Determinants
of Condom
Use
Among
Junior
High
School
Students
in a
Minority,
Inner-City
School
District
Ralph
1.
DiClemente, PhD*; Meg Durbin, MD*; David Siegel, MD,MPH*; Flora Krasnovsky, MA*; Nancy Lazarus, MD, MPHII; and
Terry Comacholl
ABSTRACT. Condoms reduce the risk of human
immu-nodeficiency virus (HIV) transmission; however, their
use among adolescents has been inconsistent. Little is
known about factors which motivate consistent condom
use, particularly among younger adolescents. In a study
designed to identify such factors, 1899 inner-city junior
high school students were surveyed. In June 1988,
stu-dents completed an anonymous self-report questionnaire
assessing HIV-related knowledge, attitudes, and
behav-iors. Among sexually active students (N 403), logistic
regression analysis evaluated the influence of demo-graphic, psychosocial, and behavioral factors on
fre-quency of condom use. Respondents who believe
con-doms are effective in preventing HIV transmission were
2.2 times more likely to report using condoms
consist-ently during sexual intercourse; those with low perceived
costs associated with condom use were 1.9 times more
likely to be consistent users. Number of lifetime sexual
partners was inversely related to frequency of condom
use. Respondents with a history of three or more sex
partners were half as likely to use condoms consistently.
Factors not associated with consistent condom use
in-dude age, age at sexual debut, ethnicity, HIV knowledge,
perceived efficacy to avoid HIV infection, and alcohol
and drug use. School- and community-based HIV
pre-vention programs will have to go beyond the didactic
transfer of factual information and include more
inter-active teaching strategies to improve adolescents’
atti-tudes toward condoms are self-efficacy to increase
con-dom use and to counter negative peer influences and
adolescents’ perceptions of invulnerability. Physicians
are an underutilized source of HIV prevention
informa-tion. They have an important role in counseling
adoles-cents about effective HIV-prevention methods and
dis-pelling misperceptions which hinder consistent condom
use. Pediatrics 1992;89:197-202; minority adolescents, hu-man immunodeficiency virus, condoms, risk behaviors.
ABBREVIATIONS. HIV, human immunodeficiency virus; AIDS,
acquired immunodeficiency syndrome; OR, odds ratio; CL,
confi-dence limit.
Many adolescents engage in sexual and
drug-re-lated behaviors which increase the risk for human
From the ‘Center for AIDS Prevention Studies, University of California, San
Francisco; Bayview-Hunter’s Point Foundation, San Francisco; §
Depart-ment of Medicine, University of California, San Francisco; and IIHuman
Population Laboratory. California Public Health Foundation, Berkeley, CA,
Received for publication Dec 3, 1990; accepted Mar 29, 1991.
Reprint requests to (R.J.D.) Center for AIDS Prevention Studies. University
of California, 74 New Montgomery St. Suite 600, San Francisco, CA 94105.
PEDIATRICS (ISSN 0031 4005). Copyright © 1992 by the American
Acad-emy of Pediatrics.
immunodeficiency virus (HIV) infection. ‘ Although
sexual abstinence is the most effective method to
prevent the transmission of HIV as well as other
sexually transmitted diseases, few adolescents adopt
this HIV-preventive behavior once they have become
sexually active. An alternative prevention strategy for
male adolescents who are sexually active is to use
condoms consistently during sexual intercourse and
for female adolescents to insist that their male
part-ners use condoms.6’7 While condoms prohibit the
transmission of viral pathogens, including HIV,8’9
their effectiveness as a risk-reduction strategy is de-pendent on appropriate and consistent use.
Unfortu-nately, increasing consistent condom use among
ad-olescents has been a formidable challenge which has
not yielded widespread success.
