CROSBY, RICHARD PhD*; DiCLEMENTE, RALPH J. PhD*†‡§; WINGOOD, GINA M. ScD, MPH*§; SIONÉAN, CATLAINN PhD*; HARRINGTON, KATHY MPH, MAEd¶; DAVIES, SUSAN L. PhD, MPH¶; HOOK, EDWARD W. III MD∥ AND; OH, M. KIM MD#
From the *Department of Behavioral Sciences and Health Education, Rollins School of Public Health; the Departments of †Pediatrics and ‡Medicine, Division of Infectious Diseases, Emory University School of Medicine; and the §Emory/Atlanta Center for AIDS Research, Atlanta, Georgia; the ¶Department of Health Behavior, School of Public Health; and the Departments of ∥Medicine, Division of Infectious Diseases, and #Pediatrics, School of Medicine, University of Alabama, Birmingham
The authors thank Jane R. Schwebke (University of Alabama School of Medicine, Division of Infectious Diseases) for providing cultures for Trichomonas vaginalis, and Kim Smith, MT, for assistance and oversight of Neisseria gonorrhoeae and Chlamydia trachomatis testing.
Supported by grant 1R01 MH54412 from the Center for Mental Health Research on AIDS, National Institute of Mental Health (to Dr. DiClemente). Drs. Crosby and Sionean were supported through an Association of Teachers of Preventive Medicine/Centers for Disease Control and Prevention STD Prevention Fellowship.
Reprint requests: Richard A. Crosby, PhD, Department of Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, 1518 Clifton Road NE, 5th Floor, Atlanta, GA 30322. E-mail: email@example.com
Received for publication May 11, 2000, revised August 9, 2000, and accepted August 15, 2000.
THE CONSTRUCT OF PERCEIVED THREAT is an important component in behavioral theories that are applied to understanding and changing sexual risk behaviors that lead to sexually transmitted disease (STD) and HIV infection. 1 For example, the Information-Motivation-Behavioral Skills model, as applied to HIV prevention, posits that the perceived threat of HIV infection contributes to individual motivation to adopt protective behavior. 2 Similar hypotheses are described in applications of the Health Belief Model, the Theory of Reasoned Action, and Protection Motivation Theory to sexual risk behavior change 3–5; however, perceived threat is an understudied construct in the field of STD and HIV prevention. 6,7
Perceived threat has been conceptualized as a product of perceived risk and perceived severity relative to a given disease or event. 8 Adolescents are likely to underestimate both the severity and their risk of STD or HIV infection. 6,9–11 This underestimation may, in part, be a mental defense mechanism. For example, Ellen and colleagues 12 assessed adolescents’ anxiety about STD and HIV infection. They found that increased anxiety, rather than less sexual risk behavior, was associated with lower perceptions of STD and HIV risk compared with the perceived risk of their peers.
Previous studies have varied widely in their measurement of perceived threat, with constructs such as perceived vulnerability, susceptibility, and worry being assessed by researchers. 7 An important aspect of perceived threat is whether the perception of threat creates worry (an indication of dissonance). Dissonance may be a strong motivating factor for behavior change, particularly if the individual perceives control over the risk behavior. 13 Alternatively, intellectual perceptions of susceptibility without feelings of dissonance are less likely to motivate behavior change. Thus, a key aspect of perceived threat may be the resulting level of worry.
Several factors may influence adolescents’ worry about STD and HIV. For example, adolescent females who perceive some risk of STDs and HIV and believe that they cannot persuade their sex partners to use condoms may be likely to experience worry about possible infection. Conversely, public perceptions that AIDS can be “cured” and STDs can be easily treated may mitigate this worry. Few published data exist regarding correlates of adolescents’ STD and HIV worry. Such an investigation is especially timely in the era of convenient single-dose oral therapies for bacterial and parasitic STDs and of effective combination therapy for HIV (e.g., highly active antiretroviral treatment). Identification of these correlates can inform the design of behavioral intervention programs to reduce adolescents’ risk of STD and HIV infection.
