Theory based safer sex intervention among African-American college students.
Abstract: Safer sex is important for protection against STDs and HIV/AIDS. The purpose of this study was to test the efficacy of a brief social cognitive theory based safer sex intervention among African-American college students. A randomized controlled design was used. Results concluded that there was no difference between a theory-based intervention and a knowledge-based intervention in terms of efficacy in developing safer sex behavioral skills. Ever diagnosed with a sexually transmitted disease, year in school and ever taking a sexuality class were significant demographic covariates. The dose of the intervention was thought to be insufficient and must be increased in future interventions.
Subject: African American universities and colleges
HIV (Viruses)
Disease transmission
Sexually transmitted diseases
Students
AIDS (Disease)
African Americans
Safe sex
Health/Growth and Development/Physiology and Sexuality/Aids and other STD's
Authors: Kanekar, Amar
Sharma, Manoj
Cottrell, Randall
Succop, Paul
Bernard, Amy L.
Pub Date: 01/01/2010
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2010 Source Volume: 25 Source Issue: 1
Accession Number: 308741531
Full Text: INTRODUCTION

The HIV/AIDS epidemic has taken a tremendous toll on the population of United States. Of the 281, 421 persons receiving diagnosis of HIV infection during 1996-2005, 45% had an AIDS diagnosis by 3 years after their HIV diagnosis (CDC, 2009). The demographic trends from 1981-2004 indicated that these cases were more frequent in males than females (71.3% vs. 28.7%), more likely in the age-group 30-44 years, (50.8%), highest in black, non-hispanics (51%), and due primarily to male to male sexual contact (43.5%) and heterosexual contact (34.0%)(CDC, 2006). African-Americans continued to bear the greatest burden such that the rate of HIV infection in males was nearly seven times higher than that of white men and for females it was twenty times that of white women (CDC, 2007).

Young adults represent the fastest growing groups of new HIV infected individuals in the United States (Hightow et al., 2005). In a study that examined the predictors of HIV/AIDS risk among college students, ethnicity, gender, academic status and substance use were highly significant (Dilorio, Dudley, & Soet, 2007). Similar factors emerged significant in a study which looked at demographic and personality factors in HIV/STD partner specific risk perceptions among young adults (Mehrotra, Noar, Zimmerman, & Palmgreen, 2009).

College students across the nation are susceptible to contracting sexually transmitted diseases including HIV/AIDS as they indulge in unsafe sex practices (Diclemente, 2000). African-Americans were disproportionately affected by HIV infection accounting for 55% of all the HIV infections among persons aged 13-24 years (CDC, 2008). Constructs from various models such as Theory of Reasoned Action, and the Health Belief Model were used in the past to predict safer sex behaviors among college students. Self-efficacy skills and expectancies to use condoms were the two variables which best predicted safer sex behaviors (Strader & Beaman, 1991). To change risky sexual behavior implied assessment of cognitive factors influencing students' decision making regarding safer sexual behavior (Patel, Gutnik, Yoskovitz, O'Sullivan, & Kauffman, 2006). Social Cognitive Theory (SCT) has been applied for primary prevention and has been used in HIV prevention programs in adolescents, nutrition education programs, smoking cessation programs and for developing problem solving skills. Another group of examples where SCT has been used in secondary and tertiary prevention are diabetes education programs, promotion of female condom use in a sexually transmitted disease clinic and dietary approaches to reducing hypertension (Sharma, and Romas, 2008). Very few of the theory constructs have been used to predict safer sex behaviors in college students (O'leary, Goodhart, Jemmot, & Daria, 1992).

Social Cognitive Theory has been used extensively along with the Information-Behavioral-Skills model in the past in reducing HIV risk behaviors and sexually transmitted diseases in heterosexual African-Americans (Darbes, Crepaz, Lyles, Kennedy, & Rutherford, 2008; Semann et al., 2002). Furthermore a review of community, family and school-based interventions for HIV/AIDS prevention in African-American adolescents shows that Social Cognitive Theory has been utilized the most. (Ickes, & Sharma, 2007).

