Female adolescents and onset of sexual intercourse: a theory-based review of research from 1984 to 1994.

PURPOSE: To review a decade of research on the correlates of early onset of sexual intercourse among female adolescents in the United States, using Social Cognitive Theory as a framework for classification. METHODS: Forty-nine studies published in peer-reviewed journals between 1984 and 1994 were reviewed and their findings coded by two independent coders. RESULTS: Findings indicate that most of the studies emphasized quantitative methodologies, using cross-sectional designs and univariate statistical analyses. Many studies lacked a theoretical framework or conceptual model to guide their investigations. When evaluating empirical findings, 61% of the studies found environmental correlates and 47% found biological factors (e.g., age and pubertal development) to be significantly associated with early initiation of sexual intercourse. CONCLUSION: These findings raise important questions about the quality of research on adolescent sexuality, as well as its relationship to the development of risk-reduction programs which tend to focus mainly on intrapersonal factors (such as attitudes, knowledge, and expectancies.

PIP: A comprehensive review of the recent research literature on the onset of sexual intercourse among female adolescents in the US was conducted, with emphasis on concepts included in Social Cognitive Theory. Of the 49 studies published in peer-reviewed journals in 1984 to 1994, 59% used cross-sectional sampling strategies and 35% used a longitudinal design. Coding of empirical results indicated that 61% of studies identified environmental correlates and 47% found biologic factors to be significantly related to early age (under 18 years) at first intercourse. Notable was a general absence of scientifically established theoretical frameworks or conceptual models to serve as a basis for data collection and analysis. Also widespread was a view of onset of sexual activity as an isolated, single, dependent variable rather than a multifaceted, multidetermined behavior. Despite the importance of personal meanings assigned to sexual activity, few studies used qualitative methods. Also revealed were gaps between research and practice. Despite the demonstrated centrality of environmental determinants of premarital sexual activity, the main focus of educational programs remains individual behavioral change.

Structure of health risk behavior among high school students.

The authors test the contention of R. Jessor's (1977) problem behavior theory that adolescent health risk behaviors comprise a single behavioral syndrome. Multidimensional scaling (MDS) and cluster analysis are used to analyze data from a statewide survey of high school students' (n = 5,537) health risk behaviors. A classical MDS analysis was calculated to test the dimensionality of the behaviors. All indicators supported a multidimensional model. An individual-differences MDS (INDSCAL) analysis revealed that a 4-dimensional solution best fit the data, with gender and racial-ethnic differences emerging in the relative salience of the dimensions. The INDSCAL dimensional coordinates for each health risk behavior were then submitted to a hierarchical cluster analysis technique. Five behavioral clusters were identified, 1 of which included many of the traditional "problem behaviors," such as smoking, unprotected sexual intercourse, and alcohol consumption. These findings support a multidimensional structure underlying adolescent health risk behavior. Implications for theory and prevention of health risk behaviors are discussed.

Cardiovascular risk factors among children after a 2 1/2-year intervention-The CATCH Study.

BACKGROUND: Cardiovascular risk factors and related behaviors begin during youth. METHODS: As part of the Child and Adolescent Trial for Cardiovascular Health, 4,019 children from four states and representing multiple ethnic groups were measured for selected risk factors both at baseline and after 2(1/2) years of intervention. Common protocols were used for both examinations at the four sites. RESULTS: Overall, changes in obesity, blood pressure, and serum lipids in the intervention group, compared with the control group, were not statistically significant. Total cholesterol, the primary physiologic outcome measure, decreased by 1.3 mg/dl over time in the intervention group and by 0.9 mg/dl (P > 0.05) in the control group. Different risk factor patterns for boys and girls and among three ethnic groups were noted. CONCLUSIONS: Although the school-based program effected significant institutional changes in food service and physical education class and although the children made significant changes in eating and physical activity behaviors, these did not translate to significant changes in risk factors at these ages. These behavioral changes, however, if sustained into adulthood, have the potential to influence cardiovascular risk reduction.

The effects of the Child and Adolescent Trial for Cardiovascular Health upon psychosocial determinants of diet and physical activity behavior.

