Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) remain significant threats to health and well being in the United States. Both adolescent and adult women are disproportionately at risk for heterosexual transmission of HIV infection in comparison to men. Heterosexual contact accounts for 84% of HIV infection in adolescent females aged 13 to 19 compared with 3% in adolescent males (Centers for Disease Control and Prevention [CDC], 2018c). As having intercourse with a male who injects drugs holds an increased risk for HIV infection (CDC, 2018b), the opioid crisis poses a further threat to adolescent girls, whether using intravenous drugs or not.
Significant racial and ethnic disparities exist among women with HIV infection, including adolescent women. The rate of diagnosis of HIV infection among Black women is over 15 times higher than White women. The rate for Latina women is nearly five times the rate of non-Latina White women (CDC, 2018d). Given the challenges of adherence and accessibility to preexposure prophylaxis in adolescent populations, we rely on behavioral approaches to reduce the risk of exposure (Hosek et al., 2016). The best means of protection against heterosexually transmitted HIV infection are abstinence or condom use for those who are sexually active. Safer sex practices are highly effective in preventing HIV infection and other sexually transmitted diseases, and include consistent and correct condom use, limitation in the number of sexual partners, choice of less risky sexual behaviors, and reduction or elimination of alcohol and other drug use before and during sex (CDC, 2018b). For the purposes of this study, safer sex practices and HIV risk reduction behaviors were conceptualized as synonymous.
Primary abstinence is defined as never having had intercourse, and secondary abstinence describes the practice of those who have had intercourse, but for various reasons are refraining from intercourse. Regardless of definition, sexual abstinence is usually not a lifelong state. In the United States, 41% of male and 38% of female high school students have a history of sexual intercourse, with the rates positively associated with age. Twenty percent of all 9th graders (male and female) have had sex as compared with 57% of all 12th graders (Kann et al., 2018). In the context of these realities, a goal of successful abstinence interventions is to delay first intercourse, while addressing the sexual decision-making and beliefs about the consequences of sexual involvement.
Although abstinence is the most effective means to prevent sexually transmitted HIV, condom use is the most effective form of protection from HIV infection for those who are sexually active. Condom use is more likely with new sexual partners (Crosby et al., 2014), and decreases as adolescent females age (Kann et al., 2018). Sex with multiple partners is associated with HIV infection. Sexual intercourse with four or more sexual partners over the course of a lifetime increases risk of HIV infection (Zaza, 2015). Despite this risk, 8% of U.S. high school females had four or more sexual partners. Further, the prevalence of four or more sexual partners increases with age; 4% of all 9th graders and 18% of all 12th graders had four or more sexual partners (Kann et al.).
Heterosexual transmission of HIV may be more prevalent among women because they may not take steps to reduce their risk for infection when involved in relationships of unequal power. A better understanding of psychological determinants that enhance HIV risk reduction behaviors may assist in designing life interventions that mitigate unequal gender relationships and maximize an adolescent girl's efforts to prevent HIV. The seminal work of Pearlin (Pearlin & Schooler, 1978) and Rosenberg (Rosenberg, 1965; Rosenberg & Pearlin, 1978) support an association between the concepts of mastery and self-esteem and enhanced health outcomes in multiple contexts. Based on this research, we investigated these concepts in relationship to HIV risk reduction behaviors among a culturally diverse group of adolescent girls.
Mastery and self-esteem help people cope with ordinary problems in their lives. Derived from stress and coping theory, mastery is the extent to which one regards life-chances as being under one's own control or power in contrast to being fatalistically ruled (Pearlin, Lieberman, Menaghan, & Mullan, 1981). Given the health-enhancing effects of mastery in promoting health and well-being, it was posited that adolescent girls with a well-developed sense of mastery might have a greater ability to actualize their sense of control or power over their lives through HIV risk reduction behaviors.
