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HIV/AIDS knowledge and sexual activity: an examination of racial differences in a college sample.

In the United States, the threat of HIV/AIDS to African Americans' health is the focus of much concern. It has raised an awareness of the health disparities primarily affecting African Americans in the incidence of HIV/AIDS, access to care, and survival rate. There is a growing racial disparity in HIV/AIDS incidence rates that primarily affects African Americans. Although they represent 12.3 percent of the U.S. population, African Americans represent 39 percent of all AIDS cases, 54 percent of annual new HIV cases, and have the poorest survival rates (Centers for Disease Control and Prevention [CDC], 2004b). For African American women this disparity is amplified, as they account for 72 percent of all new female HIV/AIDS cases nationally and experience rates at 25 times greater than white women (CDC, 2004a).

Explanations for these disparities are varied. In general, African Americans have higher rates of illness and death compared with white Americans for a broad range of health indices (CDC, 2005). These health care disparities often occur due to racially disparate clinical decisions that create an environment of misunderstanding, stereotyping, and prejudice (Institute of Medicine, 2003). A direct relationship between higher AIDS incidence and lower income exists (Diaz et al., 1994), and many African Americans have incomes at or below the federal poverty line (U.S. Census Bureau, 2000). However, socioeconomic status is an incomplete explanation of racial health disparities in HIV/AIDS. It may be more properly conceptualized as one of several contributing circumstances (MacMaster & Jones, 2005).

Today, at least half of all HIV infections in the United States occur among individuals younger than age 25 (CDC, 2002, 2004b; Rosenberg, Biggar, & Goedert, 1994). Although the overall incidence of HIV/AIDS has been declining, rates of HIV infection among young adults in the United States have not declined proportionately (CDC, 2002). College students as a population are particularly vulnerable to HIV infection. In a recent report, the CDC noted that the "epicenter of the [HIV/AIDS] epidemic is college students" (CDC, 2004c). Incidents of risky sexual behaviors are prevalent among college students, much of which occurs under the influence of drugs and alcohol (CDC, 2004c, UNAIDS, 2004). Despite the increased incidence rates, many college students remain relatively unconcerned about HIV/AIDS (Ajuluchukwu, Crumey, & Faulk, 1999; Leone et al., 2004).

The HIV/AIDS epidemic among college students is problematic not only because students are increasingly placing themselves at risk, but also because tile number of students living with HIV/AIDS is increasing among this population (Gayle et al., 1990; Leone et al., 2004). A recent study by Hightow and associates (2005) in the southeastern United States revealed that newly diagnosed HIV infection was found in 37 male college students and a sexual partner network investigation linked 21 colleges, 61 students, and eight partners or students. Historically, prevention of HIV among young people has focused on men who have sex with men (MSM); young heterosexual men are experiencing much higher rates of infection than ever before (CDC, 2004b). Similarly, prevention messages tailored only to MSM or non-MSM individuals may not reflect the current state of sexual behaviors in this country. As evidence, a recent study of HIV-positive African American male college students who have sex with men reported that 40 percent of respondents claim to also have sex with heterosexual female students (Leone et al.).

Furthermore, research on HIV/AIDS knowledge among college students has consistently shown that knowledge alone does not predict safe sex practices (Anastasi, Sawyer, & Pinciaro, 1999; Bates & Joubert, 1993; CDC, 2004c; Gupta & Weiss, 1993; Lewis, Malow, & Ireland, 1997; Opt & Loffredo, 2004). Duncan and colleagues (2002) conducted a qualitative study with African American college students and found that the most salient barriers to safer sex practices were negative views of condoms, trust issues, and spontaneity. In addition, Bazargan and colleagues (2000) conducted a study of African American college students and found that greater HIV knowledge, younger age, nonmonogamous relationship, positive experiences and attitudes about condom use, greater behavioral skills, and male gender were significant predictors of condom use.

