Patterns of Safer Sex Practices among Allied Health Students at Historically Black Colleges and Universities
Valentine, Peggy A., Wright, Denise L., Henley, Garnett L., Journal of Allied Health
With high human immunodeficiency virus (HIV) and STD transmission rates among African American young adults, there is a need to study the patterns of risk behaviors among this group for effective HIV prevention strategies. Many studies point to the problem of what is termed the knowledge-behaviour gap, as a contributing factor for high transmission rates. In this phenomenon, the risks for HIV transmission are known, yet this knowledge does not translate into safer sex practices. It is unclear if this phenomenon applies to all young adults. This study examined sexual behaviors, risks for HIV infection, condom use, and HIV testing practices among allied health students. A sample of 614 rcspondents voluntarily completed questionnaires. The respondents were from seven historically black colleges and universities and four predominantly African American physician assistant programs. The significant findings reflect that this sample of mature and informed allied health students engaged in safer sex practices. There was a higher rate of condom use among African Americans compared with other racial and ethnic groups and significant differences for gender, race, and antibody testing. The outcomes of the study have implications for using allied health students as role models in designing effective prevention programs on college campuses and in African American communities to address knowledge-behavior gap issues. J Allied Health. 2003; 32:173-178.
SINCE 1998, MORE AFRICAN AMERICANS have been reported with acquired immunodeficiency syndrome (AIDS) than any other racial/ethnic group. Researchers estimate that 240,000 to 325,000 African Americans, or about 1 in 50 African American men and 1 in 160 African American women, are infected with human immunodeficiency virus (HIV). Globally, 42 million people have been infected with HIV since the beginning of the pandemic, and there are 16,000 new infections documented on a daily basis worldwide."
HIV transmission rates among African Americans are not declining significantly in response to effective interventions compared with whites/ HIV/AIDS continues to be the leading cause of death among African American men age 25 to 44 and the third leading cause of death for African American women of the same age group. The virus has an incubation period of a few weeks to more than 10 years. It is reasonable to assume that increasing numbers of young adult African Americans may be at a higher risk of becoming infected than their majority counterparts.3
Review of the Literature
The literature confirms that college students engage in behaviors that place them at risk for HIV infection. It is estimated that greater than 80% of all college students are sexually active by their freshmen year, and less than half use condoms consistently.4-6 With low condom use, the risk of HIV transmission is increased. Jemmott and Jemmott7 found that only 20% of sexually active, unmarried, African American undergraduates at a commuter university always used condoms. In a study of 408 African American southern college students, 3.18% were diagnosed as HIV positive, higher than the 2% for comparative student populations as reported by the American College Health Association.8,9
Studies have affirmed that knowledge of risks does not deter a person from engaging in high-risk sexual behaviors that facilitate the transmission of HIV and other sexually transmitted diseases (STDs). This phenomenon, known as the knotfiejge-behaviour gap, has been cited as one of the major reasons for increased transmission rates, particularly among heterosexuals. 10-14 In the earlier stages of the HIV epidemic, many universities and colleges focused on providing students with information to dispel myths about HIV/AIDS transmission. These efforts resulted in 80% to 92% of college students possessing correct HIV/AIDS knowledge. These interventional programs that emphasized knowledge about transmission failed to produce significant changes in HIV risk behavior, however.15 The link to having accurate knowledge and the adoption of safer sex practices among college students has yet to be proved.3,16,17 It is not known if this phenomenon of the knowledge-behavior gap is consistent across different collegiate majors and disciplines.
Although more recent findings reflect a higher rate of HIV infection among African Americans than other groups, studies of this population have been limited in scope. Investigations of risk-reduction practices among African Americans largely have been samples of low-income, urban residents with the probability of high seroprevalence rates. Additionally, studies that focus on college students often have small clusters of African Americans so that meaningful inferences cannot be made.18 Interventions developed for urban settings may not be appropriate for college-aged African American youth. Studies are needed to increase the understanding of risk-taking behaviors of this population.2
This research is significant in that few studies specifically have examined what students in the health care professions know about appropriate health behaviors and what they practice in their personal lives.19 Given the core curriculum that health professions students acquire about human sexuality, health promotion, and disease prevention as well as HIV/AIDS information incorporated in the curriculum, there may be differences in sexual behaviors and practices compared with other college students. Studies on the sexual practices of African American students who are enrolled in allied health programs at historically black colleges and universities (HBCUs) would fill a void in the literature. This study examined the sexual behaviors, practices, and risks for HIV/STD transmission among allied health students attending HBCUs and predominantly African American physician assistant programs.
