0.30 -0.21 0.17 0.14
17.8%
0.088 0.043 0.029 0.018
TABLE 4 Significant Predictors of Reported Intentions: Gender Differences Gender Intention and Predictor Variables
Womenh
Men*
0
R2 Change
Ask
Inquiry offensiveness Inquiry effectiveness Variance explained Carry Condom attractiveness Motivation Condom use Condom offensiveness Perceived severity Variance explained
"CO
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HEALTH BELIEFS AND HIV-PREVENTIVE INTENTIONS
-0.36 0.28
0.131 0.076 20.7%
-0.27 0.32
0.070 0.105 17.5%
0.35 0.19 0.18
0.121 0.035 0.032
0.20
0.040
_ _
-0.33 0.24
0.110 0.056 20.6%
0.093 0.047 0.030 0.028
0.29 -0.20
0.086 0.040
0.26 -0.15
0.067 0.022 21.5%
_ _
_ —
18.8%
Use
Condom attractiveness Number of partners Condom use Age
Perceived severity Condom offensiveness Variance explained *n = 154. bn = 194.
R2 Change
0.31 -0.22 0.18 -0.17 _ —
_ _
19.8%
_ —
— —
— _
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368
ABRAHAM, SHEERAN, SPEARS, ABRAMS
women's intentions to carry condoms and a significant predictor of their intentions to use them, it was not a significant predictor of men's intentions. Similarly, perceived severity was a significant predictor of women's intentions to carry and to use condoms but was not a predictor of men's intentions. Thus, perceived condom offensiveness and perceived severity of HIV infection may be important to sexually active teenage women but not to their male counterparts. Previous condom use was a significant predictor of men's intentions to carry and to use condoms but was not a predictor of women's intentions. Motivation was a significant predictor of men's intentions to carry condoms, and, perhaps surprisingly, older men were less likely to intend to use condoms. Last, sexual experience was a predictor of both men's and women's intentions to use condoms. Table 5 shows the results of multiple regressions conducted separately for the younger (16-year-old) and older (18-year-old) cohorts. It is notable that there were more predictors of the older cohort's intentions, and several predictors accounted for more variance in the older group's intentions. Thus, the specified variables appear to provide a much better guide to the determinants of the older cohort's intentions. Inquiry offensiveness and effectiveness were important predictors for both groups. However, although inquiry effectiveness was more important for the younger group, inquiry offensiveness was much more important for the older group. Gender and environmental cues were also significant predictors of the older group's intentions to ask, and, collectively, these four variables account for slightly more than 32% of the variance in the older group's intentions to ask. Condom attractiveness was an important predictor of both groups' intentions to carry and to use condoms. It was a better predictor of the younger group's intentions to use condoms and, indeed, was the only significant predictor of these intentions. Condom offensiveTABLE 5 Significant Predictors of Reported Intentions: Cohort Differences Cohort Intention and Predictor Variables Ask Inquiry effectiveness Inquiry offensiveness Gender Cues Variance explained Carry Gender Condom attractiveness Condom offensiveness Motivation Number of partners Variance explained Use Condom attractiveness Number of partners Perceived severity Perceived vulnerability Condom offensiveness Variance explained a
/i = 177. bn = 174.
16-Year-Olds*
18-Year-Oldsb R2 Change
R2 Change 0.33 -0.26 — —
0.110 0.068 — — 17.8%
0.28 -0.44 -0.19 0.15
0.077 0.191 0.033 0.021 32.2%
0.31 0.24 -0.18 — —
0.096 0.060 0.030 — — 18.6%
0.21 0.33 -0.27 0.21 -0.17
0.045 0.111 0.073 0.044 0.025 29.8%
0.30 — —
0.088 — — 8.8%
0.22 -0.42 0.20 -0.17 -0.17
0.049 0.172 0.039 0.027 0.026 31.3%
ness, on the other hand, was a better predictor of the older group's intentions to carry and to use condoms. When these results are combined with the pattern of predictors for intention to inquire about previous sexual partners, it appeared that social barriers indicated by the offensive measures may be generally more important for the older teenagers. Gender was an important predictor of the younger group's intentions to carry condoms, indicating that younger women were less likely to intend to carry condoms. Motivation and number of previous sexual partners were both predictors of the older group's intentions to carry—with 29.8% the variance being explained. Reported lifetime partners was a very important predictor of the older teenagers' intentions to use condoms, and, following the pattern for the overall sample, those with higher partner turnover were less likely to intend to use condoms. Perceived severity and vulnerability were also significant predictors of the older group's intentions to use condoms, and it is noteworthy that those who regarded themselves as most vulnerable were least likely to intend to use condoms. Overall, five variables accounted for 31.3% of the variance in the older group's intentions to use condoms.