While a large proportion of adolescents are aware of the effectiveness of condoms to prevent transmis-sion of HIV,’#{176}a substantially smaller proportion re-port actually using condoms during sexual intercourse
or report using them consistently with each sexual
encounter.”2 Most alarming, recent findings indicate
that adolescents have not markedly changed their use
of condoms in response to the threat of AIDS.’3”4 The
National Academy of Sciences in a recent report has
recommended further research to understand the
fac-tors which influence adolescents’ use of HIV-preven-five behaviors, such as consistent condom use during sexual intercourse, as critical to developing effective programs that promote the adoption and maintenance of HIV-preventive behavior.’5
While a number of factors have been hypothesized as influencing condom use,’6 few studies have
specif-ically explored the determinants of condom use
among adolescents.’7 In one study among older,
pre-dominantly white female adolescents (mean age 17.9
years), Catania and colleagues’8 found that condom
use was associated with perceived enjoyment of
con-doms and sexual communication skills. In a random
telephone survey of Massachusetts adolescents 16
through 19 years of age, Hingson and colleagues’9
reported that adolescents were more likely to use
condoms if they believed that condoms prevent HIV
transmission and do not reduce sexual pleasure, are
not embarrassed about using condoms, and have a
higher perceived risk of contracting acquired
immu-nodeficiency syndrome (AIDS). Marijuana and
alco-hol were also identified as moderating variables
whose use also reduced adolescents’ likelihood of
using condoms.
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While informative, the relevance of these findings for minority or middle (12-15 years of age)
adoles-cents may be limited. It is particularly important to
identify the determinants of condom use among
mid-dle adolescents, whose development is marked by the
initiation and risk-taking, including sexual risk-taking
behaviors. As these behaviors become entrenched,
they become increasingly difficult to modify.20’2’ It is
also important to address HIV risks among minority
adolescents specifically, given the disproportionately high prevalence of HIV disease in blacks and Latinos overall22’23 and amon minority adolescent applicants
for military service.2 Similarly, lower prevalence of
consistent condom use among black adolescents25 and
the higher prevalence of sexual risk-taking and
sex-ually transmitted diseases among minority
adoles-cents compared with their white peers suggest that
this group is at increased risk of HIV infection.263#{176}
The present study examined the influence of
de-mographic, behavioral, and psychosocial factors on
the use of condoms among junior high school
adoles-cents, predominantly nonwhite, from an inner-city
school district in northern California.
METHODS
We conducted a baseline survey to assess adolescents’
know!-edge, attitudes, beliefs, and sexual and drug-related behaviors
related to HIV transmission in preparation for developing a school-based HIV prevention program for ethnically diverse junior high
school students in an inner-city school district in northern
Ca!ifor-nia. Students in three junior high schools (grades 7 through 9) participated after obtaining parental consent, completing an
82-item self-administered survey during a single class period. The
questionnaire assessed three general topic areas: (1)demographic
information; (2) knowledge, attitudes, and beliefs regarding HIV
disease and sexuality; and (3) sexual activity and drug use. Of the
students eligible to participate in the survey, greater than 95% at
each school returned completed questionnaires, yielding a total sample of I 899 students. Twenty-one percent of the students (403) who reported ever having had sexual intercourse comprise the sample for this report.
The Health Belief Model was used as a theoretical framework
to conceptualize variables for inclusion in the questionnaire. The
Health Belief Model has been used most often to understand factors associated with the adoption of preventive behaviors.3132 In addi-lion, this model has been reported to be useful in prior studies of
adolescents’ condom use.” According to the Health Belief Model,
the decision to adopt preventive health behaviors is the result of a
rational decision-making process in which the individual weighs
the costs and benefits associated with adopting the preventive health behavior and their health beliefs and perceptions about disease susceptibility and severity.
Measures
All measures were derived from the self-report questionnaire. Condom use, the outcome variable, was assessed using a
four-point Likert scale ranging from always’ to never.” Approximately
37% of the sample reported that condoms were “always’ used
during sexual intercourse. Those adolescents reporting condoms
‘always being used were classified as consistent condom users.
Adolescents reporting condoms “sometimes,’ “rarely.’ or “never”
being used were classified as infrequent condom users.