A total of 614 allied health students participated in the study as a component of the Centers for Disease Control (CDC)-funded project to provide HIV training. All the students were enrolled in seven schools of allied health at HBCUs, or in four predominantly African American physician assistant programs in northeastern, southeastern, and western regions of the United States. The participating schools are nationally recognized and have accredited allied health programs. Each participating program included disciplines of occupational therapy, physical therapy, physician assistant, nutrition, health administration, radiation therapy, and medical technology. The core elements of each curriculum included content on health promotion, disease prevention, and lectures on HIV/AIDS. Participants were given self-report questionnaires to assess their sexual practices and other health related behaviors. Self-report measures typically are used in AIDS-related research to examine the incidence and prevalence of sexual practices and behavioral interventions for disease transmission. Each student received a survey with a cover letter (informed consent), which described the purpose of the study and emphasized the aspects of anonymity and confidentiality of the questionnaire. Participation in the study was voluntary. The survey was administered in a classroom setting, and students were allowed 30 minutes to complete the instrument.
The authors modified a survey developed by Rutgers New Jersey Health Program, a CDC-funded grantee. A 21-item survey instrument was developed and used to collect student risk behaviors in five areas:
1. Sexual preferences and lifestyle arrangements
2. Condom use/STD prevention
3. Religious affiliation
4. Drug and alcohol use
5. Student demographics
Survey/question validation was accomplished through a discussion forum that consisted of five randomly selected Howard University allied health students who provided their understanding of the meaning and intent of all questions on the survey. The instrument was piloted on 10 other Howard students who took an average of 15 + or - 2.4 minutes to complete the survey. The National AIDS Minority Information and Education Program located at Howard University in Washington, D.C., generated the final survey instrument for the study.
Descriptive statistics were calculated for all variables and included measures of central tendency and measures of dispersion, frequencies, and graphic plots. Appropriate [chi]^sup 2^ tests were calculated for proportions. Somer's d was used when two ordered categories were compared, and the variable plots did not fit an S-shaped or U-shaped curve. Retrospective and prospective likelihoods that a particular behavior would occur were calculated for odds ratios and for relative risk. An analysis of variance (ANOVA) with Tukey's posttest was used for continuous dependent variables. The general linear model (GLM) that is a component of the SPSS Professional Statistical Software Package includes an ANOVA-based regression model. This model and Pearson's product moment were used for regression and linear determinations. Variance associated with mean deviations was reported as the standard error of the mean, to account for differences in-group sizes. All procedures were performed at a = 0. 05 within the 95% confidence interval.
A total of 614 students participated in the study. Of the study participants, 63.7% self-identified as African American, 20.3% as White, 6.5% as Asian, 2.9% as Hispanic, and 1.1% as Native American (American Indians and Alaska Natives); 33.3% did not specify ethnicity (p < 0.0005) (Table 1). Respondents were primarily female (62.5%, n = 427) with a mean age of 26.19 + or - 0.32 years; male respondents were significantly older (27.58 + or - 0.49, p < 0.05) (Table 2). Most respondents were undergraduate students and no more than 45% of students in a given ethnic group were graduate students (p < 0.005) (Table 1). Student classification, socioeconomic status, and living arrangements were not influenced by gender. Equal percentages of men and women were graduate students (males, n = 41, 21.6%; females, n = 89, 21.1%; p = 0.902). More than half of all students earned less than $30,000 (p < 0.005). Sixty-two percent of men (n = 109) and 56% of women (n = 226) earned less than $30,000 per year (p = 0.217). Reported church attendance was low, and most of the respondents attended church less than twice a year (Table 1).
SEXUAL BEHAVIOR PROFILE
Age at first sexual encounter was significantly different by ethnicity (p < 0.0005). Asians waited until age 20 (20.53 + or - 0.54 years) before becoming sexually active, and Native Americans reported sexual encounters before the age of 14 (13.71 + or - 4-61 years), with the youngest encounter occurring at age 8 (p < 0.0005) (Table 3). Prepubertal sexual experiences were found in all ethnic groups except for Asians, among whom the earliest first encounter occurred at age 16. Despite these findings, only a weak relationship existed between ethnicity and age at first sexual encounter (r =-0.196) (Figure 1).