DISCUSSION Reported intentions to question new partners about their previous sexual histories were importantly related to perceived offensiveness and to the perceived trustworthiness of replies. The majority of respondents disagreed that such inquiry was offensive, suggesting that acceptability to teenage peers could be highlighted in future campaigns. Cohort differences indicated that concerns about inquiry offensiveness may be particularly important to older teenagers. Such questioning offers no direct protection against HIV infection, but previous work suggests that raising the issue of protection is a key prerequisite of taking precautions. Studies of contraceptive use have shown that discussion between partners and perceptions of communicativeness are important predictors of effective contraception (Gold & Berger, 1983; Jorgensen, King, & Torrey, 1980; Milan & Kilmann, 1987; Polit-O'Hara & Kahn, 1985). Thus, the value of promoting questions concerning partners' sexual histories lies primarily in encouraging the initiation of a risk-appraisal dialogue. Viewed from this perspective, the importance of perceived trustworthiness is discouraging. Future campaigns might minimize the impact of perceived trustworthiness by promoting discussion of risk while warning against uncritical acceptance of potential partners' accounts. However, it is worth noting that advocating such discussion may be ineffective unless interventions also seek to foster the development of required communication skills (Catania, Kegeles, & Coates, 1990; Holland, Ramazanoglu, & Scott, 1990). In contrast to previous studies (DiClemente, J. Zorn, & Temoshok, 1986), high levels of perceived condom effectiveness were observed, and a ceiling effect may have minimized the impact of such perceptions on reported intentions to carry and use condoms. However, as in studies of contraceptive behavior (Lowe & Radius, 1987; Morrison, 1985), perceived barriers to condom use were shown to be important predictors. Beliefs concerning pleasure reduction, consensual views on awkwardness of use, and partners' likely response to suggested use were seen to be importantly related to intentions to carry and to use condoms. These findings recommend closer attention to perceptions of the perceived social consequences of particular HIV-preventive behaviors. Substantial investments have been made
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HEALTH BELIEFS AND HIV-PREVENTIVE INTENTIONS
in broadcasting young people's vulnerability to infection, the severity of infection, and condom effectiveness. Future interventions may be more influential if they focus on social acceptability barriers. Interesting gender differences emerged. Perceived severity and offensiveness were more closely related to women's reported intentions to carry and to use condoms. Perceived offensiveness was particularly important in relation to the intention to carry condoms. Thus, attempts by U.K. campaigns to persuade teenage women that "smart girls carry condoms" may be unsuccessful unless they explicitly address the connotations of promiscuity attached to planned protection and the potential offensiveness of wanting to protect oneself from a sexual partner. This may be particularly salient for younger teenage women. These findings remind us that double standards in the judgment of men's and women's sexual behaviors may have an important impact on the adoption of HIV-preventive behavior (Condor, 1986; Spears, Abrams, Sheeran, Abraham, & Marks, 1991). Gender expectations may imply that it is illegitimate for young women to publicly plan sexual behavior (Holland, Ramazanoglu, & Scott, 1990; Lees, 1986). This will inhibit their preventive intentions, disempower them in sexual negotiations, and thereby reduce preventive action (Holland, Ramazanoglu, & Scott, 1990; Holland, Ramazanoglu, Scott, Sharpe, & Thomson, 1990; Jorgensen et al., 1980). If gender roles are to be challenged, HIVpreventive interventions must change radically from provision of information to what Homans and Aggleton (1988) called "socially transformatory" approaches that explicate and question sexual norms. Compared to 16-year-olds, 18-year-olds had more previous partners and were more likely to have used condoms. The younger group's intentions were very poorly predicted by the specified HBM variables, whereas approximately one third of the variance in the older group's intentions was accounted for. This may suggest that greater maturity results in enhanced rational decision-making as proposed by HBM. In one sense, these findings are encouraging because the late teen years constitute an important HIV-risk period. However, that larger numbers of lifetime partners decreased the likelihood of intended condom carrying and use is disconcerting. The number of reported previous partners was correlated with perceived vulnerability for the total sample, suggesting that teenagers may be aware of the risks involved. Nevertheless, these results underline the importance of targeting teenagers who have high partner turnovers (Sorenson, 1973). These results also emphasize the need for further exploration of the psychological prerequisites of HIV-preventive intentions and behaviors in younger sexually active teenagers. The overall pattern of results shows that perceived barriers, particularly awareness of impression-management processes, were important predictors of teenagers' endorsement of HIV-preventive intentions. However, many of the variables specified by HBM failed to predict intentions. Ceiling and floor effects may reduce the importance of perceived condom effectiveness and perceived vulnerability, whereas high levels of knowledge and awareness may diminish the importance of memory for preventive campaigns. Variables outside the modifiable belief structure specified by HBM were also found to predict intentions (e.g., gender, number of lifetime partners). Thus, although the variables specified here included useful predictors, the results suggest that HBM is not a good guide to the psychological prerequisites of HIV-preventive intentions. Unexplained variance suggests that other important predictors could be identified.
Men and women and younger and older cohorts appeared to be differentially influenced by particular barriers. This emphasizes the importance of group-specific psychological prerequisites of HIVpreventive intentions and behavior. The sample was drawn from an area with a particular HIV-transmission problem, and it would be interesting to establish to what extent these findings generalize to teenagers in other regions. Similar studies focusing on different teenage groups would be illuminating. The study also raises methodological issues. Although a fairly substantial literature on HlV-relevant cognitions has been established, researchers have employed a variety of measures in operationalizing variables such as perceived vulnerability and severity. The difference between measures—and the unknown effect that participants' particular exposure to HIV-educational material has on their interpretation of response scales—makes clear comparisons problematic. It would be helpful if greater standardization of multiple-item measures could be achieved. The present study used a single item-to-index motivation, and the relative importance of this variable may warrant further investigation. Intentions have been shown to be important prerequisites of various preventive behaviors, and this study used a cross-sectional design to explore the psychological determinants of teenager's HIVpreventive intentions. However, longitudinal studies that relate intentions and other cognitions to HIV-preventive behaviors are required. Several such longitudinal studies of gay men have been reported (e.g., Fitzpatrick et al., 1990; McCusker, Stoddard et al., 1989; McCusker, Zapka, Stoddard, & Mayer, 1989; Siegel, Mesagno, Chen, & Christ, 1989). These reveal differences between samples and emphasize the importance of variables other than HBM components and intentions—for example, availability of social support, relationship status, drug use, and previous "unsafe" sexual behavior. Similar studies of the determinants of teenagers' HIV-preventive behaviors would be valuable to those planning interventions with this group.
ACKNOWLEDGMENTS This research was supported by Economic and Social Research Council Grant XA44 250001 (Swindon, SN2 6UQ, England). We thank three anonymous reviewers for their helpful comments on an earlier version of this article. Paschal Sheeran is now at the University of Sheffield, England.