Over the years, researchers have drawn on various psychological models to predict condom use for HIV/AIDS education and prevention. Among them, the Theory of Reasoned Action (TRA) states that HIV/AIDS prevention behaviors, such as condom use, are a function of behavioral intentions which are, in turn, a function of attitudes, subjective norms, and perceived behavioral control concerning those behaviors (Fishbein & Ajzen, 1975). Thus, intentions to use condoms are a function of attitudes--positive or negative--toward condom use and the perception of what significant others might think. Using the TRA as a framework, this study aimed to explore whether HIV/AIDS-related knowledge, attitudes, and vulnerability; normative beliefs, such as attitudes toward safer sex behaviors; and perceived behavioral control in condom use would predict white and African American college students' intention to adopt safer sex behaviors. Specific objectives of the study included the following: to examine current sexual behaviors of white and African American college students, to explore their current safer sex behaviors and intention to adopt safer sex behaviors in the future, and to investigate whether the various components of the TRA would predict safer sex behaviors among this sample.

METHOD

Participants and Procedures

Participants included several convenience samples of undergraduate students enrolled in social science classes from three public universities in the southern region of the United States. Two of the universities were major state institutions in urban areas, including the major flagship university and a historically black university; the third university was in a rural setting. This research study used a quantitative survey research design. Various professors were approached and asked for their permission to undertake the research during a portion of their class time. All participation was strictly voluntary and no identifying information was obtained on any participant. A trained research assistant read the information sheet aloud to participants and distributed the information sheet and questionnaires. Participants completed the questionnaires during class time and returned them before leaving the class; nonparticipants were asked to remain quiet or were dismissed from class early. The students were assured that their participation would have no effect on their class grade. Data collection took place in 2004.

A total of 156 students participated in the study. The analyses presented here included the 145 cases that had complete data on each of the measures described in the next section. In addition, the sample was also limited to students who self-identified as either white (n = 91) or African American (n = 54) on the questionnaire. This excluded 11 participants who self-identified as another race or ethnicity. The complete sample included 38 men and 107 women; 70 percent of the sample was between 18 and 21 years of age.

Measures

Current Sexual Activity and Condom Use. The students' extent of current sexual activity and condom use or safer sex practices were assessed by the following two questions: How would you describe your sexual life in the past 12 months? and How would you describe your use of condoms or safer sex practices in the past 12 months? The response options included 1 = none at all, 2 = rarely, 3 = sometimes, and 4 = very often (St. Lawrence, Eldridge, Reitman, & Little, 1998; Wong & Tang, 2001).

Future Sexual Activity and Condom Use. Participants' intentions for future condom use, future casual sex activity, and safer sex practices in future casual sex encounters were measured by responses to the following three questions: When having sex, will you use a condom in the future? How often will you have a "one-night stand" in the future? and Assuming that you would have a "one-night stand," how often will you use condoms?" The response options included 1 = none at all, 2 = rarely, 3 = sometimes, and 4 = very often (St. Lawrence et al., 1998; Wong & Tang, 2001).

HIV/AIDS Awareness. The International AIDS Questionnaire--English Language Version (IAQ-E), developed by Davis and associates (1999), was used to assess HIV/AIDS awareness. The instrument consists of 18 statements originally developed to assess four dimensions of HIV/AIDS awareness: (1) myths about the transmission of HIV (seven items), (2) facts about HIV/AIDS (three items), (3) understanding of personal HIV risk (three items), and (4) attitudes and prejudices toward individuals infected with HIV/AIDS (five items). Respondents were instructed to respond to each statement in the IAQ-E on a Likert scale ranging from 1 = strongly disagree to 5 - strongly agree. Example statements include "HIV can be spread through coughing and sneezing" (myths), and "I would end my friendship if my friend had AIDS" (prejudices). Responses to the IAQ-E were coded so that a lower score indicated greater HIV/AIDS awareness. The IAQ has been validated for use with both English and Chinese-speaking young adults (see Davis, Sloan, MacMaster, & Hughes, 2006; Davis et al., 1999). The IAQ-E was reviewed by two independent AIDS researchers for face validity. Content validity was established by reviewing other self-constructed scales used to measure similar concepts, such as HIV/ AIDS knowledge (Lewis et al., 1997; Li et al., 2004; Odusanya & Alakija, 2004), attitudes (Bruce & Reid, 1998; Bruce & Walker, 2001), and perceived risk (Barling & Moore, 1990; Moore & Barling, 1991). In the current sample, the Cronbach's alpha for the total IAQ-E scale was .89, and .87 for transmission myths, .83 for attitudes, .70 for personal risk, and .50 for facts subscales.

