JOIJFtNAL OF ADOLESCENT HEALTH 1991;12:385-390
RALPH Je DICLEMENTE,
Ph.D.
Data were collected from 112 sexually active adolescents incarcerated in a juvenile detention facility to identify predictors of consistent use of condoms during sexual intercourse. Adolescents completed an anonymous epidemiologic survey instrument developed by the Ceutew for Disease Control. The self-report survey assessed. demographic, psychosocial, and behavioral factors. Three factors were idlentified as associated with consistent condom use. These significant bivariate factors weice entered into a multivariate logistic regression model to identify the independent contribution of each factor. Non-Black adolescents, adolescents who communicate with their sex partners about AIDS, and those who perceive peer uorms as supporting condom use were significantly more likely to be coneistent condom users, The Iindings SU~&I that Human Immunodeficiency Virus @WV) preventsean ipr~ grams fbr incarcerated adolescents that emphasi.ze training in ccnmmunicationskills and fi.odifying pesceptions
of peer normatiw behavior may be more effective in increasing the adoption and maintenance of condom use.
RRY WORDS:
Incarcerated adolescents HIV Condom use
From the Center for AIWS Prevention Studies at the Universi$! of California and the Bayview-Hunter’s .Point Foundation. SanFran&co,
Cui$orniu.
”
Address reprint requests to: Ralph J. DiClemente, Ph.D., Centerfbr AIDS Prevention Studies, University of California, 74 New Montgomery Street, Suite 600, San Francisco, CA 94105. M!muscri~~rccepted May 21, 1991. 6 Society for Adolescent Medicine, 1991 _.. . Published by BlsevierScience Publishing Ice., Inc., b55 Avenue of tne menm,
Sexual behavior Communication ski& Perceived peer norms
Many adolescents engage in high-risk sexual and drug-related behaviors associated with hu.man immunodeficiency virus (HIV; transmission (l-4). While a considerable body of information exists describing adolescent knowledge and attitudes about acquired immunodeficiency syndrome (AIDS) (5), much of these data is derived from school-based surveillance surveys (6). Less information is available about adolescents incarcerated in juvenile detention facilities. Recent surveys have identified a high prevalence of risk behaviors among inmerated adolescents (712). Comparative studies have shown that, relative to a school-based sample, incarcerated adolescents have a substantially higher prevalence of HIVrelated sexual risk behaviors (10) while reporting less agreement with health guidelines, a lower perceived threat of HIV, lower personal efficacy to prevent HIV infeciion, and lower perceived norms i;i safe sex practices 63). Although there is some evidence to suggest that condom use has increased among incarcerated adolescents (14), it remams :I.lgnificantly lower than a school-based adolescent sample (10). For sexually active adolescen*c;, the best prevention strategy is to use condoms ct. as;stently during sexual intercourse (15,16). While Ilatex,:ondoms pro-
Net r York, NY 10010
385 01974070/9V$3.50
386
DICLFMENTE
hibit the transmission of viral pathogens, including HJ,V (17,18), their effectiveness as a risk-reduction strategy is dependent on appropriate and consistent use. Adolescents, in general, have not been consistent users of condoms. A recent survey identified a sizable proportion of incarcerated adolescents (29%) as “‘always” using condoms during sexual intercourse (10). Although a number of factors have been hypothesized as influencing condom use \19), few studies have specifically explored the predictors of condom use among adolescents (20), and most of these studies have focused on school-based or clinic samples. Although informative, the relevance of these findings fcr incarcerated adolescents may be limited. At present, there are few data describing the factors which motivate incarcerated adolescents to consistently !!se condoms. Understanding the factors associated with this HIV risk-reduction strategy may be useful in the development of prevention programs specifically targeted at this adolescent population (21). The present study examined the influence of demographic, behavioral, and psychosocial factors as predictors of consistent condom use among adolescents incarcerated in a juvenile detention facility in a high AIDS prevalence area.
JOURNAL OF ADOLESCENT HEALTH Vol. 12, Nu. 5
munication with sexual partners about threat of HIV, and prevalence of sexual behaviors. Developed as an epidemiologic survey instrument, the questionnaire contained 49 items with predefined response categories. The response categories for each item used binary responses (Yes-No), categorical responses (True-False-Unsure), or a Likert scale response format to increase readability and facilitate administration. Of the 123 adolescents e!igible to participate in the present study, 94% (n = 113) compl&ed questionnaires. Of these, 99.1% (n = 112) reported having had sexual intercourse. This sexually active group comprises the sample for this report.
Measures All measures were derived from the CDC self-report questionnaire It is important to note that the questionnaire was designed for epidemiologic surveillance of adolescent knowledge, attitudes, and behaviors and that test-retest reliability has not been established.
General AIDS Knowledge
Methods In February of 1988, adolescents incarcerated at a detention facility in San Francisco who were attending the Court Day School were asked to participate in a survey assessing their knowledge, attitudes, and behaviors related to HIV. Adolescents were administered an in-class questionnaire during a single class period as part of their educational program. The self-report questionnaire was entirely anonymous, requiring neither names or identification codes. The questionnaire used in the present study was developed by the Centers for Disease Control (CDC) in 1988 in conjunction with local and state education agencies as part of the nationwide surveillance of adolescent HIV-related knowledge, atti?&,-, ;;r,:l risk behaviors and has been administered in many school districts throughout the United States using a similar administration probcol (6). The questionnaire assessed demographic information and asked about knowledge of HIV transmission and prevention, perceived susceptibility to HIV infection, com-
The questionnaire assessed AIDS knowledge using a True-False-Unsure response format. To develop an HIV knowledge scale all correct responses to 16 knowledge items were summed yielding a composite score. Knov&dge scores ranged from l-16 with a median of 11 correct responses. High and low HIV knowledge categories were determined based on a median split of the distribution of knowledge scores. The standardized 01 coefficient for the knowledge scale, a measure of internal reliability, was 0.71.
