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Adolescent contraceptive behavior: An assessment of decision processes
Adolescent contraceptive behavior: An assessment of decision processes Nancy E. Adler, PhD, Susan M. Kegeles, PhD, Charles E. Irwin, Jr., MD, and Charles Wibbelsman, MD From the Departments of Psychiatry, Pediatrics, and Medicine, and the Division of Adolescent Medicine, Department of Pediatrics, University of California, San Francisco, and the KaiserPermanente Teenage Clinic, San Francisco, California The utility of a r a t i o n a l m o d e l of c o n t r a c e p t i v e use in a d o l e s c e n t s was e v a l u a t e d in a c o h o r t of 325 s e x u a l l y a c t i v e a d o l e s c e n t s a g e d 14 to 19 years. A d o lescents were i n t e r v i e w e d r e g a r d i n g their beliefs a b o u t the c o n s e q u e n c e s of using e a c h of four m e t h o d s of c o n t r a c e p t i o n , e v a l u a t i o n of those consequences, p e r c e p t i o n of t h e w i s h e s of others r e g a r d i n g use of e a c h m e t h o d , mot i v a t i o n to c o m p l y with those wishes, g e n e r a l a t t i t u d e t o w a r d using the m e t h o d , v i e w of g e n e r a l s o c i a l e x p e c t a t i o n s r e g a r d i n g their use of the method, a n d their intention to use the m e t h o d during the n e x t year. They were r e i n t e r v i e w e d I y e a r later to d e t e r m i n e a c t u a l use. The results support the utility of this m o d e l for und e r s t a n d i n g a d o l e s c e n t behavior. Significant a s s o c i a t i o n s were found b e t w e e n intentions to use c o n t r a c e p t i v e m e t h o d s and their a c t u a l use. Intentions were s i g n i f i c a n t l y r e l a t e d to a d o l e s c e n t s ' a t t i t u d e s t o w a r d using the m e t h o d s a n d their p e r c e p t i o n of s o c i a l e x p e c t a t i o n s r e g a r d i n g use. General a t t i t u d e s were s i g n i f i c a n t l y r e l a t e d to a summary score r e f l e c t i n g the a d o l e s c e n t s ' b e l i e f s a b o u t s p e c i f i c c o n s e q u e n c e s of use w e i g h t e d b y their e v a l u a t i o n s of them. G e n e r a l s o c i a l p e r c e p t i o n s were s i g n i f i c a n t l y r e l a t e d to a s u m m a r y score of p e r c e i v e d desires of s p e c i f i c i n d i v i d u a l s m u l t i p l i e d b y the a d o l e s c e n t ' s desire to c o m p l y with those desires. These findings i n d i c a t e that physicians c a n b e m o r e e f f e c t i v e in c l i n i c a l p r a c t i c e b y q u e r y i n g a d o l e s c e n t s a b o u t their b e l i e f s a n d intentions a n d a b o u t their p e r c e p t i o n s of s i g n i f i c a n t i n d i v i d u a l s in their lives. (J PEDIATR1990;116:463-71)
A large proportion of sexually active adolescents fail to use contraception despite its widespread availability, and the
Supported in part by grants frOm the National Institute of Child Health and Human Development (No. 5-R01 HD16137), from the John D. and Catherine T. MacArthur Foundation Research Network on Health-Promoting and Disease-Preventing Behavior (Dr. Adler), from the Bureau of Maternal and Child Health and Resources Development (No. MCJ000978) (Dr. Irwin), and from the University of California, San Francisco, Academic Senate (Dr. Sharer). Submitted for publication June 15, 1988; accepted Aug. 31, 1989. Reprint requests: Nancy E. Adler, PhD, Health PsyChology Program, Box 0844, University of California, San Francisco, Medical Center, San Francisco, CA 94143. 9/27/16492
pregnancy rate among teenagers remains high. 1 In an effort to understand the complex nature of sexual activity in the second decade of life, research has focused on numerous aspects of sexuality, contraception, and pregnancy. Demographic and sociologic studies have shown that age, race, income, and family structure are associated with sexual activity and the occurrence of unplanned pregnancy. 25 Psychologic studies have shown that female adolescents who have low self-esteem and who feel powerless, alienated, and in little control of their lives are at a higher risk for pregnancy. 6-s Biologic factors have also been shown to influence pregnancy risk; girls with earlier physiologic maturation initiate sexual activity earlier than a g e - r e l a t e d peers. 9 The factors identified in the studies cited above are not
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(Beliefsof consequences) multipliedby (Valueof consequences)
The Journal o f Pediatrics March 1990
---~.
I Generalattitude ] towardsbehaviorJ
"a I Intention I ] Performance to engage ---}11, of in behavior behavior
(Perceptionsof others'desires) multipliedby (Motivationto comply withdesires)
---l~
Generalsocial ] expectations regardingbehavior
Figure. Theoretic model taken from theory of reasoned action.
easily modified by health care providers or through educational programs. For purposes of intervention, a more useful level of analysis may be adolescents' beliefs, values, and attitudes relevant to contraceptive choice and use. Gaps in knowledge about reproduction and contraception, specific beliefs about contraceptive methods, and ambivalence or guilt over being sexually active all may contribute to ineffective contraceptive use. 1~ Studies of older population samples (i.e., college students and adults) have demonstrated the utility of "rational" decision-making models in understanding reproductive behavior. 1619 These models assume that any given behavior is guided by the person's views of the consequences (costs and benefits) of taking or not taking the action. Several models of adolescent contraceptive use have included cognitive variables.2~ However, with some exceptions,23-24there have been few empiric tests of the role of cognitive factors in accounting for adolescents' sexual behavior. The failure to apply decision models to adolescents may derive from the assumption that adolescent behavior is impulsive and cannot be described by models that presume rationality. Our study was guided by the hypotheses (1) that adolescents, like adults, guide their behavior in terms of the outcomes they expect will follow from their behaviors and (2) that a decision model could account for significant variance in contraceptive choice and behavior among adolescents. T H E O R Y OF R E A S O N E D A C T I O N Our research used the theory of reasoned action,25 which posits that a person's behavior is best predicted by his orher intention to engage in the given action. Intention to perform the action is influenced by two forces: (1) the person's gen-
eral attitude toward taking the action (i.e., whether engaging in the behavior is good or bad) and (2) the person's view of the social expectations regarding the behavior (i.e., his or her beliefs regarding what people who are important to the person think that he or she should do with respect to the behavior). In terms of contraception, the influence of these forces means that an adolescent's intention to use a given contraceptive method will predict actual use, and that intention to use the method will depend on the adolescent's general attitude toward the method and on his or her perception of the extent to which significant others want him or her to use the method. According to the theory of reasoned action, a5 which is outlined in the Figure, each of these variables (general attitude and social expectations) is, in turn, a function of a set of specific beliefs and values. General attitude is a function of the person's set of beliefs regarding the various consequences of taking the action, These consequences can be positive or negative. Therefore each belief is weighted by the value that the person attaches to experiencing that consequence. For example, an adolescent may strongly believe that using condoms is messy and may attach a moderately negative value to using a messy method of contraception. At the same time, the adolescent may believe that condoms are very likely to prevent transmission of sexually transmitted diseases, an outcome to which he or she attaches a very high positive value. According to the model, the net sum of the products of beliefs, weighted by values, is significantly associated with general attitude. Similarly, the person's view of general social expectations regarding a behavior is a function of the person's set of beliefs about what significant other people want the person to
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do regarding the behavior. These beliefs are weighted by the person's motivation to do what each of these other people wishes, and are then summed. As applied to contraceptive use, the theory of reasoned action25 posits that an adolescent's perception of general social expectations regarding use of a given method will be associated with beliefs about whether his or her partner, mother, father, and other relevant people want him or her to use themethod, weighted by the adolescent's motivation to comply with those wishes. Our study tested each link in the decision model with respect to four contraceptive methodsl A sample of sexually active male and female adolescents was used. Hypotheses were (1) that beliefs about the likelihood of specific consequences resulting from using a contraceptive method, weighted by evaluation of how good or bad each consequence would be to experience, will influence an adolescent's general attitude toward using the method; (2) that perceptions of the wishes of other people, weighted by the adolescent's motivation to comply with those wishes, will influence the adolescent's view of general social expectations regarding use of the contraceptive; (3) that the more positive the adolescent's general attitude and perception of social expectations regarding use of a contraceptive, the stronger will be his or her intention to use the method; and (4) that the intention to use a contraceptive method will predict actual use of the method during the subsequent year. METHODS Subjects. Adolescents between the ages of 14 and 19 years who were seeking health care at either of two adolescent medical clinics (University of California, San Francisco, and Kaiser-Permanente, San Francisco) were invited to participate. The protocol was approved by institutional review boards at both institutions, and informed consent was obtained before interviews were initiated. Subjects were excluded if they were married, pregnant, non-English speaking, or developmentally disabled, or if they had come to the clinic because of a major psychosocial problem. Some adolescents declined participation; most frequently the reason was the long waiting periods in the clinic before their visit, which precluded their staying for an additional hour for the interview. This influence on participation in the study seems unlikely to have introduced any particular bias. With only limited resources for interviewing, a decision was made to concentrate on obtaining a sufficiently large number of female adolescents to provide adequate statistical power for testing the theoretic model. 26 In addition to the main sample of female adolescents, a smaller sample of male adolescents was obtained. Because of our desire to oversample the female subjects, there were more female than male interviewers at any given clinic. All interviews were done by same-sex interviewers.
