Moderation and Mediation of HIV-Prevention Interventions: Relationship Status, Intentions, and...

Moderation and Mediation of HIV-Prevention

and Condom Use Among College Students' Interventions : Relationship Stat us, In tent ions,

CATHERINE A. sANDERSON2 AND JOHN B. JEMMOTT, 111 Princeton University

This study examined the effects of 2 HIV prevention interventions on condom use and mediators of condom use. College students were randomly assigned to a control condition or an intervention (communication skills or technical skills). Those who received either intervention had greater condom use self-efficacy, more positive condom use attitudes, and stronger intentions to use condoms than did controls. Furthermore, 3-month follow-up data revealed that students in either intervention who were not in a steady dating relationship reported more consistent condom use than did those in the control condition, whereas students who were in either intervention and in a relationship reported somewhat less consistent condom use than did those in the control condition. Analyses suggested that effects of the interventions on condom use were mediated by increased intentions to use condoms.

AIDS has been diagnosed in over 500,000 Americans as of June 1996 (Centers for Disease Control and Prevention [CDC], 1996), and estimates suggest that close to 1 million Americans have been infected with HIV (Karon, Rosenberg, McQuillan, Khare, Gwinn, & Petersen, 1996), which causes AIDS. Although in the U.S. the AIDS epidemic has most severely affected men who have sex with men, the potential for HIV infection in other sexually active populations is becoming increasingly clear: Statistics on new AIDS cases and AIDS-opportunistic infections suggest that heterosexual transmission now accounts for much of the dynamic growth in the AIDS epidemic (CDC, 1996).

'This research was supported by NIMH Grant R01 MH45668 to John B. Jemmott, 111, and a National Science Foundation Graduate Fellowship to Catherine A. Sanderson. Portions of this research were reported at the 1995 annual meeting of the American Psychological Association, New York, NY. We thank Pamela Bowen, Karen Gordon, and the SECH advisors at McCosh Health Center at Princeton University for their assistance with implementing the interventions, and two anonymous reviewers for their very helpful suggestions.

'Correspondence concerning this article should be addressed to Catherine A. Sanderson, Department of Psychology, Green Hall, Princeton University, Princeton, NJ 08544-1 010.

Journal of Applied Social Psychology, 1996, 26, 23, pp. 2076-2099. Copyright 0 1996 by V. H. Winston 8. Son, Inc. All rights reserved.

RELATIONSHIP STATUS MODERATES CONDOM USE 2077

The risk of sexual transmission of HIV extends to college students for a variety of reasons. In a campus environment, students encounter new inde- pendence, self-determination, and strong peer pressure to adopt unhealthful behaviors. Most college students are sexually active, and many engage in sexual activity with multiple sexual partners in a serial-monogamy pattern ( e g , Caron, Davis, Halteman, & Stickle, 1993; Goodwin & Roscoe, 1988; Reinisch, Sanders, Hill, & Ziemba-Davis, 1992). In addition, many students have sex while under the influence of alcohol or other drugs-circumstances that increase the likelihood of HIV-risk-associated behavior, including the failure to use condoms (Bowen & Michal-Johnson, 1995; Harlow, Quina, Morokoff, Rose, & Grimley, 1993; Wechsler, Davenport, Dowdall, Moeykens, & Castillo, 1994; see also Fisher & Misovich, 1990; Leigh & Stall, 1993). Given these campus behavioral norms, it is not surprising that there are high rates of sexually transmitted diseases (STDs) among young adults in general and college students in particular. For example, the results of the CDC’s seroprevalence study on 19 college campuses indicated an HIV seroprevalence rate of 0.2% (Gayle et al., 1990), and rates of other STDs such as chlamydia and gonorrhea are considerably more prevalent in the college population (Shulkin et al., 1991). Although college students are clearly at risk of acquiring an STD and HIV, motivating students to change their sexual behavior is a difficult task because young adults often believe they are generally invulner- able (Elkind, 1980; Weinstein, 1984) and impervious to HIV infection. In fact, surveys of sexually active high school and college students show little evidence of reductions in HIV-risk-associated sexual behavior (DiClemente, Forrest, Mickler, & Principal Site Investigators, 1990; McDonald et al., 1990).

Despite college students’ risk of sexually transmitted HIV infection, scant research has focused on the identification of effective ways to reduce their HIV-risk-associated sexual behavior. The few published intervention studies targeting college students have tested interventions that only provided participants with information (cf. DiClemente et al., 1989; Dommeyer, Marquard, Gibson, & Taylor, 1989; Gilliam & Seltzer, 1989; Rhodes & Wolitski, 1989)- a strategy likely to be ineffective with college students who typically have high levels of knowledge regarding HIV transmission but who still engage in HIV-risk-associated sexual behavior. Moreover, almost all HIV-risk-reduction intervention studies with college students are limited by a reliance on the assessment of immediate changes in attitudes and knowledge (e.g., Abramson, Sekler, Berk, & Cloud, 1989; Dommeyer et al., 1989), a very brief (6-week) behavioral assessment follow-up period (e.g., Gilliam & Seltzer, 1989; Hernandez & Smith, 1990), or a failure to assess changes in sexual behavior (e.g., Franzini, Sideman, Dexter, & Elder, 1990; Rhodes & Wolitski, 1989; see Fisher, Fisher, Misovich, Kimble, & Malloy, 1996, for an exception).

2078 SANDERSON AND JEMMOTT

Components of Self-Efficacy for Condom Use

The intervention approach used in the present research draws upon social cognitive theory (Bandura, 1986, 1989, 1991; O’Leary, 1985) and the theory of planned behavior (Ajzen, 1985, 199 1 ; Madden, Ellen, & Ajzen, 1992), and particularly the construct of perceived self-efficacy or perceived behavioral control. Perceived self-efficacy, namely the perceived ease or difficulty of performing a specific behavior, is an important factor in changing HIV-risk- associated behavior (cf. Fisher & Fisher, 1992; Goldman & Harlow, 1993; Jemmott, Jemmott, Spears, Hewitt, & Cruz-Collins, 1992; Maibach & Flora, 1993). Interventions incorporating procedures that should enhance perceived self-efficacy by increasing behavioral skills have had positive effects on adolescents’ use of contraceptives (Schinke, Gilchrist, & Small, 1979), Black male adolescents’ HIV-risk-associated sexual behavior (Jemmott, Jemmott, & Fong, 1992), Black female adolescents’ intentions to use condoms (Jemmott & Jemmott, 1992; Jemmott, Jemmott, Spears, et al., 1992), and homosexual men’s condom use during anal intercourse (Kelly et al., 1989; Valdiserri, Arena, Procter, & Bonati, 1989).

