Inner-City Youths and Condom Use: Health Beliefs, Clinic Care, Welfare, and the HIV Epidemic
Stiffman, Arlene Rubin, Dore, Peter, Cunningham, Renee M., Adolescence
The Secretary of Health of the United States recently announced that the rate of AIDS among heterosexual young women is growing faster than in any other group. HIV/AIDS is now the fifth leading killer of young women, who are most likely to be young, poor, from minority groups, and from metropolitan areas (Searching for Women, 1992). The current percentage of AIDS cases among heterosexuals is up 44% from that of a few years ago and is expected to rise 150% by 1995. Behavioral indicators supporting this anticipated rise include evidence that minority youths initiate sexual activity earlier (Centers for Disease Control, 1991; Jemmott, Jemmott, & Fong, 1992) and disproportionately experience unplanned pregnancy (evidence of irregular or nonuse of condoms) and sexually transmitted diseases (Bowser, Fullilove, & Fullilove, 1990; DiClemente, 1990; Johnson et al., 1992).
The study examined a largely female, black, inner-city sample of youths that is demographically similar to those populations in which the rates of both AIDS and HIV infection are rising most rapidly. The following questions were asked: Who are the high condom users? What knowledge/attitudes and beliefs influence condom use? Are the youths with high-risk behavior using condoms? Is financial situation a barrier to condom use? Does health clinic use promote condom use?
Studies of the behaviors of populations engaging in HIV-risk behavior generally show little change over time or after exposure to HIV-related information (Harris et al., 1990; Chitwood & Comerford, 1990). Drug users still have high rates of promiscuous behavior and low condom use (Dengelegi, Weber, & Torquato, 1990). This is true also for prostitutes: over one-quarter do not take any precautions, and only 14% say they require their customers to use condoms (Bellis, 1990). Studies show that only 17-19% of clinic attendees (Chang, Murphy, DiFerdinando, & Morse, 1990; Richter et al., 1992), less than 25% of inner-city youths (Keller et al., 1991), and only 17-33% of college students (Butcher, Manning, & O'Neal, 1991) regularly use condoms.
Extensive preventive interventions, relying largely on methods designed to provide information and change attitudes are being mounted on local, regional, and national levels. Early in the epidemic, the potential for educational intervention seemed high because studies showed that level of knowledge among young people was low (Strunin & Hingson, 1992). Since then, education programs have been implemented virtually worldwide (AIDS Education, 1989), and recent studies reveal a satisfactory level of knowledge among young men (Sonenstein, Pleck, & Ku, 1989), IV drug users (Chitwood & Comerford, 1990), and teenagers (DiClemente, 1990). However, these results do not appear to have stopped risky behaviors. In earlier papers, the authors reported that change in HIV-risk behaviors by inner-city young adults was not related to exposure to information, counseling, or acquaintance with those dying of AIDS (Stiffman, Cunningham, Earls, & Dore, 1991; Stiffman, Dore, Earls, & Cunningham, 1992a; Stiffman, Earls, Dore, & Cunningham, 1992b). These findings echo other studies that found no change (Brown, Fritz, & Baron, 1989; DiClemente, 1989; Weisman et al., 1989; Rotheram-Borus, Koopman, & Bradley, 1989), inadequate levels of change (Chitwood & Comerford, 1990; McCoy & Khoury, 1990; Sonenstein et al., 1989); or low maintenance of change (DiClemente, 1989).
A number of factors are known to be associated with HIV-risk behaviors, including personal and social problems which affect their ability to use and process HIV-related information (Stiffman et al., 1992a). For instance, youths in psychological distress engage in the highest levels of risky behavior (Rotheram-Borus et al., 1989; Stiffman et al., 1992a). Youths who engage in the greatest number of risk behaviors, and minority males in particular, have lower condom use and a lower level of knowledge than their peers (Sonenstein et al. …