Prevalence and correlates of STD worry are likely to differ from the prevalence and correlates of HIV worry. Studies of adolescents have focused on perceptions of HIV threat rather than perceptions of STD threat, 14 which is unfortunate because adolescents may perceive infection with HIV and infection with other STDs differently. Accordingly, the purpose of this study was to assess levels and correlates of worry about STD and HIV among a high-risk sample of black adolescent females.
From December 1996 to April 1999, project recruiters screened 1,130 female teens in adolescent medicine clinics, health department clinics, and school health classes to assess eligibility for participating in an HIV and STD prevention trial. Recruitment sites were in neighborhoods characterized by high rates of unemployment, substance abuse, violence, and STDs. Of those screened, 609 adolescents were eligible to participate in the study. Of those adolescents not eligible to participate (n = 521), the majority (98%) were not sexually active. The current study consists of 522 (85.7%) eligible adolescents who were enrolled and who completed baseline assessments. The majority of eligible teens who did not participate in the study were unavailable because of conflicts with their employment schedules. Adolescents were eligible to participate if they were black females between the ages of 14 and 18 years at the time of enrollment, sexually active in the previous 6 months, and provided written informed consent. The study protocol was approved by the Institutional Review Board Committee on Human Research before implementation.
Data collection was conducted at the Family Medicine Clinic and consisted of a self-administered survey, a structured personal interview, and collection of vaginal swab specimens. The self-administered survey was conducted in a group setting with monitors providing assistance to adolescents with limited literacy and helping to assure confidentiality of responses. Subsequently, adolescents completed a face-to-face interview that assessed sexual risk behaviors and was administered by trained black female interviewers in private examination rooms. After completing the interview, participants were asked to provide two vaginal specimens for STD testing. All subjects were reimbursed $20.00 for their participation.
Correlates were selected based on findings from related studies of adolescents. A broad range of factors associated with perceived threat may influence adolescents’ STD and HIV worry. For example, research indicating that the experience of having an STD may predict subsequent safer sex behaviors 15,16 suggests that a STD diagnosis may increase one’s perception of personal vulnerability and lead to more vigilant protective behavior. Recent sexual-risk behavior may also be an important correlate of STD and HIV worry. Adolescents are more likely to use condoms in a new relationship 17,18 or in a casual relationship, 19,20 with each of these behaviors possibly being motivated by perceived threat of STD or HIV infection. Education about STD and HIV may influence the level of perceived threat. For example, adolescents have reported a greater perceived threat of HIV after receiving intervention sessions, including those assigned to information-only control groups. 21
Two primary measures of STD and HIV risk behavior were assessed: (1) not using a condom use at last intercourse and (2) any unprotected sex in the past 30 days. Measures were assessed separately for adolescents reporting sex with a steady partner and for those reporting sex with one or more casual partners. Other measures were reporting sex with a new partner in the past 30 days, having sex while the adolescent was drinking, having sex when a partner was drinking, and acquiescing to unwanted sex without a condom.
Scales assessed several constructs hypothesized to influence adolescents’ perception of STD and HIV risk. Table 1 displays psychometric properties of these scales along with a sample item used in each scale. In addition, two single-item measures were assessed: (1) age of typical of sex partner and (2) history of STD infection (ever and during the past 6 months). History of STD infection was included as a potential psychosocial determinant based on findings from previous research and the supposition that adolescents recently infected with an STD would report higher levels of recent worry about STD or HIV.
Identification of Covariates
Because worry and depression are likely to be co-occurring emotions, we hypothesized that depression may inflate adolescents’ worry about STD and HIV. In addition, we hypothesized that perceived lack of social support may compound adolescents’ worry about STD and HIV. Accordingly, depression and social support were hypothesized to be covariates of STD and HIV worry. Depression was assessed using a brief version of the Center for Epidemiologic Studies—Depression 22 scale (α = 0.84). Social support was defined as support from family members (e.g., “my family really tries to help me”), special persons (e.g., “I have a special person who is a real source of comfort to me”), and peers (e.g., “my friends really try to help me”). We assessed social support using a 13-item scale 23 that yielded high reliability (α = 0.85). Adolescents scoring in the upper quartile on the depression scale (a natural break in the distribution, indicating greater depression) were significantly more likely to report high-perceived threat of both STD and HIV (P < 0.0001). Adolescents scoring low on the measure of social support were significantly more likely to report high-perceived threat of HIV (P < 0.0001), but not STD (P < 0.10).