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Bradbeer, C. (1987). fflV and sexual lifestyle. British Medical Journal, 294, 5-6. Bury, J. K. (1991). Teenage sexual behaviour and the impact of AIDS. Health Education Journal, 50, 43-49. Campbell, M. J., & Waters, W. (1987). Public knowledge about AIDS increasing. British Medical Journal, 294, 892-893. Catania, J. A., Kegeles, S. M., & Coates, T. J. (1990). Towards an understanding of risk behaviour: An AIDS reduction model (ARRM). Health Education Quarterly, 17, 53-72. Communicable Diseases Scotland Unit. (1988). Communicable diseases report (CDS 88/02). Glasgow: Author. Condor, S. (1986). Sex-role beliefs and traditional women: Feminist and intergroup perspectives. In S. Wilkinson (Ed.), Feminist social psychology (pp. 97-118). Milton Keynes: Open University Press. Cummings, K. M., Jette, A. M., Brock, B. M., & Heafner, D. P. (1979). Psychosocial determinants of immunization behavior in a swine influenza campaign. Medical Care, 17, 639-649. Davidson, A. R., & Jaccard, J. J. (1979). Variables that moderate the attitude behavior relation: Results of a longitudinal study. Journal ofPersonality and Social Psychology, 37,1364-1376. Davidson, A. R., & Morrison, D. M. (1983). Predicting contraceptive behavior from attitudes: A comparison of within- versus across-subjects procedures. Journal of Personality and Social Psychology, 45, 997-1009. DiClemente, R. J., Zorn, J., & Temoshok, L. (1986). Adolescents and AIDS: A survey of knowledge, attitudes and beliefs about AIDS in San Francisco. American Journal ofPublic Health, 76,1443-1448. Fisher, W. A. (1984). Predicting contraceptive behavior among university men: The role of emotions and behavioral intentions. Journal of Applied Social Psychology, 14, 104-123. Fitzpatrick, J., McLean, J., Boulton, M., Hart, G., & Dawson, J. (1990). Variation in sexual behaviour in gay men. In P. Aggleton, P. Davies, & G. Hart (Eds.), AIDS: Individual, cultural and policy dimensions (pp. 121132). Basingstoke, England: Falmer. Gallup (1987). Public attitudes to AIDS. London: Central Office for Information. Gold, D., & Berger, C. (1983). The influence of psychological and situational factors on the contraceptive behavior of single men: A review of the literature. Population and Environment, 6, 113-129. Holland, J., Ramazanoglu, C , & Scott, S. (1990). Managingriskand experiencing danger: Tensions between government AIDS health education policy and young women's sexuality. Gender and Education, 2,125-146. Holland, J., Ramazanoglu, C , Scott, S., Sharpe, S., & Thomson, R. (1990). Sex, gender and power: Young women's sexuality in the shadow of AIDS. Sociology of Health and Illness, 12, 336-350. Homans, H., & Aggleton, P. (1988). Health education, HIV infection and AIDS. In P. Aggleton & H. Homans (Eds.), Social aspects ofAIDS (pp. 154-176). Lewis, England: Falmer. Janz N. K., & Becker, H. M. (1984). The health belief model: A decade later. Health Education Quarterly, 11, 1-47. Jorgensen, S. R., King, S. L., & Torrey, B. A. (1980). Dyadic and social network influences on adolescent exposure to pregnancyrisk.Journal of Marriage and the Family, 41, 141-155. Joseph, J. G., Montgomery, S. B., Emmons, C, Kessler, R. C, Ostrow, D. G., Wortman, C. B., O'Brien, K., Eller, M., & Eshleman, S. (1987). Magnitude and determinants of behavioral risk reduction: Longitudinal analysis of a cohort atriskfor AIDS. Psychology and Health, 1, 73-96. Kilbourne, W., Buehler, J. W., & Rogers, M. F. (1990). AIDS as a cause of
death in children, adolescents and young adults. American Journal of Public Health, 80, 499-500. Lees, S. (1986). Losing out: Sexuality and adolescent girls. London: Hutchinson. Lothian Health Board HIV/AIDS Team. (1989). AIDS in Lothian: Time to take care. Edinburgh: Lothian Health Board. Lowe, C. S., & Radius, S. M. (1987). Young adults' contraceptive practices: An investigation of influences. Adolescence, 86, 291-304. Manstead, A. S. R., Proffitt, C, & Smart, J. L. (1983). Predicting and understanding mothers' infant-feeding intentions and behavior: Testing the theory of reasoned action. Journal ofPersonality and Social Psychology, 44, 657-671. McCusker, J., Stoddard, A. M., Zapka, J. G., Zorn, M., & Mayer, K. H. (1989). Predictors of AIDS-preventive behavior among homosexually active men: A longitudinal study. AIDS, 3, 443-446. McCusker, J., Zapka, J. G., Stoddard, A. M., & Mayer, K. H. (1989). Responses to the AIDS epidemic among homosexually active men: Factors associated with preventive behavior. Patient Education and Counsel-
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Milan, R. J., & Kilmann, P. R. (1987). Interpersonal factors in premarital contraception. Journal of Sex Research, 23, 289-321. Morrison, D. M. (1985). Adolescent contraceptive behavior: A review. Psychological Bulletin, 98, 538-568. Oppenheim, N. A. (1966). Questionnaire design and attitude measurement. London: Heinemann. Orton, S., & Samuels, J. (1988). What we have learnt from researching AIDS. Journal of the Market Research Society, 30(1), 3-34. Polit-O'Hara, D., & Kahn, J. (1985). Communication and contraceptive practices in adolescent couples. Adolescence, 20, 33-42. Rogers, R. W. (1975). A protection motivation theory of fear appeals and attitude change. Journal ofPsychology, 91, 93-114. Rosenstock, I. M. (1974). The health belief model and preventive health behavior. Health Education Monographs, 2, 354-386. Schechter, M. T., Craib, K., Willoughby, B., Douglas, B., Mcleod, A., Maynard, M., Constance, P., & O'Shaughnessy, M. (1988). Patterns of sexual behavior and condom use in a cohort of homosexual men. American Journal ofPublic Health, 78, 1535-1545. Sheppard, B. H., Hartwick, J., & Warshaw, P. R. (1988). The theory of reasoned action: A meta-analysis of past research with recommendations for modifications and future research. Journal of Consumer Research, 15, 325-343. Sherr, L. (1987). An evaluation of the UK government health education campaign on AIDS. Psychology and Health, 1, 61-72. Siegel, K., Mesagno, F. P., Chen, J., & Christ, G. (1989). Factors distinguishing homosexual males practicing risky and safer sex. Social Science and Medicine, 28, 561-569. Smith, R., Patel, N. B., Urquhart, G. E. D., McFaul, P., Neven, P., & Howie, P. W. (1990). Prevalence of HIV antibody and pregnancy in Tayside 1984-9: Background to screening. British MedicalJournal, 301,518-521. Sorenson, R. (1973). Adolescent sexuality in contemporary America. New York: World. Spears, R., Abrams, D., Sheeran, P., Abraham, S. C. S., & Marks, D. (1991). Social judgments of sex and blame in the context of AIDS: Gender and linguistic frame. British Journal ofSocial Psychology, 30, 37-49. Tabachnick, B. G., & Fidell, L. S. (1989). Using multivariate statistics (2nd ed.). New York: Harper & Row. Wober, M. J. (1987). Youth and television: Some patterns of behaviour, appreciation and attitudes, particularly concerning AIDS. London: Independent Broadcasting Authority.
