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AIDS: Focus group discussions about risk and decision-making
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ORIGINAL ARTICLE
Teens Speak Out About HIV/AIDS: Focus Group Discussions about Risk and Decision-Making MARILYN J. HOPPE, Ph.D., LAURIE GRAHAM, M.S.W., ANTHONY WILSDON, M.S., ELIZABETH A. WELLS, Ph.D., DEBORAH NAHOM, M.S., M.S.W., AND DIANE M. MORRISON, Ph.D.
Purpose: To better understand the factors teens consider when making decisions regarding sex and condom use. Methods: Twenty-one same-sex focus groups were conducted with a total of 92 male and female teens from a range of high school programs; schools were selected based on the range of programs and diversity of students enrolled. Focus group moderators facilitated groups using a set of open-ended key questions about sexual decision-making and HIV/AIDS for each group; discussion on a specific topic area continued until no new information was generated. Group discussions were tape-recorded and transcribed, and themes were identified through independent content analysis of the transcriptions and assistant moderator notes. Results: Although teens acquire HIV/AIDS knowledge in school and are aware of positive and negative outcomes of engaging in sexual behavior, many times the information does not seem salient or personally relevant and thus is not used in making decisions related to having sex. In general, results indicate that boys and girls seem to have different ideas/reasons for having or not having sex. Boys relate to the physical nature of sex, whereas girls relate to the emotional aspects. Teens report being bored with AIDS education, but suggest needing information that is more relevant for them. Conclusions: Attempts should be made to make HIV education more relevant for teens so that they use the information they have when making decisions about
From the University of Washington, Seattle, Washington This paper was presented at the 67th annual meeting of the Pacific Sociological Association in Seattle, WA, March 1996. Address correspondence to: Dr. Marilyn J. Hoppe, University of Washington, 927 N. Northlake Way, Suite 210, Seattle, Washington, 98103-8871. E-mail: [email protected] Manuscript accepted December 1, 2003. © Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
safer sexual behavior. Different approaches may be needed for boys and girls. © Society for Adolescent Medicine, 2004 KEY WORDS:
Adolescents HIV/AIDS education Focus groups Teens
Although trends indicate a decrease in the prevalence of adolescent sexual experience during the last decade, data from the Youth Risk Behavior Survey in 2001 found that about 41% of teenagers have had sexual intercourse by the age of 16 years and 61% by the age of 18 years [1]. Among sexually active young people, many do not consistently protect themselves from pregnancy and even fewer protect themselves from disease [2]. Self-reported condom use at 9th grade in 2001 was about 68%, but declines to about 50% by 12th grade as other methods of birth control increase [1]. Compared with adults, adolescents are at higher risk for acquiring sexually transmitted diseases (STDs) because they have multiple and potentially riskier partners and do not use condoms consistently [3]. With close to two-thirds of all STDs occurring among young people under 25 years old [4] and rates remaining higher among teenagers than any other age group [5], HIV poses an important health risk in this age group. Some estimates indicate that at least 50% of the new HIV infections in the United States are in people under the age of 25 years [6]. In the case of teens, HIV/AIDS education has 1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2003.12.002
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focused on preventing sexual transmission of HIV because that is the primary mode of transmission among young adults and teens [7,8]. Many studies have looked at knowledge related to HIV/AIDS and whether or not increased knowledge translates to safer sexual behavior [9 –13]. Although desirable, interventions that increase knowledge alone have not proven effective in changing behavior, nor have they helped teens to integrate factual knowledge with their personal sexual choices and sexuality in relationship to their family and community values [14]. In addition to increasing knowledge, interventions that produce positive changes in behavior typically include a strong grounding in theory, experiential activities that allow participants to personalize information, a strong focus on social influences and pressure, reinforcement of norms and values against unprotected sex, and skills and confidence-enhancing activities [15,16]. To develop effective interventions, information is needed about the social context in which teen sexual decisions are made. In a 1992 review of AIDS risk reduction interventions, Fisher and Fisher concluded that interventions for adolescents too often relied on informal information and were not based on elicitation interviews to determine true adolescent needs [9]. To address this lack of information from teens, focus groups were conducted in which teens were asked about what they know about risky sexual behavior and what factors they consider when deciding to have both protected and unprotected sex.
Focus Group Methods This article reports information collected from structured focus groups conducted with students in grades 9 through 12. The questions used for these focus groups had a dual purpose: eliciting information to be used to aid in updating measurement tools for the 4th year of a 7-year longitudinal study with a separate sample of adolescents described elsewhere [17], and exploring topics related to sexual decisionmaking, sexual transmission of HIV/AIDS, and AIDS education. Focus group discussion topics included student beliefs and attitudes about tobacco, alcohol, substance use, HIV/AIDS, sex, and condom use. Examples of questions used to elicit information in these areas include, “What do you think are the good/bad things that could result from a person your age who drank alcohol?” or “Some people you know have opinions about whether you should drink alcohol. Who are some of the people who you
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care about?” The first 15 to 20 minutes of each group solicited specific feedback about attitudes and beliefs by using questions like those above, leaving the remaining time to introduce questions about sex, HIV/AIDS, and condom use. For example, 10 groups (5 female, 5 male) discussed the positive and negative aspects of using condoms in response to the question, “What do you think are the good/bad things that can result from a person your age who used condoms when having sex?” Ten groups (5 female, 5 male) discussed the positive and negative aspects of having sex, and whose opinions they care about on this topic. Three groups (2 female, 1 male) discussed the transmission of AIDS through using drugs. Thirteen groups (7 female, 6 male) explored in depth the process of how AIDS is transmitted. Eight groups (4 female, 4 male) discussed their understanding of the seriousness of HIV/AIDS. An example of a question in the script was: “Some students have commented that they don’t think AIDS is that serious. What do you think of that? Do you agree? Disagree? Why?” They then discussed factors related to making a decision to have unprotected sex using more structured scenarios. An example of one of these scenarios is: “Some people think they would never have unprotected sex. For this question, try to imagine that you might have unprotected sex. How would these following factors influence your decision whether to have unprotected sex with someone?” These factors included: “when a person. . . is cute or good looking,” “. . . is willing to have an AIDS test before having sex,” “. . .is willing to discuss their past sexual experiences with you,” “. . . you think has injected drugs.” During November and December 1994, four (out of six invited) high schools from an urban school district in the Pacific Northwest agreed to participate. The schools represented the diverse range of program options available to students in the public schools. One school housed the dropout reentry and teen pregnancy programs (school A), whereas another had an active on-campus CAPE (Coalition for AIDS Peer Education) group (school B). The remaining two schools housed regular high school programs, but in geographic locations representing different demographic characteristics (schools C and D). Consent materials for the parent or guardian were mailed to a student’s home address, and project staff followed up by phone to answer questions and encourage participation following the IRB-approved protocol. Students were contacted only after obtaining consent from the parent or guardian. See Table 1
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Table 1. Number and % of Students Consenting to Study Participation School
Number Number Number Number Number
of of of of of
consents sent home refusals undecided unable to locate consents returned
A
B
C
D
Overall n (%)
182 37 29 78 38
18 1 6 1 10
160 52 19 28 61
77 14 22 19 22
437 104 (24) 76 (17) 126 (29) 131 (30)
At School “A”, consent materials were mailed to all students currently enrolled. At school “B”, only those in the CAPE group were mailed consent materials. At School “C”, a 10% random sample of students who had listed telephone numbers was mailed consents. At School “D”, students in health classes were mailed consent materials.