Similarly, self-esteem is a psychological factor that may have a bearing on HIV risk reduction behaviors in adolescent girls. Self-esteem, the extent to which a person accepts oneself, is a trait that falls on a continuum from an extremely positive to an extremely negative attitude toward oneself. A person with high self-esteem expresses the attitude that one is “good enough,” whereas low self-esteem implies self-rejection, self-dissatisfaction, and self-contempt. Although there is considerable conceptual understanding about the relationships among mastery, self-esteem, and positive health outcomes, less is known about the actual impact of mastery and self-esteem on sexual behavior.
Cultural influence on mastery and self-esteem is also unclear. Although mastery and self-esteem have been measured extensively in populations of diverse cultural backgrounds, it is not well understood whether the constructs of mastery and self-esteem are equally relevant in different cultures, and whether there are differences among cultures in the ways in which these constructs are actualized.
To further our understanding of psychological characteristics that may enhance HIV risk reduction behaviors, the purpose of the study was to explore the relationships among mastery, self-esteem, and HIV risk reduction behaviors in a culturally diverse group of adolescent girls. The specific aims of this study were to: 1) examine mastery, self-esteem, and HIV risk reduction behaviors in a culturally diverse group of adolescent females, 2) determine whether differences in mastery, self-esteem, and HIV risk reduction behaviors exist among the three cultural subgroups; Black, Latina, and White, and 3) determine whether mastery, self-esteem, and demographic variables are associated with HIV risk reduction behaviors in the total sample and three cultural subgroups.
Study Design and Methods
A cross-sectional, descriptive correlational design was used to examine the relationships among mastery, self-esteem, and HIV risk reduction behaviors. A purposive sample of multicultural adolescent girls aged 15 to 19 was recruited from an adolescent health clinic in an urban setting located in the Northeast. The age range was chosen due to the increase in initiation of sexual intercourse during this time. A power analysis revealed that a minimum sample size of 165 with 55 respondents from each cultural group (Black, Latina, and White) was needed to determine influencing factors on HIV risk reduction behaviors.
To protect the privacy of adolescent participants, a waiver of parental consent was obtained from the site's Institutional Review Board. As this study pertained to the sexual behavior of adolescent girls, parental permission to participate in the study had the potential of compromising the adolescent's need for privacy in a very sensitive area of their lives. Knowledge of an adolescent's sexual behavior carries the potential of parental reprisal; be it emotional, physical, or economic. Documentation of informed consent was obtained in writing from the adolescent participant. There were no identifiers on the survey to link a participant to her consent form.
Participants anonymously completed a written survey in the privacy of an exam room or in a secluded area away from the waiting room. The 52-question survey, written at a fourth grade level, consisted of a 25-question demographic survey, 7-item mastery scale, 10-item self-esteem scale, and 10-item HIV risk reduction behavior instrument. The demographic survey included variables potentially related to sexual behavior including: age, race, ethnicity, years in the United States, languages spoken at home, current educational level, job status, number of hours worked. Maternal and paternal level of education and employment status questions were included, as well as whether a mother and/or father lived in the home. Given the challenges of gathering accurate information about household income from adolescents, household income was inferred by zip code. Participants completed the survey in approximately 15 minutes, and were given a gift voucher to a local food court as a thank-you gift for participating.
The Pearlin Mastery and Rosenberg Self-Esteem Scales were the instruments chosen to measure mastery and self-esteem based on their widespread use and well-established psychometric properties. Sense of mastery was measured with the seven-item Pearlin Mastery Scale (range 7-28; low to high) that measures one's global sense of control in the context of stress and coping using a four-point scale: strongly agree, agree, disagree, and strongly disagree (Pearlin & Schooler, 1978). Examples of items include: “I can do just about anything I really set my mind to.” “I often feel helpless in dealing with the problems of life.” “What happens to me in the future mostly depends on me.”
Self-esteem was measured with the 10-item Rosenberg Self-Esteem Scale (RSES) (range 10-40; low to high), which assesses the direction and degree of self-worth. The RSES uses the same four-point response option as the Pearlin Mastery Scale: strongly agree, agree, disagree, or strongly disagree (Rosenberg, 1965). Examples of items include: “I feel that I'm a person of worth, at least on an equal basis with others.” “I wish I could have more respect for myself.”