Health Beliefs and Promotion of HIV-Preventive Intentions Among Teenagers: A Scottish Perspective Charles Abraham University ofDundee, Scotland
Paschal Sheeran This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Polytechnic ofEast London, England
Russell Spears University of Amsterdam, The Netherlands
Dominic Abrams University ofKent, England Beliefs concerning the spread of the human immunodeficiency virus (HIV) and preventive behaviors were examined in a sample of 351 sexually active Scottish teenagers. A postal questionnaire, including measures of variables specified by the health belief model (HBM) and preventive intentions, was employed. The relation between HBM measures and reported endorsement of HI V-preventive intentions was investigated. Results indicated that, in general, respondents intended to use condoms with new sexual partners. The majority also intended to carry condoms if they thought they might have sex with a new partner and to ask potential partners about their previous sexual history. Multiple-regression analyses showed that measures of health beliefs, gender, age, sexual experience, and previous condom use accounted for 17.8% to 24.3% of the variance in reported preventive intentions. Perceived barriers to preventive behaviors were found to be important predictors. However, the overall pattern of results raised questions concerning the adequacy of the HBM as a model of the determinants of HI V-preventive intentions, and the need for an extended model is discussed. Separate analyses were conducted for men and women and for 16- and 18-year-olds, and the implications for modeling intention formation in these subgroups are considered. The relevance of these findings to HIV-preventive campaigns is also discussed. Key words: AIDS, health beliefs, behavioral intentions, prevention, teenagers
Government-sponsored campaigns to prevent the human immunodeficiency virus (HIV) in the United Kingdom have had little impact on the behavior of the general population (Campbell & Waters, 1987; Gallup, 1987; Orton & Samuels, 1988; Sherr, 1987; Wober, 1987). Studies of gay men have, however, demonstrated the power of group-specific determinants of HIV-preventive change (e.g., Bradbeer, 1987; Fitzpatrick, McLean, Boulton, Hart, & Dawson, 1990; Joseph et al., 1987; Schechter et al., 1988). An understanding of such determinants would enable educational campaigns to address psychological and behavioral influences on HIV-preventive practices within specified groups. Sexually active teenagers have been identified as an important target group (Bury, 1991; Kilbourne, Buehler, & Rogers, 1990), and a clearer picture of HI V-relevant cognitions in this group and an awareness of distinctive subgroups of sexually active teenagers would be a useful basis for enhancing the effectiveness of future campaigns. Several models of the cognitive prerequisites of behavior could be employed to explore influences on HIV-preventive practices. The health belief model (HBM), for example, specifies a series of beliefs that have been shown to predict preventive behavior in response to a range of health risks (Becker et al., 1977; Janz & Becker, 1984;
Requests for reprints should be sent to Charles Abraham, Department of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, Scotland.
Rosenstock, 1974). The HBM has an expectancy-value and costbenefit-analysis structure and shares many elements with protection motivation theory (Rogers, 1975) and the theory of planned behavior (Ajzen & Madden, 1986). Unlike these models, however, the HBM proposes that beliefs affect behavior directly rather than through their influence on behavioral intentions. Direct belief and attitudinal influence on behavior have been reported (Fisher, 1984; Manstead, Proffitt, & Smart, 1983), but behavioral intentions have been shown to be key behavioral predictors mediating the effects of other cognitions in several areas, including condom use (Ajzen & Fishbein, 1980; Davidson & Jaccard, 1979; Sheppard, Hartwick, & Warshaw, 1988). Davidson and Morrison (1983) and Fisher (1984), for example, found positive and significant correlations between intentions to use condoms and reported condom use (rs = .78 and .44, respectively). Moreover, central HBM variables have been shown to affect preventive heath behavior through their impact on behavioral intentions (Cummings, Jette, Brock, & Heafner, 1979). The utility of HBM in describing psychological precursors of HIV-preventive practices must therefore depend on a clarification of the relations between its specified elements, HIV-preventive intentions, and HIV-preventive behaviors. The present study investigated the degree to which HBM predicts the endorsement of HIV-preventive intentions promoted by U.K. health education campaigns in sexually active teenagers. It also considers whether relations between health beliefs and preventive intentions vary as a function of teenagers' age and gender.
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ABRAHAM, SHEERAN, SPEARS, ABRAMS
METHOD
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Design The HBM incorporates six main components. The first four are (a) perceived severity (beliefs concerning the consequences of an illness), (b) perceived vulnerability (beliefs concerning the likelihood that one will contract an illness), (c) perceived effectiveness of the proposed preventive behavior, and (d) anticipated costs of or barriers to performing the behavior. The HBM also proposes that (e) environmental cues, such as exposure to media campaigns, may alert people to health threats and thereby trigger preventive behavior after other cognitive prerequisites are in place. Last, several studies have suggested that the HBM should incorporate (f) a measure of health motivation (Becker et al., 1977; Becker & Maiman, 1975). Measures of these six HBM constructs were therefore included as independent variables. The HBM proposes that the influence of demographic variables such as age and gender is mediated by differences in these beliefs. This claim was examined by including age and gender as two additional independent variables and by using them to create subsamples for separate investigation. Two other independent variables were included due to their particular relevance to the behavioral intentions under consideration: previous experience in using condoms and number of previous sexual partners (McCusker, Stoddard, Zapka, M. Zorn, & Mayer, 1989). As dependent variables, three measures of preventive intention relating to behaviors promoted by U.K. educational campaigns were included: intention to inquire about partners' sexual histories, intention to carry condoms, and intention to use condoms during sexual intercourse. Intentions relating to new partners were specified because new contacts have been highlighted as especially risky by these campaigns. We investigated the relation between these 10 independent variables and the teenagers' endorsement of the three preventive intentions. Our aim was to evaluate the utility of the HBM framework in modeling such intention formation and thereby to explore teenagerspecific prerequisites of HIV-preventive intentions. Recognizing that sexually active teenagers may fall into distinctive groups (in relation to HIV-preventive practices), we considered men and women and younger and older teenagers separately.