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Several clinics at the two institutions were used and patients were randomly sampled. The institutions serve a wide cross-section of the population of San Francisco, drawing largely from middle- and working-class families. In the university-based sample, 40% were covered by Medicaid funds, 30% by a clinical teaching subsidy (which provides partial subsidy, with the remainder paid by the patient or family), and 30% by private insurance. By definition, all patients at the Kaiser clinic are covered by insurance, generally through the employment of a parent. Another indicator of socioeconomic status, educational level of the parents, also showed a wide range: 35.1% of the mothers and 40.7% of the fathers had a high school education or less; 49.3% of mothers and 34.7% of fathers has some college or had earned a bachelor's degree; and 11.4% of mothers and 19.6% of fathers had graduate training or degree. The sample was ethnically diverse: 35.4% white, 33% black, 13.4% Hispanic, 10.1% Asian, and 8.1% "other." The average age of the male subjects was 16.7 years (SD = 1.26) and of female subjects was 17.0 (SD = 1.26) years. Although a larger study included all patients, this article discusses only those adolescents who had experienced their sexual debut before the first interview, a total of 325,234 of whom were female. Procedure. Adolescents were informed about the study and invited to participate after registering at the clinic. They were offered three dollars for participation in the initial interview and six dollars for a follow-up interview. Although the questionnaire was largely self-administered, directions were given by a same-sex interviewer who helped to clarify questions as the need arose. Permission was obtained to recontact subjects, and a follow-up interview was conducted with particiPants approximately 1 year after the initial interview. At this time they were asked about their sexual and contraceptive behaviors during the preceding year. Follow-up interviews were obtained from 151 female (58.2%) and 53 male (64.5%) subjects. The mean time between the initial interview and follow-up was 13.4 months (SD = 2.8 months). Of those who did not participate in the second interview, about half could not be located and half declined to return for a second interview. To evaluate whether the attrition introduced any bias into the sample, we compared the characteristics of the respondents who did or did not participate in the follow-up studies. These analyses revealed no significant differences in age, ethnicity, prior sexual behavior (e.g., number of partners, frequency of intercourse), or prior use of contraception. Instruments. An initial pilot study with a separate sample of 18 male and 36 female subjects was conducted to determine the adolescents' beliefs regarding consequences of using the various methods of birth control. Open-ended in-
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terviews obtained, in the adolescents' own words, what they thought were good and bad aspects of using (or having one's partner use) four contraceptive methods: the pill, condom, diaphragm, and withdrawal. Although neither clinic personnel nor the researchers consider withdrawal to be a method of contraception, it is frequently used by adolescents and was thus included in the study. A set of 25 potential consequences based on the interviews was generated. Examples are "prevents pregnancy," "makes it easy to have sex on the spur of the moment," and "is messy."* Teenagers were also asked who would care about their use of the various contraceptive methods. Persons who were commonly mentioned were partner, mother, father, physician, and best friend. The set of consequences and of significant persons supplied items for a closed-ended questionnaire to test the theory of reasoned action 25 with the new sample described above. Ratings were done on 7-point Likert-type scales. It was assumed that if adolescents had never heard of a particular contraceptive, it would be meaningless to ask their perceptions of it. Thus, before completing the questionnaire, subjects were first asked whether they had ever heard of each of the four methods. If an adolescent had not heard of a method, no further questions were asked about that method and the adolescent was not included in the analyses concerning that particular contraceptive. If an adolescent was uncertain about whether he or she had heard of a method, a short, standardized description was given. If the adolescent then recognized the contraceptive method, questions concerning it were asked. Each component, as presented in the Figure, was measured as described below. Beliefs and values o f consequences. Adolescents rated each of the 25 consequences in terms of its value: how good or bad it would be if a contraceptive method had that consequence for them. For example, respondents rated, on a 7point scale ranging from very bad to very good, how it would be to use a method that prevents pregnancy, makes it easy to have sex on the spur of the moment, is messy, and so forth. Adolescents then rated how likely they thought it was that they would experience each of the consequences if they or their partner used each of the four birth control methods. Likelihood estimates could range from very unlikely [to occur] to very likely [to occur] if they used that method. Thus, for example, adolescents rated how likely they thought it was that using condoms would make it easy to have sex on the spur of the moment, would be messy, would prevent pregnancy, and so forth. As specified in the theory of reasoned a c t i o n y the value associated with a given consequence was multiplied by the *A full set of potential consequencesis available from the first author.
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estimate of the likelihood that using the method would result in that consequence. The resulting scores were summed across the consequences to provide a "belief X value" score for each method. Perceptions o f others" desires and motivation to comply. Respondents rated how they believed each of five people would feel about his or her use of the particular contraceptive method during the next year. On 7-point scales, the adolescent indicated how each particular person would feel about the teenager's using the method, from definitely would not to d~nitely would want the adolescent to use the method. Similarly, adolescents also rated, on 7-point scales, their desire to comply with what the person would want them to do: whether they don't want to do ranging to they want to do what the person wishes. For each person rated, the adolescent's maturation to comply with the person's desires was multiplied by the perceived desire of the person regarding use of a method. The scores for these five people were summed, providing a single score for each method. General attitude. General attitude toward each method was measured by having adolescents indicate, on 7-point scales, the extent to which using that method in the coming year would be very good ranging to very bad (and, on another scale, very pleasant to very unpleasant). The general attitude toward a method was calculated by averaging the two ratings. General social expectations. General social expectations regarding each method were assessed by having adolescents rate, on 7-point scales, whether "most people who are important to me" think that they should to should not use that method in the coming year. Intention to use contraceptive. Intention to use each of the four contraceptive methods was measured by having the subject rate, on 7-point scales, the statement "If I do have intercourse in the next year, I am ([very unlikely to very likely]) to ever use [method X] for birth control." Contraceptive use. At the 1-year follow-up interview, adolescents were asked about their behavior during the previous year. In addition to obtaining a temporal account of their use or nonuse of contraception and reasons for changing methods, frequency of use of each specific method was assessed. For each method, adolescents indicated how frequently they had used it during the course of the year in relation to the number of times they had intercourse: none of the times, a few of the times, about half the times, most of the times, or all of the times. Statistical analyses. Analyses were performed separately for male and female subjects and were repeated for each of the four methods. The number of subjects included in each analysis differed for each contraceptive method because subjects lacking knowledge of a method were excluded. Analyses were based on the following numbers of subjects:
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Table I. R e g r e s s i o n a n a l y s i s of decision m o d e l for i n t e n t i o n to use c o n t r a c e p t i v e s : f e m a l e adolescents
Pill* Attitude Social expectations Condomt Attitude SociaI expectations Diaphragm:[: Attitude Social expectations Withdrawalw Attitude Social expectation
Nonstandardized regression coefficienl
S t a n d a r d error
Beta
R 2 change
/"
0.6617 0.2678
0.0735 0.0695
0.5823 0.2492
0.4975 0.0470
9.005 3.854
<0.001 <0.001
0.6520 0.1449
0.1072 0.1012
0.4813 0.I 133
0.2820 0.0104
6.083 1.432
<0.00l NS
0.4291 0.3645
0.1064 0.0899
0.3251 0.3268
0.2055 0.0904
4.032 4.053
<0.001 <0.001
0.6665 0.2058
0.1141 0.0965
0.4807 0.1755
0.3300 0.0220
5.843 2.133
<0,00 l <0,04
T. Test of whether the nonstandardizedregression coefficientis nonzero: *Pill: multiple R = 0.7379; F (2.144) = 86.08,p <0.001. ]'Condom:multipleR = 0.5408; F (2.140) = 28.93,p <0.001. SDiaphragm: multipleR = 0.5439; F (2.128) = 26.89, p <0.001. w multipleR = 0.5934; F (2.134) = 36.40, p <0.001.