Risk-Reduction Knowledge Six items on the questionnaire assessed the ,-Jolescents’ knowledge about risk-reduction strategies. A similar computational strategy was used in which all correct responses to the risk-reduction i iems were summed creating a scale specificalh assessing knowledge of risk-reduction. Scale sores ranged from O-6 with a me&an of four cortect responses. High and low risk-rcducticn knowledge categories were determined based OG a median split for the distribution of scores. The standardized c1coefficient was 0.61.
July 1991
PREDICTORS OF CONDOM 3SE AMONG ADOLESCENT::
Perceived Peer Norms Adolescents’ perceptions of peer norms was assessed on the basis of the response to the question “How many persons your age do you think are using condoms during sexual intercourse”;’ Adolescents responded using a 5-point Likert scale of “almost aH1”,“most”, “half“, “few”, and “none”. Based on tlhe distribution of consistent condom use at each level, the scale was dichotomized into two levels with C;IP response categories “ahnost all” and “mo!W:-’collapsed into a single category defined as “High” perceived peer support for condom use. The remaining cotegorie,*~7were collapsed into ~1siiagle category defined as “‘Low” perceived p-rer support for condom use.
Communication about AIDS Adolescents communication with ser. partners about AIDS was assessed by their reaponse to the question “Because of AIDS, have you ever talked with your boyfriend or girlfriend about AIDS before having sexual intercourse”?
Perceived Susceptibility Perceived susceptibility was assessed using a single
337
tent condom users while the remainder of the sample was categorized as irifrequent condom users.
Statistical Analysk The association between predictors and consistent condom use was assessed using contingency rable analyses. Thz x-square statistic and its corresponding probability level, rate ratio, and 95% confidence limits were computed to assess the significance and magnitude of these bivariate associations ‘?_ E!ctors identified as significantly associat+’ .tilth consistent condom use in bivari:,: .- analyses were entered into a multivaript, logistic regression model. Logistic regresci.:.,i 1s particularly usefui for identifying th: Independent contribution of a variable ,vnlle adjusting for the simultaneous effects of other variables in the model. The x-square statistic was used to assess the overall statistical significan;.e of the logistic model and the K statistic was used to evaluate the predictive power of the modei i,s~correctly classify adolescents into condom-use categories. An adju.‘“ad .c odds ratio (OR) was calculated for each categor 7 to a ;zess the magniturla of association between statistically significant predictors and consister-r: condom IJSP {?3).
item, “Do you think you can get AIDS’?
Results
Prevalence of Sexual Behaviors
? he demographic characteristics of the samp?e are displayed in Table 1. The samyle was disproportionakiy male (76.40/c) and Black (65%). Frequency of condom use was low; 34.6% of adolescents reported frequency of condom use as “rarely” or
These measures include age at sexual debut (12 years of age or younger, 13-14 years of age, 15-16 years of age, 17-M years of age), number of lifetime sex partners, and number of sex yzrtners in the past year (none, one, two, three, or more).
Frequency of Condom Use Frequency of condom use was assessed using a 4point Likert scale of ‘always, sometimes, rarely, and never”. Approximaccly 28.6% of the sample reported “always” using condoms ‘during sexual intercourse. The proportion of adolescents reporting “sometimes”, “rarely,” or “never” using condoms was 36.7%; 17.3%, and 17.3Y0, respectively. Given that any frequency of condom use less than “always” entails a risk for HIV/or sexually transmitted disease transmission, adolescents reporting ’ ai:&!a Ys” using condoms were categorized as consis-
Table 1. Demc;graphics Charxteristiis of Sexually Active Sample ‘X II --Gen,ier m‘tie 76.4 84 ferde
23.6
26
5’4 15-16 17-!8
io. 1 53.6 30.4
18 60 34
Race White Black Hispanic Asim Other
11.0 65.1 10.1 5.5 8.3
12 71 11 6 9
Age
_-
_-_.,.--
388
DICLEMENTE
“never”. A high
proportion of adolescents reported three or more sex partners in their lifetime (87.5%) and within the year prior to participating in the survey (73.8%). The majority also report their sexual debut before twelve years of age (52.1%). ~ivtiate associations between demographic, psychos&ial, and behavior measures and consistent condom use are displayed in Table 2. Three factors were identified as significantly associated with consistent condom use: race, perc&eddpeer norms, and communication with sex partners about AIPS. Based on the overwhelming predominance of Black adolescents in the sample, the other ethnic groups were combined into a single category (non-Black) to facilitate a comparison with Black adolescents. Only 19% of Black adolescents were cmsistmt condom users compared with 43% of adolescents in the non-Black group (P = .Ol). With respect to psychosocial factors, adolescents who communicate with their sex partners about AIDS and who perceive peer norms as supporting condom use d&kg sexual intercourse were 3.8 and 2.3 times more likely to be consistent condom users compared with adolescents who did not talk with sex partners about AIDS (59.3% versus 15.4%; P = .OOOl)or who do not perceive peer normative behavior as supporting condom use (48.1% versus 21.1; P = .008). Factors not associated with consistent condom use include age, gender, general HIV knowledge, knowlr;gc of HIV risk-reduction strategies, perceived susceptibility to HIV infection, age at sexual debut, number of lifetime sex partners, and ~-.C~~r Of partners in the year prior ,sr 31; survey. When the thaw fticirorsidentified in the bivariate ansl$ti ds significantly batiociated with consistent
condom use were entered into a multivariate logistic regression analysis, the overall model is statistically significant (x2 = 34.8; P = .OOOl).The predictive power of the model was high; the model correctly classified 78.9% of the adolescents into their condom use categories, whereas based on chance alone only 55.5% would have been correctly classified (K = 0.53; P = .oool). With respect to individual predictors’ independent contribution to the model, the three factors were independently associated with consistent condom use. Non-Blacks (adjusted OR = 10; P = .OOS), adolescents who communicate with their sex partners about AlDS (OR = 15.3; P = .0006), and those who perceive peer norms as supporting condom use (OR = 6.7; P = -01) were significantly more likely to be consistent condom users.