generated an obtainable sample of 1,075 teenagers who received questionnaires and a cover letter explaining that all responses would be kept strictly confidential. A response rate of 64% produced 690 responses.2 Only those who reported having had one or more sexual partners were included in the present analysis, and 4 outliers (reporting between 30 and 54 partners) were removed. This resulted in a sample of 351 (194 women, 154 men, and 3 of unidentified sex) with a mean age of 17.09 years. Thirty-eight percent of this group reported only 1 previous sexual partner, 71% reported between 1 and 3, and fewer than 5% reported more than 10. Seventy percent reported having used a condom during sexual intercourse. Independent and Dependent Measures Three intention items were included as dependent measures: "In future, if I have sex with anyone new I will ask them about their past sexual partners," "In future, I intend to carry condoms if I think I might be going to have sex with someone new," and "In future, I intend to use a condom if I have sex with someone new.". Five-point Likert scales were used for these and other items for which alternative response scales are not specified: strongly agree (1), agree (2), uncertain (3) disagree (4), and strongly disagree (5). Perceived severity was measured by asking "How many people who get the AIDS virus develop AIDS?" and "How many people who get AIDS actually die of it?": none (1), a few (2), some (3), about half (A), most (5), almost all (6), and all (7). Perceived vulnerability was measured by asking "How likely do you think it is that you already have the AIDS virus?" and "How likely do you think it is that you will get the AIDS virus in the next five years?": extremely unlikely (1), very unlikely (2), unlikely (3), not sure (4), likely (5), very likely (6), and extremely likely (7). The impact of environmental cues was measured by asking respondents whether they could remember eight specified U.K. campaigns (e.g., the Don't Die of Ignorance leaflet). Health motivation was measured by the "I am unlikely to change my behavior because of AIDS" item. Respondents were also asked to record their age, gender, the number of people they had had sexual intercourse with during their lives, and whether or not they had used a condom during sexual intercourse. The perceived reliability of new partners' replies to inquiries concerning their sexual histories was assumed to be crucial to the perceived effectiveness of such questioning. Inquiry effectiveness
Participants and Questionnaire The study was based in Dundee, a city on the east coast of Scotland with a population of approximately 174,000. Dundee, like its larger neighbor, Edinburgh, has a serious HIV infection problem based primarily on transmission through intravenous (IV) drug use (Communicable Diseases Scotland Unit, 1988; Lothian Health Board HIV-AIDS Team, 1989; Smith et al., 1990). High infection rates in IV drug users (currently approximately 40%) have led to concerns about spreading heterosexual infection, and young heterosexuals have become a primary target group for HIV-preventive education. Our investigation formed part of a postal survey investigating attitudes and beliefs about relationships and sexual behavior in the context of spreading HIV and relevant health education campaigns. The sample of teenagers from two cohorts (16- and 18-year-olds) was randomly drawn from current and past school lists of students below the youngest, legal school-leaving age. An opt-out permissions letter was sent to potential participants' home addresses. This
Potential participants were sent a letter describing the study and inviting them to take part. They were asked to return a provided refusal slip in a prepaid envelope if they did not wish to participate. Personal follow-ups of a sample of nonrespondents indicated no significant demographic differences from respondents. Additionally, comparisons between questionnaires returned before and after a reminder letter revealed no relevant differences. Such similarity is one reliable indicator of the representativeness of a sample (Oppenheim, 1966). 3 Pilot interviews and questionnaires suggested that the somewhat inaccurate lennAIDS virus would maximize question comprehension. 'Two additional items intended to measure perceived severity ("Getting the AIDS virus is one of the worst things I can imagine happening to me") and perceived vulnerability ("I do not think anyone I have a sexual relationship with is likely to have the AIDS virus") were included in the questionnaire. However, these items did not correlate with the other two measures of perceived severity and vulnerability and could not be combined with them in single factors or reliable scales (see results of data-reduction procedures). These two measures were therefore excluded from this analysis.
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HEALTH BELIEFS AND HIV-PREVENTIVE INTENTIONS
was therefore measured using an item referring to the trustworthiness of partners' replies: "Before deciding to sleep with someone, I would trust them to tell the truth about their past sex life." The main barrier to such inquiries was assumed to be perceived impoliteness. Thus, inquiry offensiveness was measured using the "It would seem rude to ask a new partner about their sex life" item. Several condom-effectiveness components and barriers to carrying and using condoms were considered. These were operationalized using the eight items shown in Table 1. Three effectiveness items explored beliefs concerning protection against HIV during heterosexual intercourse and contraceptive effectiveness. Barriers included perceived pleasure reduction, perceived consensus regarding awkwardness of use, anticipated partners' reactions, and anticipated implications for social reputation. TABLE 1 Factor Analysis of Perceived Condom Effectiveness and Barrier Items Item Using a condom is effective in preventing a man passing the AIDS virus to a woman. Using a condom is effective in preventing a woman passing the AIDS virus to a man. Using condoms is a good way to avoid unwanted pregnancy. Most people find condoms awkward to use. Condoms would not spoil the pleasure of having sex. A person thinking of having sex with me would probably be pleased if I suggested using a condom. I would be offended if someone who wanted to have sex with me suggested protecting themselves against the AIDS virus. People would think I wanted casual sex if I carried condoms. Factor means (ranges = 1 to 5) Factor standard deviations
Condom Condom Condom Effectiveness Attractiveness Offensiveness
0.93
0.93
0.45 -0.73
RESULTS General Response Pattern Respondents were convinced of the severity of HIV infection (80% thought between one half and all of those infected developed AIDS, and 70% thought most, almost all, or all those with AIDS died due to the disease). However, they did not feel personally vulnerable. Eighty-seven percent thought it was very unlikely or extremely unlikely that they had been infected. Fewer than 3% thought they were likely to be infected in the next 5 years, and 60% estimated that this was very unlikely or extremely unlikely. Although this may be based on a realistic risk appraisal, such perceived invulnerability may adversely affect health motivation (cf. Abrams, Abraham, Spears, & Marks, 1990). Fifteen percent of respondents reported remembering between 0 and 3 educational campaigns, and 41% reported remembering between 6 and 8 campaigns (M = 5.03, SD = 1.51). Fifty-eight percent did not regard questioning partners about previous sexual history as rude (16% were uncertain), and 58% also felt they could trust the answers they received (27% were uncertain). Eighty-six percent regarded condoms as effective, but 42% thought most people find them awkward to use, and 32% thought they would spoil sexual pleasure. Only 17% felt they would be offended by a suggestion of condom use (14% were uncertain), but 37% thought others would think they wanted casual sex if they carried them (25% were uncertain). Seventy-seven percent of respondents reported that they intended to use a condom with new sexual partners—with 23% remaining uncertain (M = 4.11, SD = 0.88). Fifty-seven percent reported intending to question new partners about their previous sexual history—with 29% remaining uncertain (M = 3.56, SD = 1.00). Similarly, 51% reported intending to carry condoms when anticipating sex with a new partner—with 29% remaining uncertain (M = 3.35, SD = 0.98). Data Reduction on Independent Variables