for information related to the rate of consent at the four high schools. Consenting students in 9th through 12th grade were invited to participate in focus groups consisting of 3 to 8 students each. Of the 131 consenting students, 92 were able to participate in focus group discussions; there were no significant differences between those who participated in groups and those who did not participate. There were 21 9th graders, 20 10th graders, 27 11th graders, and 23 12th graders who participated; one student’s grade was not known. Students were grouped by grade level as a way to avoid too much variability in sexual experience levels. In several cases, however, logistics and student availability dictated mixed-grade groups. Groups were same-sex, with same-sex moderators and assistant moderators to increase comfort and openness in discussing sensitive topics. A total of 21 ethnically diverse focus groups were conducted; 10 of the groups were male and 11 female (see Table 2). Each group was led by a trained moderator, with an assistant moderator present to take detailed written notes using a structured comment form and to operate audio taping equipment. Moderators asked questions from a prepared script, using nondirective probes to elicit full responses. Each session began with a review of the student assent form, disclosure that the session was being audio taped, and getacquainted activities. Students received a $10 gift
certificate for participating. The groups lasted approximately 1 hour and covered three to five main topic areas. Owing to the extensive range of topic areas we hoped to cover, asking all of the questions of each of the 21 groups was not possible. Therefore, during the debriefing session after each group and before convening the next group, project staff would identify a specific area of focus for that group (e.g., sex and AIDS, alcohol and cigarettes) that could be explored as exhaustively as possible in the given time. All groups were asked questions about sex and HIV/AIDS, but varying amounts of time were devoted to these topics across the 21 groups conducted. Then, questions were asked until a topic area reached saturation and no new information was generated. When the saturation point was reached, moderators moved on to a different area of questioning.
Analysis Strategy Two methods of content analysis were used to identify common themes. The first method consisted of a detailed review of the structured assistant moderator notes taken for each group, whereby common themes were identified and grouped according to gender and grade level. The assistant moderator notes included detailed notation of the question
Table 2. Gender and Ethnicity of Participating Sample School A % % % % %
Female African-American European American Asian American Native American, Hispanic, and other a b
a
77 46 31 0 23
B
C
D
Overall %
70 20 60 10 10b
55 16 53 31 0
45 30 45 25 0
58 24 49 23 4
At school “A”, the percentage of females was higher owing to the teen pregnancy program. For one student, ethnicity was not known.
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posed by the moderator keyed to the questions in the script, key points of the comments from individuals in the group, and nonverbal behavior observed during the group. The second method, carried out independently by a second analyst, consisted of reviewing transcripts of the audiotapes recorded during each session. In this analysis, focus group questions first were arranged by subject area, followed by cutting and pasting responses to these questions from each of the group transcriptions. From the compiled responses under each question, emergent themes were extracted and frequency of responses tallied by group gender. A comparison of the two independent analyses showed almost identical identification of focus group themes and frequencies, providing evidence of reliability.
Results Results reported here are limited to data from the focus groups in response to questions about sex, HIV/AIDS transmission, and AIDS education. Results are organized into the major themes that emerged and illustrative phrases and quotes from focus group participants are provided. When appropriate, responses are presented separately by gender. Perceived Positive and Negative Outcomes of Sexual Activity and Reasons for Having Sex (Note in the following transcript sections in the text, R ⫽ respondent. Two or more quotation blocks in a row from respondents indicate that the quotations were from different respondents.) When asked to share their ideas about the reasons for, and outcomes of, having sex, students gave both positive and negative responses. Some teens reported having sex “because it feels good” and as a way to get closer in a relationship. Others mentioned “regretting it later” and “contracting diseases.” Perceived outcomes for boys. When asked to list positive outcomes of, or reasons for, having sex, boys in general tended to view the benefits of sex in terms of physical pleasure, conquest, achievement (“bragging rights”) and recognition. In terms of the negative outcomes of having sex, boys more frequently cited reasons with tangible outcomes attached than did girls, namely pregnancy and sexually transmitted diseases. Perceived outcomes for girls. For girls, the pluses and minuses of sexual activity mostly fell into the
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realm of emotional attachment, love, intimacy, and connection. Like their male counterparts, female focus group members frequently identified physical pleasure as among the positive aspects of sexual activity. More girls, however, cited sex as a symbol of love and a way of increasing closeness. For many of the female participants, sex was about “relationship”; ideally, it was seen as being a special moment. R
It can make you get closer in a way to the person. If you are going to stay with him for a long time. R Sometimes, if you’re with that person for a long time, and you feel, you really feel like you care about that person and that person cares about you, and you think you’re gonna be with him for a long time, I think that’s one of the positive reasons why people, you know, usually do sleep with each other. R Personally, I think that if you don’t care about the person, you know, really, or if there’s nothin’ between you guys an’ it’s just like in the heat of the moment type of thing, then I don’t think it’s good. R It’s a special thing. It’s not just an everyday thing.
Girls tended to feel that they take sex more personally than do boys and have a greater emotional investment in the interaction. Girls’ opinions about the negative aspects of being sexually active reflected a similar concern with the emotional ramifications. Like boys, they too cited diseases and pregnancy as negatives, but they also commented on the love aspect of physical intimacy. Reputation emerged as a concern among both boys and girls; however both perceived negative reputation as more of a concern for girls, commenting as well on the double standard that exists in terms of sexually active males and females. When asked about the negative aspects of having sex, several girls in the older groups commented that if they had it to do over, they would not have had sex until they were older. They said they try to tell younger girls not to fall into the same traps they did, but concluded by saying most people just “have to find out the hard way.” Commented one young woman: R
I’m one of those people who didn’t listen. And it’s like now, you know, I found out the hard way. I’m not saying that I got any disease or anything, but you know, I got pregnant and stuff. It’s just hard. Some people, especially like little kids in middle school, they don’t listen, they don’t know. And I see girls walking around here and hanging on guys and talking about sex and all this. It’s just not cute at all. They gonna learn one day, you know.