Assessment of the Dependent Measures
A four-item scale assessed the frequency of adolescents’ worry about STD infection in the past 6 months (α = 0.90). This scale assessed adolescents’ worry that they were or would become infected and worry that their partners were or would become infected with an STD. An identical scale substituting only the term “AIDS virus” for “STD” assessed adolescents’ worry about HIV infection (α = 0.80). Distributions for scores from each scale were positively skewed and showed natural breaks at approximately the upper quintile; thus, adolescents scoring in the upper quintile on the measure of STD worry or the measure of HIV worry were classified as having high STD worry or high HIV worry, respectively.
Prevalence ratios and corresponding 95% confidence intervals were calculated to detect significant bivariate relations between hypothesized correlates and STD or HIV worry. Prevalence ratios serve the same function as odds ratios calculated at the bivariate level. However, with the exception of case-control studies, odds ratios tend to inflate the magnitude of bivariate associations, whereas prevalence ratios do not introduce an inflation factor.
Logistic regression models were used to assess the degree of independent influence exerted by significant bivariate correlates on STD and HIV worry. Both models were constructed using three steps. First, covariates were entered as a block. Second, behavioral variables that were significant in bivariate analyses were entered as a block to control for the influence of recent sexual risk behavior on worry. Finally, hypothesized psychosocial determinants were entered using a backward-elimination procedure with criteria for entry and exit set at P > 0.10 and P < 0.05, respectively.
Average age of the participants was 16 years (SD, 1.2 years). Twenty-six percent of participants reported ever having an STD, and 28% tested positive for Chlamydia trachomatis or Neisseria gonorrhoeae assessed by DNA amplification assay or Trichomonas vaginalis assessed by culture.
Adolescents’ level of worry about STD infection was generally low, as indicated by low average scores (mean, 6.7; SD, 3.2; range, 4–16) and a strong positive skew. This distribution showed a natural break between the score of 8 and 9, with approximately 20% of the adolescents scoring 9 or above, indicating higher levels of STD worry. Likewise, worry about HIV infection was generally low (mean, 6.4; SD, 2.7; range, 4–16) and positively skewed. This distribution also showed a natural break between the score of 8 and 9, with approximately 18% of adolescents scoring 9 or above, indicating higher levels of HIV worry. These measures were strongly related by Pearson Product-Moment Correlation (r, 0.71, P < 0.0001) and by chi-square analysis (P < 0.0001) after dichotomization.
Prevalence ratios and corresponding 95% CIs for the hypothesized correlates of STD and HIV worry are displayed in Table 2. Of the recent behaviors assessed, none was associated with HIV worry; however, several were associated with STD worry. Because the two measures of risky sex (noncondom use at last sex, any unprotected vaginal sex in the past 30 days) were significant for adolescents with steady partners and were marginally significant for adolescents with casual partners, new correlates were created by combining data for both steady and casual sex partners. This procedure eliminated the need for models specific to partner type (e.g., steady versus casual).
The multivariate model assessing independent influences on STD worry fit the data well (GFI χ2, 9.24; 7 df;P = 0.23). Although none of the behavioral measures retained significance in the multivariate model, three of the psychosocial measures were significant. Adolescents reporting a recent history of STD were nearly five times more likely to be classified as having high STD worry than their peers not reporting a recent STD infection (OR, 4.64; 95% CI, 2.46–8.76;P < 0.0001). Adolescents scoring low on the measure of partner communication were twice as likely to be classified as high in STD worry (OR, 2.00; 95% CI, 1.19–3.35;P = 0.008). Similarly, adolescents scoring low on the measure of perceived ability to negotiate condom use with a male partner were approximately twice as likely to be classified as high in STD worry (OR, 2.04; 95% CI, 1.22–3.38;P = 0.006).