General AIDS knowledge was assessed by summing adolescents’ correct responses to five items (AIDS is a condition that destroys the body’s ability to fight disease; AIDS is caused by a virus; only homosexual men get AIDS; there is no cure for AIDS; and you can have AIDS and not know it). High and low AIDS knowledge
categories were determined based on a median split. The
standard-ized s coefficient for the scale is 0.53. This low level of internal
consistency may indicate that the items which comprise the general
AIDS knowledge scale were assessing different dimensions of AIDS
knowledge.
A scale assessing adolescents’ misconceptions about disease
transmission was also developed by summing adolescents’ incorrect
responses to seven items about modes of HIV transmission.
Ado-Iescents scoring in the upper third of the distribution were
catego-rized as having a “high” number of misconceptions about
trans-mission, those scoring within the middle third were classified as
having an “intermediate” number of misconceptions. and those
scoring in the lower third were classified as having “low”
miscon-ceptions of transmission. The standardized a coefficient for the
misconception of HIV transmission scale is 0.77.
Adolescents’ perceived costs of condom use was assessed using
an eight-item scale (sex doesn’t feel as good when you use a condom; having to stop sex to put on a condom takes the fun out
of sex; its embarrassing to buy condoms; condoms are physically
uncomfortable; its hard to find places to buy condoms; choosing
which kind of condom to buy can be confusing; its embarrassing
to talk about condoms with a sex partner; and sex partners often
disagree about whether or not to use condoms). Each scale item
reflects physical, emotional, or accessibility concerns with condom
use. Respondents evaluated each statement using a four-point scale
ranging from (1) “strongly agree,” (2) “agree,” (3) “disagree,” to (4)
“strongly disagree,”. Responses of “strongly disagree” and “disagree”
reflect low perceived costs; responses of “strongly agree” and
“agree” reflect high perceived costs associated with condom use.
Responses were summed across the eight items yielding a
sum-mary score for each respondent. Scores ranged from 8 to 32, with
higher scores reflecting greater perceived costs to the use of
con-doms. The distribution of scores was divided into three equal
groups: low, intermediate, and high perceived costs. Adolescents
categorized as being in the high perceived cost group were
signifi-cantly less likely to be consistent condom users relative to their
peers in the intermediate and low groups (P < .01); however, there
was no statistical difference in the proportion of consistent condom users in the intermediate and low perceived costs groups. Therefore,
the intermediate group was collapsed into the low perceived costs
group. The standardized a coefficient for the perceived costs of condom use scale is 0.61.
Adolescents’ perceptions of condoms’ effectiveness in
prevent-ing HIV transmission were assessed using a four-point Likert scale.
Adolescents’ responses were recoded into two categories: high
perceived condom efficacy (“condoms work very well” and
“con-doms work pretty well to prevent AIDS”) and low perceived
condom efficacy (“condoms work only slightly” and “condoms don’t
work at all”).
Behavioral Measures
Measures of sexual and drug-related risk behaviors were also
based on adolescents’ response to Likert scales or binary choice
questions (yes-no format) from the research questionnaire. These
measures assessed age at sexual debut (12 years of age or younger,
13 through 14, 15 years of age or older); number of lifetime sex
partners (only one, two, three to five, six or more); alcohol use in
the month preceding completion of the survey (“yes,” used alcohol;
“no,” did not use alcohol); history of using street drugs and
intra-venous drugs (“yes. did use drugs; “no,” did not use drugs).
Statistical Analysis
As a prelude to developing a multivariate logistic model
pre-dicting consistent condom use, bivariate tests of proportions
eval-uated whether individual factors were associated with condom
use.33 Prevalence ratios and their 95% confidence intervals were
also calculated to determine the magnitude of the relationship
between potential predictors and consistent condom use. Factors
identified as significantly associated with consistent condom use in
the bivariate analysis were entered into a multivariate logistic
regression analysis to assess the independent contribution of each
factor in predicting condom use.34 Adjusted odds ratios (ORs) and
confidence limits (CLs) were also calculated to assess magnitude of
association between factors and condom use.
RESULTS
The demographic characteristics and frequency of
relative to the overall population are described in Table 1. The sexually active sample was
dispropor-tionately male and black. Frequency of condom use
was low; 36.6% of sexually active adolescents
re-ported using condoms “rarely” or “never” during
sex-ual intercourse.