BACKGROUND: The Child and Adolescent Trial for Cardiovascular Health is a multisite study of a school-based intervention to reduce or prevent the development of risk factors for cardiovascular disease. The purpose of this paper is to present the evaluation results of the 3-year intervention, focusing upon the psychosocial variables conceptualized as determinants of dietary and physical activity behaviors. METHODS: A total of 96 schools across four study sites (California, Louisiana, Minnesota, and Texas) were randomized to two treatment conditions: intervention and control. Pre- and postmeasurements on the health behavior questionnaire were collected from over 6,000 students. The data analyses utilized a nested design approach in which schools served as the primary unit of analysis. Repeated-measures multivariate analyses were applied to investigate effect sizes for each determinant and to explore theoretical relationships among the determinants over time. RESULTS: The findings indicated sustained significant effects in improved knowledge, intentions, self-efficacy, usual behavior, and perceived social reinforcement for healthy food choices (P < 0.0001 for these five variables) after 3 years. Intermittent effects were observed for perceived support and self-efficacy for physical activity. No gender by determinant interaction effects were observed, and girls reported significantly greater perceived reinforcement for healthy eating than did boys. CONCLUSION: The CATCH program was effective in changing the psychosocial variables likely to influence a reduction in behavior for cardiovascular disease. The study is significant in that it demonstrates the viability and effectiveness of a sustained multifaceted intervention in a preadolescent population. The results point to a need for greater understanding of adolescent developmental issues and the role of community environment (particularly social support) in creating effective curricula.

Tobacco use measurement, prediction, and intervention in elementary schools in four states: the CATCH Study.

BACKGROUND: The Child and Adolescent Trial for Cardiovascular Health (CATCH) is a multistate field trial examining the effects of school environment, classroom curricula, and family intervention components in promoting the cardiovascular health of elementary school students. The purpose of this paper is to describe the CATCH tobacco use intervention and measurement, including the adoption of tobacco-free school policies. METHODS: In this study, changes in school tobacco use policies and smoking experimentation among students were assessed. Smoking experimentation was measured in all CATCH schools when the students were in their fifth-grade year. A total of 6,527 subjects in 96 schools in California, Louisiana, Minnesota, and Texas answered questions about behaviors and potential correlates of smoking as part of the CATCH health behavior questionnaire in Spring 1994. School tobacco use policy, an important complement to classroom- and home-based prevention efforts, was promoted as part of the CATCH intervention. The degree to which such policy was implemented was measured using surveys of school officials. RESULTS: At the end of fifth grade, only 4.8% of the subjects indicated that they had experimented with tobacco. School intervention condition was not a factor in the prediction of experimentation. Those whose best friend or sibling smoked, or who had ready access to cigarettes in the home, were more likely to have experimented with smoking. In the 3 years of the study, the percentages of tobacco-free schools went up from 49.7 to 76.8%. Though differences in the rate of policy adoption could not be directly attributed to the CATCH intervention, the implementation of the tobacco-free schools' policies did vary substantially from state to state. Minnesota and Texas, with stronger state laws supporting local policy, had nearly completely smoke-free schools. In spite of a statewide tobacco control initiative, California was slower to implement school policies. Louisiana, which allows local decision making regarding smoking policy, had the most difficulty establishing a policy for all districts. CONCLUSION: Future studies should examine the impact of parallel policy interventions that are ongoing at both school and state levels. Tobacco-free policies appear to be a crucial part of school-based interventions and must be tailored to political and regional factors affecting a given school district.

Using process data to explain outcomes. An illustration from the Child and Adolescent Trial for Cardiovascular Health (CATCH).

The purpose of this article is to illustrate the use of process evaluation for understanding study outcomes. Data from the Child and Adolescent Trial for Cardiovascular Health (CATCH), a large school-based field trial, are used. Teacher characteristics, measures of classroom curriculum implementation, and competing influences are linked to changes in dietary knowledge, intentions, and self-efficacy of students in the intervention schools. Multiple regression analyses indicate that teacher characteristics did not predict program implementation. Teacher characteristics and program fidelity, or the number of modifications made to the classroom curriculum during implementation, had direct and independent effects on student outcomes.