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Reasons for having sex. In exploring why young people decide to become sexually active, “peer pressure/because friends are” and “as a way to gain experience/part of growing up” were the main reasons given. Implicit within both is a kind of normative “keeping up with the Joneses” component to behavior that may be important to address in strategizing ways to approach teen health and sexuality education. Participants identified the influence of various forms of media as another source of pressure. They felt that television, in particular, communicated the message that everybody’s “doing it” and that having sex makes you “normal” as a teen. Decision-making About Protection and Salience of HIV Risk In general, the teens we talked with had accurate knowledge of what is and is not risky in terms of HIV sexual transmission. Students in all groups understood the concept of HIV transmission from semen and vaginal fluids exchanged during unprotected sexual activity, but this knowledge did not always carry over into their decision-making process. Several interesting sub-themes emerged when assessing teens’ knowledge of risk and the factors they consider when making personal decisions about unprotected sexual activity. Physical characteristics. Students acknowledged that even though you cannot tell by how someone looks if they have a disease, physical appearance, as in “looks” and/or “cleanliness” often carries a lot of weight in decision-making. In a closer look at the compiled responses, participants differed from each other on how attractiveness was interpreted. Some teens said that looks would sway them to have unprotected sex because “someone who is cute [or clean and neat] probably wouldn’t have AIDS,” or sway them not to because “someone who is cute has probably slept around a lot.” R
People don’t think when they have sex about other partners a person has had. You go on looks— he’s cute. I can feel he doesn’t have AIDS. He’s okay, if he looks good. R The proudest ones be the nastiest ones! R Yeah! R They’re the main ones! ⬘Cause the finer guys, you know that they get it quick ⬘cause all the girls are willing to give it up ⬘cause they look good. (female group)
Another group of girls picked up on this theme:
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R
I think people really judge on appearance, like if he’s cute. . . R . . .he doesn’t have AIDS. No way, not him. R And they go for it. You can have HIV and look really healthy, but people still have the mentality that if you have HIV, it’s like something you can see.
Several male groups provided their viewpoints on the issue of “looks” and unprotected sexual activity: R
Good-looking, in a way it would probably. . .it depends, it probably could decrease the risk [of disease], because they might, they MIGHT take better care of themselves than others. R Looks can be deceiving. I mean, their looks doesn’t tell you what’s under their skin. What they have, you know, in them.
Type of relationship/knowing your partner. In terms of engaging in unprotected sex, the type of relationship involved had a significant bearing on the decisions teens make, but often with contrary reasoning. When discussing “one night stands,” for example, some groups voiced the opinion that this type of unprotected sexual involvement would be safer than sex in an ongoing relationship because “you had sex only once, so you only had one chance to get a disease like AIDS.” Other groups thought “one night stands” would be more risky because “you probably would not know the person’s sexual history or background” and it would be more risky because “you can get AIDS the first time you sleep with somebody.” Teens of both sexes felt very strongly about more serious relationships and expressed a great need to have relationships based on love and trust. A number of groups, especially the female groups, held the view that friendship and love were key to building trust in a relationship. In addition, the time element of relationships plays a major role in helping teens to decide whether to become sexually intimate, because knowing someone over time means “you can trust what they’re saying” and know whether or not they are telling the truth. Again, however, divergence of opinion existed on this issue. A number of participants voiced their concern that just because you’ve been in a relationship over time doesn’t mean you can trust your girlfriend/boyfriend to tell you the truth. It doesn’t mean you know where they are at all times. It doesn’t mean that they even know if they have a disease.
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HIV testing. In discussions of unprotected sexual activity, teens consistently mentioned HIV blood tests as important to consider. Even so, they expressed a lack of confidence in their ability to tactfully and openly question a potential sexual partner about being tested. They also expressed concern that merely suggesting a blood test to one’s boyfriend/ girlfriend would imply a lack of trust. R
It would be absurd to ask someone that you were planning to sleep with and were involved in a relationship with. . .it would be absurd to say, ‘Well, shall we do the blood test thing?’ I mean, it’s just like saying, ‘I think you have a disease,’ and you don’t say that kind of thing. (male)
Although teens recognized the importance of HIV testing, some of their comments revealed a foggy understanding of how blood testing actually works. Opinions varied widely about the time delay between infection with HIV and antibodies showing up in a blood test. While commenting on the time factor, one group of girls also pointed out the scariness of getting tested and the latency of the virus. R
I’ve heard it can take even longer [than 3– 6 months.] R Yeah, I’ve heard that, too. R I guess it depends on your blood type, I dunno. R What scares me is that I may. . .I could have AIDS from someone I had sex with the first time. That’s one of the things that scared me when I went to go take an AIDS test is that, I was thinkin’ about the person I’m with now doesn’t have it, but what about somebody else down my line. They could’ve had it, you know? I was scared though.
Salience of AIDS risk. Comments throughout the focus group discussions revealed that some participants did not seriously consider themselves at risk of acquiring HIV. Though acknowledging the seriousness of AIDS, many believed the disease strikes when you get older. One 11th grade girl explained, “Like at this school people aren’t going to worry about getting AIDS because it’s high school and people don’t get AIDS in high school.” In part this belief stems from the assumption that many kids their age are only just becoming sexually active, making previous exposure to disease unlikely. Focus group teens also pointed out that because young people know most of the people they have sex with, as well as who the person’s previous sexual partners have been, risk of infection is greatly reduced. Many
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respondents commented on the tendency to depersonalize and deny risk at the individual level. One student commented about teens having a sense of destiny about AIDS. Not unlike being struck by lightning or hit by a car, if it is meant to happen to you, it will happen. Girls stated a perception that their male counterparts see themselves as invincible to the dangers of STDs, including HIV/AIDS, and don’t take potential risk seriously. Views on AIDS Education: At School and at Home Attitudes about school-based AIDS education varied from group to group. While acknowledging the seriousness of AIDS and other STDs, most teens voiced their boredom with hearing the same information presented from year to year with little variation. R
You hear it so many times, like there’s a limit in your head, where if you hear it too many times, you kind of begin to tune it out and then you don’t really listen any more. And you can be hearing different things, but it still sounds the same. (female) R I feel like I know possibly everything to know and maybe too much. I’ve just heard so much. . .we let it go in one ear and out the other. We might hear something the first time and then say okay and then forget it. (male)
Interestingly, despite this repetitiveness in health education (or perhaps because of it), most of the teens questioned could not explain sexually transmitted HIV. They knew it involved blood, semen and/or vaginal fluid, but only a very few discussed absorption through mucus membranes or cuts. Another gap in health education cited by focus groups was between knowing the information and understanding how to apply it. Teens readily acknowledged the importance of using condoms, for example, but many confessed to not knowing how to put them on. Other comments underscored the need for improved skills training and practice. Several young men used the example of paramedic training to explain how, even when one knows what he is supposed to do, he may forget everything he has been taught about risk-reduction when actually in a sexual situation. When asked how health and AIDS/STD prevention education could be improved, students enthusiastically recommended such alternatives as peer education, outside speakers, and more visual images. They discussed wanting more specific details about
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HIV/AIDS and sex; not the generalities they believe they have been getting. Many commented on making education more personal and more real: R
I think the way to get people to listen is to tell the personal stories. People seem to respond more to things that are personal, rather than facts. I mean, you get facts in school. A lot of people would. . .Like speakers that come in and talk—that affects me a lot more than just a teacher up there telling you this is this and this is this and this is how you get it and. . . (female)
Several groups mentioned wanting to know how to be intimate with a partner without “going all the way.” “Why don’t they teach us that?” queried one young woman. Another explained the absolute, black and white quality of the message: R
[I]f you’re talking about AIDS or sexually transmitted diseases, they say either you should have sex and make it protected, or practice abstinence. And most people consider abstinence not doing anything, and so they’ll be like, ‘No, I don’t want to do that.’ They don’t really make it clear that there’s other things that you could do instead of having [sexual intercourse].