73 male and 225 female subjects regarding the pill, 83 male and 218 female subjects regarding the condom, 59 male and 200 female subjects regarding the diaphragm, and 75 male and 212 female subjects regarding the withdrawal method. The Pearson correlation coefficient was used to test hypotheses 1, 2, and 4. Hypothesis 3 was tested by means of hierarchical ordinary least squares regression on the SPSS-X Statistical Package for the Social Sciences software program (SPSS Inc., Chicago, Ill.), as described below. RESULTS Hypothesis 1: Association of general attitudes with specific beliefs and values. The first hypothesis was that general attitudes toward a contraceptive method would reflect beliefs about the consequences of use, weighted by the values associated with those outcomes. For female subjects, general attitude was significantly correlated (,p <0,001) with the summary "belief X value" score (described in the "instruments" section) for all four methods; correlation coefficients ranged from 0.21 for diaphragm to 0.42 for the pill. For male subjects the correlations of general attitude and summary "belief X value" scores were significant for the condom, pill, and withdrawal (correlation coefficients ranged from 0.24 to 0.36) but was not significant for the diaphragm. Hypothesis 2: Associations of general social expectations with perceived views of other people and motivation to comply. The second hypothesis was that general social expectations would reflect beliefs about specific people's wishes regarding the adolescent's use of the method, weighted by the adolescent's desire to comply with those wishes. For all four
contraceptive methods the correlation between the general perception and the sum of ratings regarding specific people was significant among both male and female adolescents (correlation coefficients ranged from 0.58 to 0.79 for female subjects and from 0.58 to 0.81 for male subjects, all p <0.001), providing strong support for the second hypothesis. Hypothesis 3: Association of general attitude and social expectations with intention to use a contraceptive. The third hypothesis was that intention to use a contraceptive method would reflect general attitudes and perceptions of social expectations regarding the method. Regression analyses were performed for each of the four contraceptive methods. To determine whether it was advisable to pool data across all age groups, we first examined whether age was related to intention to use a given contraceptive method. Age was not correlated with intention to use any of the four methods for either male or female subjects and thus was not included in the regression equation., Tables I and II present, for female and male subjects, respectively, the results of the regression analyses. For each contraceptive method, general attitude was entered first into the hierarchical regression, followed by perceived social expectations regarding use of method. At the bottom of each table, the multiple correlation coefficient (multiple R) provides information about the strength of association between the two components of the model (attitude and social expectations) with intention to use the contraceptive method. For female subjects the multiple Rs (0.54 for the condom and diaphragm, 0.59 for withdrawal, and 0.74 for the pill) are all significant at
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T a b l e II. R e g r e s s i o n a n a l y s i s o f d e c i s i o n m o d e l for i n t e n t i o n to use c o n t r a c e p t i v e s : M a l e a d o l e s c e n t Nonstandardized regression coefficient
Standard error
Beta
R 2 change
0.0837 0.4214
0.2381 0.1817
0.0602 0.3974
0.0714 0.1151
0.352 2.318
-0.03
0.1639 0.3305
0.1253 0.1600
0.2004 0.3163
0.1228 0.0775
1.308 2.065
-0.04
0.2603 0.1815
0.3364 0.2713
0.1910 0.1651
0.0930 0.0143
0.374 0.662
---
0.3233 0.7191
0.1474 0.1318
0.2554 0.6353
0.4317 0,2424
2.193 5.454
Pill* Attitude Social expectations Condomt Attitude Social expectations Diaphragm~ Attitude Social expectations Withdrawalw Attitude Social expectation
/"
p
0.03 <0.001
T, Test of whether the nonstandardized regression coefficientis nonzero. *Pill: multiple R = 0.4318; F (2.38) = 4.36, p <0.02. tCondom: multiple R = 0.4476; F (2.44) = 5.51, p <0.01. :[:Diaphragm: multiple R = 0.3275; F (2.28) = 1.68, p = 0.20. w multiple R = 0.8210; F (2.40) = 41.36, p <0.001.
T a b l e III. Correlation of intention to use method with frequency of use in following year
Pill Condom Diaphragm Withdrawal
Female subjects
Male subjects
0.42:~ 0.35~ 0.27:}: 0.20I
0.10 0.25* 0.27* 0.465
*p <0.05. tp <0,01. ~p <0.001.
p <0.001. For male subjects the association of attitude and social expectations with intention is highly significant for withdrawal (multiple R = 0.8 2, p <0.001), and is somewhat less strong but still significant for the pill and condoms (multiple Rs = 0.43 and 0.45, respectively; p <0.0l and <0.02). The multiple R was lower for the diaphragm (0.33) and did not reach significance. To examine the effects of race, we conducted an additional set of regression analyses on a sample of white and black female subjects, the only groups in which there were sufficient numbers to permit such an analysis. For each method, race was entered into the regression equation after the entry of the two components of the model. For none of the four methods was there a significant increment in the variance in intention associated with being white versus black. The multiple regressions presented above do not provide information on the unique contribution of attitudes versus social expectations to intention to use a contraceptive
method. In a hierarchical regression analysis, when the predictor variables have overlapping variance with the dependent variable (as is the case for general attitude and social expectation), this shared variance is allocated to the first variable entered into the regression equation. Semipartial correlation coefficients were examined to understand the unique and separate contribution of general attitude versus social expectations regarding adolescents' intentions to use contraceptives. These coefficients express the degree of association of attitude alone and of social expectations alone with intention to use a method. Among female adolescents, perceived social expectations had a statistically significant but small relationship with contraceptive intentions. Social expectations did not explain much unique variance in intentions above and beyond the variance shared with general attitude toward using the method. In contrast, general attitudes about the contraceptive methods showed a strong independent relationship to intention to use the methods. Thus, for female adolescents, although the perception of social expectations contributed significant variance, personal attitudes about contraceptives were much more strongly associated with intention to use a given method. Among male adolescents, both general attitude and social expectations made significant independent contributions to intention to use withdrawal, but only general attitude showed a significant relationship to intention to use the condom. In contrast, the semipartial correlations of social expectations, but not of general attitude, were significant for intention for the partner to use the pill and diaphragm. Thus, for male adolescents, the social expectations were more predictive of intention to use the " f e m a l e " methods of
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contraception than were attitudes, whereas general attitudes were more predictive of intention to use the condom, and both components were important for withdrawal. These analyses support the hypothesis that intention to use contraceptive methods reflects the beliefs, values, and perceptions of social expectations regarding contraceptive use by the adolescent. Hypothesis 4: Prediction of behavior. The fourth hypothesis was that adolescents' contraceptive behavior during the year after the interview would be predicted by their intention regarding use of each method. Table III presents the correlation coefficients between strength of intention to use a given contraceptive method and the frequency with which the method was used during the following Year. The Pearson correlation coefficient between intention to use the method and subsequent use was significant for all four contraceptive methods for female adolescents and was particularly strong for the pill. Among male adolescents the correlation between intention and behavior was not statistically significant for the pill. The correlation between intention and behavior was significant for the other three methods, and was particulary strong for withdrawal. These results support the hypothesis that contraceptive behaviors during a 1-year period reflect the adolescents' intentions regarding engaging in those behaviors. In the follow-up interview, the female subjects also reported whether they had become pregnant during the previous year; 28 (18.9%) did report occurrence of a pregnancy. Occurrence of pregnancy is determined in part by contraceptive behavior but also by frequency and timing of intercourse and by biologic factors. As a result, we did not predict a relationship between intention and subsequent pregnancy but were interested in examing the relationship. Point-biserial correlations were computed between strength of intention to use each method and pregnancy occurrence. The correlations were significant, although small, for intention to use condoms and the diaphragm (r = -0.14 for each, p = 0.05), and were not significant for either withdrawal or the pill. DISCUSSION Physicians have often taken the view that adolescents are "risk takers" and do not behave in a rational manner.27 This view of lack of rational behavior, accompanied by the perception that adolescents see themselves as invulnerable, has contributed to the lack of development of effective intervention programs. 2a Recently DuRant et al. 2~ showed that a theoretical model that includes components of the decision-making model that we tested is helpful in predicting contraceptive use in a national survey of unmarried women. The variables that contributed most to contraceptive nonuse included previous negative contraceptive behavior and not