Hence, this study was designed to test a Social Cognitive Theory based brief intervention for safer sex behavioral change among a target population of African-American college students. The purpose of this study was to determine to what extent constructs of Social Cognitive Theory (i.e., situational perceptions for safer sex, expectations for safer sex--including expectancies for safer sex, self-efficacy for safer sex, self-efficacy in overcoming barriers for indulging in safer sex, and self-control for safer sex and safer sex behavior were changed after an SCT-based intervention when compared to a non-theory-based program (knowledge-based) among African-American college students.

METHODS

Study design. This study was conducted in summer of 2009. The design used for testing the theory-based intervention among target population of African American college students was a randomized controlled design. A pretest, post-test and six week follow up were administered. One group of college students was offered a theory-based intervention program (experimental group) and the other group was given a knowledge-based intervention program focusing on HIV/AIDS and sexually transmitted diseases.

Sample size and recruitment. The African American Cultural Center and Ethnic Programs & Services, a university based student organization for African American college students was approached to recruit students into the study. Students were recruited with the help of this organization via flyers posted at various locations on campus, such as the university student union, student recreation center, libraries, and residence halls. Furthermore announcements regarding the details of Health Promotion activity workshops were made at meetings conducted at the African-American Cultural Center and Student Ethnic Services and information sent to the members via listservs.

A convenience sample of 141 African-American undergraduate and graduate college students from all academic majors, were randomized into two groups of the intervention such that there were 73 students in the intervention (theory-based) group and 68 students in the non-theory (knowledge-based) groups. This sample size was calculated to be required to have 80% power considering an alpha level of 0.05, with a power of 0.80 and an estimated effect size of 0.50 (Durlak, 1995; Polit & Hungler, 1999).

Randomization and intervention. The intervention for each group of African American college students was workshop-based. Each workshop was two hours in length and consisted of four half-hour sessions. Fourteen workshops offered at different times and days were conducted for the intervention (theory-based groups) and fourteen workshops offered at different times and days were conducted for the knowledge-based (non-theory) group. Each workshop had approximately five participants.

The workshops for the intervention (theory-based) arm were based on the constructs of situational perception for safer sex, self-efficacy towards safer sex, self-efficacy towards overcoming barriers for safer sex, expectations about safer sex and self-control for safer sex. Methods such as informational talk, brainstorming, demonstration and group discussion were used. The workshops for the non-theory (knowledge-based) arm were based on knowledge about HIV/AIDS and sexually transmitted diseases. All workshops were conducted by the same researcher at the African-American Cultural and Research Center at a large Midwest university campus. The researcher had a master's degree in public health, was a doctoral candidate in health promotion and education and was nationally certified health education specialist.

Measures and instrumentation. A cross-sectional study design was used in the instrument development process. Self-report scales were developed for constructs of social cognitive theory that included situational perceptions for safer sex, self-efficacy towards safer sex, self-efficacy in overcoming barriers for safer sex, expectations for safer sex, self-control for safer sex and safer sex behaviors. Content validity, face validity and readability of items were established by a panel of six experts and the first author in two round review process.

For construct validation a confirmatory factor analysis using maximum likelihood method was done that confirmed a single-component solution satisfying criteria of Eigen value over 1(Eigen values are variance in all variables that is accounted for by that factor). The scales were found to be construct valid, internally consistent with most Cronbach alphas over 0.70 and satisfactory test-retest reliability coefficients over 0.70 (Kanekar, & Sharma, 2009).

Process evaluation was done to ascertain that each session was presented as planned. To assess the consistency and discrepancy between the planned program and the program actually occurring for each of the eight sessions [four theory-based and four non-theory (knowledge-based] tally sheets were prepared. Face and content validity of these sheets were established by simultaneously comparing the sessions with the tally sheets by four experts and the researcher (three university professors and one public health educators) in a two-round review process.