JOURNAL OF ADOLBSCEN’FHE.4LTH Vol. 12, No. 5
The interaction between ethnicity (Black versus non-Black) and perceived peer norms and communication with sex partners about AIDS was examined arcd found not to be sllgnificant (P = .45 and P = Table 2. Association Between Predictors and Consistent Condom 1Jse
Characteristic
n
Consistent condom use (% reporting)
PR
95% CL
DEMOGRAPHICS Gender Female Male Age 16 or younger 17 or older’ Ethnic@ Non-Black’ Black’
(28) (78)
45.0 24.4
1.8 -
l&3.4 -
(15) (83)
20.0 30.1
0.7 -
0.3-1.9 -
(32) (63)
43.8 19.0
2.3 -
1.2-4.4 -
HIV-RELATED KNOWLEDGE General HIV knowledge (56) 32.1 LOW’ 0.5-1.6 (42) 23.8 0.9 High Knowledge about risk-redution strategies (42) 31.8 Low’ 8.4-1.4 (56) 26.8 0.7 High PSYCHOSOCIAL FACTORS Talk with sex partners about AIDS 10 -5 (27) 59.3 3.8 Yes 1’;a No’ (52) Perception of rip*: r:Giiid supporting condom use (27) 48.1 2.3 High 1.M.l (71) 21.1 Low’ Perceived susceptibiiity to HIV infection (70) 27.1 0.8 Yes 0.4-1.6 (27) 33.3 No’ EEHAVIOEAL FACTORS Age at Sexual Debut (49) 24.5 512 years (27) 22.2 0; 13-14 years 0.4-2.1 (15) 26.7 1.1 215 years 0.4-2.9 Number of lifetime sex partners (18) 30.0 1.1 one or two 0.4-3.0 (69) 27.5 5 three’ Number of sex partners (previous year) 33.3 1.3 0.6-2.7 one or two 25.8 zthree’ PR, Prevalence ratio; 95% CL, =95% confidence limits. ‘Referent category for calculation of prevalence ratio. ‘Includes adolescents self-identifying as White, Asian, Latino, and Other.
P
July 1991
PREDICTORS OF CONDOM USE AMONG ADOLESCENTS
.91, respectively). Moreover, sexual communication was not significantly associated with perception of peer norms (P = .59).
The findirigs demonstrate that differences in ethnicity, perception of peer norms, and communicating with sex partners about AIDS are significant and independent predictors of consistent condom use among incarcerated adolescents. With respect to ethnic differences, the present findings with incarcerated adolescents confirm data demonstrating that Black adolescents, in generai, have a higher prevalence of sexual risk behaviors than other ethnic graups (24). The lack of an association between ethnicnty and perceived peer norms and communicdtton with sex partners about AIDS suggests that ethnic differences are independent of these psychosocial factors. Thus, cultural variables-not assessed in this study-may be more relevant to explaining the strong association between being a Black adolescent and having a higher prevalence of sexual risk-taking behavior (25). Another factor influencing tile use of condoms is adolescents’ perception of peer normative behavior. n. .-:. _;i;r;J referent-group norms are those behavioral patterns that adolescents perceive as being sanctioned by their peers (26). This concept, though similar to peer pressure, is differentiated by the fact that it reflects adolescents’ perception of what they consider normative behavior by their peer referent group. The perception that a majority of other adolescents consistently use condoms during bexual intercourse, the perceived behavioral norm, exerts considerable influence on their use of condoms. If adolescents, even high-risk adolescents, can be convinced that their use of condoms is consistent with referent-group norms, they may be murtr IlKely to practice low-risk behaviors (27). The most powerful predictor of consistent condom use was communicating with sex partners about AI% .il?recent report has also identified communica&& as positively influencing condom use among adolescents in a population of older, White female adolescents (28). Thus, the present finding of a relationship between communication with sex partners about AIDS and consistent condom use corroborates and extends this research to a high-risk, predominantly Black male population. A number of factors were not related to consistent condom use. Two, in particular, were knowledge
389
about HIV and, more ~~e,-lf&iiy, kntitiledge about risk-reduction strategies. Clearly, HIV knowledge is necessary for adolescents to identify behaviors which are effective risk-reduction strategies and, as important, those which are not. However, the present findings confirm numerous other studies which indicate that HIV knowledge, in and of itself, is not sufficient to motivate the adoption and maintenance of HIV-preventive behaviors (19,20).
Limitations of the Study The present study is not without limitations. Foremost, this study used a cross-sectional research design. Additional studies using a prospective cohort design. will be necessary to evaluate the significance and stability of these predictors to influence consistent condom use over time. Second, the sample size was small; especially the number of non-Black adolescents. This may limit the reliability of the findings, especially as they relate to ethnic differences, Unfortunately, due to the very small number of no~iBlack adolescents, other ethnic groups were collapsed to form a referent comparison (non-Black). While demonstrating a lower likelihood of consistent condom use among Black adolescents, collapsing ethnic groups which have distinct cultural variation reduces the utility of the findmgs. i+,~tire t.$Jdies with sufficiently large multicultural representation are needed Co identify cultural diticcences as they relate to condom use. Third, while the research questionnaire assessed a number of relevant psychosocial constructs that may influence condom use, it is limited in scope primarily because it was constructed as an epidemiologic survey instrument rather than an in-depth assessment tool. Additional constructs not able to be assessed in the present sbndy that could influence condom use include cultural measures such as acculturation, behavioral indices such as drug and aicohoP use and type of sexual activities, additional psychosocial measures such as self-esteem and self-efficacy, barriers to condom use, and developmental constructs. Further, while the use of predcfined response categories significantly increased the likelihood that adolescents, particularly those with limited reading ability, could complete the self-report questionnaire, this data collection methodology limits the variability of responses. More detailed information could be gatheied through other data-collection methodologies such as in-depth interviews with open-ended responae formats.