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acquiring a birth control method at the initial family planning visit. In addition, DuRant et al. 2~showed that adolescents who had more frequent visits to the family planning clinic were more likely to use a more effective method of birth control. The results of our study further support the hypothesis that adolescents behave in a rational manner regarding contraceptive use. Critical predictors of their use of contraceptives include the following: (1) their general attitude regarding the use of specific contraceptive methods, which reflects their beliefs about the consequences of using a method and the values they ascribe to these consequences; (2) their view of general social expectations (or the perceptions of the social environment), which reflects their beliefs about the wishes of others who are important to them (including parents, physicians, sexual partners) regarding their contraceptive use and the desire of the adolescent to comply with these wishes; and (3) their intention to use the contraceptive method. Because the sample was based on adolescents who were seeking health care, the results may not be generalizable to all adolescents. It is possible that adolescents sampled in a clinic setting, particularly those who are seeking contraceptive care, may be more consistent in their reasoning and behavior than would a random sample of adolescents. However, there is not likely to be a strong bias in the sample because it included patients seeking care for a range of health problems, including required school or sports physical examinations and treatment for acute problems. There were some general similarities and differences regarding the utility of the model for male and female adolescents. We point out these differences with some degree of caution, noting that we did not compare our male and female subjects statistically for two reasons: (1) the size of the male sample was small, and (2) the behaviors needed for using each method are gender-specific and in some cases involve the behavior of the partner. For example, we found that the male adolescents' intention for their partners to use the pill did not predict its subsequent use and that, for female adolescents, the correlation of intention and subsequent behavior is strongest for this contraceptive method than for any other. With withdrawal, we found similar effects.but in the opposite direction for each gender. Among female adolescents, general attitudes and social expectations contributed significantly to the decisionmaking process, with attitudes showing a stronger association. Therefore physicians may want to explore with their female patients the patients' beliefs regarding consequences of use and the values associated with these consequences for each method. It would be most useful to address those beliefs that may not be accurate and that could adversely affect an adolescent's resolve to use a method. In addition, re-
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male adolescents are also influenced by social expectations, and it would be important to spend some time in the clinical encounter exploring the perceived views of parents, sexual partners, and others who are important to the young woman. In male adolescents the critical factor appears to be social expectations for withdrawal and use of the diaphragm, and attitude for condom use. Given the desirability of male adolescents' using condoms for protection against sexually transmitted disease in addition to avoiding pregnancy, it would be important to discuss with them the beliefs they have regarding condoms and social pressures that might inhibit their use. The female subjects in this study were able to tell us 1 year earlier about their subsequent behavior during the next year, as were male subjects for all methods but the partner;s use of the pill (the one method which is independent of coitus and thus not readily influenced by the male partner). In addition, despite the influence of factors beyond contraceptive use on the occurrence of pregnancy, female subjects with a stronger intention to use condoms and the diaphragm were less likely to become pregnant during the next year. These findings cast further light on previous research. 2~ 29 In a clinic sample, Litt et al. 29 found that the best predictors of contraceptive compliance were adolescents' making their own appointment and coming to the clinic to receive birth control. D u R a n t et al. 2~ found that the frequency of attending a family planning clinic was correlated with contraceptive use. These variables may reflect strength of intention to use a contraceptive. Our study provides the clinician with a simple way, which has predictive value, to ask young people whether they intend to use a given contraceptive during the next year. If adolescents do not believe themselves able to use the contraceptive during the next year, the clinician will need to explore the barriers that they believe they will experience and help them determine whether there are ways to reduce such obstacles. AS pointed out in the recent Report of the U.S. Preventive Services Task Force, Guide to Clinical Services, 3~ the most effective interventions are those which target the personal health behaviors of patients. In the past, clinicians working with adolescents have often felt futile in the area of influencing sexual behavior because the clinicians conceptualized the behavior as an irrational act. Our study adds to the growing body of literature that underscores the importance of talking with adolescents about their current behavior and future intention, helping them to clarify their beliefs regarding certain contraceptives and to develop strategies to deal with their social environment. 31 We gratefully acknowledge Mary-Ann Shafer, MD, for her involvement in pilot research and the assistance of M. Margaret
The Journal of Pediatrics March 1990
Dolcini, Cynthia Holmes, Victor Yatom, and Joseph Catania in collecting data, of Vicki Wong and Doris Lovrin in providing clinic coordination, and of Lance Pollack in data management and analyses. REFERENCES
1. Hofferth SL, Hayes CP, eds. Risking the future: adolescent sexuality, pregnancy and childbearing; vol 2. Washington, D.C.: National Academy Press, 1987. 2. Kanter J, Zelnik M. Contraception and pregnancy: experience of young unmarried women in the United States. Faro Plann Perspect 1973;5:21-35. 3. Zelnik M, Shah FK. First intercourse among young Americans. Faro Ptann Perspect 1983;t5:64-70. 4. Hornick JP, Doran L, Crawford SH. Premarital contraceptive usage among male and female adolescents. Faro Coord 1979; 28:181-90. 5. Furstenberg FF Jr. Unplanned parenthood: the social consequences of teenage childbearing. New York: Free Press, 1976. 6. Rosen RH, Ager JW. Self-concept and contraception: preconception decision-making. Popul Environ 1981;4:11-23. 7. Herold ES, Goodwin MS, Lero DS. Self-esteem, locus of control, and adolescent contraception. J Psychol 1979;101:83-8. 8. Adler NE. Unwanted pregnancy in adolescent and adult women. Professional Psychology 1981 ;12:56-66. 9. Udry J, Talbert L, Morris NM. Bisocial foundations for adolescent female sexual behavior. Demography 1986;23:217-27. 10. Hayes CP, ed. Risking the future: adolescent sexuality, pregnancy and childbearing; vol 1. Washington, D.C.: National Academy Press, 1987. 11. Byrne D. Sex without contraception. In: Byrne D, Fisher WA, eds. Sex and contraception. Hillsdale, N.J.: Lawrence Erlbaum, 1983:3-3I. 12. Oskamp S, Mindic B, Berger P. A longitudinal study of success versus failure in contraceptive planning. J Popul i978;1:6983. 13. Lindemann C. Birth control and unmarried young women. New York: Springer-Verlag, 1974. 14. Rains P. Becomiug an unwed mother. Chicago: A[dine, 1971. 15. Forrest JD, tfenshaw, SK. What U.S. women think and do about contraception. Fam Plann Perspect 1983; 15:157-66. 16. Smetana J, Adler NE. Decision-making regarding abortion: a value • expectancy analysis. J Popu[ 1979;2:348-57. 17. Jaccard J J, Davidson AR. Toward an understanding of family planning behaviors: an initial investigation. J Appl Soc Psychot 1972;2:228-35. 18. McCarty D. Changing contraceptive usage intentions: a test of the Fishbein model of intention. J Appl Soc Psychol 1981; 11:192-211. 19. Pagel MD, Davidson AR. A comparison of three socialpsychological models of attitude and behavioral plan: prediction of contraceptive behavior. J Pers Soc Psychol 1984;47:51733. 20. DuRant RH, Sanders JM Jr, Jay S, et al. Analysis of contraceptive behavior of sexually active female adolescents in the United States. J Pediatr 1988;113:930-6. 21. DeLamater J. An intrapersonal and interactional model of contraceptive behavior. In: Byrne D, Fisher WA, eds. Adolescents, sex, and contraception. Hillsdale, N.J.: Lawrence Erlbaum Associates, 1983:3.3-48. 22. Nathanson CA, Becket MH. Contraceptive behavior among
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23. 24. 25. 26.