Gender-wise, women were 2.37 years older than men at first sexual encounter (p < 0.0005) and averaged fewer sexual encounters over a period of 90 days (p = 0.137) (Table 4). As shown in Table 4, monogamous sexual encounters for men (15.27 + or - 2.20) varied slightly from women (11.12 + or - 1.76) during the reporting period of the last 90 days (p = 0.166), and there were few polygamous encounters by gender (males 0.58 + or -0.18; females 0.27 + or - 0.08; p = 0.112). There was no relationship between the different ethnic groups and polygamous encounters (r = 0.151).
Items were included in the survey to assess for high-risk sexual practices. African Americans were more likely to use condoms than other ethnic groups (p < 0.0005). Comparing the two largest racial/ethnic groups of the sample, 36.3% (n = 41) of the whites reported using condoms compared with 72.4% (n = 247) of African Americans. Most whites (82.6%, n = 100) indicated they were in a monogamous relationship compared with 68% of African Americans (Table 1).
Differences in condom use were noted among students who reported living on or off campus. Students living on campus were more likely to use condoms than students who lived in off-campus housing. This was particularly true for on-campus female students, who were 3.6 times more likely to use condoms than off-campus female students (p < 0.0005). Although not statistically significant, the odds ratios showed that on-campus male students were 1.58 times more likely to use condoms than their counterparts who lived off campus (p = 0.217).
HIV ANTIBODY TESTING
African American students voluntarily tested for HIV antibody more often than whites and Asians and were 2.4 times more likely to know their HIV status than students in the other ethnic groups. More than 62.3% of African Americans had heen HIV tested compared with 52.6% of whites (Tahle 1). Of sexually active, single African American respondents, 75.5% (n = 123) had been HIV tested compared with 14.1% (n = 23) whites, 2.5% (n = 4) of Asians, 1.8% (n = 3) of Hispanics, and 1.2% (n = 2) for Native Americans (p < 0.005) (Table 1). Gender-wise, men tested more frequently than women (2.64 + or - 0.19 versus 2.12 + or - 0.16; p < 0.005, Table 4), and a greater percentage of men reported being HIV tested than women (65.3%, n = 130; versus 49.2%, n = 210; p < 0.0005) (Table 3).
Our analyses of data revealed three important findings. First, this sample of allied health students practice safer sex compared with similar student populations. Beitran et al.20 found that safer sex knowledge was greater among university students 21 years old and older. Because most of this sample was older than 21 years (mean age 26.6 years), age may have been a mediating factor for safer sex practices.
The second significant finding was for condom use. Our finding that allied health students were likely to use condoms was in contrast to the outcomes of similar college student studies in the United States and abroad10,11,14,21-23 as well as another study of allied health students.19 In these studies, students had engaged in high-risk sexual practices and did not use condoms on a consistent basis with multiple partners. Beitz19 found in her sample of allied health students that more than 18% of the respondents who identified themselves as being single acknowledged sexual activity without safer sex practices, although 61% considered themselves very knowledgeable about AIDS.
The subsample of students in our study who indicated they were married or living with a primary partner used condoms on a regular basis. Of the respondents who were married, 27.7% indicated they used condoms, and 82.1% of respondents with a primary live-in partner used them. This finding was in contrast to studies that looked at relationship-level factors as a correlate of condom use.24 Civic25 surveyed 210 undergraduates and found that half the respondents reported consistent condom use in the first month of their relationships; after the first month, condom use decreased to 34%.
Differences in condom use also were found among ethnic groups in our study. African Americans were more likely to use condoms regardless of relationship status compared with whites. Only 36.3% of white allied health students used condoms; however, most were in a monogamous relationship.