390
DICLEMENTE
Recommendations for IkrogramDevelopment The findings have implications for the development of I-W-prevention programs for this high-risk adolescent population. Programs whTch emphasize the didactic transfer of information about HIV transmission or risk-reduction strategies are not likely to be effective in modifying adolescent sexual risk behavior. Based on the prrsent findings, one recommendation would be to emphasize skills training and norm-setting activities such as developing and redefining communication skills around sexual negotiation and modifying perceptions about peer norms with respect to safer sex behavior. These skillbased programs may be more effective in increasing the likelihood that adolescents will adopt or maintain HIV-preventive behaviors (29-31JD
References 1. DiClemente RJ. The emergence of adolescents as a risk group for human immunodeficiencv virus infection. loumal of :1dol Research 1998;5:7-17. a 2. Hein K. AIDS in adoiescence. J Adolesc Health Care 1989;10:18S-35. 3. Hein K. Commentary on adolescent acquired immunodeficiency syndrome: The next wave of the human immilnodeficiency virus epidemic. J Pediatr 1989;114:144-9. 4. D’AngeIo t, Sondheimer D. Adolescents and HIV infection: Struggling not to bc forgotten. Pediatric AIDS and HIV Infection 1998;1:75-7. 5. DiClemente RJ. Adolescents and AIDS: Current research, prevention strategies and public policy. In: Temoshak L, Baum A, eds. Psychosocial Perspectives on AIDS: Etiology, Prevention, and Treatment. New Jersey: Erlbaum, 1998: 5164. 6. ICannL, Nelson CD. Jones JT, et al. Establishing a system of complementary school-be& surveys to annually assess HIVrelated knowledge, beliefs, and behaviors among adolescents. J Sch Health 1989;59:55-8. 7. Council on Scientific Affairs. Health status of detained and incarcerated youths. JAMA 1998;263~987-91. 8. Alexander-Rodriguez T, Vermund SH. Gonorrhea and sy philis in incarcerated urban adolescents: Prevalence and physical signs. Pediatrics 1987;80:561-4. 9. Bell TA, Farrow JA, Stamm WE, et al. Sexually transmitted diseases in females in a juvenile detention center. Sex Transm Dis 1985;12:14&144. 10. DiClemente RJ, Lanier MM, Horsn PF, et al. Comparison of AIDS knowledge, attitudes, and behaviors among ado& cents in a juvenile detention facility and public schoo!s in San Francisco. Am J Public Health 1991;81:628-38. 11. Lanier MM, McCarthy BR. AIDS awareness and the impact of AIDS education in juvenile corrections. Criminal Justice 1989;16:395-4ii.
JOURNAL OF ADOLESCENT HEALTH Vol. 12, No. 5
12. Larder M, DiClemente RJ, Horan PF. The impact of ecological factors and cultural diversity: Incarcerated adolescents’ AID3 awareness and precautionary measures. CriminaI Justice 1991;19:257-62. Nader PR, WexIer DB, Patterson TL, et al. Comparison of 13. beIiefs about AIDS among urban, suburban, incarcerated, and gay adolescents. J Adolesc Health Care 1989;10:413-8. 14. EBenbein DS, Weber FT, Grob G. Condom usage by a pop ulation of delinquent southern male adolescents. J Adolesc Health Care 1991;12:35-7. 15. Goldsmith M. Ser. in the age of AIDS calls for common sense and “condom sense”. JAMA 1987;257:2261-6. 16. Stone KM, Grimes DA, Magder LS. Primary prevention of sexually transmitted diseases. JAMA 1986;255:1763-6. 17. Conant M, Hardy D, Sematinger J, et al. Condoms prevent of AIDS-associated retrovirus. JAMA transmission 1986;255~1706. 18. Van de Perre P, Jacobs D, Sprecher-Goldberger S. The latex condom, an efficient barrier against sexual transmission of AIDS-related viruses. AIDS 1987;1:49-52. 19. DiCIemente RJ. Psychosocial predictors of adolescents’ HIVrelated risk-taking behavior. In: D’AngeIo L, Ma T, eds. HIV and Youth. New York: Elsevier, in press. 20. Becker MH, Joseph JG. AIDS and behavioral change to reduce risk: A review. Am J Public Health 1988;78:394-410. 21. Miller HG, Turner CF, Moses LE. AIDS The Second Decade. Summary. Washington, DC: National Academy Press, 1990. 22. Fleiss JL. Statistical Methods for Rates and Proportions. New York, John Wiley & Sons, 1973. 23. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York, John Wiley & Sons, 1989. 24. FuBiIove MT, Weinstein M, Fullilove RE, et al. Race/gender issues in sexual transmission of AIDS. In: Volberding P, Jacobson MA, eds. AIDS Clinical Review. New York: Marcel Dekker, 199% 25-62. 25. Bowser BP, FuIiiiove MT, FuiIiIove RE. African-American youth dnd AIDS high-risk behaviors. Youth dr Society 1990;2254-66. 26. r’isher JD. Possible effects of reference group-based social infiue.nce on AIDS-risk behavior and AIDS prevention. Am Psycho1 1988;43:914-2c. 27. Fisher JD, Miscovich SJ. Social intluence and AIDS-preventive behavior. in: Edwards J, Tir.daio RS, Heath L eds. Social Influence Processes and Prevention. New York: Plenum, laso: 39-70. 28. Catania JA, Dolcini MM, Coates TJ, et al. Predictors of condom use and multiple partnered sex among sexually-active adolescent women: Implications for AIDS-related health interventions. J Sex Res 1989;26:514-24. 29. Flora JA, Thoresen CE. Components of a comprehensive strategy for reducing the risk of AIDS in adolescents. In: Mays VM, Albee GW, Schneider, SF, eds. Primary Prevention of AIDS. Newbury Park: Sage, 1989: 374-389. 30. Schmke S, Blythe B, Gilchrist L. Cognitive-behavioral prevention of adolescent pregnancy. J Couns Psycho1 1981;28:451-4. 31. DiClemente‘ItJ, Boyer CB, Miis S. Prevention of AIDSamong adnlescents: Strategies for the devebpment of comprehensave risk-redu&on health education programs. Health Educ Res 1987;2:287-91.