Data collection and analyses. Implementation of this study and data collection was done during the period May-July 2009. A pretest survey questionnaire was given to all workshop participants at the beginning of each workshop. Food incentive was provided to all the participants for workshop participation and monetary incentives for completing surveys at one week ($ 4 cash) and six weeks ($ 4 cash) post-intervention workshops. The Statistical Package for Social Sciences (SPSS) version 16 was utilized for descriptive statistics while the repeated measures analyses of variance were carried out using the Statistical Analysis Software (SAS) version 9.1.

RESULTS

Descriptive statistics. A total of 141 African-American college students at a large Mid-western University were recruited for this study. These students were randomly assigned to an experimental (theory-based) intervention group [n=73] or a knowledge-based (non-theory) intervention group [n = 68]. A comparison of demographic characteristics of the experimental (theory-based) and the knowledge-based (non-theory) groups is depicted in Tables 1, 2, and 3. From Table 1, it is evident that approximately half of the students were undergraduates (n = 72, 51.1%), and female (n = 75, 53.2%) while a large majority had never been diagnosed with a sexually transmitted disease (n = 130, 92.2%). From Table 2, it is evident that approximately the same number of students were in the freshman (n = 28, 19.9%), sophomore (n = 34, 24.1%), junior (n = 30, 21.3%) and senior years (n = 36, 25.5%). A majority of the students had a grade point average between 3 and 3.5 and had not ever taken a sexuality class (n = 89, 63.1%). From Table 3, it can be seen that the majority of students had a maximum of two partners in the past year (n = 92, 65.2%), had initiation of sexual intercourse between 16-18 years of age (n = 83, 58.9%) and were not taking a sexuality class at present (n = 139, 98.6%).

Inferential statistics. Analyses of variances were conducted on constructs of social cognitive theory including (a) situational perceptions for safer sex, (b) expectations for safer sex, (c) self-efficacy for safer sex, (d) self-efficacy in overcoming barriers for safer sex, (e) self-control for safer sex and (f) safer sex behavioral skills. The results of these analyses, conducted by group-(experimental [theory-based] vs. knowledge-based [non-theory]), and time post-test (1 vs. 6 weeks indicated that there were no differences between the experimental (theory-based) intervention group and the knowledge-based (non-theory) intervention group in the change of (a) mean situational perceptions for safer sex score (group p = 0.94; time x group p = 0.74), (b) mean expectations for safer sex score (group p=0.28; time x group p = 0.81), (c) mean self-efficacy for safer sex score (group p = 0.69; time x group p=0.34), mean self-efficacy in overcoming barriers for safer sex score (group p=0.09; time x group p =0.55), mean self-control for safer sex score (group p = 0.52; time x group p = 0.44), and mean safer sex behavioral skills score (group p = 0.99; time x group p = 0.85).

The main effect of time was significant (p <0.04) for the construct of self-efficacy in overcoming barriers for safer sex implying that while there was no significant difference between the groups, both groups improved between the pretest and the post-test. Having been ever diagnosed with a sexually transmitted disease (p<0.02) and year in school (p<0.01) were significant demographic covariates for the construct of self-efficacy in overcoming barriers for safer sex. For the construct of self-control for safer sex, having been ever diagnosed with a sexually transmitted disease (p<0.03) and ever having taken a sexuality class (p<0.01) were significant demographic covariates.

DISCUSSION

This study tested the effects of a brief intervention based on the constructs of social cognitive theory (experimental intervention) compared to a knowledge-based (non-theory) intervention in modifying safer sex behavioral skills in a sample of African-American college students. This was a onetime intervention [where the intervention was in the form of a two-hour workshop conducted among African-American student participants at a large Mid-western university; the contact time per group was two hours]. There were no significant differences observed in mean score change for various constructs (situational perceptions for safer sex, expectations for safer sex, self-efficacy for safer sex, self-efficacy towards barriers for safer sex, and self-control for safer sex) of the social cognitive theory at 1-week posttest and at 6-week posttest, in the experimental (theory-based) intervention and knowledge-based (non-theory) intervention groups. This may primarily be attributed to the insufficient dose of intervention that the student participants were exposed to in this study. It seems very probable that a onetime intervention exposure of 2-hours duration is insufficient to modify constructs of social cognitive theory and increase safer sex behavioral skills.