27.
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unmarried young women: a theoretical framework for research. Popul Environ 1983;6:39-59. Whitley BE Jr, Schofield JW. A meta-analysis on adolescent contraceptive use. Popul Environ 1985 1986;8:173-203. Morrison DM. Adolescent contraceptive behavior: a review. Psychol Bull t985;98:538-68. Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs, N.J.: Prentice-Hall, 1980. Cohen J, Cohen P. Applied multiple regression/correlation analyses for the behavioral sciences, 2nd ed. Hillsdale, N.J.: Lawrence Erlbaum, 1983. Irwin CE Jr, Millstein SG. Biopsychosocial correlates of risk
28.
29. 30.
31.
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taking behavior during adolescence: can the physician intervene? J Adolesc Health Care 1986;7:82S-96S. Irwin CE Jr, ed. Adolescent social behavior and health new directions for child development. No. 37. San Francisco: Jossey Bass, 1987:1-12. Litt IF, Cuskey WR, Rudd S. Identifying adolescents at risk for noncompliance. J Pediatr 1980;96:742-5. U.S. Preventive Services Task Force. An assessment of the effectiveness of 169 interventions. Baltimore, Md.: Williams & Wilkins, 1989:341-9. Brooks-Gunn J, Furstenberg FF. Adolescent sexual behavior. Am Psychol 1989;44:249-57.
FELLOWSHIPS Available fellowships in pediatric subspecialties and those for general academic pediatric training are listed once a year, in May, in THE JOURNAL OF PEDIATRICS. Each October, forms for listing such fellowships are sent to the Chairman of the Department of Pediatrics at most major hospitals in the United States and Canada. Should you desire to list fellowships, a separate application must be made each year for each position. All applications must be returned to The C.V. Mosby Company by February 15 of the listing year to ensure publication. Additional forms will be supplied on request from 'the Journal Editing Department, The C.V. Mosby Company, 11830 Westline Industrial Drive, St. Louis, M O 63146-3318/314-872-8370.
A large proportion of sexually active adolescents fail to use contraception despite its widespread availability, and the
Supported in part by grants frOm the National Institute of Child Health and Human Development (No. 5-R01 HD16137), from the John D. and Catherine T. MacArthur Foundation Research Network on Health-Promoting and Disease-Preventing Behavior (Dr. Adler), from the Bureau of Maternal and Child Health and Resources Development (No. MCJ000978) (Dr. Irwin), and from the University of California, San Francisco, Academic Senate (Dr. Sharer). Submitted for publication June 15, 1988; accepted Aug. 31, 1989. Reprint requests: Nancy E. Adler, PhD, Health PsyChology Program, Box 0844, University of California, San Francisco, Medical Center, San Francisco, CA 94143. 9/27/16492
pregnancy rate among teenagers remains high. 1 In an effort to understand the complex nature of sexual activity in the second decade of life, research has focused on numerous aspects of sexuality, contraception, and pregnancy. Demographic and sociologic studies have shown that age, race, income, and family structure are associated with sexual activity and the occurrence of unplanned pregnancy. 25 Psychologic studies have shown that female adolescents who have low self-esteem and who feel powerless, alienated, and in little control of their lives are at a higher risk for pregnancy. 6-s Biologic factors have also been shown to influence pregnancy risk; girls with earlier physiologic maturation initiate sexual activity earlier than a g e - r e l a t e d peers. 9 The factors identified in the studies cited above are not
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(Beliefsof consequences) multipliedby (Valueof consequences)
The Journal o f Pediatrics March 1990
---~.
I Generalattitude ] towardsbehaviorJ
"a I Intention I ] Performance to engage ---}11, of in behavior behavior
(Perceptionsof others'desires) multipliedby (Motivationto comply withdesires)
---l~
Generalsocial ] expectations regardingbehavior
Figure. Theoretic model taken from theory of reasoned action.
easily modified by health care providers or through educational programs. For purposes of intervention, a more useful level of analysis may be adolescents' beliefs, values, and attitudes relevant to contraceptive choice and use. Gaps in knowledge about reproduction and contraception, specific beliefs about contraceptive methods, and ambivalence or guilt over being sexually active all may contribute to ineffective contraceptive use. 1~ Studies of older population samples (i.e., college students and adults) have demonstrated the utility of "rational" decision-making models in understanding reproductive behavior. 1619 These models assume that any given behavior is guided by the person's views of the consequences (costs and benefits) of taking or not taking the action. Several models of adolescent contraceptive use have included cognitive variables.2~ However, with some exceptions,23-24there have been few empiric tests of the role of cognitive factors in accounting for adolescents' sexual behavior. The failure to apply decision models to adolescents may derive from the assumption that adolescent behavior is impulsive and cannot be described by models that presume rationality. Our study was guided by the hypotheses (1) that adolescents, like adults, guide their behavior in terms of the outcomes they expect will follow from their behaviors and (2) that a decision model could account for significant variance in contraceptive choice and behavior among adolescents. T H E O R Y OF R E A S O N E D A C T I O N Our research used the theory of reasoned action,25 which posits that a person's behavior is best predicted by his orher intention to engage in the given action. Intention to perform the action is influenced by two forces: (1) the person's gen-
eral attitude toward taking the action (i.e., whether engaging in the behavior is good or bad) and (2) the person's view of the social expectations regarding the behavior (i.e., his or her beliefs regarding what people who are important to the person think that he or she should do with respect to the behavior). In terms of contraception, the influence of these forces means that an adolescent's intention to use a given contraceptive method will predict actual use, and that intention to use the method will depend on the adolescent's general attitude toward the method and on his or her perception of the extent to which significant others want him or her to use the method. According to the theory of reasoned action, a5 which is outlined in the Figure, each of these variables (general attitude and social expectations) is, in turn, a function of a set of specific beliefs and values. General attitude is a function of the person's set of beliefs regarding the various consequences of taking the action, These consequences can be positive or negative. Therefore each belief is weighted by the value that the person attaches to experiencing that consequence. For example, an adolescent may strongly believe that using condoms is messy and may attach a moderately negative value to using a messy method of contraception. At the same time, the adolescent may believe that condoms are very likely to prevent transmission of sexually transmitted diseases, an outcome to which he or she attaches a very high positive value. According to the model, the net sum of the products of beliefs, weighted by values, is significantly associated with general attitude. Similarly, the person's view of general social expectations regarding a behavior is a function of the person's set of beliefs about what significant other people want the person to
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do regarding the behavior. These beliefs are weighted by the person's motivation to do what each of these other people wishes, and are then summed. As applied to contraceptive use, the theory of reasoned action25 posits that an adolescent's perception of general social expectations regarding use of a given method will be associated with beliefs about whether his or her partner, mother, father, and other relevant people want him or her to use themethod, weighted by the adolescent's motivation to comply with those wishes. Our study tested each link in the decision model with respect to four contraceptive methodsl A sample of sexually active male and female adolescents was used. Hypotheses were (1) that beliefs about the likelihood of specific consequences resulting from using a contraceptive method, weighted by evaluation of how good or bad each consequence would be to experience, will influence an adolescent's general attitude toward using the method; (2) that perceptions of the wishes of other people, weighted by the adolescent's motivation to comply with those wishes, will influence the adolescent's view of general social expectations regarding use of the contraceptive; (3) that the more positive the adolescent's general attitude and perception of social expectations regarding use of a contraceptive, the stronger will be his or her intention to use the method; and (4) that the intention to use a contraceptive method will predict actual use of the method during the subsequent year. METHODS Subjects. Adolescents between the ages of 14 and 19 years who were seeking health care at either of two adolescent medical clinics (University of California, San Francisco, and Kaiser-Permanente, San Francisco) were invited to participate. The protocol was approved by institutional review boards at both institutions, and informed consent was obtained before interviews were initiated. Subjects were excluded if they were married, pregnant, non-English speaking, or developmentally disabled, or if they had come to the clinic because of a major psychosocial problem. Some adolescents declined participation; most frequently the reason was the long waiting periods in the clinic before their visit, which precluded their staying for an additional hour for the interview. This influence on participation in the study seems unlikely to have introduced any particular bias. With only limited resources for interviewing, a decision was made to concentrate on obtaining a sufficiently large number of female adolescents to provide adequate statistical power for testing the theoretic model. 26 In addition to the main sample of female adolescents, a smaller sample of male adolescents was obtained. Because of our desire to oversample the female subjects, there were more female than male interviewers at any given clinic. All interviews were done by same-sex interviewers.