The effects of the child and adolescent trial for cardiovascular health intervention on psychosocial determinants of cardiovascular disease risk behavior among third-grade students.

PURPOSE: The Child and Adolescent Trial for Cardiovascular Health is a multi-site study of a school-based intervention designed to reduce or prevent the development of risk factors for cardiovascular disease. The goal was to change (or prevent) related risk behaviors and the psychosocial variables that theoretically influence those behaviors. DESIGN: A nested design was used in which schools served as the primary unit of analysis. Twenty-four schools participated at each of four sites (Austin, San Diego, Minneapolis, and New Orleans). Each site had 10 control and 14 intervention schools. SETTING AND SUBJECT: Ninety-six schools (with more than 6000 students) in the four sites were randomized to three treatment conditions: control, school-based interventions, and school-plus-family interventions. The sample included approximately equal numbers of males and females and was 67.5% white, 13.9% African-American, 13.9% Hispanic, and 4.7% other. MEASURES: The psychosocial determinants included improvements in dietary knowledge, intentions, self-efficacy, usual behavior, perceived social reinforcement for healthy food choices, and perceived reinforcement and self-efficacy for physical activity. RESULTS: The findings indicated significant improvements in all the psychosocial determinants measured (p < .0001). The results revealed a greater impact in the school-plus-family intervention schools for two determinants, usual dietary behavior and intentions to eat heart-healthy foods. CONCLUSIONS: These findings support theory-based interventions for changing selected psychosocial determinants of cardiovascular disease risk behavior among children.

Measurement of self-efficacy for diet-related behaviors among elementary school children.

Health promotion interventions intended to improve dietary behavior frequently incorporate self-efficacy as a construct to enhance behavior change. This paper presents results from a study to establish psychometric properties of a scale to measure children's self-efficacy for selecting healthful food. As part of a series of pilot studies to develop instrumentation for the Child and Adolescent Trial for Cardiovascular Health (CATCH), data were collected on third and fourth grade students (n = 1,127). Data analyses were conducted to estimate internal consistency, test-retest reliability, factorial validity, and criterion related validity. Results revealed acceptable estimates of internal consistency for the dietary self-efficacy scale (coefficient alpha = .84). Self-efficacy was strong associated with the children's usual food choices, accounting for about 34% of variance (Multiple R = .58). Findings support using such an instrument for evaluating intervention programs addressing nutrition behavior and for studies to determine the association of self-efficacy to dietary behavior or related constructs.

Implications for the alcohol/drug education specialist working with children of alcoholics: a review of the literature from 1988 to 1992.

This article reviews the scientific literature on children of alcoholics (COAs) from 1988 to 1992. First the publications were divided into two classifications: practitioner-oriented and research-oriented literature. Each practitioner-oriented article was evaluated on the following criteria: program description, theoretical model, recommendations substantiated by research, behavioral indicators of COAs, suggestions for intervening, and resource lists. For each of the research-oriented articles, the variables measured, sample source, sample size, and number of COAs in the sample are listed. Additionally, those articles are evaluated for research design, instruments, and analytical techniques. Reviews of early research in this area identified severe methodological limitations across the majority of articles. However, results of this more recent review indicate that research on COAs no longer suffers from previously common methodological weaknesses and sampling biases. The research-based literature also indicated that a larger number of COAs are resilient, which calls into question common assumptions about the inevitable negative effects of familial alcoholism. Alcohol/drug education specialists need to be cognizant of the more recent results on non-clinical samples of COAs in designing and implementing sensitive programs.

Enhancing adoption of an alcohol abuse prevention program: An application of diffusion theory.

The purpose of this study was to apply diffusion theory (Rogers, 1983) to an alcohol abuse prevention program in order to enhance program adoption. Three of the four stages of diffusion theory (dissemination, adoption, and implementation) are discussed relative to the development and implementation of a program designed to increase awareness of the destructive effects upon children who live with an addicted parent of living with that parent. The program also focused upon resiliency building strategies to use with children in order to mitigate the harmful effects of addiction in the home. Empirical data are presented concerning the dissemination, adoption and implementation phases of the program.