Discussion and Implications Results from this study suggest that although high school youth are getting enough information regarding HIV/STD prevention, they seem to find it difficult to personalize and use this information to make individual decisions about their own sexual behavior. In practice, they use other criteria in their sexual decision-making, have different ideas about sex and sexuality based on gender, and don’t feel a sense of risk with regard to contracting HIV or AIDS. This implies a need for a different approach to education programs.
Sexual Decision-making Data from our focus groups suggest that young people use factors such as physical characteristics, trust, length of relationship, and how well they “know” their partner when making decisions about whether to engage in protected or unprotected sex; decisions which could elevate instead of reduce their risk for STDs and HIV. Similarly, Williams et al [18] found that college students used “implicit personality theory” in their sexual decision-making. Students
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in their sample based decisions about sexual activity on whether they knew and liked a person, even though these things were unrelated to whether or not this person was risky as a sexual partner. This finding is important because a common public health message for STD and HIV prevention is to “know” your partner. However, the results here suggest that “knowing” means different things to different people. Unless definitions are made explicit, teens may continue to make sexual decisions that base “knowing” their partner on personality characteristics and familiarity, but not STD or HIV status [18,19]. Paramount in any skill development must be equipping teens with the skills to make responsible decisions in the face of counteracting influences. As Bandura points out, the weaker one’s perceived self-efficacy, the more susceptible he or she is to influences that might lead to risky sexual behavior [20]. Kasen et al reported that 10th graders in their study lacked confidence in skills related to condom use, communication with potential sexual partners, and refusing intercourse [21]. Further, they found that lower skills levels translated into being more likely to have had unprotected intercourse. Ways to normalize talking about sexual history should be developed so that such a discussion becomes a natural and accepted step before two people enter into a sexual relationship. For example, communication skills could be part of a role play, script, or video presented in a high school health class or even in a drama class. The challenge for educators is to make safer sex something that everyone feels comfortable about discussing [22]. However, this is easier said than done, especially given that the development of sexuality education in the United States has been fraught with social, political, and religious barriers to presenting information in a comfortable manner. Historically, sexuality education is rooted in views of adolescent sexuality as either a moral or a medical problem [23,24]. Even the most recent impetus to universal sexuality education (i.e., the AIDS epidemic) addresses sexual behavior in the context of a health risk. Gender Differences Different themes emerged in the male and female groups that highlight the continued existence of cultural double standards for men and women. One approach to dismantling these inequities is to openly recognize the differences, as well as similarities, that exist for many adolescent males and females in
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attitude and motivation to be sexually active. Physical intimacy, for example, may be as much about physical pleasure for girls as it is for their male counterparts, yet cultural constructs continue to penalize girls for exploring their sexuality as openly. Structured, nonthreatening mixed-gender discussions would allow teens to confront misconceptions and stereotypes, while at the same time exploring honest differences in opinion and experience. In addition, teens could begin to examine the different qualities males and females bring to relationships, and that elements of pleasure and emotional investment are equally valid feelings for teens of either gender to experience. Finally, with confidence in one’s ability to refuse sexual activities [25], a broader understanding of attitude and motivation coupled with skills training could contribute significantly to teens’ feelings of control and self-efficacy when making choices about sex [26].
Salience of AIDS Risk Teens in this study reported they feel that AIDS is not something they need to worry about. Because the prevalence of HIV/AIDS is relatively low in most high schools and HIV infection is not visibly apparent, many teens do not find the risk of acquiring HIV salient.
Improved Education Young people have received a lot of information about sex and HIV/AIDS, but as made clear by focus group comments, this information may not necessarily factor into their decision-making. Teens here asked for information that they could find more practical and applicable to their lives. They expressed an interest in knowing more about alternate forms of intimacy in their relationships, rather than having to learn by experience or from unreliable sources. The consensus statement on adolescent sexual health developed by the 1994 National Commission on Adolescent Sexual Health further suggests that several topics should be addressed to provide adolescents with the skills needed to evaluate their readiness for mature sexual relationships. These include messages that address intimacy, sexual limit setting, benefits of abstinence from intercourse, pregnancy and STD prevention, and resisting social, media, peer, and partner pressure [27]. In addition to the individual themes reported above, several ideas cut across themes. Teens in our
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groups made it clear that information must be personalized to engage them. It must be real. Communication must be perceived as presented in an honest and open fashion. To be optimally effective, the message should convey practical applications to individual lives and social contexts. These conclusions are consistent with the research of others who underscore the importance of a realistic, personal, contextual approach [10,28 –30].
Limitations Several limitations exist in our focus group data, most notably in their lack of generalizability and failure to address the importance of cultural differences in teens’ beliefs and behaviors. Moderators and participants in each group were the same gender, so we do not know how mixed gender groups would have affected responses. Still, the data provide useful and cogent information from which to formulate ideas that can be tested using more traditional quantitative methods. Data from this study are not readily generalizable because they represent students in the public schools in one city in 1994 –95 and were limited to convenience samples with relatively low overall response rates. However, even with these limitations, there are a number of reasons to think the data provide valuable insights. Our sampling included a variety of the programs represented in the school district, including the main dropout program. In addition, the ethnic and gender mix of our sample closely mirrors that of the district, making a stronger case for their utility. The information from these focus groups may help those trying to develop more effective sexuality education and AIDS education programs by providing some insight into the thinking of teens and the kinds of information they use to make decisions related to sexual activity. Data from these focus groups revealed that teens are caught in a number of contradictions related to sexual decision-making and HIV/AIDS education. Addressing these contradictions and normalizing communication about sexual issues may encourage teens to engage in safer behavior and become sexually healthy adults.
Grant DA07047 from the National Institute on Drug Abuse funded this study. The authors wish to thank the staff of the Children’s Health Awareness Project and the Seattle School District for their assistance in collecting these data.