RALPH Je DICLEMENTE,
Ph.D.
Data were collected from 112 sexually active adolescents incarcerated in a juvenile detention facility to identify predictors of consistent use of condoms during sexual intercourse. Adolescents completed an anonymous epidemiologic survey instrument developed by the Ceutew for Disease Control. The self-report survey assessed. demographic, psychosocial, and behavioral factors. Three factors were idlentified as associated with consistent condom use. These significant bivariate factors weice entered into a multivariate logistic regression model to identify the independent contribution of each factor. Non-Black adolescents, adolescents who communicate with their sex partners about AIDS, and those who perceive peer uorms as supporting condom use were significantly more likely to be coneistent condom users, The Iindings SU~&I that Human Immunodeficiency Virus @WV) preventsean ipr~ grams fbr incarcerated adolescents that emphasi.ze training in ccnmmunicationskills and fi.odifying pesceptions
of peer normatiw behavior may be more effective in increasing the adoption and maintenance of condom use.
RRY WORDS:
Incarcerated adolescents HIV Condom use
From the Center for AIWS Prevention Studies at the Universi$! of California and the Bayview-Hunter’s .Point Foundation. SanFran&co,
Cui$orniu.
”
Address reprint requests to: Ralph J. DiClemente, Ph.D., Centerfbr AIDS Prevention Studies, University of California, 74 New Montgomery Street, Suite 600, San Francisco, CA 94105. M!muscri~~rccepted May 21, 1991. 6 Society for Adolescent Medicine, 1991 _.. . Published by BlsevierScience Publishing Ice., Inc., b55 Avenue of tne menm,
Sexual behavior Communication ski& Perceived peer norms
Many adolescents engage in high-risk sexual and drug-related behaviors associated with hu.man immunodeficiency virus (HIV; transmission (l-4). While a considerable body of information exists describing adolescent knowledge and attitudes about acquired immunodeficiency syndrome (AIDS) (5), much of these data is derived from school-based surveillance surveys (6). Less information is available about adolescents incarcerated in juvenile detention facilities. Recent surveys have identified a high prevalence of risk behaviors among inmerated adolescents (712). Comparative studies have shown that, relative to a school-based sample, incarcerated adolescents have a substantially higher prevalence of HIVrelated sexual risk behaviors (10) while reporting less agreement with health guidelines, a lower perceived threat of HIV, lower personal efficacy to prevent HIV infeciion, and lower perceived norms i;i safe sex practices 63). Although there is some evidence to suggest that condom use has increased among incarcerated adolescents (14), it remams :I.lgnificantly lower than a school-based adolescent sample (10). For sexually active adolescen*c;, the best prevention strategy is to use condoms ct. as;stently during sexual intercourse (15,16). While Ilatex,:ondoms pro-
Net r York, NY 10010
385 01974070/9V$3.50
386
DICLFMENTE
hibit the transmission of viral pathogens, including HJ,V (17,18), their effectiveness as a risk-reduction strategy is dependent on appropriate and consistent use. Adolescents, in general, have not been consistent users of condoms. A recent survey identified a sizable proportion of incarcerated adolescents (29%) as “‘always” using condoms during sexual intercourse (10). Although a number of factors have been hypothesized as influencing condom use \19), few studies have specifically explored the predictors of condom use among adolescents (20), and most of these studies have focused on school-based or clinic samples. Although informative, the relevance of these findings fcr incarcerated adolescents may be limited. At present, there are few data describing the factors which motivate incarcerated adolescents to consistently !!se condoms. Understanding the factors associated with this HIV risk-reduction strategy may be useful in the development of prevention programs specifically targeted at this adolescent population (21). The present study examined the influence of demographic, behavioral, and psychosocial factors as predictors of consistent condom use among adolescents incarcerated in a juvenile detention facility in a high AIDS prevalence area.
JOURNAL OF ADOLESCENT HEALTH Vol. 12, Nu. 5
munication with sexual partners about threat of HIV, and prevalence of sexual behaviors. Developed as an epidemiologic survey instrument, the questionnaire contained 49 items with predefined response categories. The response categories for each item used binary responses (Yes-No), categorical responses (True-False-Unsure), or a Likert scale response format to increase readability and facilitate administration. Of the 123 adolescents e!igible to participate in the present study, 94% (n = 113) compl&ed questionnaires. Of these, 99.1% (n = 112) reported having had sexual intercourse. This sexually active group comprises the sample for this report.
Measures All measures were derived from the CDC self-report questionnaire It is important to note that the questionnaire was designed for epidemiologic surveillance of adolescent knowledge, attitudes, and behaviors and that test-retest reliability has not been established.
General AIDS Knowledge
Methods In February of 1988, adolescents incarcerated at a detention facility in San Francisco who were attending the Court Day School were asked to participate in a survey assessing their knowledge, attitudes, and behaviors related to HIV. Adolescents were administered an in-class questionnaire during a single class period as part of their educational program. The self-report questionnaire was entirely anonymous, requiring neither names or identification codes. The questionnaire used in the present study was developed by the Centers for Disease Control (CDC) in 1988 in conjunction with local and state education agencies as part of the nationwide surveillance of adolescent HIV-related knowledge, atti?&,-, ;;r,:l risk behaviors and has been administered in many school districts throughout the United States using a similar administration probcol (6). The questionnaire assessed demographic information and asked about knowledge of HIV transmission and prevention, perceived susceptibility to HIV infection, com-
The questionnaire assessed AIDS knowledge using a True-False-Unsure response format. To develop an HIV knowledge scale all correct responses to 16 knowledge items were summed yielding a composite score. Knov&dge scores ranged from l-16 with a median of 11 correct responses. High and low HIV knowledge categories were determined based on a median split of the distribution of knowledge scores. The standardized 01 coefficient for the knowledge scale, a measure of internal reliability, was 0.71.