Although overall perceived self-efficacy has been found to be important in decreasing HIV-risk-associated behavior, in this research we were primarily interested in the diverse aspects of self-efficacy and the implication that interventions can focus on its different components. For example, a distinction can be drawn between communication or negotiation skills self-efficacy- people’s belief that they can persuade a sexual partner that condoms should be used, and technical skills self-efficacy-people’s belief that they can use condoms correctly and easily without ruining the mood (Jemmott, Jemmott, & Hacker, 1992; Jemmott & Jones, 1993). These two types of self-efficacy beliefs imply different types of intervention training. Training to increase communication skills self-efficacy, for example, might include exercises to develop effective responses to resist partner pressure to engage in unsafe sexual activities and role-playing to rehearse communication and assertiveness skills relevant to safer sex negotiations. In contrast, training to enhance technical skills self-efficacy might include experience handling condoms, practice placing condoms on a model, and discussion of ways to use condoms without interfer- ing with sexual enjoyment (e.g., eroticizing condom use; Solomon & DeJong, 1989; Tanner & Pollack, 1988).

HIV-risk-reduction interventions have included activities that would enhance both types of perceived self-efficacy, but have not contrasted their effectiveness (Jemmott, Jemmott, & Fong, 1992; Jemmott, Jemmott, Spears, et al., 1992; Kelly et al., 1989). It is possible, for example, that individuals who gain confidence in the communication skills needed to negotiate condom use


effectively will be successful without training to enhance their perceived technical facility with condoms. It is also possible, however, that individuals who have confidence in their ability to easily and erotically incorporate condom use into sexual activity may not need training in communication skills self-efficacy. The issue not only has theoretical importance, but also practical importance since not all settings that provide HIV education will be willing to provide training to increase both types of self-efficacy. It is difficult to imagine a church group training young adolescents to eroticize condom use, for example. This research therefore compared the effectiveness of training in these two types of self-efficacy in increasing condom use attitudes, intentions to use condoms, and actual condom use.

Relationship Status as a Moderator of Intervention Effectiveness

Several recent reviews of HIV prevention research (e.g., Fisher & Fisher, 1992; Jemmott & Jones, 1993; Kelly, Murphy, Sikkema, & Kalichman, 1993) have posited that the effects of HIV risk-reduction interventions may differ systematically among different individuals as a function of age, race/ethnicity, racial/ethnic identification, sexual orientation, gender, or personality variables. Although the notion that certain variables may moderate individuals’ responsiveness to interventions is persuasive theoretically, little research has at- tempted to establish empirically the characteristics of intervention participants that might moderate the effectiveness of HIV-risk-reduction interventions. Knowledge of key moderators of intervention effects, however, could be used to tailor interventions to suit the needs of specific populations, and hence, presumably to maximize their effects. Petty and colleagues (Petty, Gleicher, & Jarvis, 1993), for example, suggest that HIV-avoidance persuasion messages that are effective for conservative Southern Baptists may be ineffective if used with urban teenagers.

One characteristic that may moderate intervention effectiveness among college students is whether they are involved in a steady dating relationship. Although individuals in intimate relationships actually engage in higher levels of HIV-risk-related behavior (e.g., Bowen & Michal-Johnson, 1989), for a variety of reasons HIV-risk-reduction interventions may be less effective with students who are in a steady dating relationship than among those who are not in a steady dating relationship. First of all, individuals in a steady dating relationship may believe that there is no need to use condoms because they “know” and trust their partner (e.g., Williams et al., 1992). In addition, they are likely to have established with their partner a pattern of sexual behavior, including precautionary practices, and it may be difficult for them to introduce changes into the relationship because of the anticipated negative reactions of


their sexual partner. A study by Hammer, Fisher, Fitzgerald, and Fisher (1 996), for example, found that college students in steady dating relationships may fail to use condoms due to concerns regarding questioning interpersonal trust and commitment. Accordingly, the present experiment examined whether relationship status moderates the effectiveness of HIV-risk-reduction interventions in creating behavior change, and specifically whether students who were not in a steady dating relationship at the time of receiving an HIV-risk-reduction intervention will show greater increases in condom use as compared with those who were in such a relationship.

Overview

In the present experiment, college students were randomly assigned to one of two HIV risk-reduction interventions (communication skills training vs. technical skills training) or to a waiting-list control condition. The experiment had two primary aims. First, we compared the attitudinal, intentional, and behavioral effects of a communication skills self-efficacy intervention and a technical skills self-efficacy intervention, as compared to the waiting-list control. Second, we examined whether relationship status moderates the effectiveness of HIV-risk-reduction interventions, and specifically whether HIV-risk- reduction interventions have a more positive impact on condom use among students not involved in a steady dating relationship than among those involved in a steady dating relationship.

Method

Participants

The participants were 136 university students (87 women, 49 men; M age =

19.80, SD = 1.45) who had responded to campus advertisements recruiting volunteers for a safer sex education study involving discussion groups on HIV and condom use. The majority of the participants (97.1%) were heterosexual.’ About 71% (N = 96) had engaged in sexual intercourse at least once, with a mean age of 17.12 years (SD = 1.46) at first intercourse. Among the sexually experienced participants, the mean number of lifetime sexual partners was 5.42 (SD = 12.50), and only 32.5% reported engaging in sexual intercourse with more than one partner in the previous 3 months. Participants in the two

3Four of the participants reported their sexual orientation as homosexual (N = 3) or bisexual (N = 1). When these participants were removed from the analyses, no differences in the findings on any of the measures emerged, and hence they are included in the analyses reported.


intervention conditions (technical skills: N = 44; communication skills: N = 44) were paid a total of $40 for completing the entire project (pretest, two intervention sessions, posttest, and 3-month follow-up). Waiting-list control participants ( N = 48) were paid a total of $50 for completing the entire project because they were asked to complete the questionnaire at one additional session. Of the original 141 participants, 5 did not attend the second session of their two-session intervention and were therefore eliminated from all anal- y ~ e s . ~ Of the remaining 136 students, only 3 failed to complete the 3-month follow-up (a return rate of 97.8%).5 There were no significant differences by gender in any of the analyses in this study. Thus, we have collapsed across gender for all reported analyses.

Focus Group and Pilot Testing

A focus group was conducted with eight undergraduate students several months prior to implementation of this study. This group made suggestions regarding appropriate payment rates to encourage student participation, the best times to offer the intervention sessions, and effective advertising strategies. The focus group members felt that there would be interest in the interventions, but that advertising should emphasize learning about sexual activity and condom use, as opposed to HIV or AIDS. They also felt that interventions should be offered at multiple times (e.g., evenings, weekends, late afternoons) because students had varied schedules.