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Several clinics at the two institutions were used and patients were randomly sampled. The institutions serve a wide cross-section of the population of San Francisco, drawing largely from middle- and working-class families. In the university-based sample, 40% were covered by Medicaid funds, 30% by a clinical teaching subsidy (which provides partial subsidy, with the remainder paid by the patient or family), and 30% by private insurance. By definition, all patients at the Kaiser clinic are covered by insurance, generally through the employment of a parent. Another indicator of socioeconomic status, educational level of the parents, also showed a wide range: 35.1% of the mothers and 40.7% of the fathers had a high school education or less; 49.3% of mothers and 34.7% of fathers has some college or had earned a bachelor's degree; and 11.4% of mothers and 19.6% of fathers had graduate training or degree. The sample was ethnically diverse: 35.4% white, 33% black, 13.4% Hispanic, 10.1% Asian, and 8.1% "other." The average age of the male subjects was 16.7 years (SD = 1.26) and of female subjects was 17.0 (SD = 1.26) years. Although a larger study included all patients, this article discusses only those adolescents who had experienced their sexual debut before the first interview, a total of 325,234 of whom were female. Procedure. Adolescents were informed about the study and invited to participate after registering at the clinic. They were offered three dollars for participation in the initial interview and six dollars for a follow-up interview. Although the questionnaire was largely self-administered, directions were given by a same-sex interviewer who helped to clarify questions as the need arose. Permission was obtained to recontact subjects, and a follow-up interview was conducted with particiPants approximately 1 year after the initial interview. At this time they were asked about their sexual and contraceptive behaviors during the preceding year. Follow-up interviews were obtained from 151 female (58.2%) and 53 male (64.5%) subjects. The mean time between the initial interview and follow-up was 13.4 months (SD = 2.8 months). Of those who did not participate in the second interview, about half could not be located and half declined to return for a second interview. To evaluate whether the attrition introduced any bias into the sample, we compared the characteristics of the respondents who did or did not participate in the follow-up studies. These analyses revealed no significant differences in age, ethnicity, prior sexual behavior (e.g., number of partners, frequency of intercourse), or prior use of contraception. Instruments. An initial pilot study with a separate sample of 18 male and 36 female subjects was conducted to determine the adolescents' beliefs regarding consequences of using the various methods of birth control. Open-ended in-
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Adler et al.
terviews obtained, in the adolescents' own words, what they thought were good and bad aspects of using (or having one's partner use) four contraceptive methods: the pill, condom, diaphragm, and withdrawal. Although neither clinic personnel nor the researchers consider withdrawal to be a method of contraception, it is frequently used by adolescents and was thus included in the study. A set of 25 potential consequences based on the interviews was generated. Examples are "prevents pregnancy," "makes it easy to have sex on the spur of the moment," and "is messy."* Teenagers were also asked who would care about their use of the various contraceptive methods. Persons who were commonly mentioned were partner, mother, father, physician, and best friend. The set of consequences and of significant persons supplied items for a closed-ended questionnaire to test the theory of reasoned action 25 with the new sample described above. Ratings were done on 7-point Likert-type scales. It was assumed that if adolescents had never heard of a particular contraceptive, it would be meaningless to ask their perceptions of it. Thus, before completing the questionnaire, subjects were first asked whether they had ever heard of each of the four methods. If an adolescent had not heard of a method, no further questions were asked about that method and the adolescent was not included in the analyses concerning that particular contraceptive. If an adolescent was uncertain about whether he or she had heard of a method, a short, standardized description was given. If the adolescent then recognized the contraceptive method, questions concerning it were asked. Each component, as presented in the Figure, was measured as described below. Beliefs and values o f consequences. Adolescents rated each of the 25 consequences in terms of its value: how good or bad it would be if a contraceptive method had that consequence for them. For example, respondents rated, on a 7point scale ranging from very bad to very good, how it would be to use a method that prevents pregnancy, makes it easy to have sex on the spur of the moment, is messy, and so forth. Adolescents then rated how likely they thought it was that they would experience each of the consequences if they or their partner used each of the four birth control methods. Likelihood estimates could range from very unlikely [to occur] to very likely [to occur] if they used that method. Thus, for example, adolescents rated how likely they thought it was that using condoms would make it easy to have sex on the spur of the moment, would be messy, would prevent pregnancy, and so forth. As specified in the theory of reasoned a c t i o n y the value associated with a given consequence was multiplied by the *A full set of potential consequencesis available from the first author.
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estimate of the likelihood that using the method would result in that consequence. The resulting scores were summed across the consequences to provide a "belief X value" score for each method. Perceptions o f others" desires and motivation to comply. Respondents rated how they believed each of five people would feel about his or her use of the particular contraceptive method during the next year. On 7-point scales, the adolescent indicated how each particular person would feel about the teenager's using the method, from definitely would not to d~nitely would want the adolescent to use the method. Similarly, adolescents also rated, on 7-point scales, their desire to comply with what the person would want them to do: whether they don't want to do ranging to they want to do what the person wishes. For each person rated, the adolescent's maturation to comply with the person's desires was multiplied by the perceived desire of the person regarding use of a method. The scores for these five people were summed, providing a single score for each method. General attitude. General attitude toward each method was measured by having adolescents indicate, on 7-point scales, the extent to which using that method in the coming year would be very good ranging to very bad (and, on another scale, very pleasant to very unpleasant). The general attitude toward a method was calculated by averaging the two ratings. General social expectations. General social expectations regarding each method were assessed by having adolescents rate, on 7-point scales, whether "most people who are important to me" think that they should to should not use that method in the coming year. Intention to use contraceptive. Intention to use each of the four contraceptive methods was measured by having the subject rate, on 7-point scales, the statement "If I do have intercourse in the next year, I am ([very unlikely to very likely]) to ever use [method X] for birth control." Contraceptive use. At the 1-year follow-up interview, adolescents were asked about their behavior during the previous year. In addition to obtaining a temporal account of their use or nonuse of contraception and reasons for changing methods, frequency of use of each specific method was assessed. For each method, adolescents indicated how frequently they had used it during the course of the year in relation to the number of times they had intercourse: none of the times, a few of the times, about half the times, most of the times, or all of the times. Statistical analyses. Analyses were performed separately for male and female subjects and were repeated for each of the four methods. The number of subjects included in each analysis differed for each contraceptive method because subjects lacking knowledge of a method were excluded. Analyses were based on the following numbers of subjects:
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Table I. R e g r e s s i o n a n a l y s i s of decision m o d e l for i n t e n t i o n to use c o n t r a c e p t i v e s : f e m a l e adolescents
Pill* Attitude Social expectations Condomt Attitude SociaI expectations Diaphragm:[: Attitude Social expectations Withdrawalw Attitude Social expectation
Nonstandardized regression coefficienl
S t a n d a r d error
Beta
R 2 change
/"
0.6617 0.2678
0.0735 0.0695
0.5823 0.2492
0.4975 0.0470
9.005 3.854
<0.001 <0.001
0.6520 0.1449
0.1072 0.1012
0.4813 0.I 133
0.2820 0.0104
6.083 1.432
<0.00l NS
0.4291 0.3645
0.1064 0.0899
0.3251 0.3268
0.2055 0.0904
4.032 4.053
<0.001 <0.001
0.6665 0.2058
0.1141 0.0965
0.4807 0.1755
0.3300 0.0220
5.843 2.133
<0,00 l <0,04
T. Test of whether the nonstandardizedregression coefficientis nonzero: *Pill: multiple R = 0.7379; F (2.144) = 86.08,p <0.001. ]'Condom:multipleR = 0.5408; F (2.140) = 28.93,p <0.001. SDiaphragm: multipleR = 0.5439; F (2.128) = 26.89, p <0.001. w multipleR = 0.5934; F (2.134) = 36.40, p <0.001.