A comprehensive review of the literature in the arena of safer sex interventions in African-American adolescents in the settings of community, family or school concluded that duration of intervention (length of individual sessions and the number of sessions) and the time-span over which they were distributed was critical for making a significant behavioral change among participants (Ickes, & Sharma, 2007). Furthermore it can be said that more frequent interventions e.g. seven versus three sessions (while keeping the total instructional time the same) produced greater behavioral change in study participants (Rotheram-Borus, Gwadz, Fernandez, & Srinivasan, 1998). A meta-analytic review on behavioral interventions for risk reduction related to HIV/AIDS and sexually transmitted diseases in heterosexual African-Americans suggested that interventions with increased instructional time and session frequency spread over multiple weeks show significant behavioral change (Darbes et al., 2008). The current study was a novel attempt to test the efficacy of a brief intervention utilizing five constructs of the social cognitive theory in promoting safer sex behaviors.

LIMITATIONS

This study had a number of limitations. The set of instruments developed for this study used and operationalised five different constructs of social cognitive theory for the first time. Although the instrument had acceptable reliability and validity further improvement is possible. Some of the constructs such as situational perceptions and self-control could have been operationalized in greater detail. The expectations construct also could have been more comprehensively operationalized. Some modifications could have served a dual role of not only improving the measurement of these constructs but also comprehensively addressing the dimensions that these constructs were supposed to be measuring while also developing them to quantify the affect of a theoretically based intervention.

Self-reports were used for data collection (which was the only way of collecting sensitive data as needed in this study). There are potential drawbacks to self-reported data collection such as deliberate or unconscious distortions of data (Polit, & Hungler, 1991). Some of these may be due to an inability to recall events. Social desirability bias may have been evident in this study, especially when students were asked to reveal whether they had any sexually transmitted diseases in the past, or the number of sexual partners they had in last year. There may have been a selection bias as students volunteering for this study had higher than average grade point averages. Underreporting the number of partners or over reporting the number of partners was also a possibility and there was no way for this to be controlled.

Finally, the study sample of African-American students (from a large Mid-western university) was not randomly selected and hence the results of this study cannot be generalized to other African-American students at this campus or other campuses.

CONCLUSIONS

Based on the results of this study, it can be concluded that there is no difference between a brief Social Cognitive Theory-based intervention and a brief non-theory-based knowledge intervention in terms of efficacy in developing safer sex behavioral skills in a study sample of African-American college students at a large Mid-western University. The constructs of expectations for safer sex, self-efficacy for safer sex, self-efficacy towards barriers for safer sex, and self-control for safer sex showed a mean improvement in scores from baseline to 6-weeks posttest for both the experimental (theory-based) and knowledge-based (non-theory) intervention groups (which was neither statistically nor practically significant).

Dose of the intervention was an important factor which emerged from this efficacy study. The experimental (theory-based) intervention failed to show efficacy in eliciting changes in the constructs of social cognitive theory along with safer sex behavioral changes. This lack of findings was thought to be due to an inadequate intervention.

This study provides a small but important additional amount of information for behavioral interventions addressing HIV/AIDS and sexually transmitted disease prevention among an African-American adolescent/college population. This is the first research study in which an attempt was made to operationalize five constructs of social cognitive theory in a measurement instrument that met acceptable standards of reliability and validity. Furthermore this study had a rigorous research design and comprehensive statistical analyses were performed. Finally although the follow-up period was not extensive, this study met very high standards for participant retention and had only six participants lost-to-follow-up.