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15. Dailey DM. The failure of sexuality education: Meeting the challenge of behavioral change in a sex-positive context. Sexuality Education in Postsecondary and Professional Training Settings. J Psychol Human Sex 1997;9:87–97. 16. Kirby D. Understanding what works and what doesn’t in reducing adolescent sexual risk-taking. Fam Plann Perspect 2002;34:191–7. 17. Nahom D, Wells E, Gillmore MR, et al. Differences by gender and sexual experience in adolescent sexual behavior: Implications for education and HIV prevention. J Sch Health 2001;71: 153–8. 18. Williams SS, Kimble DL, Covell NH, et al. College students use implicit personality theory instead of safer sex. J Appl Soc Psychol 1992;22:921–33. 19. Stone N, Ingham R. Factors affecting British teenagers’ contraception use at first intercourse: The importance of partner communication. Perspect Sex Reprod Health 2002;34:191–7. 20. Bandura A. A social cognitive approach to the exercise of control over AIDS infection. In: DiClemente R (ed). Adolescents and AIDS: A Generation in Jeopardy. Newbury Park, CA: Sage Publications, 1992:89 –116. 21. Kasen S, Vaughan RD, Walter H.J. Self-efficacy for AIDS preventive behaviors among tenth grade students. Health Educ Q 1992;19:187–202. 22. Moore SM, Barling NR. Developmental status and AIDS attitudes in adolescence. J Genet Psychol 1991;152:5–16. 23. Arney WR, Bergen BJ. Power and visibility: The invention of teenage pregnancy. Soc Sci Med 1984;18:11–9. 24. Odem ME. Delinquent Daughters: Protecting and Policing Adolescent Female Sexuality in the United States, 1885–1920. Chapel Hill, NC: The University of North Carolina Press, 1995. 25. Hovell M, Blumberg E, Sipan C, et al. Skills training for pregnancy prevention and AIDS prevention in Anglo and Latino youth. J Adolesc Health 1998;23:139 –49. 26. Blinn-Pike L. Why abstinent adolescents report they have not had sex: Understanding sexually resilient youth. Fam Relat 1999;48:296 –300. 27. Haffner DW. Facing facts: Sexual health for American adolescents. J Adolesc Health 1998;22:453–9. 28. Hacker SS. AIDS education is sex education: Rural and urban challenges. J Soc Work Hum Sex 1989;8:155–70. 29. Hein K. “Getting real” about HIV in adolescents. Am J Public Health 1993;83:492–4. 30. Tanaka G, Warren J, Tritsch L. What’s real in health education. J Health Educ 1993;(Suppl):6 –9.
ORIGINAL ARTICLE
Teens Speak Out About HIV/AIDS: Focus Group Discussions about Risk and Decision-Making MARILYN J. HOPPE, Ph.D., LAURIE GRAHAM, M.S.W., ANTHONY WILSDON, M.S., ELIZABETH A. WELLS, Ph.D., DEBORAH NAHOM, M.S., M.S.W., AND DIANE M. MORRISON, Ph.D.
Purpose: To better understand the factors teens consider when making decisions regarding sex and condom use. Methods: Twenty-one same-sex focus groups were conducted with a total of 92 male and female teens from a range of high school programs; schools were selected based on the range of programs and diversity of students enrolled. Focus group moderators facilitated groups using a set of open-ended key questions about sexual decision-making and HIV/AIDS for each group; discussion on a specific topic area continued until no new information was generated. Group discussions were tape-recorded and transcribed, and themes were identified through independent content analysis of the transcriptions and assistant moderator notes. Results: Although teens acquire HIV/AIDS knowledge in school and are aware of positive and negative outcomes of engaging in sexual behavior, many times the information does not seem salient or personally relevant and thus is not used in making decisions related to having sex. In general, results indicate that boys and girls seem to have different ideas/reasons for having or not having sex. Boys relate to the physical nature of sex, whereas girls relate to the emotional aspects. Teens report being bored with AIDS education, but suggest needing information that is more relevant for them. Conclusions: Attempts should be made to make HIV education more relevant for teens so that they use the information they have when making decisions about
From the University of Washington, Seattle, Washington This paper was presented at the 67th annual meeting of the Pacific Sociological Association in Seattle, WA, March 1996. Address correspondence to: Dr. Marilyn J. Hoppe, University of Washington, 927 N. Northlake Way, Suite 210, Seattle, Washington, 98103-8871. E-mail: [email protected] Manuscript accepted December 1, 2003. © Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
safer sexual behavior. Different approaches may be needed for boys and girls. © Society for Adolescent Medicine, 2004 KEY WORDS:
Adolescents HIV/AIDS education Focus groups Teens
Although trends indicate a decrease in the prevalence of adolescent sexual experience during the last decade, data from the Youth Risk Behavior Survey in 2001 found that about 41% of teenagers have had sexual intercourse by the age of 16 years and 61% by the age of 18 years [1]. Among sexually active young people, many do not consistently protect themselves from pregnancy and even fewer protect themselves from disease [2]. Self-reported condom use at 9th grade in 2001 was about 68%, but declines to about 50% by 12th grade as other methods of birth control increase [1]. Compared with adults, adolescents are at higher risk for acquiring sexually transmitted diseases (STDs) because they have multiple and potentially riskier partners and do not use condoms consistently [3]. With close to two-thirds of all STDs occurring among young people under 25 years old [4] and rates remaining higher among teenagers than any other age group [5], HIV poses an important health risk in this age group. Some estimates indicate that at least 50% of the new HIV infections in the United States are in people under the age of 25 years [6]. In the case of teens, HIV/AIDS education has 1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2003.12.002
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focused on preventing sexual transmission of HIV because that is the primary mode of transmission among young adults and teens [7,8]. Many studies have looked at knowledge related to HIV/AIDS and whether or not increased knowledge translates to safer sexual behavior [9 –13]. Although desirable, interventions that increase knowledge alone have not proven effective in changing behavior, nor have they helped teens to integrate factual knowledge with their personal sexual choices and sexuality in relationship to their family and community values [14]. In addition to increasing knowledge, interventions that produce positive changes in behavior typically include a strong grounding in theory, experiential activities that allow participants to personalize information, a strong focus on social influences and pressure, reinforcement of norms and values against unprotected sex, and skills and confidence-enhancing activities [15,16]. To develop effective interventions, information is needed about the social context in which teen sexual decisions are made. In a 1992 review of AIDS risk reduction interventions, Fisher and Fisher concluded that interventions for adolescents too often relied on informal information and were not based on elicitation interviews to determine true adolescent needs [9]. To address this lack of information from teens, focus groups were conducted in which teens were asked about what they know about risky sexual behavior and what factors they consider when deciding to have both protected and unprotected sex.
Focus Group Methods This article reports information collected from structured focus groups conducted with students in grades 9 through 12. The questions used for these focus groups had a dual purpose: eliciting information to be used to aid in updating measurement tools for the 4th year of a 7-year longitudinal study with a separate sample of adolescents described elsewhere [17], and exploring topics related to sexual decisionmaking, sexual transmission of HIV/AIDS, and AIDS education. Focus group discussion topics included student beliefs and attitudes about tobacco, alcohol, substance use, HIV/AIDS, sex, and condom use. Examples of questions used to elicit information in these areas include, “What do you think are the good/bad things that could result from a person your age who drank alcohol?” or “Some people you know have opinions about whether you should drink alcohol. Who are some of the people who you
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care about?” The first 15 to 20 minutes of each group solicited specific feedback about attitudes and beliefs by using questions like those above, leaving the remaining time to introduce questions about sex, HIV/AIDS, and condom use. For example, 10 groups (5 female, 5 male) discussed the positive and negative aspects of using condoms in response to the question, “What do you think are the good/bad things that can result from a person your age who used condoms when having sex?” Ten groups (5 female, 5 male) discussed the positive and negative aspects of having sex, and whose opinions they care about on this topic. Three groups (2 female, 1 male) discussed the transmission of AIDS through using drugs. Thirteen groups (7 female, 6 male) explored in depth the process of how AIDS is transmitted. Eight groups (4 female, 4 male) discussed their understanding of the seriousness of HIV/AIDS. An example of a question in the script was: “Some students have commented that they don’t think AIDS is that serious. What do you think of that? Do you agree? Disagree? Why?” They then discussed factors related to making a decision to have unprotected sex using more structured scenarios. An example of one of these scenarios is: “Some people think they would never have unprotected sex. For this question, try to imagine that you might have unprotected sex. How would these following factors influence your decision whether to have unprotected sex with someone?” These factors included: “when a person. . . is cute or good looking,” “. . . is willing to have an AIDS test before having sex,” “. . .is willing to discuss their past sexual experiences with you,” “. . . you think has injected drugs.” During November and December 1994, four (out of six invited) high schools from an urban school district in the Pacific Northwest agreed to participate. The schools represented the diverse range of program options available to students in the public schools. One school housed the dropout reentry and teen pregnancy programs (school A), whereas another had an active on-campus CAPE (Coalition for AIDS Peer Education) group (school B). The remaining two schools housed regular high school programs, but in geographic locations representing different demographic characteristics (schools C and D). Consent materials for the parent or guardian were mailed to a student’s home address, and project staff followed up by phone to answer questions and encourage participation following the IRB-approved protocol. Students were contacted only after obtaining consent from the parent or guardian. See Table 1
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Table 1. Number and % of Students Consenting to Study Participation School
Number Number Number Number Number
of of of of of
consents sent home refusals undecided unable to locate consents returned
A
B
C
D
Overall n (%)
182 37 29 78 38
18 1 6 1 10
160 52 19 28 61
77 14 22 19 22
437 104 (24) 76 (17) 126 (29) 131 (30)
At School “A”, consent materials were mailed to all students currently enrolled. At school “B”, only those in the CAPE group were mailed consent materials. At School “C”, a 10% random sample of students who had listed telephone numbers was mailed consents. At School “D”, students in health classes were mailed consent materials.