Bivariate associations between demographic,
atti-tudinal, and behavior measures and frequency of
condom use are presented in Table 2.
Four factors were identified as significantly associ-ated with consistent condom use (the 95% confidence limits did not include unity): gender, perceived costs
of condom use, perceived effectiveness of condoms
to prevent AIDS, and number of lifetime sexual part-ners. Forty-four percent of girls reported that their
male sex partners always used condoms compared
with approximately 3 1 % of boys who reported that
they always used condoms (P = .015). Adolescents
with low perceived barrier to condom use scores were more likely to be consistent users (42.1%) compared
with peers in the high perceived bamers group (P =
.003), and those who perceived condoms as effective
at preventing AIDS were more likely to report
con-sistent condom use compared with those who
be-lieved that condoms were not effective (P = .001).
An inverse relationship was identified between the
number of lifetime sexual partners and frequency of
consistent condom use, with adolescents who
re-ported more partners less likely to be con5istent
con-dom users during sexual intercourse (P = .002).
Among adolescents reporting one, two, three to five,
or six or more lifetime sex partners, consistent condom
use was reported by approximately 50%, 39.0%,
27.4%, and 272%, respectively.
Factors not associated with consistent condom use
include age, ethnicity, general HIV knowledge,
knowledge of HIV transmission, adolescents’ percep-tion of their ability to protect themselves from
con-tracting AIDS, age at first sexual intercourse, and
alcohol and drug use. On the basis of bivariate anal-yses demonstrating that the proportion of adolescents
TABLE 1. Demographic Characteristics and Frequency of
Con-dom Use
Popu
%
lation
No.
Sexually Active Sample
% No.
Gender
Male 48.0 879 64.2 246
Female 52.0 951 35.8 137
Age, y
11-12 8.9 162 7.8 30
13-14 61.1 1108 59.5 228
15-16 30.0 543 32.6 125
Ethnicity
White 4.7 84 6.2 19
Black 31.3 555 57.6 215
Latino 23.9 425 20.6 77
Asian 33.4 592 10.5 39
Other 4.9 87 6.2 23
Frequency of condom use
Always Sometimes
. . . . . .
. . . . . .
37.1 144
26.3 102
Rarely Never
. . . . . .
. . . . . .
15.2 59 21.4 83
who reported consistent condom use with three to
five and six or more lifetime sex partners was similar,
number of lifetime partners was recoded into three
categories (one partner only, two partners, or three or more partners).
The factors identified in the bivariate analysis as
significantly associated with consistent condom use
were entered into a multivariate logistic regression analysis. The results of this analysis are presented in Table 3.
Three of the four factors-perceived costs of
con-dom use, perceived efficacy of condoms to prevent
AIDS, and having had three or more lifetime sexual
partners-are identified as independent determinants
of consistent condom use. Adolescents reporting low
perceived costs associated with condom use were
almost twice as likely to use condoms consistently
during sexual intercourse compared with peers
re-porting high perceived costs (OR = 1.9; 95% CL =
1 .1 to 3.3). Adolescents reporting three lifetime part-ners were less likely to use condoms consistently than
peers reporting one sex partner (OR = 0.46; 95% CL
= 0.21 to 0.88). Perception of condoms’ efficacy in
preventing AIDS was the most powerful determinant
of consistent condom use (OR = 2.21; 95% CL 1.2
to 4.2). In the logistic regression model, gender was no longer significant. Interaction effects between ad-olescents’ number of lifetime sex partners, perceived
barriers to condom use, and perceived condom
effi-cacy were examined and found not to be significant.