0.69
0.55
0.81
0.68 4.08
3.09
2.63
0.63
0.60
0.80
The four items measuring perceived vulnerability and severity were reduced to two measures by calculating respondents' mean response across the two items corresponding to each construct. This simplification was supported by principal-components analysis with varimax rotation. The two emergent factors corresponded to the two HBM constructs explaining 39.9% and 34.6% of the variance with loadings ranging from .83 to .88. The same procedures were used to reduce the eight condomeffectiveness and condom-barrier items to three measures. The results of the factor analysis are shown in Table 1. The three factors group the three perceived effectiveness items and divide the five barrier items. The factors and corresponding measures were labeled Condom Effectiveness, Condom Attractiveness, and Condom Offensiveness and accounted for 26.1%, 18.1%, and 13.5% of the variance, respectively. Statistical Analyses Standard stepwise multiple regressions were performed (Tabachnick & Fidell, 1989). Measures of age, gender, experience in using condoms, number of previous sexual partners, health motivation, environmental cues, perceived vulnerability, perceived severity,
-0.11* 0.11* 0.08 0.10* 0.29** 0.09*
0.14* 0.06 0.11* 0.00 0.14** 0.30** 0.27**
0.10
0.13**
0.01 -0.27** 0.02 0.02 0.06 -0.01
-0.11*
0.18** 0.12* 0.27** -0.05 -0.10* -0.01
0.04
-0.20**
-0.05 -0.00
0.07
-0.36**
-0.02
0.05
-0.02
0.11*
0.09
0.17*
0.08
0.35**
-0.02
0.07
0.03
-0.05
0.04
0.23**
0.05
0.14*
0.37**
0.25**
0.02
1.00
1.00
1.00
0.10*
1.00
*p < .05. **p < .01.
Age
Gender
use
Intention to ask Intention to carry Intention to use Perceived severity Perceived vulnerability Health motivation Environmental cues Condom effectiveness Condom attractiveness Condom offensiveness Inquiry effectiveness Inquiry offensiveness Number of partners Condom
Variable
Intention to Carry
-0.01 0.04 0.06
0.16*
0.01
-0.07
-0.13**
-0.08
-0.08 -0.04 0.03
-0.07
-0.05
0.11*
-0.02
-0.01
0.03
0.06
-0.05 -0.07
1.00
0.02
1.00
0.08 -0.03 0.10*
-0.18**
-0.09
0.09*
-0.06
-0.04
0.11*
1.00
Perceived EnvironIntention Perceived VulnerHealth ability Motivation mental Cues Severity to Use
0.02 0.05 -0.05
0.01
0.03
0.02
-0.12*
0.15**
1.00
Condom Effectiveness
Variable
1.00
Inquiry Effectiveness
0.01
0.13**
1.00
Inquiry Offensiveness
-0.09* 0.01 0.25** 0.14** -0.13** -0.01
-0.28**
0.13** -0.15**
0.04
1.00
Condom Offensiveness
0.14** -0.12* -0.02 0.03 -0.14** -0.01
-0.13**
-0.01
0.13**
-0.15**
1.00
Condom Attractiveness
TABLE 2 Correlation Matrix of Variables Used in Regression Analyses
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Intention to Ask
6
366
0.06 0.28** 0.11*
1.00 1.00 0.04 0.08
Number Condom of Partners Use
1.00 -0.01 1.00
Gender Age
367
perceived effectiveness, and perceived barriers were entered as the independent variables. When reported intention to ask about previous partners constituted the dependent variable, measures of perceived inquiry, effectiveness, and offensiveness were included. However, in the case of intentions to carry and to use condoms, perceived condom effectiveness and the two condom-barrier measures (condom attractiveness and offensiveness) were included. The correlation matrix for the variables entered into the regressions is presented in Table 2. The three preventive intentions were positively correlated. Perceived condom effectiveness and attractiveness were also positively correlated, and both were negatively correlated with perceived condom offensiveness. Similarly, inquiry offensiveness was negatively correlated with inquiry effectiveness, and the two offensiveness measures were positively correlated. However, it should be noted that none of the correlations approached levels at which multicollinearity between independent variables became problematic (e.g., r = .70; Tabachnick & Fidell, 1989). The results of these multiple regressions are shown in Tables 3 through 5. The tables list the independent variables that were significant predictors of each of the three reported intentions (hereafter abbreviated to "ask," "carry," and "use"). It is worth noting here that the measures are self-reports and that predictor or predictors is used with reference to the regression analyses rather than in a causal sense. All Fs were significant (p < .001). Dashes in the tables represent independent variables that were not significant predictors for a particular subsample. The tables show the standardized regression coefficients (f$s), the proportion of the squared multiple correlation predictable from each significant independent variable (R2 change), and the total percentage of variation explained. Predictors of Preventive Intentions
the variance. Thirteen percent of the variance in intention to carry condoms is accounted for by condom attractiveness and offensiveness, whereas condom attractiveness accounted for 8.8% of the variance in intentions to use condoms. Thus, perceived barriers (inquiry offensiveness, condom attractiveness, condom offensiveness) and, in the case of intention to ask, perceived effectiveness, were shown to be important predictors. Women were less likely to report intending to carry condoms but more likely to report intending to ask. Indeed, gender appears as an important predictor of the intention to carry. Perhaps surprisingly, respondents reporting larger numbers of previous sexual partners were less likely to intend to use condoms. Thus, those with the most "risky" life styles seem least intent on taking precautions. Previous condom use is a significant but weak predictor of intentions to use condoms, suggesting that such intentions are not strongly tied to established habit and may therefore be modifiable. These findings emphasize the importance of perceived costs and benefits of the specified preventive behaviors but do not support the overall HBM framework. Perceived severity and motivation were weak predictors, and perceived condom effectiveness, perceived vulnerability, and environmental cues were not significant predictors of behavioral intention. Moreover, individual characteristics such as gender and sexual experience appeared to have direct effects on intention formation. Table 4 shows the results of multiple regressions conducted separately for men and women. Inquiry offensiveness and effectiveness were important predictors for both men and women. Inquiry offensiveness was a better predictor of men's intentions to ask, but inquiry effectiveness was a better predictor of women's intentions. Condom attractiveness was an important predictor of men's and women's reported intentions to use and to carry condoms. However, although condom offensiveness was an important predictor of
Table 3 shows the results of the three multiple regressions applied to the total sample. Between 17.8% and 24.3% of the variance is accounted for by the independent variables. In the case of intention to ask, inquiry offensiveness and effectiveness account for 22.1% of TABLE 3 Significant Predictors of Reported Intentions: Total Sample Intention and Predictor Variables
0
R2 Change
-0.37 0.29 -0.16
0.139 0.082 0.022
Ask
Inquiry offensiveness Inquiry effectiveness Gender Variance explained Carry Condom attractiveness Gender Condom offensiveness Perceived severity Motivation Variance explained
24.3% 0.29 0.27 -0.22 0.14 0.11
23.1%
0.083 0.071 0.047 0.018 0.012
Use
Condom attractiveness Number of partners Perceived severity Condom use Variance explained Note. N = 351.