Condom Use Self-efficacy. A measure designed to assess college students' perceived ability to negotiate and intentions in the use of condoms was used to measure condom use self-efficacy (Schwarzer, Hahn, & Wegner, 1993; Wong & Tang, 2001). Participants were instructed to rate 12 statements, assuming that they have a sex partner, on a Likert scale ranging from 1 = very untrue to 4 = very true. Examples of items in this set include "I am certain that I would use a condom with every new partner" and "Even if I intended to use a condom, I'm not sure whether I really will when the situation arises." Content and face validity were established by reviewing similar instruments measuring self-efficacy of condom use (Barkley & Burns, 2000; Marin, Tschann, Gomez, & Gregorich, 1998; St. Lawrence et al., 1998), and satisfactory reliability was established with a Cronbach's alpha coefficient of .78. Responses were coded such that a high score indicated greater condom use self-efficacy.

Attitudes toward Safer Sex. To measure attitudes toward safer sex practices, participants were again instructed to assume that they have a sex partner and respond to 17 statements (Barker, Battle, Cummings, & Bancroft, 1998; Marin et al., 1998; Wong & Tang, 2001). Each item was rated on a Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Examples of the safer sex attitudes statements include "I am likely to talk to my partner about safer sex practices" and "I believe that using a condom can prevent me from getting HIV disease." Responses were coded so that higher scores indicated positive attitudes toward safer sex practices. Satisfactory reliability was established with a Cronbach's alpha coefficient of .76.

RESULTS

The data analysis plan involved descriptive statistics to report on HIV/AIDS knowledge and attitudes, condom self-efficacy, safer sex attitudes, and current and future sexual behaviors; analysis of variance (ANOVA) to explore group differences with regard to race and sexual status (active versus not active) on HIV/AIDS knowledge and attitudes, condom self-efficacy, safer sex attitudes, and current and future sexual behaviors; and Pearson correlations to explore associations among HIV/AIDS knowledge and attitudes, condom self-efficacy, safer sex attitudes, and current and future sexual behaviors.

Sexual Behaviors and Safer Sex Behaviors

In general, the means obtained revealed that the sample was relatively knowledgeable about HIV/ AIDS and had positive attitudes toward safer sex practices (Table 1). About 77 percent of respondents (n = 112) indicated that they were currently sexually active. Of the white respondents, 64 (70 percent) indicated that they were sexually active in the past 12 months, and 48 (89 percent) of the African American respondents reported that they were sexually active in the past 12 months (p > .05). Of those who were sexually active, only 36 percent of the white respondents compared with 52 percent of the African American respondents reported that they used condoms frequently [F(1,110) = 6.46,p < .05]. In addition, 52 percent of the white students and 69 percent of the African American students indicated that they would use condoms regularly in the future [F(1, 110) = 4.23,p < .05]. Sixty-five percent of the total sample reported that they would not have a one-night stand in the future. However, if they were to have a one-night stand, 81 percent of the total sample said that they would use condoms frequently. There were no significant racial differences in intentions to have a one-night stand or to use condoms in the event of a one-night stand (Table 2).