The two interventions were pilot tested with groups of seven students each. These pilot tests provided information about the length of time needed for each of the intervention activities, methods of eliciting and focusing discussion of specific topics, and the appropriate developmental and intellectual level of intervention activities and videos. Using the information from these pilot tests, the final versions of interventions were developed.

Procedure

This study was approved by the Institutional Review Panel of Princeton University. Prospective participants were told that some students would be placed on a waiting-list to receive the intervention in about 3 months. Participants

4 0 f the five participants who failed to attend the second session of their intervention, three were in the technical skills condition and two were in the communication skills condition. When these participants were included in the analyses, in adherence to the intent-to-treat principle, the findings did not differ in any way.

'Of the three participants who failed to complete the 3-month follow-up, two were in the control condition and one was in the technical skills condition.


completed pretest questionnaires in large groups and were then randomly assigned to one of three conditions: communication skills training, technical skills training, or waiting-list control. Those in the two intervention conditions met in small groups of five to nine students led by specially trained peer co-facilitators for a total of 3 hr, divided into two sessions 1 week apart. Participants completed posttest measures immediately following the second session and again 3 months later. Participants in the waiting-list control condition completed the questionnaires at the same times as the intervention participants, but did not receive any education until after the 3-month follow-up. To reduce demand characteristics and social desirability effects, the peer facilitators were not involved in any way in the questionnaire data collection and only code numbers, not names, were used on the questionnaires.

HIV-Risk-Reduction Intervention Conditions

The intervention activities for both conditions were based on prior safer sex education interventions for adolescents (e.g., Jemmott, Jemmott, & Fong, 1992; Jemmott, Jemmott, Spears, et al., 1992), social cognitive theory, the theory of planned behavior, and information gathered from the focus group and pilot study conducted with members of the study population. The interventions included safer sex videos, games, exercises, and group discussions. The intervention materials and activities were designed to have an impact on the putative theory-based mediators of behavior change, including attitudes toward condoms, perceived vulnerability to HIV infection, perceived self-efficacy to use condoms, and condom-use intentions. In addition, the activities were designed to be entertaining and engaging. For example, HIV Jeopardy was a competitive question-and-answer game about HIV/AIDS used in the interventions. Two activities were designed to increase perceived vulnerability to HIV/AIDS: watching a video on HIV testing and reading a story about a young heterosexual woman who is HIV positive. The only differences between the interventions were the activities specifically designed to influence technical skills self-efficacy or communication skills self-efficacy, and hence approximately half of the time spent in the interventions consisted of the same activities in both conditions.

Technical skills self-efficacy condition. The technical skills self-efficacy condition included several activities designed to increase participants’ belief that they could use condoms correctly, with facility, and without ruining the mood. The emphasis was on comfort, familiarity, and hedonistic beliefs concerning condom use. Participants took part in a condom exercise in which they handled a variety of condoms and then rated them on such dimensions as texture, taste, and appearance. They practiced putting condoms on models and


discussed methods of eroticizing condom use, the use of condoms during foreplay, and condom use as a strategy to prolong sexual intercourse.

Communication skills self-eficacy condition. The communication skills self- efficacy condition included several activities designed to increase participants’ belief that they could communicate with and negotiate safer sex with their partners. Participants discussed effective methods of communicating about issues related to safer sex, including ways to initiate conversations about sensitive issues such as HIV testing, to probe partners about prior sexual experiences, and to share personal beliefs about various sexual behaviors. Role plays of scenes typical for college students were used to enhance participants’ confidence that they could suggest alternatives to sexual intercourse, discuss having an HIV test prior to sexual intercourse, and persuade a partner that condoms should be used.

Facilitators

The intervention groups were led by pairs of specially trained undergraduate peer facilitators (14 women, 2 men), who were between 19 and 22 years of age. These peer facilitators were recruited from a student organization in the campus health center that provided college students with information and counsel- ing regarding birth control, HIV and STD prevention, and safer sex techniques, and hence were experienced in and comfortable leading discussions and an- swering questions about sexual behavior and condom use. Facilitators were randomly assigned to receive 4 hr of training on the specifics of either the communication skills intervention or the technical skills intervention. The training emphasized strict adherence to the intervention protocol, namely that all facilitators of the same intervention must implement it in the same way so that participants in all groups within the same condition would receive the same treatment. Analyses conducted to test for the effects of the specific small group the participants were in revealed no effects of either the group or facilitators, although with 16 facilitators the power may be too low to detect any differences among the groups or facilitators.

Measures

Condom use self-efficacy. Participants’ self-effcacy for condom use was assessed using the Condom Use Self-Efficacy Scale (Brafford & Beck, 1991), which was specifically designed for use with college populations. Each item on this 28-item scale (a = .93) was answered on a scale from 1 (strongly disagree) to 5 (strongly agree). Sample items include “I feel confident in my ability to discuss condom usage with any partner I might have,” and “I feel confident that I could use a condom with a partner without ‘breaking the mood.”’


We created two subscales of the Condom Use Self-Efficacy Scale to assess self-efficacy specific to technical skills and communication skills. The nine- item technical skills self-efficacy subscale had an alpha of 37 . Sample items include “I feel confident in my ability to put a condom on myself or my partner,” “I feel confident that I could use a condom successfully,” and “I feel confident in my ability to incorporate putting a condom on myself or my partner into foreplay.” The seven-item communication skills self-efficacy subscale had an alpha of .78. Sample items include “I would not feel comfortable suggesting using condoms with a new partner because I would be afraid he or she would think I’ve had a past unsafe experience,” “I feel confident in my ability to persuade a partner to accept using a condom when we have intercourse,” and “I feel confident in my ability to suggest using condoms with a new partner.”

Attitudes toward condoms. Participants’ attitudes toward condoms were assessed with Brown’s (1984) Attitudes Toward Condoms Scale (a = .73). Each item on this 40-item instrument was answered on scale from 1 (disagree strongly) to 5 (agree strongly). Sample items include “Using a condom requires taking time out of foreplay, which interrupts the pleasure of sex,” and “There is no reason why someone should be embarrassed to suggest a condom.” Higher scores on this scale indicate more positive attitudes toward condom use.

Perceived vulnerability to HIV. Participants completed nine items assessing their perceived vulnerability to HIVIAIDS (a = .77). These items were answered on a scale from 1 (disagree stronglylextremely unlikely) to 5 (agree strongly1 extremely likely). Sample items include “HOW likely do you think it is that you are at risk for getting HIV/AIDS?” and “I am worried that I could get HIVIAIDS.”