for information related to the rate of consent at the four high schools. Consenting students in 9th through 12th grade were invited to participate in focus groups consisting of 3 to 8 students each. Of the 131 consenting students, 92 were able to participate in focus group discussions; there were no significant differences between those who participated in groups and those who did not participate. There were 21 9th graders, 20 10th graders, 27 11th graders, and 23 12th graders who participated; one student’s grade was not known. Students were grouped by grade level as a way to avoid too much variability in sexual experience levels. In several cases, however, logistics and student availability dictated mixed-grade groups. Groups were same-sex, with same-sex moderators and assistant moderators to increase comfort and openness in discussing sensitive topics. A total of 21 ethnically diverse focus groups were conducted; 10 of the groups were male and 11 female (see Table 2). Each group was led by a trained moderator, with an assistant moderator present to take detailed written notes using a structured comment form and to operate audio taping equipment. Moderators asked questions from a prepared script, using nondirective probes to elicit full responses. Each session began with a review of the student assent form, disclosure that the session was being audio taped, and getacquainted activities. Students received a $10 gift
certificate for participating. The groups lasted approximately 1 hour and covered three to five main topic areas. Owing to the extensive range of topic areas we hoped to cover, asking all of the questions of each of the 21 groups was not possible. Therefore, during the debriefing session after each group and before convening the next group, project staff would identify a specific area of focus for that group (e.g., sex and AIDS, alcohol and cigarettes) that could be explored as exhaustively as possible in the given time. All groups were asked questions about sex and HIV/AIDS, but varying amounts of time were devoted to these topics across the 21 groups conducted. Then, questions were asked until a topic area reached saturation and no new information was generated. When the saturation point was reached, moderators moved on to a different area of questioning.
Analysis Strategy Two methods of content analysis were used to identify common themes. The first method consisted of a detailed review of the structured assistant moderator notes taken for each group, whereby common themes were identified and grouped according to gender and grade level. The assistant moderator notes included detailed notation of the question
Table 2. Gender and Ethnicity of Participating Sample School A % % % % %
Female African-American European American Asian American Native American, Hispanic, and other a b
a
77 46 31 0 23
B
C
D
Overall %
70 20 60 10 10b
55 16 53 31 0
45 30 45 25 0
58 24 49 23 4
At school “A”, the percentage of females was higher owing to the teen pregnancy program. For one student, ethnicity was not known.
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posed by the moderator keyed to the questions in the script, key points of the comments from individuals in the group, and nonverbal behavior observed during the group. The second method, carried out independently by a second analyst, consisted of reviewing transcripts of the audiotapes recorded during each session. In this analysis, focus group questions first were arranged by subject area, followed by cutting and pasting responses to these questions from each of the group transcriptions. From the compiled responses under each question, emergent themes were extracted and frequency of responses tallied by group gender. A comparison of the two independent analyses showed almost identical identification of focus group themes and frequencies, providing evidence of reliability.
Results Results reported here are limited to data from the focus groups in response to questions about sex, HIV/AIDS transmission, and AIDS education. Results are organized into the major themes that emerged and illustrative phrases and quotes from focus group participants are provided. When appropriate, responses are presented separately by gender. Perceived Positive and Negative Outcomes of Sexual Activity and Reasons for Having Sex (Note in the following transcript sections in the text, R ⫽ respondent. Two or more quotation blocks in a row from respondents indicate that the quotations were from different respondents.) When asked to share their ideas about the reasons for, and outcomes of, having sex, students gave both positive and negative responses. Some teens reported having sex “because it feels good” and as a way to get closer in a relationship. Others mentioned “regretting it later” and “contracting diseases.” Perceived outcomes for boys. When asked to list positive outcomes of, or reasons for, having sex, boys in general tended to view the benefits of sex in terms of physical pleasure, conquest, achievement (“bragging rights”) and recognition. In terms of the negative outcomes of having sex, boys more frequently cited reasons with tangible outcomes attached than did girls, namely pregnancy and sexually transmitted diseases. Perceived outcomes for girls. For girls, the pluses and minuses of sexual activity mostly fell into the
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realm of emotional attachment, love, intimacy, and connection. Like their male counterparts, female focus group members frequently identified physical pleasure as among the positive aspects of sexual activity. More girls, however, cited sex as a symbol of love and a way of increasing closeness. For many of the female participants, sex was about “relationship”; ideally, it was seen as being a special moment. R
It can make you get closer in a way to the person. If you are going to stay with him for a long time. R Sometimes, if you’re with that person for a long time, and you feel, you really feel like you care about that person and that person cares about you, and you think you’re gonna be with him for a long time, I think that’s one of the positive reasons why people, you know, usually do sleep with each other. R Personally, I think that if you don’t care about the person, you know, really, or if there’s nothin’ between you guys an’ it’s just like in the heat of the moment type of thing, then I don’t think it’s good. R It’s a special thing. It’s not just an everyday thing.
Girls tended to feel that they take sex more personally than do boys and have a greater emotional investment in the interaction. Girls’ opinions about the negative aspects of being sexually active reflected a similar concern with the emotional ramifications. Like boys, they too cited diseases and pregnancy as negatives, but they also commented on the love aspect of physical intimacy. Reputation emerged as a concern among both boys and girls; however both perceived negative reputation as more of a concern for girls, commenting as well on the double standard that exists in terms of sexually active males and females. When asked about the negative aspects of having sex, several girls in the older groups commented that if they had it to do over, they would not have had sex until they were older. They said they try to tell younger girls not to fall into the same traps they did, but concluded by saying most people just “have to find out the hard way.” Commented one young woman: R
I’m one of those people who didn’t listen. And it’s like now, you know, I found out the hard way. I’m not saying that I got any disease or anything, but you know, I got pregnant and stuff. It’s just hard. Some people, especially like little kids in middle school, they don’t listen, they don’t know. And I see girls walking around here and hanging on guys and talking about sex and all this. It’s just not cute at all. They gonna learn one day, you know.
