October 23, th APHA meeting, Atlanta1 Abstinence From Sex and Condom Use Among Asian American Adolescents Inseon Hwang, DNSc, RN

Acknowledgement This dissertation and doctoral training were supported by National Research Service Award from National Institute of Nursing Research

Outline of Presentation Research Questions Theoretical Framework Definitions Study Design Methodology Sampling Limitations Data analysis Measures Results Conclusions Implications

October 23, th APHA meeting, Atlanta4 Research Questions What are the factors related to abstinence from sex and condom use among Asian American Adolescents?

October 23, th APHA meeting, Atlanta5 Research Questions (continued) 1. What is the strongest predictor of intention to abstain: attitudes, subjective norms, self-efficacy, or demographic background variables? 2.What is the strongest predictor of reported abstinence behaviors: attitudes, subjective norms, self-efficacy, demographic background, or intention variables? 3. What is the strongest predictor of intention to use condoms: attitudes, subjective norms, self-efficacy, or demographic background variables? 4.What is the strongest predictor of reported condom use behaviors: attitude, subjective norms, self-efficacy, demographic background, or intention variables?

October 23, th APHA meeting, Atlanta6 Theoretical Framework Demographics. Sex. Age. Ethnicity. Parental education. Family structure. Acculturation status Behavioral beliefs * Outcome evaluations Normative beliefs * Motivation to comply Attitude Subjective norm Self-efficacy IntentionBehavior

October 23, th APHA meeting, Atlanta7 Definitions 1. Adolescent : person whose age is between 10 to 19 years 2. Asian American : person having origins in any of the original peoples of the Far East, Southeast Asia, and the Indian subcontinent (Office of Management and Budget, 1978) 3. Intention : one’s probability judgment of how the person intends to behave 4. Attitude : evaluation of the favorability of the target behavior 5. Behavioral belief : perceived likelihood that the behavior will lead to certain outcomes 6. Outcome evaluation : evaluation of each of the outcomes

October 23, th APHA meeting, Atlanta8 Definitions (continued) 7. Subjective norm : one’s judgment concerning the perceived pressure to perform or not perform the behavior 8. Normative belief : perceived likelihood that specific individuals or groups want the person to perform the behavior 9. Motivation to comply : willingness to follow the expectations of the specific individuals or groups 10. Self-efficacy : perceived capability to perform behavior in question under different circumstances 11. Acculturation comprehends those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original culture patterns of either or both groups (Redfield, Linton, & Herskovits, 1936).

October 23, th APHA meeting, Atlanta9 Study Design Phase Purpose Period Participants I: Open-endedElicit Information 4-7, Questionnaire To validate tools from previous study II: Pilot study Evaluate tool’s readibility 10-11, & understandability Evaluate reliability & validity of 3 instruments III: Final surveyIdentify factors related to 2-3, abstinence from sex and condom use

October 23, th APHA meeting, Atlanta10 Methodology A self-administered survey A convenience sample of 84 Asian American adolescents (Chinese & Korean) in New York City Recruited from street and a church

October 23, th APHA meeting, Atlanta11 Sampling A convenience sample was obtained from areas surrounding local high schools and a church in Queens Criteria for inclusion were AAA who identify themselves as Asian Americans, read and understand English, and had consent from parents. Adolescents were defined as between 15 to 18 years of age.

October 23, th APHA meeting, Atlanta12 Limitations Limited to AAA living in one neighborhood New York City during Feb to March, 2000 Limited to AAA who received permission from their parents Participant bias Self-reported outcome behaviors Cultural variation within each Asian country and between countries

13 Measures Demographics. Sex (1). Age (1). Ethnicity (1). Parental education (2). Family structure (1). Acculturation status (21) Behavioral beliefs (AB:27 CO:26) Outcome evaluations (AB:27 CO 26) Normative beliefs (AB:4 CO:4) Motivation to comply (AB & CO:4) Attitude (AB:1 CO:1) Subjective norm (AB:1 CO:1) Self-efficacy (AB:14 CO:15) Intention (AB:1 CO:1) Behavior (AB:2 CO:2) * # in parentheses indicates # of questions of each scale. AB: abstinence CO: condom

14 Independent Variables Direct abstinence attitude (1) Abstinence behavioral beliefs (27)* Abstinence outcome evaluations (27)* Direct abstinence subjective norm (1) Abstinence normative beliefs (4) Motivation to comply (4) Direct abstinence self-efficacy (1) Indirect abstinence self-efficacy (14)* Direct condom use attitude (1) Condom use behavioral beliefs (26)* Condom use outcome evaluations (26)* Direct condom use subjective norm (1) Condom use normative beliefs (4) Direct condom use self-efficacy (1) Condom Use Self Efficacy Scale (CUSES) (15) * Developed by researcher (New scale) Asian Acculturation Scale (21) Demographics: Age (1), Sex (1), Ethnicity (1), Parental education (2), Family structure (1), Steady partner info (4), and others (8)

October 23, th APHA meeting, Atlanta15 Dependent Variables Intention to abstain from sex (1) Intention to condom use (1) Vaginal intercourse behavior with steady and casual partner (2) Condom use frequency with steady and casual partner (2)

October 23, th APHA meeting, Atlanta16 Measures: example of abstinence items Intention: How likely is it that you will decide to abstain from sex in the next 3 months? Direct Attitude: How do you feel about abstaining from sex in the next 3 months? Behavioral beliefs: I am too young to have sex. Outcome evaluations: In your opinion, having sex at young age is Direct subjective norm: Would most people who are important to you approve or disapprove of you abstaining from sex in the next 3 months? Normative beliefs: Would your mother approve or disapprove of abstaining from sex in the next 3 months? Motivation to comply: In general, how important to you are your mother’s opinions about what you do?