Intentions to use condoms. Participants responded to two items assessing intentions to use condoms (a = .72): “In my future sexual encounters either myself or my partner will use a condom,” and “How likely is it that you will use condoms if you decide to have sex in the next 3 months?” These items were both scored on 5-point scales (1 = disagree stronglylvery unlikely and 5 = agree strongly/very likely, respectively).

Condom use. Participants’ self-reported frequency of condom use during sexual intercourse was measured using the item: “In the past 3 months, how often have you used condoms when engaging in sexual intercourse?” This item was answered on a scale from 1 (never) to 5 (always).

Relationship status. Participants’ relationship status was measured using the item “Are you currently in a relationship?” At the pretest, 78 participants were in a relationship (57%) and 58 were not (43%). Those who were in a relationship were asked to indicate how long they had been with their current partner: Responses to this question ranged from 1 to 84 months ( M = 14.76, SD = 14.71). Because our sexual behavior items referred to behavior specifically in the last


3 months, we classified those who were in a relationship but had been with their partner for less than 3 months as “not in a relationship,” for a total of 62 participants in a relationship (46%) and 74 participants not in a relationship (54%). There were no differences among the three conditions on the percentage of participants in steady relationships.

Reactions to the interventions. Intervention participants completed a seven- item debriefing questionnaire assessing their reactions to the interventions. These questions asked how much they liked the program, the videos/films, their small group, their group facilitators, and the activities; how much they learned from the program; and whether they would recommend the program to their fnends. All items were answered on 5-point scales with appropriately labeled values (e.g., 1 = did not like very much to 5 = liked very much).

Results

Integrity of the Interventions

A series of t tests assessed any differences between conditions on each of the items in the debriefing questionnaire. Only one difference was significant and two were marginally significant. The students in the technical skills condition ( M = 4.34) liked the program more than did those in the communication skills condition (M = 4.06), t(S1) = 2.1 1, p < .04. Students in the technical skills condition, as compared with those in the communication skills condition, reported that they learned marginally more from the program (Ms = 4.32 vs. 4.02), t(73) =

1.7 1, p < .09, and that they would be rnarginally more likely to recommend the program to other students (Ms = 4.50 vs. 4.2 l), t(79) = 1.67, p < .lo.

There were no significant differences between the intervention conditions on liking of the films/videos, their small group, the facilitators, and the activities. Although there were two marginally significant differences and one significant difference between the two intervention conditions, the means across both groups on all seven measures were between 3.80 and 4.34 on a 5-point scale, which suggests that reactions to participating in either intervention condition were generally positive. There were no significant differences on any of the measures as a function of the interaction between relationship status and treatment condition, indicating that relationship status did not influence liking of either treatment condition.

Social Cognitive Variables

Posttest analyses. The data from the posttest measure were analyzed using analyses of covariance (ANCOVAs), controlling for pretest scores of the


Table 1

Mean Adjusted Posttest Scores on Social Cognitive Measures

Means Contrast between

Technical Communica- both treatment skills tion skills Control conditions and

Measure condition condition condition the control

Attitudes toward

Condom use

Vulnerability to HIV 3.67 3.92 3.63 F(1, 127) = 6.11** Intentions to use

condoms 4.59 4.48 4.30 F(1, 127) = 6.74**

condoms 4.20 4.07 3.89 F(1, 127) = 22.42***

self-efficacy 4.36 4.23 4.07 F(1, 127) = 19.81***

Note. Pretest scores were controlled for in these analyses. **p = .01. ***, = .0001.

relevant criterion, and planned contrasts to test our hypothesis that the participants in the two HIV-risk-reduction intervention conditions would score higher on the social cognitive measures than would those in the control condition. The contrast weights were 1, 1, and -2 for the technical skills, communication skills, and waiting-list conditions, respectively. As shown in Table 1, these analyses did reveal that participants in the HIV-risk-reduction intervention conditions had more positive attitudes toward condoms, greater condom use self-efficacy, greater intentions to use condoms, and greater perceived vulnerability to HIV than did those in the waiting-list control condition.

We were also interested in whether there were differences between the two HIV-risk-reduction conditions. Although there was no difference between the two interventions on postintervention intentions to use condoms, planned contrasts (weights = 1-10, respectively) revealed that participants in the communication skills condition had greater perceived vulnerability to HIV than did participants in the technical skills condition, F(1, 134) = 9.55, p < .002. Participants in the technical skills condition, however, had more positive attitudes toward condoms, F(1, 134) = 4.38, p < .04, and greater condom use self-efficacy, F(1, 134) = 4.96, p < .03, than did those in the communication skills condition.


Additional contrasts were performed on the two self-efficacy subscales: technical skills self-efficacy and communication skills self-efficacy. As ex- pected, students in the technical skills condition ( M = 4.44) scored significantly higher in technical skills self-efficacy than did those in the communication skills condition ( M = 4.04), F(1, 134) = 16.70, p < .0001, or control condition (3.91), F(1, 134) = 3 0 . 8 4 , ~ < .0001. This analysis indicates that the technical skills condition was successful in increasing participants’ self-efficacy for the technical skills relevant for condom use. Contrasts revealed that students in the communication skills condition (M = 4.33) were nonsignificantly higher on communication skills self-efficacy than were those in the technical skills condition ( M = 4.25), F(3, 132) = 1 . 5 6 , ~ < .22, and significantly higher than were those in the control condition ( M = 4.15), F(3, 132) = 6 . 8 9 , ~ < .01.

Inspection of the pretest means revealed that scores on this measure (i.e., communication skills self-efficacy) were substantially higher in subjects in all three conditions (approximately 4.20) compared to scores on the technical skills self-efficacy measure (3.80), suggesting a ceiling effect on the communication skills self-efficacy subscale. Furthermore, gaining technical skills for implementing condom use may have increased comfort with the communication skills needed for implementing condom use. Students may have felt more confident in persuading a partner to use condoms when they were confident that they could easily and erotically use a condom.

Three-month follow-up analyses. The data from the 3-month follow-up were also assessed using ANCOVA and planned contrasts in order to determine whether the immediate social cognitive changes were maintained over time. As described in Table 2, the analyses revealed significant differences on attitudes toward condoms and condom use self-efficacy, and a marginally significant difference on intentions between the treatment conditions and the control condition. Once again, participants in the treatment conditions had higher scores on all of these measures compared with participants in the control condition. There were no significant differences between the treatment conditions and the control condition on perceived vulnerability to HIV.