73 male and 225 female subjects regarding the pill, 83 male and 218 female subjects regarding the condom, 59 male and 200 female subjects regarding the diaphragm, and 75 male and 212 female subjects regarding the withdrawal method. The Pearson correlation coefficient was used to test hypotheses 1, 2, and 4. Hypothesis 3 was tested by means of hierarchical ordinary least squares regression on the SPSS-X Statistical Package for the Social Sciences software program (SPSS Inc., Chicago, Ill.), as described below. RESULTS Hypothesis 1: Association of general attitudes with specific beliefs and values. The first hypothesis was that general attitudes toward a contraceptive method would reflect beliefs about the consequences of use, weighted by the values associated with those outcomes. For female subjects, general attitude was significantly correlated (,p <0,001) with the summary "belief X value" score (described in the "instruments" section) for all four methods; correlation coefficients ranged from 0.21 for diaphragm to 0.42 for the pill. For male subjects the correlations of general attitude and summary "belief X value" scores were significant for the condom, pill, and withdrawal (correlation coefficients ranged from 0.24 to 0.36) but was not significant for the diaphragm. Hypothesis 2: Associations of general social expectations with perceived views of other people and motivation to comply. The second hypothesis was that general social expectations would reflect beliefs about specific people's wishes regarding the adolescent's use of the method, weighted by the adolescent's desire to comply with those wishes. For all four
contraceptive methods the correlation between the general perception and the sum of ratings regarding specific people was significant among both male and female adolescents (correlation coefficients ranged from 0.58 to 0.79 for female subjects and from 0.58 to 0.81 for male subjects, all p <0.001), providing strong support for the second hypothesis. Hypothesis 3: Association of general attitude and social expectations with intention to use a contraceptive. The third hypothesis was that intention to use a contraceptive method would reflect general attitudes and perceptions of social expectations regarding the method. Regression analyses were performed for each of the four contraceptive methods. To determine whether it was advisable to pool data across all age groups, we first examined whether age was related to intention to use a given contraceptive method. Age was not correlated with intention to use any of the four methods for either male or female subjects and thus was not included in the regression equation., Tables I and II present, for female and male subjects, respectively, the results of the regression analyses. For each contraceptive method, general attitude was entered first into the hierarchical regression, followed by perceived social expectations regarding use of method. At the bottom of each table, the multiple correlation coefficient (multiple R) provides information about the strength of association between the two components of the model (attitude and social expectations) with intention to use the contraceptive method. For female subjects the multiple Rs (0.54 for the condom and diaphragm, 0.59 for withdrawal, and 0.74 for the pill) are all significant at
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T a b l e II. R e g r e s s i o n a n a l y s i s o f d e c i s i o n m o d e l for i n t e n t i o n to use c o n t r a c e p t i v e s : M a l e a d o l e s c e n t Nonstandardized regression coefficient
Standard error
Beta
R 2 change
0.0837 0.4214
0.2381 0.1817
0.0602 0.3974
0.0714 0.1151
0.352 2.318
-0.03
0.1639 0.3305
0.1253 0.1600
0.2004 0.3163
0.1228 0.0775
1.308 2.065
-0.04
0.2603 0.1815
0.3364 0.2713
0.1910 0.1651
0.0930 0.0143
0.374 0.662
---
0.3233 0.7191
0.1474 0.1318
0.2554 0.6353
0.4317 0,2424
2.193 5.454
Pill* Attitude Social expectations Condomt Attitude Social expectations Diaphragm~ Attitude Social expectations Withdrawalw Attitude Social expectation
/"
p
0.03 <0.001
T, Test of whether the nonstandardized regression coefficientis nonzero. *Pill: multiple R = 0.4318; F (2.38) = 4.36, p <0.02. tCondom: multiple R = 0.4476; F (2.44) = 5.51, p <0.01. :[:Diaphragm: multiple R = 0.3275; F (2.28) = 1.68, p = 0.20. w multiple R = 0.8210; F (2.40) = 41.36, p <0.001.
T a b l e III. Correlation of intention to use method with frequency of use in following year
Pill Condom Diaphragm Withdrawal
Female subjects
Male subjects
0.42:~ 0.35~ 0.27:}: 0.20I
0.10 0.25* 0.27* 0.465
*p <0.05. tp <0,01. ~p <0.001.
p <0.001. For male subjects the association of attitude and social expectations with intention is highly significant for withdrawal (multiple R = 0.8 2, p <0.001), and is somewhat less strong but still significant for the pill and condoms (multiple Rs = 0.43 and 0.45, respectively; p <0.0l and <0.02). The multiple R was lower for the diaphragm (0.33) and did not reach significance. To examine the effects of race, we conducted an additional set of regression analyses on a sample of white and black female subjects, the only groups in which there were sufficient numbers to permit such an analysis. For each method, race was entered into the regression equation after the entry of the two components of the model. For none of the four methods was there a significant increment in the variance in intention associated with being white versus black. The multiple regressions presented above do not provide information on the unique contribution of attitudes versus social expectations to intention to use a contraceptive
method. In a hierarchical regression analysis, when the predictor variables have overlapping variance with the dependent variable (as is the case for general attitude and social expectation), this shared variance is allocated to the first variable entered into the regression equation. Semipartial correlation coefficients were examined to understand the unique and separate contribution of general attitude versus social expectations regarding adolescents' intentions to use contraceptives. These coefficients express the degree of association of attitude alone and of social expectations alone with intention to use a method. Among female adolescents, perceived social expectations had a statistically significant but small relationship with contraceptive intentions. Social expectations did not explain much unique variance in intentions above and beyond the variance shared with general attitude toward using the method. In contrast, general attitudes about the contraceptive methods showed a strong independent relationship to intention to use the methods. Thus, for female adolescents, although the perception of social expectations contributed significant variance, personal attitudes about contraceptives were much more strongly associated with intention to use a given method. Among male adolescents, both general attitude and social expectations made significant independent contributions to intention to use withdrawal, but only general attitude showed a significant relationship to intention to use the condom. In contrast, the semipartial correlations of social expectations, but not of general attitude, were significant for intention for the partner to use the pill and diaphragm. Thus, for male adolescents, the social expectations were more predictive of intention to use the " f e m a l e " methods of
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contraception than were attitudes, whereas general attitudes were more predictive of intention to use the condom, and both components were important for withdrawal. These analyses support the hypothesis that intention to use contraceptive methods reflects the beliefs, values, and perceptions of social expectations regarding contraceptive use by the adolescent. Hypothesis 4: Prediction of behavior. The fourth hypothesis was that adolescents' contraceptive behavior during the year after the interview would be predicted by their intention regarding use of each method. Table III presents the correlation coefficients between strength of intention to use a given contraceptive method and the frequency with which the method was used during the following Year. The Pearson correlation coefficient between intention to use the method and subsequent use was significant for all four contraceptive methods for female adolescents and was particularly strong for the pill. Among male adolescents the correlation between intention and behavior was not statistically significant for the pill. The correlation between intention and behavior was significant for the other three methods, and was particulary strong for withdrawal. These results support the hypothesis that contraceptive behaviors during a 1-year period reflect the adolescents' intentions regarding engaging in those behaviors. In the follow-up interview, the female subjects also reported whether they had become pregnant during the previous year; 28 (18.9%) did report occurrence of a pregnancy. Occurrence of pregnancy is determined in part by contraceptive behavior but also by frequency and timing of intercourse and by biologic factors. As a result, we did not predict a relationship between intention and subsequent pregnancy but were interested in examing the relationship. Point-biserial correlations were computed between strength of intention to use each method and pregnancy occurrence. The correlations were significant, although small, for intention to use condoms and the diaphragm (r = -0.14 for each, p = 0.05), and were not significant for either withdrawal or the pill. DISCUSSION Physicians have often taken the view that adolescents are "risk takers" and do not behave in a rational manner.27 This view of lack of rational behavior, accompanied by the perception that adolescents see themselves as invulnerable, has contributed to the lack of development of effective intervention programs. 2a Recently DuRant et al. 2~ showed that a theoretical model that includes components of the decision-making model that we tested is helpful in predicting contraceptive use in a national survey of unmarried women. The variables that contributed most to contraceptive nonuse included previous negative contraceptive behavior and not