DISCUSSION
In this cross-sectional study of sexually active
ad-olescents from three inner-city, predominantly
non-white junior high schools in northern California, we
found that adolescents’ perceived costs associated
with condom use, the perception that condoms are
effective in preventing AIDS, and a history of fewer
than three sex partners were the most influential
determinants of consistent condom use. The finding
that adolescents with low perceived costs associated
with condom use and those who perceived condoms
as effectively preventing AIDS were more likely to
use condoms consistently corroborates and extends
previous research’8”9 to a minority, middle adolescent
population. Unlike previous studies, however, we did
identify a strong relationship between number of sex
partners and less frequent condom use. This finding is especially alarming since, all things being equal, a history of multiple sexual partners constitutes a sep-arate risk factor for HIV exposure above and beyond that degree of risk attributable to infrequent condom use alone.35
Many of the adolescents who never use condoms
report high perceived costs associated with condom
use, although they had no direct experience with
condoms. In this study, 48.7% of adolescents who
reported “never” using condoms during sexual
inter-course reported high perceived costs of condom use.
As the proportion of adolescents using condoms
in-creased, the proportion of adolescents reporting high
perceived costs decreased. For codom frequency of
“al-Characteristic No. % Reporting PR# 95%
Consistent CL**
Condom Use
1.4 1.1-1.8
ai 1-12 years of age is the referent category.
t White is the referent ethnic category.
t Low human immunodeficiency virus (HIV) general knowledge is the referent category.
§Low misconceptions of HIV transmission is the referent category.
II
Younger than 13 years is the referent category.II One lifetime sex partner is the referent category.
# Prevalence ratio.
** 95% confidence limits.
TABLE 2. Bivanate Association Between Potential Determinants and Consistent Condom Use
Gender
Female Male Age
11-12 y
13-14 y
15-16 y
Ethnicity White Asian Black Latino
General HIV knowledge Low
Intermediate High
Misconceptions about HIV transmission
Low
Intermediate High
Self-assessment of ability to protect themselves from contracting AIDS Can protect myself
Cannot protect myself Perceived costs of condom use
Low
High
Perceived condom efficacy to prevent AIDS
High
Low
Age at first intercourse II
12 y
13-14 y
15 y
Alcohol use (in past month)
Yes
No
No. of sex partners (lifetime)1!
1
2 3-5
History of using street drugs
Yes
No
History of injecting street drugs
Yes
No
132 43.9
240 31.3
27 44.4
224 36.2
122 32.0
19 47.4
38 29.0
207 35.8
76 32.9
101 33.7
117 35.0
173 39.9
145 41.4
144 30.6
103 38.8
340 36.8
49 34.7
235 42.1
109 25.7
260 43.5
128 22.2
237 35.0
114 37.7
37 43.2
125 38.4
171 42.7
121 49.6
100 39.0
84 27.4
81 27.2
37 37.8
243 39.5
15 33.3
262 39.7
0.8 0.5-1.3
0.7 0.4-1.2
0.6 0.3-1.2
0.8 0.4-1.3
0.7 0.4-1.2
1.0 0.7-1.5
1.2 0.8-1.6
0.7 0.5-1.0
0.9 0.7-1.3
1.0 0.7-1.6
1.6 1.2-2.3
2.0 1.3-2.9
1.1 0.8-1.4
1.2 0.8-1.8
0.9 0.7-1.2
0.8 0.6-1.1
0.5 0.4-0.8
0.5 0.4-0.8
1.0 0.6-1.5
0.8 0.4-1.7
ways,” the proportion at each category reporting high
perceived costs of condom use was 48.7%, 41.5%,
25.6%, and 22%, respectively. In the absence of direct
personal experience with condoms, adolescents’
neg-ative perceptions may be the result of peer influences and perceived social norms. Although we were unable to assess the influence of peer norms in this study, there are data suggesting that adolescents, particularly
middle adolescents, may be more likely to discount
adult authorities and rely more heavily on peer influ-ences in the formulation of beliefs and behaviors.36
The present findings were derived from a
school-based anonymous survey. While identifying
poten-tially important determinants of condom use, these
TABLE 3. Results of Multivariate Logistic Analysis*
Characteristic OR Consistent Condom Use
95% CL PValue
Gender
Male 1.00
Female 1.33 0.8-2.2 .32
No. of lifetime sexual part-nerst
1 1.00
2 0.64 0.34-1.2 .24
3 or more 0.46 0.21-0.88 .02
Perceived costs of condom
use High
Low
1.00
1.90 1.1-3.3 .02
Perceived effectiveness of
condoms to prevent
AIDS
Low 1.00
High 2.21 1.2-4.2 .01
* Abbreviations: OR, adjusted odds ratio; 95% CL, 95%
confi-dence limits; AIDS, acquired immunodeficiency syndrome.
tOne sex partner is the referent category.
studies should also include objective surrogate
assess-ments of condom use, whenever possible, as one
means of validating adolescents’ self-report. One
ob-jective measure of condom use, for example, would
be to assess the prevalence of sexually transmitted diseases among adolescents.