Evaluation of sex education curricula: measuring up to the SIECUS guidelines. Sex Information and Education Council of the U.S.

Most sexuality education curricula developed the past 20 years were not thoroughly evaluated. This study provides results from a content analysis of 10 sexuality education curricula for junior and senior high school students. Nine nationally available sexuality education curricula and one curriculum guide comprised the sample. The basis for analysis was the Guidelines for Comprehensive Sexuality Education, developed by the Sex Information and Education Council of the U.S. (SIECUS) and an instrument developed to measure bias in the curricula. Trained coders found that Sex Respect and Teen Aid addressed less than half the topics suggested by the SIECUS guidelines. Several of the curricula contained gender and sexual orientation bias. Certain key concepts such as "Sexual Behavior" and "Society and Culture" were not adequately addressed by most of the curricula. Findings indicate that of 10 curricula, only six are considered acceptable for educating junior and senior high school students.

The problematic promotion of abstinence: an overview of Sex Respect.

A content evaluation of the abstinence-based sexuality education curriculum Sex Respect was conducted, focusing on the curriculum's message and presentation. The four primary goals for a human sexuality education curriculum according to the SIECUS guidelines, as well as a methodology for designing, using and evaluating health education materials developed by the Pan American Health Organization provided the framework for the evaluation. Results indicate Sex Respect omits basic content and includes misinformation, especially in the areas of reproductive health and human sexual response. Authors conclude that Sex Respect fails to meet professional standards for a comprehensive sexuality education curriculum, and needs further evaluation and revision. Specific topics for future assessments are discussed.

PIP: The reemergence of religious and political conservatism, the abortion controversy, AIDS, and teenage pregnancy in the US over the past two decades are associated with a proliferation of sexuality education curricula which emphasize the teaching of abstinence. The authors report findings from a content evaluation of the abstinence-based sexuality education curriculum Sex Respect, paying particular attention to the curriculum's message and presentation. The authors focus upon Sex Respect because it is one of the highest profiled abstinence-based curricula in the US. SIECUS guidelines for an human sexuality education curriculum in combination with Pan American Health Organization methodology for designing, using, and evaluating, health education materials provided the framework for the evaluation. The assessment found that Sex Respect omits basic content and includes misinformation, especially in the areas of reproductive health and human sexual response. Sex Respect fails to meet professional standards for a comprehensive sexuality education curriculum, and needs further evaluation and revision. In fact, most abstinence-based education programs have been found to omit critical information, contain medical misinformation, include sexist and anti-choice bias, and often have a foundation in fundamentalist religious beliefs. Specific topics for future assessments are discussed.

CATCH: challenges of conducting process evaluation in a multicenter trial.

This paper discusses the challenges faced when collecting process evaluation information in a school-based, multicenter field trial. Experiences from the Child and Adolescent Trial for Cardiovascular Health (CATCH) are shared as a means of illustrating the challenges that are presented and ways of meeting the challenges. The scope and magnitude of the trial (96 schools across four sites) and the diverse population participating in the trial (including children and adults representing a cultural and socioeconomic mix) present challenges that are compounded by conducting research in a highly structured school setting. In such a trial, thoughtful consideration must be paid to what data should be collected, how data should be collected, how to collect data on tailored interventions, gaining and maintaining schools' cooperation, collecting data in year-round schools, and assuring data quality.

CATCH: classroom process evaluation in a multicenter trial.

The purpose of this paper is to describe the process evaluation model for the classroom curricula of the Child and Adolescent Trial for Cardiovascular Health (CATCH) Project. The process evaluation plan specifically targets how much each curriculum was implemented, to what degree it was implemented as designed, and the barriers to implementation. Additionally, the rationale for each of the process evaluation measures and the instrument development process are presented. Data resulting from these measures will be essential in order to answer questions regarding the internal validity of the main outcomes of the project. Specific examples and sample results are provided from the CATCH third-grade classroom curriculum, which was implemented the first year of CATCH. A discussion also is presented of how the findings from a sample of these measures were used to gain additional insight on the salient features of the curriculum, and how those features may be related to student outcomes.