HIV/AIDS Awareness, Condom Use Self-efficacy, and Safer Sex Attitudes

Results from an ANOVA comparing HIV/AIDS-related awareness and attitudes, perceived condom use self-efficacy, and normative beliefs about safer sex behaviors are displayed in Table 2. There was a race effect on the total IAQ-E and on each subscale with the exception of the Facts subscale. In each case, white students showed more awareness of HIV/AIDS and less prejudiced attitudes toward individuals living with HIV/AIDS. In addition, there was a significant effect of sexual status on transmission myth beliefs and prejudiced attitudes (and on the total IAQ-E). The abstaining students were more knowledgeable about HIV/AIDS (active: M = 2.04, SD = .81 ; inactive: M = 1.57, SD = .54) and less prejudiced toward individuals living with HIV/AIDS (active: M = 2.04, SD =.9; inactive: M = 1.58, SD = .50) (as mentioned, lower scores indicated greater awareness and lower prejudice) than the sexually active students. Interestingly, the effect of sexual status on HIV/AIDS awareness appears to have accounted for tile racial differences in the IAQ-E scores. Among the sexually active students, there were no racial differences in HIV/AIDS awareness. The sample was too small to test for an interaction between race and sexual status--only six of the African American students were not sexually active. There was no main effect of race (in the total sample or among the sexually active) on condom use self-efficacy or attitudes toward safer sex. There was, however, a main effect of sexual status on condom use self-efficacy. The abstaining/inactive students reported greater self-efficacy in condom use than the sexually active students (active: M = 3.0, SD = .44; inactive: M = 3.4, SD = .41).

Associations between Awareness, Behaviors, and Attitudes

The Pearson correlation coefficients measuring the associations between HIV/AIDS awareness, perceived condom use self-efficacy, and normative beliefs about safer sex behaviors are presented in Table 3. As expected, the IAQ-E subscales and the total IAQ-E were positively correlated with each other. In addition, condom use self-efficacy and safer sex attitudes were both positively correlated with the total IAQ-E. Current sexual activity and current condom use were not correlated with HIV/AIDS awareness. However, current condom use was significantly correlated with condom use self-efficacy and safer sex attitudes.

Although current sex practices were not significantly associated with any of the dimensions of HIV/AIDS awareness, we found correlations between future sexual intentions and the IAQ-E. Having intentions for a one-night stand was positively associated with the IAQ-E, indicating an inverse relationship between HIV/AIDS awareness and an intention for a one-night stand. Intentions for condom use in a one-night stand were negatively correlated with the IAQ-E, indicating that greater intentions for condom use in a casual sex encounter occur with greater HIV/AIDS awareness. Future intentions to use condoms were also significantly correlated with increased condom use self-efficacy and positive safer sex attitudes.

DISCUSSION

Exploring racial differences in current sexual behaviors and safer sex practices, HIV/AIDS awareness, condom use-self efficacy, and attitudes toward safer sex practices in a sample of U.S. college students, we found the key racial differences were in current and future safe sex practices. Contrary to earlier studies (Bazargan et al., 2000; Jemmott & Jemmott, 1991), the sexually active African American students reported more condom use and greater intentions to use condoms or other safe sex practices in the future than the sexually active white students. No racial differences were found in intentions for future casual sex, condom use self-efficacy, or attitudes toward safer sex practices.

Although initially it appeared that white students were more aware of HIV/AIDS than African American students, this effect was explained when we considered sexual status. The sexually active participants reported less knowledge about HIV/ AIDS transmission and more prejudiced attitudes toward individuals living with HIV/AIDS than the abstaining students. When the white and African American students were compared within the sexually active sample, there were no racial differences in HIV/AIDS awareness. On one hand, it might be disconcerting that even among this population of educated young adults we find that students who are currently sexually active are less knowledgeable about HIV/AIDS than those who are not sexually active. On the other hand, it might be that students with increased knowledge about HIV/AIDS are more likely to practice abstinence. Regardless of interpretation, the sexually active students reported less perceived condom use self-efficacy than the abstaining students, which has important implications for social work practice in the area of HIV/AIDS prevention and education.