The HIV risk reduction behaviors instrument consisted of 10 items and was adapted from the validated High Risk Sexual Relationship of the Adolescent Problem Severity Index (Metzger, Kushner, & McLellan, 1991). Examples of items from this scale include: “Have you ever had sex (oral, anal, or vaginal intercourse)?” “In the past year, how many different partners have you had sex with?” “Have you ever had a sexually transmitted disease?”
All instruments had a reliability index greater than 0.70 when used in this study sample and were considered satisfactory for use. Descriptive statistics, analysis of variance, and hierarchical regression analysis were used respectively to describe the variables of interest, determine if differences existed among cultural subgroups, and determine whether mastery, self-esteem, and demographic variables were predictive of HIV risk reduction behaviors in the total sample and the cultural subgroups.
The total sample consisted of 224 participants with 49% (n = 109) of the respondents identifying themselves as Black, 26% (n = 58) as Latina, and 25% (n = 57) as White. The majority of the respondents (71%) reported that they had had intercourse (oral, anal, or vaginal) at least once with a median age of first intercourse at age 15 (Table 1).
Of those participants who reported a history of intercourse, 61% had a history of having sex without taking precautions to avoid a sexually transmitted disease (STD), whereas 20% reported a history of an STD. Although 50% had one sexual partner, 13% of respondents had four or more sexual partners in the last year. Twenty-two percent of participants reported that they had been pregnant in the past. Sixteen percent had a history of forced sex, and 36% responded that they had used alcohol or other drugs before having sex (Table 1). Of those adolescent girls aged 15 and 16 years, 32% had a history of intercourse in comparison to 52% of girls 17 to 19 years. Eleven percent of those who had sex had first intercourse before age 13.
For the total sample, the mean Pearlin Mastery Scale score for the total sample was 21 with a range of 11 to 28 (possible range 7-28). The subgroup means were: 22.1 for Black participants, 20.6 for Latina participants, and 20.9 for White participants. Black participants had significantly higher mastery scores than the Latina participants (p < .05). The difference in mastery scores between the Black and White participants was not significant.
The mean RSES score for the total sample was 31.5 with a range of 16 to 40 (possible range 10-40). The subgroup means were: 32.5 for Black participants, 30.6 for Latina participants, and 30.5 for White participants. Black participants had significantly higher self-esteem scores than Latina and White participants (p < .05).
The range for the HIV Risk Reduction Behaviors Scale was 0-11 (possible range 0-11; low to high) with a mean score for the total sample of 6.6. The means for the respective groups were: 6.4 in the Black group of participants, 6.7 in the Latina group of participants, and 6.9 in the White group. There were no significant differences in HIV risk reduction behavior scores among cultural groups. There was also no significant difference between mean mastery and self-esteem scores for those adolescent girls who never had sex and those who had.
Although many significant correlations existed among the independent variables of mastery, self-esteem, and demographics, there were no significant relationships between mastery or self-esteem and HIV risk reduction behaviors in the total sample or cultural subgroups. Demographic factors identified as significant in the correlation analysis (age, hours worked, mom in home, and income) were entered into the hierarchical multiple regression model first, followed by the mastery and self-esteem variables. This analysis confirmed that mastery and self-esteem did not predict HIV risk reduction behaviors in the total sample or in the cultural subgroups. Controlling for confounding influence, age was inversely related to HIV risk reduction behaviors in the total sample and in the Black group of participants with older adolescent girls reporting fewer HIV risk reduction behaviors. Household income was positively associated with HIV risk reduction behaviors in only the Black cultural subgroup.
Results of the study support the need for nurses to search for opportunities to screen and counsel adolescent girls to mitigate sexual risk and promote sexual health. Descriptive data depict a profile of adolescent girls at higher risk for HIV and other STDs than their national female high school counterparts (Kann et al., 2018), but consistent with other urban adolescent female populations at high risk for HIV (CDC, 2017). The low socioeconomic status of the study sample may have had a bearing on the differences in sexual activity between this sample and the national population of adolescent girls. Whether adolescent girls are at high or average risk for heterosexually transmitted HIV, nurses and other healthcare professionals have the ability to intervene and support them in their efforts to reduce sexual risk. In the context of wellness or illness care, looking for opportunities to screen for not only risk behaviors, but protective factors as well, is important to the promotion of adolescent health. Although it is not always possible in a busy clinical setting to both screen and intervene to reduce risk factors, identifying a need is important and allows the nurse to plan for later intervention.