IMPLICATIONS FOR PREVENTION
The present findings have several implications for
the development of HIV prevention programs. If
pre-venting the initiation of HIV risk behaviors is the
principal goal of such programs, then they must be
implemented early, before sexual risk behaviors
be-come entrenched. Given the proportion of
adoles-cents engaging in sexual risk-taking while still in
junior high school, prevention programs should be
initiated early, optimally before puberty, to facilitate the development of positive attitudes and self-esteem
as a foundation for reinforcing health-promoting
be-haviors.
The findings also suggest that school- and
com-munity-based HIV prevention programs which
pri-manly emphasize transfer of AIDS information will
not succeed in promoting adolescents’ use of
HIV-preventive measures based on the lack of a significant
influence for both general HIV knowledge and HIV
transmission. The finding of no association between
knowledge and preventive behavior has been
re-ported often’7 and suggests that prevention programs
should avoid relying strictly on didactic methods. To
be effective, prevention programs should employ a
broad spectrum of interactive health education and
communication strategies. Such strategies, including decision-making exercises, rehearsal of self-protective behaviors, and group discussions regarding the value of condoms, may be more effective in increasing
self-esteem and promoting positive attitudes and,
ulti-mately, greater self-efficacy regarding condom
use.37’38 While girls do not use condoms themselves, similar training and skills can be important in influ-encing their male partner to use condoms consistently or avoiding unprotected sexual intercourse.
While school- and community-based prevention
efforts are undoubtedly important, perhaps the most
underutilized prevention channel may be
pediatri-cians and adolescent medicine specialists because
many teenagers will become sexually active while still under their care.39 Further, because many adolescents perceive physicians as the most authoritative source of HIV information,40 they can capitalize on this trust
to enhance the link between the provision of health
care and HIV prevention education. However, a
re-cent survey found that while 80% of adolescents saw
a physician in the year prior to the study, only 13%
were counseled about AIDS.41 Recent findings also
indicate that adolescents who discussed AIDS with a
physician were significantly more likely to be consist-ent condom users.’9 Thus, more consistent assessment
of adolescents’ sexual behavior by physicians and
discussion of effective prevention methods, such as
condom use during sexual intercourse, may dispel
adolescents’ misperceptions and result in increased use of this HIV-preventive behavior. Moreover, while
physicians are an important source of AIDS and
contraception information, they can also serve to
stimulate adolescents to use the information they may
have already received from school- or
community-based programs and reinforce this information as well as clarify issues which remain ambiguous.
ACKNOWLEDGMENT
This research was supported by a grant from the University of
California Universitywide Task Force on AIDS.
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OH! - RATS!
Some of the finest rats on the East Coast line up on the judging bench...
It’s the fall show sponsored by the Northeast Rat and Mouse Club, a group
beguiled by the rodents that most people love to loathe. Rat fanciers, especially, confess that until they found the club, theirs was a lonely and more or less secret passion. “We kind of soft-pedaled it because we didn’t want to be pegged as kooks,” says Elizabeth Fucci, club president.
Ms. Fucci. . . is an ardent rat booster. As pets, she explains, they are both loving
and low-maintenance. “Rats greet you, they interact, they try to please,” she says. “They are as close to a dog as you’re going to get in a rodent”...
Fancy rats. . . have been bred and shown in England for almost a century. Shows
in this country began about 20 years ago in Southern California. In 1988, Ms. Fucci
and four other fanciers started the Northeast Rat and Mouse Club. Today, it has
about 100 members, divided about evenly between “ratters” and “mousers,” as they
sometimes call themselves.