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acquiring a birth control method at the initial family planning visit. In addition, DuRant et al. 2~showed that adolescents who had more frequent visits to the family planning clinic were more likely to use a more effective method of birth control. The results of our study further support the hypothesis that adolescents behave in a rational manner regarding contraceptive use. Critical predictors of their use of contraceptives include the following: (1) their general attitude regarding the use of specific contraceptive methods, which reflects their beliefs about the consequences of using a method and the values they ascribe to these consequences; (2) their view of general social expectations (or the perceptions of the social environment), which reflects their beliefs about the wishes of others who are important to them (including parents, physicians, sexual partners) regarding their contraceptive use and the desire of the adolescent to comply with these wishes; and (3) their intention to use the contraceptive method. Because the sample was based on adolescents who were seeking health care, the results may not be generalizable to all adolescents. It is possible that adolescents sampled in a clinic setting, particularly those who are seeking contraceptive care, may be more consistent in their reasoning and behavior than would a random sample of adolescents. However, there is not likely to be a strong bias in the sample because it included patients seeking care for a range of health problems, including required school or sports physical examinations and treatment for acute problems. There were some general similarities and differences regarding the utility of the model for male and female adolescents. We point out these differences with some degree of caution, noting that we did not compare our male and female subjects statistically for two reasons: (1) the size of the male sample was small, and (2) the behaviors needed for using each method are gender-specific and in some cases involve the behavior of the partner. For example, we found that the male adolescents' intention for their partners to use the pill did not predict its subsequent use and that, for female adolescents, the correlation of intention and subsequent behavior is strongest for this contraceptive method than for any other. With withdrawal, we found similar effects.but in the opposite direction for each gender. Among female adolescents, general attitudes and social expectations contributed significantly to the decisionmaking process, with attitudes showing a stronger association. Therefore physicians may want to explore with their female patients the patients' beliefs regarding consequences of use and the values associated with these consequences for each method. It would be most useful to address those beliefs that may not be accurate and that could adversely affect an adolescent's resolve to use a method. In addition, re-
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male adolescents are also influenced by social expectations, and it would be important to spend some time in the clinical encounter exploring the perceived views of parents, sexual partners, and others who are important to the young woman. In male adolescents the critical factor appears to be social expectations for withdrawal and use of the diaphragm, and attitude for condom use. Given the desirability of male adolescents' using condoms for protection against sexually transmitted disease in addition to avoiding pregnancy, it would be important to discuss with them the beliefs they have regarding condoms and social pressures that might inhibit their use. The female subjects in this study were able to tell us 1 year earlier about their subsequent behavior during the next year, as were male subjects for all methods but the partner;s use of the pill (the one method which is independent of coitus and thus not readily influenced by the male partner). In addition, despite the influence of factors beyond contraceptive use on the occurrence of pregnancy, female subjects with a stronger intention to use condoms and the diaphragm were less likely to become pregnant during the next year. These findings cast further light on previous research. 2~ 29 In a clinic sample, Litt et al. 29 found that the best predictors of contraceptive compliance were adolescents' making their own appointment and coming to the clinic to receive birth control. D u R a n t et al. 2~ found that the frequency of attending a family planning clinic was correlated with contraceptive use. These variables may reflect strength of intention to use a contraceptive. Our study provides the clinician with a simple way, which has predictive value, to ask young people whether they intend to use a given contraceptive during the next year. If adolescents do not believe themselves able to use the contraceptive during the next year, the clinician will need to explore the barriers that they believe they will experience and help them determine whether there are ways to reduce such obstacles. AS pointed out in the recent Report of the U.S. Preventive Services Task Force, Guide to Clinical Services, 3~ the most effective interventions are those which target the personal health behaviors of patients. In the past, clinicians working with adolescents have often felt futile in the area of influencing sexual behavior because the clinicians conceptualized the behavior as an irrational act. Our study adds to the growing body of literature that underscores the importance of talking with adolescents about their current behavior and future intention, helping them to clarify their beliefs regarding certain contraceptives and to develop strategies to deal with their social environment. 31 We gratefully acknowledge Mary-Ann Shafer, MD, for her involvement in pilot research and the assistance of M. Margaret
The Journal of Pediatrics March 1990
Dolcini, Cynthia Holmes, Victor Yatom, and Joseph Catania in collecting data, of Vicki Wong and Doris Lovrin in providing clinic coordination, and of Lance Pollack in data management and analyses. REFERENCES
1. Hofferth SL, Hayes CP, eds. Risking the future: adolescent sexuality, pregnancy and childbearing; vol 2. Washington, D.C.: National Academy Press, 1987. 2. Kanter J, Zelnik M. Contraception and pregnancy: experience of young unmarried women in the United States. Faro Plann Perspect 1973;5:21-35. 3. Zelnik M, Shah FK. First intercourse among young Americans. Faro Ptann Perspect 1983;t5:64-70. 4. Hornick JP, Doran L, Crawford SH. Premarital contraceptive usage among male and female adolescents. Faro Coord 1979; 28:181-90. 5. Furstenberg FF Jr. Unplanned parenthood: the social consequences of teenage childbearing. New York: Free Press, 1976. 6. Rosen RH, Ager JW. Self-concept and contraception: preconception decision-making. Popul Environ 1981;4:11-23. 7. Herold ES, Goodwin MS, Lero DS. Self-esteem, locus of control, and adolescent contraception. J Psychol 1979;101:83-8. 8. Adler NE. Unwanted pregnancy in adolescent and adult women. Professional Psychology 1981 ;12:56-66. 9. Udry J, Talbert L, Morris NM. Bisocial foundations for adolescent female sexual behavior. Demography 1986;23:217-27. 10. Hayes CP, ed. Risking the future: adolescent sexuality, pregnancy and childbearing; vol 1. Washington, D.C.: National Academy Press, 1987. 11. Byrne D. Sex without contraception. In: Byrne D, Fisher WA, eds. Sex and contraception. Hillsdale, N.J.: Lawrence Erlbaum, 1983:3-3I. 12. Oskamp S, Mindic B, Berger P. A longitudinal study of success versus failure in contraceptive planning. J Popul i978;1:6983. 13. Lindemann C. Birth control and unmarried young women. New York: Springer-Verlag, 1974. 14. Rains P. Becomiug an unwed mother. Chicago: A[dine, 1971. 15. Forrest JD, tfenshaw, SK. What U.S. women think and do about contraception. Fam Plann Perspect 1983; 15:157-66. 16. Smetana J, Adler NE. Decision-making regarding abortion: a value • expectancy analysis. J Popu[ 1979;2:348-57. 17. Jaccard J J, Davidson AR. Toward an understanding of family planning behaviors: an initial investigation. J Appl Soc Psychot 1972;2:228-35. 18. McCarty D. Changing contraceptive usage intentions: a test of the Fishbein model of intention. J Appl Soc Psychol 1981; 11:192-211. 19. Pagel MD, Davidson AR. A comparison of three socialpsychological models of attitude and behavioral plan: prediction of contraceptive behavior. J Pers Soc Psychol 1984;47:51733. 20. DuRant RH, Sanders JM Jr, Jay S, et al. Analysis of contraceptive behavior of sexually active female adolescents in the United States. J Pediatr 1988;113:930-6. 21. DeLamater J. An intrapersonal and interactional model of contraceptive behavior. In: Byrne D, Fisher WA, eds. Adolescents, sex, and contraception. Hillsdale, N.J.: Lawrence Erlbaum Associates, 1983:3.3-48. 22. Nathanson CA, Becket MH. Contraceptive behavior among
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