Eleven percent of those participants who had sex had first intercourse before the age of 13. The importance of screening for sexual abuse is inherent in this finding. Whether or not an adolescent or child provides consent, intercourse or sexual contact with an individual under the age of 13 is considered a crime, and hence is deemed sexual abuse (Pegasus Legal Services for Children, 2018). Inquiring in nonjudgmental ways about the realities of adolescent girls' lives is critical to successful interventions that mitigate risk, not only for HIV but for abusive relationships as well. As it has long been appreciated that adolescents consider healthcare providers to be one of their most valued sources of information on issues of sexuality, nurses are ideal individuals to counsel and support choices for sexual health and well-being.
The lack of significant associations between mastery and self-esteem and HIV risk reduction behaviors was surprising given the preponderance of literature supporting positive associations between mastery and self-esteem and improved health status in multiple contexts. Although no studies were found that explored the relationship between mastery and HIV risk reduction behaviors, there were a limited number of studies in which the impact of self-esteem on sexual risk was explored, but with mixed findings.
Lower self-esteem was shown to be associated with increased sexual risk in a study of African-American girls (Danielson et al., 2014). Similarly, adolescent girls with lower self-esteem were 1.7 times more likely to have higher risky sexual behaviors compared with adolescents with higher self-esteem (Enejoh et al., 2016). Lower self-esteem was associated with risky sexual behaviors, but the converse was not observed. High self-esteem was not associated with high HIV risk reduction behaviors. Alternatively, self-esteem was neither positively nor negatively associated with sexual behaviors in a study of African-American adolescent girls (Sales et al., 2012). This finding was consistent with the results of this study where self-esteem carried no influence on HIV risk reduction behaviors.
In reconsidering the theoretical rationale for this study, we gained appreciation for why mastery and self-esteem did not explain HIV risk reduction behaviors in our sample of adolescent females. HIV risk reduction behaviors related to heterosexual transmission of HIV infection involve the very specific behavior of negotiating condom use for those who are sexually active and refraining from intercourse for those who are not. The global nature of mastery and self-esteem may not lend these characteristics to be resources in the circumstance of negotiating condom use with members of the opposite sex. The specific and challenging nature of negotiating condom use, often against cultural norms with more powerful members of the opposite sex, raises questions about the impact of a global intrapsychic personal resource, such as mastery or self-esteem. As mastery is a global sense of control and self-esteem is the value placed on self, an adolescent young woman in the process of negotiating condom use may find herself in the situation of not being in control and not being valued. Even with a high sense of mastery and self-esteem to fall back on, perhaps what is needed is a requisite skill set and the belief that one can use these skills, that is, self-efficacy related to condom use. As agents of empowerment, nurses can make a significant contribution in assisting adolescent girls to acquire the self-efficacy skills that lead to healthy behaviors.
Similarly, in adolescent girls who are not sexually active, skills related to supporting the desire to refrain from intercourse are perhaps what is most needed. Problem solving with an adolescent girl to structure her circumstances to support a desire not to engage in intercourse (e.g., not going to a boyfriend's house when no one else is home) may be of greater use than her inherent sense of mastery and self-esteem (Long-Middleton et al., 2013). Although an adolescent girl's sense of mastery and self-esteem may undergird her desire not to have intercourse, it may be that it is the acquisition of situation-specific skills that allows her to operationalize this desire to abstain.
What people do is often different from what they think and feel. The interplay of cognitive, behavioral, and environmental factors may carry a greater and overriding influence on HIV risk reduction behaviors than the global psychological traits of mastery and self-esteem. The perception that “all my friends use condoms” may lend to the acquisition of negotiation and condom use skills while reinforcing the individual's belief that condom use is important. Similarly, the perception that one's friends are abstaining from sex may build skills in abstinence negotiation while affirming one's understanding that abstinence is worthwhile.