Furthermore, although current condom use is associated with condom use self-efficacy and positive attitudes toward safer sex practices among the sexually active students, condom use is not significantly correlated with HIV/AIDS awareness. Thus, although the sample was generally knowledgeable about HIV/AIDS, this knowledge did not necessarily translate into safer sex behaviors. HIV/AIDS awareness was, however, inversely associated with intentions for future casual sex encounters and was positively correlated with intentions to use condoms in the event of a one-night stand. Earlier research suggests that HIV/AIDS is a significant issue on U.S. college campuses (Hightow et al., 2005; Leone et al., 2004) and that many college students remain relatively unconcerned about HIV/AIDS (Ajuluchukwu et al., 1999). Findings from the current study support these earlier studies, with only 36 percent of sexually active white participants and 52 percent of sexually active African American participants reporting frequent condom use. Of further concern is the finding that nearly 20 percent of the sample does not always plan to use a condom during future one-night stands.

This study is not without limitations. Our sample is limited to a convenience sample of predominantly female college students at three universities in a single southern state in the United States. The present study attempted to minimize, but could not rule out, the shortcomings of the self-reported method, which may be subject to self-selection, social desirability, and recall bias. Participants were not asked about their marital status or sexual orientation, which may have influenced their frequency of condom use. Another limitation with regard to sexual behavior is that intentions may not equal actual behavior. Despite these limitations, these results are significant as they provide evidence on the current and future sexual behaviors of this sample population.

Intervention-based research needs to be conducted on how to increase safer sex practices among this vulnerable population and increase condom self-efficacy. This study and earlier research of HIV/ AIDS knowledge among college students has consistently shown that knowledge alone does not predict safer sex practices (Anastasi et at., 1999; Bates & Joubert, 1993; CDC, 2004c; Gupta & Weiss, 1993, Lewis et al., 1997; Opt & Loffredo, 2004). AIDS/HIV prevention programs have been the primary focus of controlling the spread of this disease since the epidemic was discovered, but effective interventions require the understanding of the target groups' characteristics, their particular stage of needs, and predicting factors specific to their behavior change. Future studies should focus on understanding the social and psychological factors that hamper safer sex practices among this population as well as successful intervention strategies to overcome these barriers. Social workers are in a variety of settings dealing with young adults and adolescents, which provides them with unique opportunities to educate and intervene with this population on practicing safer sex behaviors.

Original manuscript received August 10. 2005

Final revision received February 14, 2006

Accepted June 20, 2006

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Cindy Davis, PhD, is associate professor, College of Social Work, University of Tennessee, 193E Polk Avenue, Nashville, TN 37210; e-mail: cdavis3@utk.edu. Melissa Sloan, PhD, is assistant professor of sociology and behavioral science, Drew University, Madison, NJ. Samuel MacMaster, PhD, is assistant professor, University of Tennessee, Nashville. Barbara Kilbourne, PhD, is associate professor, Tennessee State University, Nashville.
Table 1: Relative Means and Standard Deviations of College Students'
Attitudes toward and Intention to Use Safer Sex BehavioAfrican

 White American
 (n = 91) (n = 54)

 Relative Relative
Variable Mean SD Mean SD

Current sexual activity 2.56 1.18 2.80 .87
Current condom use for currently
 sexually active (a) 2.77 1.15 3.27 .86
Intention for future condom use 3.27 .95 3.49 .84
Intention for future one-night
 stand 1.49 .85 1.64 .89
Intention for condom use in
 future one-night stand 3.79 .61 3.63 .73
IAQ-E
 Transmission myths 1.83 .75 2.10 .81
 Attitudes 1.82 .83 2.14 .82
 Personal risk 1.83 .81 2.12 .93
 Facts 1.79 .61 1.83 .79
 Total 1.80 .56 2.07 .71
Self-efficacy toward condom use 3.09 .45 3.06 .46
Attitude toward safer sex 3.28 .41 3.21 .56

 Total
 (N = 145)

 Relative
Variable Mean SD

Current sexual activity 2.65 1.08
Current condom use for currently
 sexually active (a) 2.98 1.06
Intention for future condom use 3.35 .91
Intention for future one-night
 stand 1.55 .87
Intention for condom use in
 future one-night stand 3.71 .68
IAQ-E
 Transmission myths 1.93 .78
 Attitudes 1.94 .84
 Personal risk 1.94 .87
 Facts 1.80 .68
 Total 1.90 .63
Self-efficacy toward condom use 3.08 .46
Attitude toward safer sex 3.25 .47

Notes: IAQ-E = International AIDS Questionnaire-English Language
Version. A low mean on the IAQ-E and subscales indicates greater
HIV/AIDS knowledge and awareness.