0.30 -0.21 0.17 0.14
17.8%
0.088 0.043 0.029 0.018
TABLE 4 Significant Predictors of Reported Intentions: Gender Differences Gender Intention and Predictor Variables
Womenh
Men*
0
R2 Change
Ask
Inquiry offensiveness Inquiry effectiveness Variance explained Carry Condom attractiveness Motivation Condom use Condom offensiveness Perceived severity Variance explained
"CO
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HEALTH BELIEFS AND HIV-PREVENTIVE INTENTIONS
-0.36 0.28
0.131 0.076 20.7%
-0.27 0.32
0.070 0.105 17.5%
0.35 0.19 0.18
0.121 0.035 0.032
0.20
0.040
_ _
-0.33 0.24
0.110 0.056 20.6%
0.093 0.047 0.030 0.028
0.29 -0.20
0.086 0.040
0.26 -0.15
0.067 0.022 21.5%
_ _
_ —
18.8%
Use
Condom attractiveness Number of partners Condom use Age
Perceived severity Condom offensiveness Variance explained *n = 154. bn = 194.
R2 Change
0.31 -0.22 0.18 -0.17 _ —
_ _
19.8%
_ —
— —
— _
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368
ABRAHAM, SHEERAN, SPEARS, ABRAMS
women's intentions to carry condoms and a significant predictor of their intentions to use them, it was not a significant predictor of men's intentions. Similarly, perceived severity was a significant predictor of women's intentions to carry and to use condoms but was not a predictor of men's intentions. Thus, perceived condom offensiveness and perceived severity of HIV infection may be important to sexually active teenage women but not to their male counterparts. Previous condom use was a significant predictor of men's intentions to carry and to use condoms but was not a predictor of women's intentions. Motivation was a significant predictor of men's intentions to carry condoms, and, perhaps surprisingly, older men were less likely to intend to use condoms. Last, sexual experience was a predictor of both men's and women's intentions to use condoms. Table 5 shows the results of multiple regressions conducted separately for the younger (16-year-old) and older (18-year-old) cohorts. It is notable that there were more predictors of the older cohort's intentions, and several predictors accounted for more variance in the older group's intentions. Thus, the specified variables appear to provide a much better guide to the determinants of the older cohort's intentions. Inquiry offensiveness and effectiveness were important predictors for both groups. However, although inquiry effectiveness was more important for the younger group, inquiry offensiveness was much more important for the older group. Gender and environmental cues were also significant predictors of the older group's intentions to ask, and, collectively, these four variables account for slightly more than 32% of the variance in the older group's intentions to ask. Condom attractiveness was an important predictor of both groups' intentions to carry and to use condoms. It was a better predictor of the younger group's intentions to use condoms and, indeed, was the only significant predictor of these intentions. Condom offensiveTABLE 5 Significant Predictors of Reported Intentions: Cohort Differences Cohort Intention and Predictor Variables Ask Inquiry effectiveness Inquiry offensiveness Gender Cues Variance explained Carry Gender Condom attractiveness Condom offensiveness Motivation Number of partners Variance explained Use Condom attractiveness Number of partners Perceived severity Perceived vulnerability Condom offensiveness Variance explained a
/i = 177. bn = 174.
16-Year-Olds*
18-Year-Oldsb R2 Change
R2 Change 0.33 -0.26 — —
0.110 0.068 — — 17.8%
0.28 -0.44 -0.19 0.15
0.077 0.191 0.033 0.021 32.2%
0.31 0.24 -0.18 — —
0.096 0.060 0.030 — — 18.6%
0.21 0.33 -0.27 0.21 -0.17
0.045 0.111 0.073 0.044 0.025 29.8%
0.30 — —
0.088 — — 8.8%
0.22 -0.42 0.20 -0.17 -0.17
0.049 0.172 0.039 0.027 0.026 31.3%
ness, on the other hand, was a better predictor of the older group's intentions to carry and to use condoms. When these results are combined with the pattern of predictors for intention to inquire about previous sexual partners, it appeared that social barriers indicated by the offensive measures may be generally more important for the older teenagers. Gender was an important predictor of the younger group's intentions to carry condoms, indicating that younger women were less likely to intend to carry condoms. Motivation and number of previous sexual partners were both predictors of the older group's intentions to carry—with 29.8% the variance being explained. Reported lifetime partners was a very important predictor of the older teenagers' intentions to use condoms, and, following the pattern for the overall sample, those with higher partner turnover were less likely to intend to use condoms. Perceived severity and vulnerability were also significant predictors of the older group's intentions to use condoms, and it is noteworthy that those who regarded themselves as most vulnerable were least likely to intend to use condoms. Overall, five variables accounted for 31.3% of the variance in the older group's intentions to use condoms.