An additional consideration is that those with high mastery may also be the risk-takers in life. A global sense of control may enhance one's sense of invincibility, a particularly apt issue in adolescence. Thus, the more invincible one feels to HIV, the less likely one may be to take the appropriate precautions against contracting the virus.
Differences in mastery and self-esteem among the three cultural groups did not demonstrate any significant differences in HIV risk reduction behaviors. However, Black participants had significantly higher mastery scores than Latina participants, and significantly higher self-esteem scores than both the Latina and White participants. Limited research related to the influence of culture on mastery and self-esteem makes comparisons with other studies difficult.
Limitations of this study are consistent with other survey methodologies. Measurement by self-report is subjective, and response bias may come into play. The participants may have felt pressure to provide answers that they perceived were socially acceptable, despite completing the surveys anonymously. The measurement of mastery and self-esteem may also be influenced by circumstances, good or bad, at point of testing. Consequently, measurement of a participant's sense of mastery or self-esteem may not be reflective of the adolescent's true sense of mastery or self-esteem. The participants in this study were adolescent girls who sought healthcare services at a primary care practice, limiting the generalizability to those adolescent girls who are not able to access primary care services.
These results nonetheless bear consideration for practice. The lack of association between HIV risk reduction behaviors and mastery and self-esteem direct our interventions toward behavioral change, such as condom and abstinence self-efficacy. Motivational interviewing and behavioral skills building are techniques that can guide interventions that inform, motivate, and build skills that support an adolescent girl's desire to mitigate risk for HIV. These modes of behavioral intervention have proven to be efficacious and are dynamic and flexible enough to address cultural inclusiveness and sensitivity (CDC, 2018a). Given the discipline's emphasis on health promotion and disease prevention, nurses are ideal agents to empower adolescent girls to mitigate HIV risk through evidence-based behavioral interventions.
Our findings suggest the need for equal intention toward HIV preventive efforts regardless of perceived level of mastery and self-esteem. Presented with an adolescent young woman who projects a high level of mastery and self-esteem; that is, a sense of “I am and I can,” the nurse may be lulled into thinking that HIV prevention counseling is less important, or not a priority for the healthcare visit. The nurse may be tempted to spend less time with her in teaching and coaching activities related to HIV risk reduction behaviors than her counterparts, who may present in a less confident and self-assured manner. It is important that HIV preventive efforts not be lessened for those adolescent girls who present with a sense of self-assuredness reflective of high mastery and self-esteem. The inverse relationship between age and HIV risk reduction behaviors provides direction for practice and suggests the need to intensify HIV preventive interventions as adolescents age.
This knowledge provides direction for further research to develop and tailor interventions that mitigate sexual risk and build skills that prevent sexually transmitted HIV in adolescent girls. In conclusion, HIV prevention efforts should be universal, regardless of an adolescent girl's presumed level of mastery and self-esteem, and need to intensify as adolescent girls age.
Suggested Clinical Implications
- Understanding the risk for sexually acquired HIV in adolescent girls informs our screening efforts.
- HIV prevention efforts should be universal, regardless of the adolescent girl's presumed level of mastery and self-esteem.
- HIV prevention efforts need to intensify as adolescent girls age.
- As agents of empowerment, nurses can make a significant contribution in assisting adolescent girls to acquire the skills that lead to health-enhancing behaviors.
The first author (Ellen R. Long-Middleton) was supported by the National Institute of Nursing Research (Award Nos. 5F31NE07195 and T32NR007081) and the Maternal Child Health Bureau, Department of Health and Human Resources, Leadership Education in Adolescent Health Training Grant (MCH/HRSA T71MC00009).
The first author (Ellen R. Long-Middleton) was a participant in the 2014 NLN Scholarly Writing Retreat, sponsored by the NLN Foundation for Nursing Education and Pocket Nurse.
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