IMPLICATIONS FOR PRACTICE

The findings of this study have important implications for health promotion professionals who are developing and validating an instrument based on five constructs of social cognitive theory and implementing a brief theory-backed intervention for safer sex promotion. Future studies need to be conducted that compare brief interventions with more intense interventions. Although self-efficacy and expectancies were some of the important components identified in previous successful safer sex promotions (Strader, & Beaman, 1991; Wulfert, & Wan, 1995), in this study the baseline scores for these constructs were relatively higher (i.e. the means of these constructs were quite high at baseline in this particular study sample of African-American college students). The high baseline scores made demonstrating a significant modification due to the interventions much more difficult One of the limitations of the social cognitive theory is that it may not be a strong behavior change theory like the stages of change theory (especially when assessing the readiness of the study sample for behavior modification)(Nelson, & Williams, 2007). Finally, as discussed earlier, the addition of other components to constructs such as expectations for safer sex and situational perceptions for safer sex along with detailed operationalization of self-control for safer sex (practitioners can use educational processes which address self-monitoring of safer sex activities such as consistent condom usage or practicing monogamy and compare their actual practice with their self-set goal) will strengthen the measurement instrument along with improving the intervention effect.

RECOMMENDATIONS FOR FUTURE RESEARCH

This brief interventional study showed no significant difference between an experimental (theory-based) and a knowledge-based (non-theoretical) intervention program in modifying SCT constructs or altering safer sex behaviors. Recommendations for future research can be made primarily on two aspects of this study a) the measurement instrument and b) the intervention dose and duration.

The measurement instrument can be further modified by developing other subscales such as situational perceptions for safer sex, and expectations for safer sex from systematic qualitative inquiry. Some of the constructs such as self-control for safer sex can be expanded by operationalization of all of the underlying dimensions.

This was a brief interventional study (of six weeks) duration that included a pretest, two randomly assigned interventions and two follow-up post-tests at the end of one week and after six weeks post-intervention.

Behavioral interventions recommended for future researchers based on this study should aim at the following issues: improved operationalization of the theory and increased frequency of sessions (i.e. spread out the intervention over a longer time interval).

Based on this information, a prototype design that is recommended for future researchers is:

* a baseline pretest;

** an intervention comprising----about seven sessions

** the interventions may be based on the experimental [theory-based] and/or the knowledge-based [non-theory] approaches with each intervention session being about 90-120 minutes in duration). The intervention sessions should be spread over 4 weeks in total;

* a post-test 3 months after the last intervention session;

** 2-booster intervention sessions in the following two weeks;

** another post-test 6 months post-intervention.

It would also be useful to include a control group in this study design, such as one involving general health promotion that would focus on topics like nutrition, physical activity and stress reduction to provide a comparator to the intervention groups to promote safer sex behavioral skills such as higher frequency and consistency in condom usage,. (Diclemente, & Wingood, 1995; Diclemente, et al., 2004; Jemmott, Jemmott, & Fong, 1998). Furthermore a control group in the form of a delayed HIV educational session or the usual campus health-related knowledge awareness group (including knowledge about sexuality issues) could be incorporated into future studies.

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Amar Kanekar, MBBS, MPH, CHES, CPH

Manoj Sharma, MBBS, PhD

Randall Cottrell, D.Ed., CHES

Paul Succop, PhD

Amy L. Bernard, PhD

Amar Kanekar, MBBS, MPH, CHES, CPH, is an Assistant Professor of the Department of Health Studies East Stroudsburg University of Pennsylvania, 200 Prospect Street, East Stroudsburg, PA, 18301-2999. Tel: (570)-422-3748. Fax: (570)-422-3848. E-mail: akanekar@po-box.esu.edu. Manoj Sharma, MBBS, PhD, is a Professor of Health Promotion & Education, University of Cincinnati. PO Box 210068. Cincinnati, OH 45221-0068. Tel: (513) 556-3878 Fax: (513) 556-3898 E-mail: manoj.sharma@uc.edu. Randall Cottrell, D.Ed., CHES, is a Professor & Program Director, Health Promotion and Education Program, University of Cincinnati, PO Box 210068, Cincinnati, OH 45221-0068. Tel: (513) 556-3861. Fax: (513) 556-3898. E-mail: Randall.cottrell@uc.edu. Paul Succop, PhD, is a Professor, Department of Environmental Health, Division of Epidemiology and Biostatistics, University of Cincinnati Medical Center, P.O. Box 670056 Cincinnati, OH, 45267-0056. Amy L. Bernard, PhD, is an Associate Professor, Health Promotion and Education, University of Cincinnati. PO Box 210068, Cincinnati, OH 45221-0068, Tel: 513-556-2126, Fax: 513-556-3898. E-mail: amy.bernard@uc.edu.
Table 1. Descriptive statistics on age, gender, and STD diagnosis
variables: Experimental (n = 73) and knowledge-based (n = 68)
intervention groups of African American college students