Risk-Reduction Knowledge Six items on the questionnaire assessed the ,-Jolescents’ knowledge about risk-reduction strategies. A similar computational strategy was used in which all correct responses to the risk-reduction i iems were summed creating a scale specificalh assessing knowledge of risk-reduction. Scale sores ranged from O-6 with a me&an of four cortect responses. High and low risk-rcducticn knowledge categories were determined based OG a median split for the distribution of scores. The standardized c1coefficient was 0.61.
July 1991
PREDICTORS OF CONDOM 3SE AMONG ADOLESCENT::
Perceived Peer Norms Adolescents’ perceptions of peer norms was assessed on the basis of the response to the question “How many persons your age do you think are using condoms during sexual intercourse”;’ Adolescents responded using a 5-point Likert scale of “almost aH1”,“most”, “half“, “few”, and “none”. Based on tlhe distribution of consistent condom use at each level, the scale was dichotomized into two levels with C;IP response categories “ahnost all” and “mo!W:-’collapsed into a single category defined as “High” perceived peer support for condom use. The remaining cotegorie,*~7were collapsed into ~1siiagle category defined as “‘Low” perceived p-rer support for condom use.
Communication about AIDS Adolescents communication with ser. partners about AIDS was assessed by their reaponse to the question “Because of AIDS, have you ever talked with your boyfriend or girlfriend about AIDS before having sexual intercourse”?
Perceived Susceptibility Perceived susceptibility was assessed using a single
337
tent condom users while the remainder of the sample was categorized as irifrequent condom users.
Statistical Analysk The association between predictors and consistent condom use was assessed using contingency rable analyses. Thz x-square statistic and its corresponding probability level, rate ratio, and 95% confidence limits were computed to assess the significance and magnitude of these bivariate associations ‘?_ E!ctors identified as significantly associat+’ .tilth consistent condom use in bivari:,: .- analyses were entered into a multivaript, logistic regression model. Logistic regresci.:.,i 1s particularly usefui for identifying th: Independent contribution of a variable ,vnlle adjusting for the simultaneous effects of other variables in the model. The x-square statistic was used to assess the overall statistical significan;.e of the logistic model and the K statistic was used to evaluate the predictive power of the modei i,s~correctly classify adolescents into condom-use categories. An adju.‘“ad .c odds ratio (OR) was calculated for each categor 7 to a ;zess the magniturla of association between statistically significant predictors and consister-r: condom IJSP {?3).
item, “Do you think you can get AIDS’?
Results
Prevalence of Sexual Behaviors
? he demographic characteristics of the samp?e are displayed in Table 1. The samyle was disproportionakiy male (76.40/c) and Black (65%). Frequency of condom use was low; 34.6% of adolescents reported frequency of condom use as “rarely” or
These measures include age at sexual debut (12 years of age or younger, 13-14 years of age, 15-16 years of age, 17-M years of age), number of lifetime sex partners, and number of sex yzrtners in the past year (none, one, two, three, or more).
Frequency of Condom Use Frequency of condom use was assessed using a 4point Likert scale of ‘always, sometimes, rarely, and never”. Approximaccly 28.6% of the sample reported “always” using condoms ‘during sexual intercourse. The proportion of adolescents reporting “sometimes”, “rarely,” or “never” using condoms was 36.7%; 17.3%, and 17.3Y0, respectively. Given that any frequency of condom use less than “always” entails a risk for HIV/or sexually transmitted disease transmission, adolescents reporting ’ ai:&!a Ys” using condoms were categorized as consis-
Table 1. Demc;graphics Charxteristiis of Sexually Active Sample ‘X II --Gen,ier m‘tie 76.4 84 ferde
23.6
26
5’4 15-16 17-!8
io. 1 53.6 30.4
18 60 34
Race White Black Hispanic Asim Other
11.0 65.1 10.1 5.5 8.3
12 71 11 6 9
Age
_-
_-_.,.--
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“never”. A high
proportion of adolescents reported three or more sex partners in their lifetime (87.5%) and within the year prior to participating in the survey (73.8%). The majority also report their sexual debut before twelve years of age (52.1%). ~ivtiate associations between demographic, psychos&ial, and behavior measures and consistent condom use are displayed in Table 2. Three factors were identified as significantly associated with consistent condom use: race, perc&eddpeer norms, and communication with sex partners about AIPS. Based on the overwhelming predominance of Black adolescents in the sample, the other ethnic groups were combined into a single category (non-Black) to facilitate a comparison with Black adolescents. Only 19% of Black adolescents were cmsistmt condom users compared with 43% of adolescents in the non-Black group (P = .Ol). With respect to psychosocial factors, adolescents who communicate with their sex partners about AIDS and who perceive peer norms as supporting condom use d&kg sexual intercourse were 3.8 and 2.3 times more likely to be consistent condom users compared with adolescents who did not talk with sex partners about AIDS (59.3% versus 15.4%; P = .OOOl)or who do not perceive peer normative behavior as supporting condom use (48.1% versus 21.1; P = .008). Factors not associated with consistent condom use include age, gender, general HIV knowledge, knowlr;gc of HIV risk-reduction strategies, perceived susceptibility to HIV infection, age at sexual debut, number of lifetime sex partners, and ~-.C~~r Of partners in the year prior ,sr 31; survey. When the thaw fticirorsidentified in the bivariate ansl$ti ds significantly batiociated with consistent
condom use were entered into a multivariate logistic regression analysis, the overall model is statistically significant (x2 = 34.8; P = .OOOl).The predictive power of the model was high; the model correctly classified 78.9% of the adolescents into their condom use categories, whereas based on chance alone only 55.5% would have been correctly classified (K = 0.53; P = .oool). With respect to individual predictors’ independent contribution to the model, the three factors were independently associated with consistent condom use. Non-Blacks (adjusted OR = 10; P = .OOS), adolescents who communicate with their sex partners about AlDS (OR = 15.3; P = .0006), and those who perceive peer norms as supporting condom use (OR = 6.7; P = -01) were significantly more likely to be consistent condom users.