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Reasons for having sex. In exploring why young people decide to become sexually active, “peer pressure/because friends are” and “as a way to gain experience/part of growing up” were the main reasons given. Implicit within both is a kind of normative “keeping up with the Joneses” component to behavior that may be important to address in strategizing ways to approach teen health and sexuality education. Participants identified the influence of various forms of media as another source of pressure. They felt that television, in particular, communicated the message that everybody’s “doing it” and that having sex makes you “normal” as a teen. Decision-making About Protection and Salience of HIV Risk In general, the teens we talked with had accurate knowledge of what is and is not risky in terms of HIV sexual transmission. Students in all groups understood the concept of HIV transmission from semen and vaginal fluids exchanged during unprotected sexual activity, but this knowledge did not always carry over into their decision-making process. Several interesting sub-themes emerged when assessing teens’ knowledge of risk and the factors they consider when making personal decisions about unprotected sexual activity. Physical characteristics. Students acknowledged that even though you cannot tell by how someone looks if they have a disease, physical appearance, as in “looks” and/or “cleanliness” often carries a lot of weight in decision-making. In a closer look at the compiled responses, participants differed from each other on how attractiveness was interpreted. Some teens said that looks would sway them to have unprotected sex because “someone who is cute [or clean and neat] probably wouldn’t have AIDS,” or sway them not to because “someone who is cute has probably slept around a lot.” R
People don’t think when they have sex about other partners a person has had. You go on looks— he’s cute. I can feel he doesn’t have AIDS. He’s okay, if he looks good. R The proudest ones be the nastiest ones! R Yeah! R They’re the main ones! ⬘Cause the finer guys, you know that they get it quick ⬘cause all the girls are willing to give it up ⬘cause they look good. (female group)
Another group of girls picked up on this theme:
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R
I think people really judge on appearance, like if he’s cute. . . R . . .he doesn’t have AIDS. No way, not him. R And they go for it. You can have HIV and look really healthy, but people still have the mentality that if you have HIV, it’s like something you can see.
Several male groups provided their viewpoints on the issue of “looks” and unprotected sexual activity: R
Good-looking, in a way it would probably. . .it depends, it probably could decrease the risk [of disease], because they might, they MIGHT take better care of themselves than others. R Looks can be deceiving. I mean, their looks doesn’t tell you what’s under their skin. What they have, you know, in them.
Type of relationship/knowing your partner. In terms of engaging in unprotected sex, the type of relationship involved had a significant bearing on the decisions teens make, but often with contrary reasoning. When discussing “one night stands,” for example, some groups voiced the opinion that this type of unprotected sexual involvement would be safer than sex in an ongoing relationship because “you had sex only once, so you only had one chance to get a disease like AIDS.” Other groups thought “one night stands” would be more risky because “you probably would not know the person’s sexual history or background” and it would be more risky because “you can get AIDS the first time you sleep with somebody.” Teens of both sexes felt very strongly about more serious relationships and expressed a great need to have relationships based on love and trust. A number of groups, especially the female groups, held the view that friendship and love were key to building trust in a relationship. In addition, the time element of relationships plays a major role in helping teens to decide whether to become sexually intimate, because knowing someone over time means “you can trust what they’re saying” and know whether or not they are telling the truth. Again, however, divergence of opinion existed on this issue. A number of participants voiced their concern that just because you’ve been in a relationship over time doesn’t mean you can trust your girlfriend/boyfriend to tell you the truth. It doesn’t mean you know where they are at all times. It doesn’t mean that they even know if they have a disease.
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HIV testing. In discussions of unprotected sexual activity, teens consistently mentioned HIV blood tests as important to consider. Even so, they expressed a lack of confidence in their ability to tactfully and openly question a potential sexual partner about being tested. They also expressed concern that merely suggesting a blood test to one’s boyfriend/ girlfriend would imply a lack of trust. R
It would be absurd to ask someone that you were planning to sleep with and were involved in a relationship with. . .it would be absurd to say, ‘Well, shall we do the blood test thing?’ I mean, it’s just like saying, ‘I think you have a disease,’ and you don’t say that kind of thing. (male)
Although teens recognized the importance of HIV testing, some of their comments revealed a foggy understanding of how blood testing actually works. Opinions varied widely about the time delay between infection with HIV and antibodies showing up in a blood test. While commenting on the time factor, one group of girls also pointed out the scariness of getting tested and the latency of the virus. R
I’ve heard it can take even longer [than 3– 6 months.] R Yeah, I’ve heard that, too. R I guess it depends on your blood type, I dunno. R What scares me is that I may. . .I could have AIDS from someone I had sex with the first time. That’s one of the things that scared me when I went to go take an AIDS test is that, I was thinkin’ about the person I’m with now doesn’t have it, but what about somebody else down my line. They could’ve had it, you know? I was scared though.
Salience of AIDS risk. Comments throughout the focus group discussions revealed that some participants did not seriously consider themselves at risk of acquiring HIV. Though acknowledging the seriousness of AIDS, many believed the disease strikes when you get older. One 11th grade girl explained, “Like at this school people aren’t going to worry about getting AIDS because it’s high school and people don’t get AIDS in high school.” In part this belief stems from the assumption that many kids their age are only just becoming sexually active, making previous exposure to disease unlikely. Focus group teens also pointed out that because young people know most of the people they have sex with, as well as who the person’s previous sexual partners have been, risk of infection is greatly reduced. Many
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respondents commented on the tendency to depersonalize and deny risk at the individual level. One student commented about teens having a sense of destiny about AIDS. Not unlike being struck by lightning or hit by a car, if it is meant to happen to you, it will happen. Girls stated a perception that their male counterparts see themselves as invincible to the dangers of STDs, including HIV/AIDS, and don’t take potential risk seriously. Views on AIDS Education: At School and at Home Attitudes about school-based AIDS education varied from group to group. While acknowledging the seriousness of AIDS and other STDs, most teens voiced their boredom with hearing the same information presented from year to year with little variation. R
You hear it so many times, like there’s a limit in your head, where if you hear it too many times, you kind of begin to tune it out and then you don’t really listen any more. And you can be hearing different things, but it still sounds the same. (female) R I feel like I know possibly everything to know and maybe too much. I’ve just heard so much. . .we let it go in one ear and out the other. We might hear something the first time and then say okay and then forget it. (male)
Interestingly, despite this repetitiveness in health education (or perhaps because of it), most of the teens questioned could not explain sexually transmitted HIV. They knew it involved blood, semen and/or vaginal fluid, but only a very few discussed absorption through mucus membranes or cuts. Another gap in health education cited by focus groups was between knowing the information and understanding how to apply it. Teens readily acknowledged the importance of using condoms, for example, but many confessed to not knowing how to put them on. Other comments underscored the need for improved skills training and practice. Several young men used the example of paramedic training to explain how, even when one knows what he is supposed to do, he may forget everything he has been taught about risk-reduction when actually in a sexual situation. When asked how health and AIDS/STD prevention education could be improved, students enthusiastically recommended such alternatives as peer education, outside speakers, and more visual images. They discussed wanting more specific details about
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HIV/AIDS and sex; not the generalities they believe they have been getting. Many commented on making education more personal and more real: R
I think the way to get people to listen is to tell the personal stories. People seem to respond more to things that are personal, rather than facts. I mean, you get facts in school. A lot of people would. . .Like speakers that come in and talk—that affects me a lot more than just a teacher up there telling you this is this and this is this and this is how you get it and. . . (female)
Several groups mentioned wanting to know how to be intimate with a partner without “going all the way.” “Why don’t they teach us that?” queried one young woman. Another explained the absolute, black and white quality of the message: R
[I]f you’re talking about AIDS or sexually transmitted diseases, they say either you should have sex and make it protected, or practice abstinence. And most people consider abstinence not doing anything, and so they’ll be like, ‘No, I don’t want to do that.’ They don’t really make it clear that there’s other things that you could do instead of having [sexual intercourse].