We were also interested in testing whether the differences between the two treatment conditions on the social cognitive measures seen at the immediate posttest were maintained over the 3 months following the intervention. There were no significant differences between the two treatment conditions at the follow-up on attitudes toward condoms, condom use self-efficacy, or intentions to use condoms. There was, however, a significant difference on perceived vulnerability to HIV between the two treatment conditions, F(1, 127) =

7.79, p < .006, with participants in the communication skills condition report- ing significantly greater perceived vulnerability to HIV as compared with those in the technical skills condition.


Table 2

Mean Adjusted -?-Month Follow- Up Scores on Social Cognitive and Behavior Measures

Means Contrast between

Technical Communica- both treatment skills tion skills Control conditions and

Measure condition condition condition the control

Attitudes toward

Condom use

Vulnerability to HIV 3.69 3.91 3.69 F(1, 127) = 2.46 Intentions to use

Frequency of

condoms 4.11 4.02 3.89 F(1, 127) = 9.87**

self-efficacy 4.17 4.16 4.01 F(1, 127) = 7.77**

condoms 4.34 4.38 4.12 F(1, 127) = 3.60*

condom use 3.19 3.04 3.35 F(1, 69) < 1

Note. Pretest scores were controlled for in these analyses. *p = .06. **p = .01.

Relationship status. ANCOVAs and planned interaction contrasts performed on each of the social cognitive measures (at posttest and follow-up) to determine whether participants were differentially responsive to the intervention conditions as a function of relationship status were statistically nonsignificant.

Three-Month Follow-Up Condom Use

Main effects analyses. An ANOVA and planned contrasts on self-reported frequency of condom use at the 3-month follow-up were conducted on those participants (N = 74) who were sexually active during the previous 6 months. These analyses revealed that the technical skills condition (A4 = 3.19) and communication skills condition ( M = 3.04) did not differ from the control condition ( M = 3.35), F(1,73) < 1, or from each other, F(1,73) < 1, controlling for pretest condom use.

Relationship status by condition analyses. As described previously, we hypothesized that effects of the interventions would be enhanced among participants


who were not in a relationship at the time of the interventions. To test this hypothesis, we analyzed the data on frequency of condom use during sexual intercourse from the 3-month follow-up with a Condition x Relationship Status ANOVA and a planned interaction contrast, controlling for pretest condom use. Among those not in a relationship, the contrast weights were 1, 1, and -2 for those in the technical skills, communication skills, and control conditions, respectively; among those in a relationship, the contrast weights were - 1, - 1, and 2 for those in the technical skills, communication skills, and control conditions, respectively. As shown in Figure 1, the interaction contrast was significant, F(1, 72) = 5.95, p < .02. As hypothesized, the effects of the HIV interventions on condom use were greater among students who were not in steady dating relationships as compared with those in such relationships.

Additional contrast analyses comparing each treatment condition to the control condition revealed that the effects of the communication skills intervention on condom use were significantly greater among students who were not in steady dating relationships, F(1, 72) = 5.80, p < .02, than among those in relationships (Ms = 3.66 vs. 2.66, respectively), whereas the effects of the technical skills intervention were marginally significantly greater among those not in dating relationships, F(1, 72) = 3.21, p < .08 (Ms = 3.53 vs. 2.91, respectively). These analyses indicate that both intervention conditions led to greater condom use for those who were in casual dating situations as compared with those in steady dating relationships. Interestingly, participants who were in a steady dating relationship and received either treatment condition reported lower levels of condom use at the 3-month follow-up, compared to those in the control condition.

Mediation Analyses

Additional analyses were performed to determine whether effects of the Communication Skills x Relationship Status interaction on condom use were mediated by postintervention changes in social cognitive variables. Mediation was assessed using a standard procedure described by Baron and Kenny (1986): To establish mediation, it is necessary to show (a) that the independent variable affects the dependent variable, (b) that the independent variable affects the putative mediator, and (c) that the mediator has a significant effect on the dependent variable when the independent variable is controlled. The first criterion has already been met because the Communication Skills x Relation- ship Status interaction (the independent variable) on condom use (the dependent variable) was statistically significant.

Multiple regression analyses on postintervention measures of social cognitive variables were conducted in order to determine whether the second criterion

SANDERSON AND JEMMOTT

Communication Skills 0 Technical Skills 0 Control Condition

Not in a Steady In a Steady Dating Relationship Dating Relationship

Figure 1. Condom use at the 3-month follow-up as a function of intervention condition and relationship status. Pretest scores were controlled for in these analyses.

was met. In these analyses, the predictors were two contrast-coded intervention condition variables,6 relationship status, the two Relationship Status x Interven- tion Condition contrast-coded interactions, and preintervention measure of the particular social cognitive variable. The Relationship Status x Communication Skills intervention interaction was significant on postintervention intentions to use condoms, b = -.24, t(134) = 2.29, p < .02, but not on the other variables. The effects of the communication skills intervention on condom use intentions was greater among those not in relationships than among those in relationships, revealing that intentions to use condoms met the second criterion.

In order to test the third criterion, condom use was then regressed on postintervention intentions to use condoms, preintervention intentions to use

60n one contrast coded intervention condition variable, the contrast weights were 0, 1 , and - 1 for those in the technical skills, communication skills, and control conditions, respectively. On the other, the contrast weights were 1,0, and -1 for those in the technical skills, communication skills, and control conditions, respectively.


condoms, two contrast-coded intervention condition variables, relationship status, and the two Relationship Status x Intervention Condition contrast-coded interactions. The effects of postintervention intentions to use condoms were statistically significant, b = SO, t(83) = 2 . 1 0 , ~ < .04, meeting the third criterion for establishing mediation. Thus, these analyses provided evidence that intervention-induced intentions mediated self-reported behavior change and are consistent with the view that the Communication Skill x Relationship Status interaction on condom use at the 3-month follow-up was mediated by postintervention intentions to use condoms.

Discussion

The present experiment revealed that relatively brief (3-hr) but intensive interventions can cause positive changes on theory-based motivational deter- minants of HIV-risk-associated sexual behavior among college students. As suggested by prior research as well as several theoretical frameworks (e.g., social cognitive theory, theory of planned behavior, information-motivation- behavioral skills model), attitudes, self-efficacy, perceived vulnerability, and intentions are important factors in creating sexual behavior change, and both HIV-prevention interventions in the present study produced positive changes on these variables. Although the interventions did not have a significant effect on condom use considering the sample as a whole, a significant Intervention x Relationship Status interaction revealed intervention effects on condom use among the subsample of participants who were not in a steady dating relationship at the time of the study. Additional analyses indicated that intervention effects were mediated by changes in intentions to use condoms, which is consistent with theories such as the theory of planned behavior and its prede- cessor the theory of reasoned action that emphasize intentions as the sole direct determinant of behavior. This research extends prior findings from research with ethnic minority women and adolescents (e.g., Hobfoll, Jackson, Lavin, Britton, & Shepard, 1994; Jemmott, Jemmott, & Fong, 1992; Kalichman, Hunter, & Kelly, 1992; St. Lawrence et al., 1995) and homosexual men (e.g., Kelly et al., 1989) indicating that HIV-prevention interventions can be effective in changing condom use attitudes, self-efficacy, and intentions, and is one of the first published studies to examine behavior change as a function of interventions in the college student population (Fisher et al., 1996).