JOURNAL OF ADOLBSCEN’FHE.4LTH Vol. 12, No. 5
The interaction between ethnicity (Black versus non-Black) and perceived peer norms and communication with sex partners about AIDS was examined arcd found not to be sllgnificant (P = .45 and P = Table 2. Association Between Predictors and Consistent Condom 1Jse
Characteristic
n
Consistent condom use (% reporting)
PR
95% CL
DEMOGRAPHICS Gender Female Male Age 16 or younger 17 or older’ Ethnic@ Non-Black’ Black’
(28) (78)
45.0 24.4
1.8 -
l&3.4 -
(15) (83)
20.0 30.1
0.7 -
0.3-1.9 -
(32) (63)
43.8 19.0
2.3 -
1.2-4.4 -
HIV-RELATED KNOWLEDGE General HIV knowledge (56) 32.1 LOW’ 0.5-1.6 (42) 23.8 0.9 High Knowledge about risk-redution strategies (42) 31.8 Low’ 8.4-1.4 (56) 26.8 0.7 High PSYCHOSOCIAL FACTORS Talk with sex partners about AIDS 10 -5 (27) 59.3 3.8 Yes 1’;a No’ (52) Perception of rip*: r:Giiid supporting condom use (27) 48.1 2.3 High 1.M.l (71) 21.1 Low’ Perceived susceptibiiity to HIV infection (70) 27.1 0.8 Yes 0.4-1.6 (27) 33.3 No’ EEHAVIOEAL FACTORS Age at Sexual Debut (49) 24.5 512 years (27) 22.2 0; 13-14 years 0.4-2.1 (15) 26.7 1.1 215 years 0.4-2.9 Number of lifetime sex partners (18) 30.0 1.1 one or two 0.4-3.0 (69) 27.5 5 three’ Number of sex partners (previous year) 33.3 1.3 0.6-2.7 one or two 25.8 zthree’ PR, Prevalence ratio; 95% CL, =95% confidence limits. ‘Referent category for calculation of prevalence ratio. ‘Includes adolescents self-identifying as White, Asian, Latino, and Other.
P
July 1991
PREDICTORS OF CONDOM USE AMONG ADOLESCENTS
.91, respectively). Moreover, sexual communication was not significantly associated with perception of peer norms (P = .59).
The findirigs demonstrate that differences in ethnicity, perception of peer norms, and communicating with sex partners about AIDS are significant and independent predictors of consistent condom use among incarcerated adolescents. With respect to ethnic differences, the present findings with incarcerated adolescents confirm data demonstrating that Black adolescents, in generai, have a higher prevalence of sexual risk behaviors than other ethnic graups (24). The lack of an association between ethnicnty and perceived peer norms and communicdtton with sex partners about AIDS suggests that ethnic differences are independent of these psychosocial factors. Thus, cultural variables-not assessed in this study-may be more relevant to explaining the strong association between being a Black adolescent and having a higher prevalence of sexual risk-taking behavior (25). Another factor influencing tile use of condoms is adolescents’ perception of peer normative behavior. n. .-:. _;i;r;J referent-group norms are those behavioral patterns that adolescents perceive as being sanctioned by their peers (26). This concept, though similar to peer pressure, is differentiated by the fact that it reflects adolescents’ perception of what they consider normative behavior by their peer referent group. The perception that a majority of other adolescents consistently use condoms during bexual intercourse, the perceived behavioral norm, exerts considerable influence on their use of condoms. If adolescents, even high-risk adolescents, can be convinced that their use of condoms is consistent with referent-group norms, they may be murtr IlKely to practice low-risk behaviors (27). The most powerful predictor of consistent condom use was communicating with sex partners about AI% .il?recent report has also identified communica&& as positively influencing condom use among adolescents in a population of older, White female adolescents (28). Thus, the present finding of a relationship between communication with sex partners about AIDS and consistent condom use corroborates and extends this research to a high-risk, predominantly Black male population. A number of factors were not related to consistent condom use. Two, in particular, were knowledge
389
about HIV and, more ~~e,-lf&iiy, kntitiledge about risk-reduction strategies. Clearly, HIV knowledge is necessary for adolescents to identify behaviors which are effective risk-reduction strategies and, as important, those which are not. However, the present findings confirm numerous other studies which indicate that HIV knowledge, in and of itself, is not sufficient to motivate the adoption and maintenance of HIV-preventive behaviors (19,20).
Limitations of the Study The present study is not without limitations. Foremost, this study used a cross-sectional research design. Additional studies using a prospective cohort design. will be necessary to evaluate the significance and stability of these predictors to influence consistent condom use over time. Second, the sample size was small; especially the number of non-Black adolescents. This may limit the reliability of the findings, especially as they relate to ethnic differences, Unfortunately, due to the very small number of no~iBlack adolescents, other ethnic groups were collapsed to form a referent comparison (non-Black). While demonstrating a lower likelihood of consistent condom use among Black adolescents, collapsing ethnic groups which have distinct cultural variation reduces the utility of the findmgs. i+,~tire t.$Jdies with sufficiently large multicultural representation are needed Co identify cultural diticcences as they relate to condom use. Third, while the research questionnaire assessed a number of relevant psychosocial constructs that may influence condom use, it is limited in scope primarily because it was constructed as an epidemiologic survey instrument rather than an in-depth assessment tool. Additional constructs not able to be assessed in the present sbndy that could influence condom use include cultural measures such as acculturation, behavioral indices such as drug and aicohoP use and type of sexual activities, additional psychosocial measures such as self-esteem and self-efficacy, barriers to condom use, and developmental constructs. Further, while the use of predcfined response categories significantly increased the likelihood that adolescents, particularly those with limited reading ability, could complete the self-report questionnaire, this data collection methodology limits the variability of responses. More detailed information could be gatheied through other data-collection methodologies such as in-depth interviews with open-ended responae formats.