Discussion and Implications Results from this study suggest that although high school youth are getting enough information regarding HIV/STD prevention, they seem to find it difficult to personalize and use this information to make individual decisions about their own sexual behavior. In practice, they use other criteria in their sexual decision-making, have different ideas about sex and sexuality based on gender, and don’t feel a sense of risk with regard to contracting HIV or AIDS. This implies a need for a different approach to education programs.
Sexual Decision-making Data from our focus groups suggest that young people use factors such as physical characteristics, trust, length of relationship, and how well they “know” their partner when making decisions about whether to engage in protected or unprotected sex; decisions which could elevate instead of reduce their risk for STDs and HIV. Similarly, Williams et al [18] found that college students used “implicit personality theory” in their sexual decision-making. Students
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in their sample based decisions about sexual activity on whether they knew and liked a person, even though these things were unrelated to whether or not this person was risky as a sexual partner. This finding is important because a common public health message for STD and HIV prevention is to “know” your partner. However, the results here suggest that “knowing” means different things to different people. Unless definitions are made explicit, teens may continue to make sexual decisions that base “knowing” their partner on personality characteristics and familiarity, but not STD or HIV status [18,19]. Paramount in any skill development must be equipping teens with the skills to make responsible decisions in the face of counteracting influences. As Bandura points out, the weaker one’s perceived self-efficacy, the more susceptible he or she is to influences that might lead to risky sexual behavior [20]. Kasen et al reported that 10th graders in their study lacked confidence in skills related to condom use, communication with potential sexual partners, and refusing intercourse [21]. Further, they found that lower skills levels translated into being more likely to have had unprotected intercourse. Ways to normalize talking about sexual history should be developed so that such a discussion becomes a natural and accepted step before two people enter into a sexual relationship. For example, communication skills could be part of a role play, script, or video presented in a high school health class or even in a drama class. The challenge for educators is to make safer sex something that everyone feels comfortable about discussing [22]. However, this is easier said than done, especially given that the development of sexuality education in the United States has been fraught with social, political, and religious barriers to presenting information in a comfortable manner. Historically, sexuality education is rooted in views of adolescent sexuality as either a moral or a medical problem [23,24]. Even the most recent impetus to universal sexuality education (i.e., the AIDS epidemic) addresses sexual behavior in the context of a health risk. Gender Differences Different themes emerged in the male and female groups that highlight the continued existence of cultural double standards for men and women. One approach to dismantling these inequities is to openly recognize the differences, as well as similarities, that exist for many adolescent males and females in
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attitude and motivation to be sexually active. Physical intimacy, for example, may be as much about physical pleasure for girls as it is for their male counterparts, yet cultural constructs continue to penalize girls for exploring their sexuality as openly. Structured, nonthreatening mixed-gender discussions would allow teens to confront misconceptions and stereotypes, while at the same time exploring honest differences in opinion and experience. In addition, teens could begin to examine the different qualities males and females bring to relationships, and that elements of pleasure and emotional investment are equally valid feelings for teens of either gender to experience. Finally, with confidence in one’s ability to refuse sexual activities [25], a broader understanding of attitude and motivation coupled with skills training could contribute significantly to teens’ feelings of control and self-efficacy when making choices about sex [26].
Salience of AIDS Risk Teens in this study reported they feel that AIDS is not something they need to worry about. Because the prevalence of HIV/AIDS is relatively low in most high schools and HIV infection is not visibly apparent, many teens do not find the risk of acquiring HIV salient.
Improved Education Young people have received a lot of information about sex and HIV/AIDS, but as made clear by focus group comments, this information may not necessarily factor into their decision-making. Teens here asked for information that they could find more practical and applicable to their lives. They expressed an interest in knowing more about alternate forms of intimacy in their relationships, rather than having to learn by experience or from unreliable sources. The consensus statement on adolescent sexual health developed by the 1994 National Commission on Adolescent Sexual Health further suggests that several topics should be addressed to provide adolescents with the skills needed to evaluate their readiness for mature sexual relationships. These include messages that address intimacy, sexual limit setting, benefits of abstinence from intercourse, pregnancy and STD prevention, and resisting social, media, peer, and partner pressure [27]. In addition to the individual themes reported above, several ideas cut across themes. Teens in our
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groups made it clear that information must be personalized to engage them. It must be real. Communication must be perceived as presented in an honest and open fashion. To be optimally effective, the message should convey practical applications to individual lives and social contexts. These conclusions are consistent with the research of others who underscore the importance of a realistic, personal, contextual approach [10,28 –30].
Limitations Several limitations exist in our focus group data, most notably in their lack of generalizability and failure to address the importance of cultural differences in teens’ beliefs and behaviors. Moderators and participants in each group were the same gender, so we do not know how mixed gender groups would have affected responses. Still, the data provide useful and cogent information from which to formulate ideas that can be tested using more traditional quantitative methods. Data from this study are not readily generalizable because they represent students in the public schools in one city in 1994 –95 and were limited to convenience samples with relatively low overall response rates. However, even with these limitations, there are a number of reasons to think the data provide valuable insights. Our sampling included a variety of the programs represented in the school district, including the main dropout program. In addition, the ethnic and gender mix of our sample closely mirrors that of the district, making a stronger case for their utility. The information from these focus groups may help those trying to develop more effective sexuality education and AIDS education programs by providing some insight into the thinking of teens and the kinds of information they use to make decisions related to sexual activity. Data from these focus groups revealed that teens are caught in a number of contradictions related to sexual decision-making and HIV/AIDS education. Addressing these contradictions and normalizing communication about sexual issues may encourage teens to engage in safer behavior and become sexually healthy adults.
Grant DA07047 from the National Institute on Drug Abuse funded this study. The authors wish to thank the staff of the Children’s Health Awareness Project and the Seattle School District for their assistance in collecting these data.
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