Although future research needs to verify these results in this and other populations, this is also one of the first studies to show that receiving training in either type of behavioral skill (communication or technical) may serve equally well in creating relatively long-term (3-month) changes on social cognitive variables. This finding has substantial practical implications because


health educators in certain settings (e.g., schools, churches) may be reluctant to provide HIV-prevention education that emphasizes the technical skills associated with condom use for fear of encouraging sexual activity. Interestingly, training in the technical skills needed to implement condom use increased scores on individuals’ self-efficacy not only for these types of skills, but also for negotiating condom use. Training in the technical aspects of condom use may, in fact, increase one’s confidence in implementing the interpersonal aspects of condom use.

This research also provides evidence that HIV-prevention education can have different effects on participants in different life situations (in this case, relationship status). Although relationship status did not influence participants’ experience of the interventions (as assessed by the debriefing questionnaire) or scores on social cognitive variables, it appears that relationship status did influence the extent to which students were able to implement actual behavior changes. For participants in both intervention conditions, only those who were not in steady dating relationships were apparently able to use the skills they learned to effectively implement condom use in their casual sexual relationships, and hence had the greatest frequency of condom use at the 3-month follow-up. Although it might be argued that those in a steady dating relationship felt that their partner was “safe” and posed little threat of HIV infection and hence did not show an increase in condom use, postintervention perceived vulnerability to HIV infection was not significantly lower among those involved in a steady dating relationship. We believe that the students involved in an ongoing dating relationship were concerned about their partners’ reactions to their insistence on condom use and in particular the potential destructive inferences regarding monogamy and trust (e.g., Hammer et al., 1996; Sacco, Levine, Reed, & Thompson, 199 1; Valdiserri et al., 1989). When participants enter a new dating relationship, however, they may be more likely to insist on the use of condoms because they have now acquired skills relevant for enacting condom use.

The interaction between intervention and relationship status suggests that greater attention is needed to developing interventions for people who are in steady romantic relationships so that changes in conceptual variables among them will translate into behavioral changes. In fact, our findings indicated that participants in a steady dating relationship who received either treatment condition actually had lower levels of condom use than those in the control condition. Although this finding was unexpected, it may be that those who are in a steady relationship and who attend an HIV-prevention intervention feel more comfortable and secure in their relationship as a result of hearing about the comparatively riskier sexual behavior of their peers. This increased comfort, in turn, may lead to decreased condom use specifically among those who are in a treatment condition, but not in the control condition. Alternatively,


those who are in a dating relationship and who receive an intervention may feel more confident about discussing sexual history with their partners and perhaps even decide to get tested for HIV/STDs, and as a result may reduce condom use. These explanations for the lower condom use among the intervention participants involved in a dating relationship compared with their counterparts in the control condition are purely speculative, but future research should include measures to test these possibilities.

Although the design of this study involved random assignment to conditions and the return rate at follow-up was extremely high, a number of issues must be considered when interpreting the present results. First of all, the participants were middle class students at a predominantly White university and, accordingly, the results may not generalize to other populations (e.g., students at larger, more diverse schools or subgroups of students, such as male homosexual students). Although this sample is not currently at high risk of HIV infection compared to the more frequently studied populations, the college student population is one that is increasingly at risk of HIV infection yet shows little evidence of reducing the frequency of unsafe sexual behavior (cf. Gayle et al., 1990; Goodwin & Roscoe, 1988). Future research should examine the role of both communication and technical skills training in changing attitudes, intentions, and behavior in other populations. It is possible that individuals in certain populations will benefit more from one type of condom use skill than another: Adolescents, for example, may be particularly in need of communication skills whereas homosexual men may be more responsive to learning technical skills for condom use. Similarly, some of the measures used in this study were designed for use with college students and were relatively complex (e.g., the Condom Use Self-Efficacy Scale; Brafford & Beck, 1991) and may be inappropriate for use in other populations.

Second, this study was based on a relatively small sample size (136 participants), which decreases the power and presumably made it more difficult to detect intervention effects, After all, a sizable proportion (nearly 30%) of the participants in this study reported never engaging in sexual intercourse. Given our small sample size and their relatively low level of sexual activity, however, it is particularly remarkable that the effects of the intervention conditions persisted for 3 months following the intervention, and that we found increased condom use in a subset of the participants (e.g., those not in a steady relationship). Furthermore, both treatment conditions increased participants’ intentions to use condoms in the future, which is seen as predicting actual behavior in various theoretical frameworks (e.g., theory of planned behavior; Ajzen, 1985) as well as in empirical research (cf. Fisher, 1984). Greater changes in behavior across all participants might, in fact, occur over time as more participants become sexually active or enter new dating relationships. Some research


with junior high school students, for example, has shown that those who are not yet sexually active when they receive skills training have safer sexual behavior when they do engage in sexual activity as compared to those who receive such training following the onset of sexual activity (Howard & McCabe, 1990).

Third, like virtually all published HIV-risk-reduction studies, this study relied on self-reported behavior and skills, which can be inaccurate. We took steps, however, to increase confidence about the accuracy of the self-reports in the present study. To facilitate the ability of participants to recall accurately their behavior, we used a relatively brief recall period (i.e., 3 months). For instance, it might have been more difficult for them to recall accurately behavior that occurred 6 or 12 months earlier (Kauth, St. Lawrence, & Kelly, 1991). To make it less likely that the respondents would intentionally misreport their sexual behaviors, participants were assured that their responses would be kept confidential, code numbers rather than names were used on the questionnaires, and the facilitators who implemented the interventions were not involved in any way in the data collection. Nevertheless, future research should include more detailed sexual behavior measures (e.g., our assessment of condom use was based on a single item), as well as measures that rely on actual demonstrated skills (e.g., role plays on communication strategies and technical skills with condoms) in addition to self-report.