October 23, th APHA meeting, Atlanta17 Measures: scoring of abstinence items Response Score convert Total Intention (1) Direct attitude (1) Indirect attitude (19) behavioral belief outcome evaluations Direct subjective norm (1) Indirect subjective norm (4) normative belief motivation to comply

October 23, th APHA meeting, Atlanta18 Data Analysis SPSS 9.0 window version Reliability and validity analyses for new scales Descriptive analyses Bivariate analyses (Chi-square, Pearson product moment correlation, & T-tests) Logistic regression analysis: Multiple and Univariate analysis

October 23, th APHA meeting, Atlanta19 Data Analysis (continued) How to dichotomize ordinal variables - Observed frequencies - Divided into three groups: positive, neutral, and negative - Positive group (1) vs. Neutral and negative group (0)

October 23, th APHA meeting, Atlanta20 Results - demographics Average age: 16.4 years old Females (61%) vs. Males (39%) Mainly Chinese (50%) and Korean (44%) American adolescents Born in US (61%) vs. Immigrated (39%)

October 23, th APHA meeting, Atlanta21 Results – demographics (continued) Living with both parent (79%) vs. singles or relatives (21%) Parental education: not college graduate (40%) vs. college graduate and more (60%) 37% of participants were in boy/girlfriend relationship 18% of participants had ever vaginal sex 6 out of 15 participants were ‘Always Condom Users’

October 23, th APHA meeting, Atlanta22 Q1:Predictors of intention to abstain Multiple logistic regression analysis Positive direct abstinence attitude (OR=15, p=.0002) Positive indirect abstinence subjective norms (OR=4.8, p=.0261) Living with both parent (OR=3.9, p=.0861)

October 23, th APHA meeting, Atlanta23 Q2: Predictors of abstinence behaviors Univariate logistic regression analyses Not having a partner (OR=42, p=.0005) Direct positive abstinence attitude (OR=28, p=.0019) Positive abstinence intention (OR=17, p=.0001) Indirect positive abstinence attitudes (OR=7, p=.0190) Indirect positive abstinence self-efficacy (OR=6, p=.0083) Living with both parent (OR=5, p=.0205) Direct positive abstinence self-efficacy (OR=3, p=.0602) Younger age (OR=.44, p=.0311).

October 23, th APHA meeting, Atlanta24 Q2: Sub-group analysis (abstainers vs non- abstainers among those in partner relationship Multiple logistic regression Positive direct abstinence attitude (OR=33, p=.0034)

October 23, th APHA meeting, Atlanta25 Q2: Sub-group analysis (relationship between abstinence beliefs and abstinence behaviors) Category Abstinence Behavioral Beliefs Virginity beliefs I believe that a teen should be a virgin. I believe that I will proud of myself if I remain a virgin during my teen years I believe that women should not have sex until they get married. Beliefs about I believe that I am too young to have sex. delaying sex I believe that I would prefer to wait until I am older to begin having sex. Prevention beliefs I believe that if I have sex, I am likely to get AIDS. I believe that if I have sex, then I am likely to get STDs. Future focusing I believe that if I have sex during my teen years, then I am less likely beliefs to graduate from high school. I believe that if I have sex during my teen years, then I am less likely to have the career that I hope for. Intimacy beliefs I believe that if I don’t have sex, it means that I don’t really love my boyfriend/girlfriend.

October 23, th APHA meeting, Atlanta26 Q3: Factors related to use condoms Multiple logistic regression Positive direct condom use attitude (OR=16.5, p=.0098) Positive indirect condom use subjective norm (OR=8.9, p=.0678)

October 23, th APHA meeting, Atlanta27 Q4: Factors related to condom use behaviors Due to small number of condom users no predictors were found to have significant relationship from bivariate analysis

October 23, th APHA meeting, Atlanta28 Conclusions: abstinence Protective factors: high value for virginity and delaying sex, future- focused, positive attitude & subjective norm about abstinence, positive family structure, and support from peers Negative factors: intimacy beliefs The role of self-efficacy is not clear.

October 23, th APHA meeting, Atlanta29 Conclusion: condom use Positive factors: positive attitude and subjective norm about using condoms Role of self-efficacy is not clear.

October 23, th APHA meeting, Atlanta30 Conclusion: measures Theory of reasoned action - attitude and subjective norm can be applicable to Asian American youth - moderate correlation between direct and indirect measures implies the possibility of dropping outcome evaluations and motivation to comply for shorter questionnaires - Improvement of instrument; changing double negative items, factor analyses of indirect attitude measures, and separate items for motivation to comply for abstinence and condom use

October 23, th APHA meeting, Atlanta31 Conclusion: measures (continued) Self-efficacy - role of self-efficacy is not clear - high score of abstinence self-efficacy - low score of condom use self-efficacy - Improvement of abstinence self-efficacy items

October 23, th APHA meeting, Atlanta32 Implications: abstinence Encouraging children’s academic achievement & career development Expressing values around virginity and later sex Discussing about the development of romantic relationship Skill training to resist partner or friends’ influences Optional information about condoms

October 23, th APHA meeting, Atlanta33 Implications: condom use Teaching ways to ask their partners about using condoms Teaching the fact that partners are expecting their request to use condoms Encouraging assertive attitudes, ‘no condom = no sex’ before developing relationship Teaching how to carry condoms always Teaching facts about condom’s effectiveness and proper use Teaching where to get free condoms