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Recommendations for IkrogramDevelopment The findings have implications for the development of I-W-prevention programs for this high-risk adolescent population. Programs whTch emphasize the didactic transfer of information about HIV transmission or risk-reduction strategies are not likely to be effective in modifying adolescent sexual risk behavior. Based on the prrsent findings, one recommendation would be to emphasize skills training and norm-setting activities such as developing and redefining communication skills around sexual negotiation and modifying perceptions about peer norms with respect to safer sex behavior. These skillbased programs may be more effective in increasing the likelihood that adolescents will adopt or maintain HIV-preventive behaviors (29-31JD
References 1. DiClemente RJ. The emergence of adolescents as a risk group for human immunodeficiencv virus infection. loumal of :1dol Research 1998;5:7-17. a 2. Hein K. AIDS in adoiescence. J Adolesc Health Care 1989;10:18S-35. 3. Hein K. Commentary on adolescent acquired immunodeficiency syndrome: The next wave of the human immilnodeficiency virus epidemic. J Pediatr 1989;114:144-9. 4. D’AngeIo t, Sondheimer D. Adolescents and HIV infection: Struggling not to bc forgotten. Pediatric AIDS and HIV Infection 1998;1:75-7. 5. DiClemente RJ. Adolescents and AIDS: Current research, prevention strategies and public policy. In: Temoshak L, Baum A, eds. Psychosocial Perspectives on AIDS: Etiology, Prevention, and Treatment. New Jersey: Erlbaum, 1998: 5164. 6. ICannL, Nelson CD. Jones JT, et al. Establishing a system of complementary school-be& surveys to annually assess HIVrelated knowledge, beliefs, and behaviors among adolescents. J Sch Health 1989;59:55-8. 7. Council on Scientific Affairs. Health status of detained and incarcerated youths. JAMA 1998;263~987-91. 8. Alexander-Rodriguez T, Vermund SH. Gonorrhea and sy philis in incarcerated urban adolescents: Prevalence and physical signs. Pediatrics 1987;80:561-4. 9. Bell TA, Farrow JA, Stamm WE, et al. Sexually transmitted diseases in females in a juvenile detention center. Sex Transm Dis 1985;12:14&144. 10. DiClemente RJ, Lanier MM, Horsn PF, et al. Comparison of AIDS knowledge, attitudes, and behaviors among ado& cents in a juvenile detention facility and public schoo!s in San Francisco. Am J Public Health 1991;81:628-38. 11. Lanier MM, McCarthy BR. AIDS awareness and the impact of AIDS education in juvenile corrections. Criminal Justice 1989;16:395-4ii.
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12. Larder M, DiClemente RJ, Horan PF. The impact of ecological factors and cultural diversity: Incarcerated adolescents’ AID3 awareness and precautionary measures. CriminaI Justice 1991;19:257-62. Nader PR, WexIer DB, Patterson TL, et al. Comparison of 13. beIiefs about AIDS among urban, suburban, incarcerated, and gay adolescents. J Adolesc Health Care 1989;10:413-8. 14. EBenbein DS, Weber FT, Grob G. Condom usage by a pop ulation of delinquent southern male adolescents. J Adolesc Health Care 1991;12:35-7. 15. Goldsmith M. Ser. in the age of AIDS calls for common sense and “condom sense”. JAMA 1987;257:2261-6. 16. Stone KM, Grimes DA, Magder LS. Primary prevention of sexually transmitted diseases. JAMA 1986;255:1763-6. 17. Conant M, Hardy D, Sematinger J, et al. Condoms prevent of AIDS-associated retrovirus. JAMA transmission 1986;255~1706. 18. Van de Perre P, Jacobs D, Sprecher-Goldberger S. The latex condom, an efficient barrier against sexual transmission of AIDS-related viruses. AIDS 1987;1:49-52. 19. DiCIemente RJ. Psychosocial predictors of adolescents’ HIVrelated risk-taking behavior. In: D’AngeIo L, Ma T, eds. HIV and Youth. New York: Elsevier, in press. 20. Becker MH, Joseph JG. AIDS and behavioral change to reduce risk: A review. Am J Public Health 1988;78:394-410. 21. Miller HG, Turner CF, Moses LE. AIDS The Second Decade. Summary. Washington, DC: National Academy Press, 1990. 22. Fleiss JL. Statistical Methods for Rates and Proportions. New York, John Wiley & Sons, 1973. 23. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York, John Wiley & Sons, 1989. 24. FuBiIove MT, Weinstein M, Fullilove RE, et al. Race/gender issues in sexual transmission of AIDS. In: Volberding P, Jacobson MA, eds. AIDS Clinical Review. New York: Marcel Dekker, 199% 25-62. 25. Bowser BP, FuIiiiove MT, FuiIiIove RE. African-American youth dnd AIDS high-risk behaviors. Youth dr Society 1990;2254-66. 26. r’isher JD. Possible effects of reference group-based social infiue.nce on AIDS-risk behavior and AIDS prevention. Am Psycho1 1988;43:914-2c. 27. Fisher JD, Miscovich SJ. Social intluence and AIDS-preventive behavior. in: Edwards J, Tir.daio RS, Heath L eds. Social Influence Processes and Prevention. New York: Plenum, laso: 39-70. 28. Catania JA, Dolcini MM, Coates TJ, et al. Predictors of condom use and multiple partnered sex among sexually-active adolescent women: Implications for AIDS-related health interventions. J Sex Res 1989;26:514-24. 29. Flora JA, Thoresen CE. Components of a comprehensive strategy for reducing the risk of AIDS in adolescents. In: Mays VM, Albee GW, Schneider, SF, eds. Primary Prevention of AIDS. Newbury Park: Sage, 1989: 374-389. 30. Schmke S, Blythe B, Gilchrist L. Cognitive-behavioral prevention of adolescent pregnancy. J Couns Psycho1 1981;28:451-4. 31. DiClemente‘ItJ, Boyer CB, Miis S. Prevention of AIDSamong adnlescents: Strategies for the devebpment of comprehensave risk-redu&on health education programs. Health Educ Res 1987;2:287-91.