In conclusion, although the results of this research are preliminary and should be replicated in this and other populations, they are encouraging in two ways. First of all, this is one of the few intervention studies to compare the effectiveness of different types of self-efficacy messages in creating attitude, intention, and behavior change. This is also one of the first intervention studies that focuses specifically on college students who, after all, are at increasing risk of HIV infection (Fisher et al., 1996). Second, this is one of the first experiments to demonstrate that individual difference variables can moderate the effectiveness of HIV-prevention interventions. Our finding that relationship status moderates the effectiveness of such interventions is in line with anecdotal reports from other studies indicating that those individuals who are in steady dating relationships have considerable trouble implementing condom use (e.g., Fisher et al., 1996; Hammer et al., 1996). Although our research focused on relationship status as a moderator of the effectiveness of HIV education for college students, it is probable that other individual difference variables also moderate the effectiveness of various HIV-prevention messages in this and other populations. As Kelly and colleagues (Kelly et al., 1993) suggest, behavior change messages need to be tailored to fit individuals’ needs and lifestyle characteristics. Future research should examine the extent to which other individual differences moderate responsiveness to HIV-prevention messages.


References

Abramson, P. R., Sekler, J. C., Berk, R., & Cloud, M. Y. (1 989). An evaluation of an undergraduate course on AIDS. Evaluation Review, 13, 5 16-532.

Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl & J. Backman (Eds.), Action-control, from cognitions to behavior (pp. 1 1-39). Heidelberg, Germany: Springer.

Ajzen, I. (1 99 1). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-2 1 1.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive approach. Englewood Cliffs, NJ: Prentice-Hall.

Bandura, A. (1989). Perceived self-efficacy in the exercise of control over AIDS infection. In V. M. Mays, G. W. Albee, & S. F. Schneider (Eds.), Primaryprevention of AIDS (pp. 128-141). Newbury Park, CA: Sage.

Bandura, A. (1 99 1). Self-efficacy mechanism in physiological activation and health-promoting behavior. In J. Madden, S. Matthyse, & J. Barchas (Eds.), Adaptation, learning and affect (pp. 229-269). New York, NY: Raven.

Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology,

Bowen, S. P., & Michal-Johnson, P. (1989). The crisis of communicating in relationships: Confronting the threat of AIDS. AIDS h Public Policy Journal, 4, 10-19.

Bowen, S. P., & Michal-Johnson, P. (1 995). HIV/AIDS: A crucible for under- standing the dark side of sexual interactions. In S. Duck & J. Wood (Eds.), Confronting relationship challenges (pp. 150-1 80). Thousand Oaks, CA: Sage.

Brafford, L. J., & Beck, K. H. (1991). Development and validation of a condom self-efficacy scale for college students. Journal of American College Health, 29, 219-225.

Brown, I. S. (1984). Development of a scale to measure attitude toward condom as a method of birth control. Journal of Sex Research, 20,255-263.

Caron, S. L., Davis, C. M., Halteman, W. A., & Stickle, M. (1993). Predictors of condom-related behaviors among first-year college students. Journal of Sex Research, 30,252-259.

Centers for Disease Control and Prevention. (1996). HIV/AIDS Surveillance Report, 8, 1-33.

DiClemente, R. J., Forrest, K. A., Mickler, S., & Principal Site Investigators. (1990). College students’ knowledge and attitudes about AIDS and changes in HIV-preventative behaviors. AIDS Education and Prevention, 2,201-212.

51, 1173-1182.


DiClemente, R. J., Pies, C. A., Stoller, E. J., Straits, C., Olivia, G. E., Haskin, J., & Rutherford, G. W. (1989). Evaluation of school-based AIDS education curricula in San Francisco. Journal of Sex Research, 26,

Dommeyer, C. J., Marquard, J. L., Gibson, J. E, & Taylor, R. L. (1989). The effectiveness of an AIDS education campaign on a college campus. Jour- nal ofAmerican College Health, 38, 131-135.

Elkind, D. (1980). Strategic interactions in early adolescence. In J. Adelson (Ed.), Handbook of adolescent psychology (pp. 432-444). New York, NY: John Wiley & Sons.

Fisher, J. D., & Fisher, W. A. (1992). Changing AIDS risk behavior. Psycho- logical Bulletin, 111,455-474.

Fisher, J. D., Fisher, W. A., Misovich, S. J., Kimble, D. L, & Malloy, T. E. (1996). Changing AIDS risk behavior: Effects of an intervention empha- sizing AIDS risk reduction information, motivation, and behavioral skills in a college student population. Health Psychology, 15, 114-123.

Fisher, J. D., & Misovich, S. J. (1990). Evaluation of college students’ AIDS- related behavioral responses, attitudes, knowledge, and fear. AIDS Educa- tion and Prevention, 2, 322-337.

Fisher, W. A. (1 984). Predicting contraceptive behavior among university men: The role of emotions and behavioral intentions. Journal of Applied Social

Franzini, L. R., Sideman, L. M., Dexter, K. E., & Elder, J. P. (1990). Promoting AIDS risk reduction via behavioral training. AIDS Education and Preven- tion, 2, 313-321.

Gayle, H. D., Keeling, R. P., Garcia-Tunon, M., Kilbourne, B. W., Narkusnas, J. P., Ingram, F. R., Rogers, M. F., & Curran, J. W. (1990). Prevalence of the human immunodeficiency virus among college students. New England Journal ofktedicine, 323, 1538-1541.

Gilliam, A., & Seltzer, R. (1989). The efficacy of educational movies on AIDS knowledge and attitudes among college students. Journal of American College Health, 31,261-265.

Goldman, J. A., & Harlow, L. L. (1993). Self perception variables that mediate AIDS-preventive behavior in college students. Health Psychology, 12,

Goodwin, M. P., & Roscoe, B. (1988). AIDS: Students’ knowledge and attitudes at a midwestern university. Journal ofAmerican College Health, 36,

Hammer, J. C., Fisher, J. D., Fitzgerald, P., & Fisher, W. A. (1996). When two heads aren’t better than one: AIDS risk behavior in college-age couples. Journal of Applied Social Psychology, 26, 375-397.

188-198.

Psychology, 14, 104-123.

489-498.

214-222.


Harlow, L. L., Quina, K., Morokoff, P. J., Rose, J. S., & Grimley, D. M. (1993). HIV risk in women: A multifaceted model. Journal ofApplied Biobehav- ioral Research, 1, 3-38.

Hernandez, J. T., & Smith, F. J. (1990). Abstinence, protection, and decision- making: Experimental trials on prototypic AIDS program. Health Educa- tion Research, 5,309-320.

Hobfoll, S. E., Jackson, A. P., Lavin, J., Britton, P. J., & Shepard, J. B. (1994). Reducing inner-city women’s AIDS risk activities: A study of single, pregnant women. Health Psychology, 13,397-403.