(a) Total number of currently sexually active participants was 112
(64 white and 48 African American).

Table 2: Summary of ANOVA Results for All Participants (N = 145)

 Race
 Sexual Effect
 Race Status among
 Main Main Sexually
 Effect Effect Active
 F Value F Value F Value

Current sexual activity 1.69 -- --
Current use of condoms -- -- 6.46 *
Intention for future condom use 2.09 0.679 4.23 *
Intention for future one-night stand .990 6.55 * .096
Intention for condom use in future
 one-night stand 2.62 3.10 * .0463
IAQ-E
 Transmission myths 4.61 * 9.95 ** 2.67
 Attitudes 5.51 * 8.48 ** 1.73
 Personal risk 4.35 * .10 1.64
 Facts .176 .006 1.31
 Total 7.06 ** 6.19 * 3.74
Self-efficacy toward condom use .104 14.88 *** .478
Attitude toward safer sex .990 .122 .119

Notes: ANOVA = analysis of variance. IAQ-E = International AIDS
Questionnaire-English Language Version.

* p < .05. ** p < .01.

Table 3: Correlation Matrix among Variables for Total Participants
(N = 145)

Variable (1) (2) (3) (4)

IAQ-E
(1) Transmission myths --
(2) Attitudes .605 *
(3) Personal risk .644 * .509 *
(4) Facts .346 * .309 * .343 *
(5) Total .901 * .823 * .771 * .527 *
(6) Self-efficacy toward
 condom use .263 -.437 * .227 -.482 *
(7) Attitude toward safer
 sex .201 -.448 * -.280 * -.484 *
(8) Current sexual activity -.047 -.055 .090 .062
(9) Current condom use -.033 .179 .032 .165
(10) Future condom use -.182 -.204 -.212 -.270
(11) Intention for future
 one-night stand .359 * .469 * .358 * -.389
(12) Intention for condom
 use in future
 one-night stand -.327 * -.269 * -.499 * .332

Variable (5) (6) (7) (8)

IAQ-E
(1) Transmission myths
(2) Attitudes
(3) Personal risk
(4) Facts
(5) Total
(6) Self-efficacy toward
 condom use -.417 *
(7) Attitude toward safer
 sex -.407 * .569 *
(8) Current sexual activity -.012 .237 -.065
(9) Current condom use -.084 .311 * .429 * --
(10) Future condom use -.247 .321 * .357 * -.084
(11) Intention for future
 one-night stand .497 * -.439 * -.381 * -.095
(12) Intention for condom
 use in future
 one-night stand -.403 * .301 * .297 * -.071

Variable (9) (10) (11)

IAQ-E
(1) Transmission myths
(2) Attitudes
(3) Personal risk
(4) Facts
(5) Total
(6) Self-efficacy toward
 condom use
(7) Attitude toward safer
 sex
(8) Current sexual activity
(9) Current condom use
(10) Future condom use .301 *
(11) Intention for future
 one-night stand .152 -.234
(12) Intention for condom
 use in future
 one-night stand -.178 .400 * .415 ***

Notes: IAQ-E = International AIDS Questionnaire--English Language
Version. A low score on the IAQ-E and suhscales indicates greater
HIV/AIDS knowledge and awareness.

(a) Correlations among currently sexually active students only.

* p < .001 (two-tailed) with Bonferroni adjustment for Type I errors.
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Author:Davis, Cindy; Sloan, Melissa; MacMaster, Samuel; Kilbourne, Barbara
Publication:Health and Social Work
Article Type:Report
Geographic Code:1USA
Date:Aug 1, 2007
Words:5182
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