DISCUSSION Reported intentions to question new partners about their previous sexual histories were importantly related to perceived offensiveness and to the perceived trustworthiness of replies. The majority of respondents disagreed that such inquiry was offensive, suggesting that acceptability to teenage peers could be highlighted in future campaigns. Cohort differences indicated that concerns about inquiry offensiveness may be particularly important to older teenagers. Such questioning offers no direct protection against HIV infection, but previous work suggests that raising the issue of protection is a key prerequisite of taking precautions. Studies of contraceptive use have shown that discussion between partners and perceptions of communicativeness are important predictors of effective contraception (Gold & Berger, 1983; Jorgensen, King, & Torrey, 1980; Milan & Kilmann, 1987; Polit-O'Hara & Kahn, 1985). Thus, the value of promoting questions concerning partners' sexual histories lies primarily in encouraging the initiation of a risk-appraisal dialogue. Viewed from this perspective, the importance of perceived trustworthiness is discouraging. Future campaigns might minimize the impact of perceived trustworthiness by promoting discussion of risk while warning against uncritical acceptance of potential partners' accounts. However, it is worth noting that advocating such discussion may be ineffective unless interventions also seek to foster the development of required communication skills (Catania, Kegeles, & Coates, 1990; Holland, Ramazanoglu, & Scott, 1990). In contrast to previous studies (DiClemente, J. Zorn, & Temoshok, 1986), high levels of perceived condom effectiveness were observed, and a ceiling effect may have minimized the impact of such perceptions on reported intentions to carry and use condoms. However, as in studies of contraceptive behavior (Lowe & Radius, 1987; Morrison, 1985), perceived barriers to condom use were shown to be important predictors. Beliefs concerning pleasure reduction, consensual views on awkwardness of use, and partners' likely response to suggested use were seen to be importantly related to intentions to carry and to use condoms. These findings recommend closer attention to perceptions of the perceived social consequences of particular HIV-preventive behaviors. Substantial investments have been made
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HEALTH BELIEFS AND HIV-PREVENTIVE INTENTIONS
in broadcasting young people's vulnerability to infection, the severity of infection, and condom effectiveness. Future interventions may be more influential if they focus on social acceptability barriers. Interesting gender differences emerged. Perceived severity and offensiveness were more closely related to women's reported intentions to carry and to use condoms. Perceived offensiveness was particularly important in relation to the intention to carry condoms. Thus, attempts by U.K. campaigns to persuade teenage women that "smart girls carry condoms" may be unsuccessful unless they explicitly address the connotations of promiscuity attached to planned protection and the potential offensiveness of wanting to protect oneself from a sexual partner. This may be particularly salient for younger teenage women. These findings remind us that double standards in the judgment of men's and women's sexual behaviors may have an important impact on the adoption of HIV-preventive behavior (Condor, 1986; Spears, Abrams, Sheeran, Abraham, & Marks, 1991). Gender expectations may imply that it is illegitimate for young women to publicly plan sexual behavior (Holland, Ramazanoglu, & Scott, 1990; Lees, 1986). This will inhibit their preventive intentions, disempower them in sexual negotiations, and thereby reduce preventive action (Holland, Ramazanoglu, & Scott, 1990; Holland, Ramazanoglu, Scott, Sharpe, & Thomson, 1990; Jorgensen et al., 1980). If gender roles are to be challenged, HIVpreventive interventions must change radically from provision of information to what Homans and Aggleton (1988) called "socially transformatory" approaches that explicate and question sexual norms. Compared to 16-year-olds, 18-year-olds had more previous partners and were more likely to have used condoms. The younger group's intentions were very poorly predicted by the specified HBM variables, whereas approximately one third of the variance in the older group's intentions was accounted for. This may suggest that greater maturity results in enhanced rational decision-making as proposed by HBM. In one sense, these findings are encouraging because the late teen years constitute an important HIV-risk period. However, that larger numbers of lifetime partners decreased the likelihood of intended condom carrying and use is disconcerting. The number of reported previous partners was correlated with perceived vulnerability for the total sample, suggesting that teenagers may be aware of the risks involved. Nevertheless, these results underline the importance of targeting teenagers who have high partner turnovers (Sorenson, 1973). These results also emphasize the need for further exploration of the psychological prerequisites of HIV-preventive intentions and behaviors in younger sexually active teenagers. The overall pattern of results shows that perceived barriers, particularly awareness of impression-management processes, were important predictors of teenagers' endorsement of HIV-preventive intentions. However, many of the variables specified by HBM failed to predict intentions. Ceiling and floor effects may reduce the importance of perceived condom effectiveness and perceived vulnerability, whereas high levels of knowledge and awareness may diminish the importance of memory for preventive campaigns. Variables outside the modifiable belief structure specified by HBM were also found to predict intentions (e.g., gender, number of lifetime partners). Thus, although the variables specified here included useful predictors, the results suggest that HBM is not a good guide to the psychological prerequisites of HIV-preventive intentions. Unexplained variance suggests that other important predictors could be identified.
Men and women and younger and older cohorts appeared to be differentially influenced by particular barriers. This emphasizes the importance of group-specific psychological prerequisites of HIVpreventive intentions and behavior. The sample was drawn from an area with a particular HIV-transmission problem, and it would be interesting to establish to what extent these findings generalize to teenagers in other regions. Similar studies focusing on different teenage groups would be illuminating. The study also raises methodological issues. Although a fairly substantial literature on HlV-relevant cognitions has been established, researchers have employed a variety of measures in operationalizing variables such as perceived vulnerability and severity. The difference between measures—and the unknown effect that participants' particular exposure to HIV-educational material has on their interpretation of response scales—makes clear comparisons problematic. It would be helpful if greater standardization of multiple-item measures could be achieved. The present study used a single item-to-index motivation, and the relative importance of this variable may warrant further investigation. Intentions have been shown to be important prerequisites of various preventive behaviors, and this study used a cross-sectional design to explore the psychological determinants of teenager's HIVpreventive intentions. However, longitudinal studies that relate intentions and other cognitions to HIV-preventive behaviors are required. Several such longitudinal studies of gay men have been reported (e.g., Fitzpatrick et al., 1990; McCusker, Stoddard et al., 1989; McCusker, Zapka, Stoddard, & Mayer, 1989; Siegel, Mesagno, Chen, & Christ, 1989). These reveal differences between samples and emphasize the importance of variables other than HBM components and intentions—for example, availability of social support, relationship status, drug use, and previous "unsafe" sexual behavior. Similar studies of the determinants of teenagers' HIV-preventive behaviors would be valuable to those planning interventions with this group.
ACKNOWLEDGMENTS This research was supported by Economic and Social Research Council Grant XA44 250001 (Swindon, SN2 6UQ, England). We thank three anonymous reviewers for their helpful comments on an earlier version of this article. Paschal Sheeran is now at the University of Sheffield, England.
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