Howard, M., & McCabe, J. B. (1990). Helping teenagers postpone sexual involvement. Family Planning Perspectives, 22, 2 1-26.

Jemmott, J. B., 111, Jemmott, L. S., & Fong, G. T. (1992). Reductions in HIV risk-associated behaviors among Black male adolescents: Effects of an AIDS prevention intervention. American Journal of Public Health, 83,

Jemmott, J. B., 111, Jemmott, L. S., & Hacker, C. I. (1992). Predicting intentions to use condoms among African American adolescents: The theory of planned behavior as a model of HIV-risk-associated behavior. Journal of Ethnicity and Disease, 2,371-380.

Jemmott, J. B., 111, Jemmott, L. S., Spears, H., Hewitt, N., & Cruz-Collins, M. (1 992). Self-efficacy, hedonistic expectancies, and condom-use intentions among inner-city Black adolescent women: A social cognitive approach to AIDS risk behavior. Journal of Adolescent Health, 13,

Jemmott, J. B., 111, & Jones, J. M. (1993). Social psychology and AIDS among ethnic minority individuals: Risk behaviors and strategies for changing them. In J. B. Pryor & G. D. Reeder (Eds.), The socialpsychology of HIV infection (pp. 183-224). Hillsdale, NJ: Lawrence Erlbaum.

Jemmott, L. S., & Jemmott, J. B., 111. (1 992). Applying the theory of reasoned action to AIDS risk behavior: Condom use among Black women. Nursing Research, 40,228-234.

Kalichman, D. C., Hunter, T. L., & Kelly, J. A. (1992). Perceptions of AIDS susceptibility among minority and nonminority women at risk for HIV infection. Journal of Consulting and Clinical Psychology, 60, 725-732.

Karon, J. M., Rosenberg, P. S., McQuillan, G., Khare, M., Gwinn, M., & Petersen, L. R. (1996, July 10). Prevalence of HIV infection in the United States, 1984 to 1992. JAMA, 276, 126-131.

Kauth, M. R., St. Lawrence, J. S., & Kelly, J. A. (1991). Reliability of retrospective assessments of sexual HIV risk behavior: A comparison of biweekly, three-month, and twelve-month self-reports. AIDS Education and Prevention, 3,207-214.

372-377.

5 12-5 19.


Kelly, J. A., Murphy, D. A., Sikkema, K. J., & Kalichman, S. C. (1993). Psychological interventions to prevent HIV infection are urgently needed: New priorities for behavioral research in the second decade of AIDS. American Psychologist, 48, 1023-1034.

Kelly, J. A., St. Lawrence, J. S., Hood, H. V., & Brasfield, T. L. (1989). Behavioral intervention to reduce AIDS risk activities. Journal of Consult- ing and Clinical Psychology, 57, 60-67.

Leigh, B. C., & Stall, R. (1993). Substance use and risky sexual behavior for exposure to HIV: Issues in methodology, interpretation, and prevention. American Psychologist, 48, 1035-1045.

Madden, T. J., Ellen, P. S., & Ajzen, I. (1992). A comparison of the theory of planned behavior and the theory of reasoned action. Personality and Social Psychology Bulletin, 18, 3-9.

Maibach, E., & Flora, J. A. (1993). Symbolic modeling and cognitive rehearsal: Using video to promote AIDS prevention self-efficacy. Communication Research, 20, 517-545.

McDonald, N. E., Wells, G. A., Fisher, W. A., Warren, W. K., King, M. A., Doherty, J. A., & Bowie, W. R. (1 990). High-risk STD/HIV behavior among college students. Journal of the American Medical Association, 263,3 155-3 159.

O’Leary, A. (1 985). Self-efficacy and health. Behavioral Research and Ther- apy, 23,437-45 1 ,

Petty, R. E., Gleicher, F., & Jarvis, W. B. G . (1993). Persuasion theory and AIDS prevention. In J. B. Pryor & G. D. Reeder (Eds.), The socialpsychology of HIV infection (pp. 155- 182). Hillsdale, NJ: Lawrence Erlbaum.

Reinisch, J. M., Sanders, S. A., Hill, C. A., & Ziemba-Davis, M. (1992). High-risk sexual behavior among heterosexual undergraduates at a midwestern university. Family Planning Perspectives, 24, 1 16- 12 1 .

Rhodes, R., & Wolitski, R. (1989). Effect of instructional videotapes on AIDS knowledge and attitudes. Journal of American College Health, 37,266-27 1 .

Sacco, W. P., Levine, B., Reed, D. L., & Thompson, K. (1991). Attitudes about condom use as an AIDS-relevant behavior: Their factor structure and relation to condom use. Psychological Assessment, 3,265-272.

Schinke, S. P., Gilchrist, L. D., & Small, R. W. (1979). Preventing unwanted adolescent pregnancy: A cognitive behavioral approach. American Jour- nal of Orthopsychiatry, 49, 81-88.

Shulkin, J. J., Mayer, J. A,, Wessel, L. G., de Moor, C., Elder, J. P., & Franzini, L. R. (1991). Effects of a peer-led AIDS intervention with university students. College Health, 40, 75-79.

Solomon, M. Z., & DeJong, W. (1989). Preventing AIDS and other STDs through condom promotion: A patient education intervention. American Journal of Public Health, 79,453-458.


St. Lawrence, J., B-asfield, T., Jefferson, K., Alleyne, E., 0’ Brannon, R., & Shirley, A. (1995). Cognitive behavioral intervention to reduce African American adolescents’ risk for HIV infection. Journal of Consulting and Clinical Psychology, 63, 221-237.

Tanner, W. M., & Pollack, R. H. (1988). The effect of condom use and erotic instructions on attitudes toward condoms. Journal of Sex Research, 25, 537-541.

Valdiserri, R. O., Arena, V. C., Proctor, D., & Bonati, F. A. (1989). The relationship between women’s attitudes about condoms and their use: Implica- tions for condom promotion programs. American Journal ofpublic Health,

Wechsler, H., Davenport, A., Dowdall, G., Moeykens, B., & Castillo, S. (1994). Health and behavioral consequences of binge drinking in college: A national survey of students at 140 campuses. Journal of the American Medical Association, 272, 1672-1 677.

Weinstein, N. D. (1984). Why it won’t happen to me: Perceptions of risk factors and susceptibility. Health Psychology, 3,43 1-457.

Williams, S. S., Kimble, D. L., Covell, N. H., Weiss, L. H., Newton, K. J., Fisher, J. D., & Fisher, W. A. (1992). College students use implicit personality theory instead of safer sex. Journal of Applied Social Psychol-

79,499-503.

OD, 22,921-933.

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