The multivariate model assessing independent influences on HIV worry also fit the data well (GFI χ2, 5.19; 5 df;P = 0.39). Although less prominent than in the model for STD worry, a recent history of STD was associated with increased HIV worry (OR, 1.98; 95% CI, 1.03–3.81;P = 0.04). Also, adolescents scoring high on the measure assessing partner-related barriers to condom use were nearly twice as likely to be classified as high on the measure of HIV worry (OR, 1.94; 95% CI, 1.06–3.24;P = 0.01).
Despite ample evidence of adolescents’ high-risk behavior, including laboratory-confirmed STDs, levels of STD and HIV worry were low, suggesting complacency about STD and HIV infection. Several reasons may account for this complacency. For example, adolescents may perceive HIV as an unlikely event because they trust their partner’s safety 24 or because they do not see evidence of HIV infection among their peers. In an era of effective antiretroviral therapies and relatively little media attention regarding the US AIDS epidemic, HIV infection may have little salience for the current generation of adolescents. Further, adolescents may feel that they are exempt from HIV infection based on their perceived absence of infection despite repeated episodes of risk behavior. This phenomenon has been described as an “absent-exempt” hypothesis, in that individuals reason they must not be vulnerable because they have practiced risky behavior, yet they remain uninfected by HIV. 8 Indeed, in the current study, none of the risky behavior variables was associated with HIV worry.
Although lack of salience may be one reason why HIV worry was generally low, familiarity with STD infection may explain why STD worry was generally low. The history and prevalence of STDs among these adolescents were high, even though the participants were not recruited from STD clinics. Familiarity with STD infection and the rapid and effective treatments for many STDs may have contributed to the observed complacency. This familiarity may have resulted from either personal or vicarious (i.e., friends, partners) experiences with STD infection and treatment.
Our investigation of associations between correlates and STD and HIV worry indicated that adolescents who reported moderate (versus low) STD and HIV worry may have experienced this worry for different reasons. After controlling for observed covariates and recent sexual risk behavior, the most important correlate of STD worry was a recent history of STD infection, with this correlate being much more important in the model examining STD worry. This finding suggests that adolescent females may worry about STD as a result of recently having an STD rather than considering their recent sexual risk behaviors. However, recent diagnosis of an STD was a far less important correlate of HIV worry. Thus, some adolescents may have compartmentalized STD risk from HIV risk, thereby failing to perceive the intersection between the risk behaviors that led to the STD infection and their subsequent risk of HIV infection. This separation of HIV risk from STD risk is especially unfortunate in a population at relatively high risk of HIV infection. The results also showed that STD worry and HIV worry were related to different psychosocial correlates. Infrequent communication and low perceived ability to negotiate condom use were related to STD worry, whereas only perceived partner barriers to condom use were related to HIV worry.
Findings are limited by several factors other than the inherent limitations of a cross-sectional study design. The most important limitation is reliance on self-reported behaviors and how closely the measures of perceived worry correspond to adolescents’ actual worry about STD and HIV infection. Regression models for both STD and HIV worry did not show an abundance of significant psychosocial correlates, which suggests that existing measures may not have captured the full range of salient constructs related to STD and HIV worry.
Despite being at high risk, adolescents were generally complacent about the threat of infection with STD and HIV. Perceived worry about STD and HIV infection had different sets of correlates. Interventions designed to promote safer sex behavior among female adolescents may benefit from using adolescents’ worry about STD infection to motivate protective behavior against both STD and HIV infection. For example, teaching adolescent females to view a recent diagnosis with an STD as an event that predisposes to STD-reinfection or HIV-infection, may help motivate their learning and application of safer sex behaviors. Prevention efforts may also simultaneously emphasize the STD and HIV risk associated with lack of sexual communication and negotiation while teaching adolescent females the skills they need to overcome these barriers.
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