The patterns of sexual practices in our study were compared with the findings of Bazargan et al.3 In that study, 60.9% of the sample had more than one partner over a 90-day period; comparatively, only 31.51% of the allied health respondents reported having sex with more than one partner. In the analysis of gender and condom use, it was found that women had monogamous and nonmonogamous sex less frequently than men within a 90-day period, although this was not statistically significant. Although a higher percentage of allied health respondents were in a monogamous relationship, frequent condom use was reported-62% in our study versus 57% in the Bazargan study. The differences in findings with these similar groups of respondents indicate that age may be a mediating factor (the mean age of students in the Bazargan study was 20.0 years versus 26.6 years in our study). A solid baseline knowledge of STD/HIV transmission may be another factor in the outcomes.
The third significant finding was for HIV antibody testing. Most of the study participants had been tested more than once, which reflects national trends found in other research studies.26,27 The CDC26 conducted a national study to examine the prevalence of voluntary HIV testing among the general U.S. population. They found that voluntary HIV testing among U.S. adults had increased from 1993 to 1996. Additionally, adults who identified as low to no risk were more likely to be HIV tested than adults at medium or high risk for HIV infection.28 Of the respondents in our study, 52% reported being tested for HIV at least twice. It is difficult to determine if these allied health students were being tested due to personal or occupational concerns. A topic for further inquiry is to determine the reasons for repeated HIV testing.
Our findings indicate that the gap between behavior and knowledge is minimal for allied health students, and risk behaviors among the African American students is low compared with similar student populations in other studies.3,18 Less than 1% of our sample (two respondents) reported being HIV positive. Several studies contrast our findings, indicating that college students possessed relatively high levels of knowledge about HIV/AIDS, however, many do not adopt safer sex practice.29-34 The Latman and Latman study showed that sexually active college students engaged in high-risk behaviors for HIV transmission, despite their reported knowledge about HIV. Bruce and Walker,22 who measured college students' attitudes about AIDS over a 15-year period, also noted that knowledge about HIV/AIDS did not affect their views on being at risk.22
The knowledge-behavior gap that has been cited as a problematic issue in HIV prevention and intervention programs should be investigated further by examining specific factors that govern safer sex practices among allied health students. The consistent exposure of allied health students to HIV educational content in their didactic and clinical curriculums may explain the differences in risk behaviors compared with college students. The allied health curriculum can be viewed as an intervention that may have a positive influence on health-related behaviors among students. There may be elements of the curriculum that could be used for all college students. Baseline knowledge and practices of students in other university communities and their training about what constitutes risk behaviors should be considered.
Given the growing number of STDs and HIV cases among college-age young adults in the United States and abroad that is disproportionately affecting students of color, it is crucial to intervene. Although larger samples of allied health students need to be examined to determine patterns or trends over time, effective models for prevention could shape policy and inform university administrators of programs tailored for university students, young adults, and people of color.
The shift in the HIV/AIDS-infected population in the United States from the white gay male community to women and populations of color requires that attention be focused on college students representative of these groups. The allied health students in this study represent role models and a prospective leadership pool for HIV prevention in populations of color.
The authors thank Dr. Wayne Greaves, Majid Ali, Rochelle Glymph, Cynthia Bartholomew, and Ora Lee Chapman, staff of the National AIDS Minority Information and Education Program of Howard University. They also gratefully acknowledge the students and faculty of the participating allied health programs.
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Peggy A. Valentine, EdD, PA-C
Denise L. Wright, PhD, LPC
Garnett L. Henley, MS
Dr. Valentine is associate dean and associate professor and Dr. Wright is assistant professor, College of Pharmacy, Nursing and Allied Health Sciences, and Mr. Henley is associate professor, College of Dentistry, Howard University, Washington, D.C.
Received September 1, 2000; accepted September 9, 2002.
Funding for this project was through a cooperative agreement from the Centers for Disease Control and Prevention.
Address correspondence and reprint requests to: Dr. Peggy Valentine, Howard University, Annex I, Rm 106, Washington, DC 20059; e-mail: email@example.com.…
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Publication information: Article title: Patterns of Safer Sex Practices among Allied Health Students at Historically Black Colleges and Universities. Contributors: Valentine, Peggy A. - Author, Wright, Denise L. - Author, Henley, Garnett L. - Author. Journal title: Journal of Allied Health. Volume: 32. Issue: 3 Publication date: Fall 2003. Page number: 173. © Association of Schools of Allied Health Professions Winter 2008. Provided by ProQuest LLC. All Rights Reserved.
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