Variable         Theory-based     Non-theory   Statistical   p-value
                 Frequency (%)    Frequency      Test *
                                     (%)

Age (in years)
  16-20          35(48.6)         37 (51.4)      15.50        0.687
  21-25          29 (53.7)        25 (46.3)
  > 25           9 (60)           6 (40)

Gender
  Male           38 (57.6)        28 (42.4)      1.67         0.196
  Female         35 (46.7)        40 (53.3)

STD diagnosis
  Yes            5 (45.5)          6 (54.5)      0.191        0.662
  No             68 (52.3)        62 (47.7)

* Age, Gender and STD diagnosis were tested with Chi-statistic

Table 2. Descriptive statistics on year at school,
grade point average and sexuality class taken ever
variables: Experimental (n = 73) and knowledge-based
(n = 68) intervention groups of African-American
college students

Variable           Theory-based   Non-theory
                   Frequency (%)  Frequency (%)

Year
Freshman           13 (46.4)      15 (53.6)
Sophomore          15 (44.1)      19 (55.9)
Junior             16 (53.3)      14 (46.7)
Senior             21 (58.3)      15 (41.7)
Graduate           8 (61.5)       5 (38.5)

Grade point avg.
> 1.5 and < 2.5    9 (50)         9 (50)
[greater than or   22(48.9)       23 (51.1)
  equal to]  2.5
  and < 3.0
[greater than or   34(52.3)       31 (47.7)
  equal to] 3.0
  and < 3.5
[greater than or   8(61.5)        5 (38.5)
  equal to] 3.5
  and [less than
  or equal to]
  4.0.

Sexuality class
  ever
  Yes              26 (50)        26 (50)
  No               47(52.8)       42 (47.2)

Variable           Statistical  p-value
                   Test **

Year
Freshman           2.265        0.687
Sophomore
Junior
Senior
Graduate

Grade point avg.
> 1.5 and < 2.5    40.29        0.671
[greater than or
  equal to]  2.5
  and < 3.0
[greater than or
  equal to] 3.0
  and < 3.5
[greater than or
  equal to] 3.5
  and [less than
  or equal to]
  4.0.

Sexuality class
  ever
    Yes            0.104        0.747
    No

* Year, Grade point average and sexuality
class ever were tested with chi-statistic

Table 3. Descriptive statistics on sexual partners, age at first
sexual intercourse and sexuality class at present variables:
Experimental (n = 73) and knowledge-based (n = 68) intervention
groups of African-American college students

Variable       Theory-based    Non-theory      Statistical   p-value
               Frequency (%)   Frequency (%)   Test *
Sexual
  partners
  (py)
    0-2        51 (55.4)       41 (44.6)       4.766         0.782
    3-5        9 (42.2)        26 (57.8)
    6-8        2 (66.7)        1 (33.3)
    > 8        1 (100.0)       0 (0.0)

Age at first
  sex Int.
    10-12      1 (33.3)        2 (66.7)        9.814         0.632
    13-15      20 (48.8)       21 (51.2)
    16-18      44 (53.0)       39 (47.0)
    19-21      7 (58.3)        5 (41.7)
    > 21       1 (50.0)        1 (50.0)

Sexuality
  class
  (present)
    Yes        2 (100.0)       0 (0.0)         1.890         0.169
    No         71 (51.0)       68 (49.0)

(Py = past year sex.int = sexual intercourse)

* Sexual partners, Age at first sexual intercourse and sexuality
class were tested with chi-statistic.
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