The development of a model to predict drinking behavior from attitudes in university students.

The major purposes of the study were: a) to examine the relationship between attitudes and self-reported levels of drinking; and b) to develop a stable prediction equation that included attitudes as a predictor of drinking behavior. A Likert-type survey was developed to measure college student's attitudes toward alcohol. The survey was administered to a sample of college students (n=1049). The coefficient alpha reliability estimate was found to be .91. Stepwise multiple regression procedures were used to ascertain the relationships between attitudes and other psychosocial constructs of drinking. The dependent variable was an alcohol consumption index. The analysis revealed that the seven variable model was the most parsimonious (R (2) =.46), and attitudes toward drinking was the strongest predictor of self-reported drinking behavior. A double cross-validation of the regression model indicated that the model was very stable, and therefore could be generalized to similar samples. The substantive findings related to students' self-reported drinking practices are also reported.

Drug use and life satisfaction among college students.

Individuals use a variety of drugs for a host of reasons and college students are no exception. Reasons provided for specific types of "recreational" drug use have included, but have not been limited to, medicinal, social, mood enhancement, and experimentation. In an attempt to discern the relationship between drug use and life satisfaction among college students, a slightly modified version of the National Institute on Drug Abuse (NIDA) Monitoring the Future Survey was administered to 683 students attending a major research university located in the southwestern United States. Based on the obtained study results a life satisfaction composite variable was created via factor analysis. Additionally, a polynomial multiple regression analysis was conducted to discern the association between the derived life satisfaction composite variable and drug use indices.

Personal and social motivations as predictors of substance use among college students.

The Drug Use Survey was administered via a direct mail to a simple random sample of 2200 students enrolled at a large southwestern U.S. university. A purpose of the study was to determine the predictability of self-reported drug use utilizing motivations (personal and social) commonly reported by substance users. Two subscales were developed, one for each category of motivations. Reliability for each subscale as estimated by coefficient alpha was .80 and .86, respectively. A series of step-wise multiple regression analyses were computed in which individual drug use indices served as criterion variables, while the predictor variables were the personal motivations subscale (PMS) and the social motivation subscale (SMS) for each model. The results indicated that the PMS was the stronger predictor in every model with the exception of the model that predicted the alcohol use index. The SMS was the best predictor for alcohol use.

Discerning the epidemiology of drug use among a sample of college students.

Although estimates concerning the prevalence of various forms of substance abuse vary considerably, it is critical to note that even the more conservative estimates indicate a major public health problem. Furthermore, increased drug experimentation has been frequently associated with the college experience. Utilizing a slightly modified version of the National Institute on Drug Abuse (NIDA) Monitoring the Future Survey, the present study examined the epidemiology of self-reported drug taking behaviors (e.g., alcohol, marijuana, tranquilizers, stimulants, psychedelics, etc.) among a sample (n = 683) of students attending a major public university. Data analyses focused on the specific settings and social groupings in which drug use occurred as well as on the frequency and type(s) of drug taking behaviors. Based on the results yielded from a disjoint cluster analysis, four distinct groups of drug users were identified. These four groups then served as categories of the dependent variable in a discriminant function analysis. A general linear models procedure was employed to identify the more efficacious discriminating (i.e., independent) variables.

Proposed definition of a smokeless tobacco user based on "potential" nicotine consumption.

This study examined and operationally defined "light," "moderate," and "heavy" users of smokeless tobacco according to the potential amounts of nicotine consumed per week from chewing tobacco and/or snuff products. Fifty adult male smokeless tobacco users ranging in ages from 18-85 were tested to determine nicotine content of smokeless tobacco products consumed. The smokeless tobacco products were blindly analyzed by gas chromatography to determine nicotine content. Mean nicotine yield per week was calculated by multiplying the number of cans and/or pouches used per week and placed on a normal probability distribution. The mean nicotine yielded 238 mg/wk and the categories emerged as "light" less than or equal to 87 mg/wk, "moderate" 88-388 mg/wk and "heavy" users greater than or equal to 389 mg/wk. Differences regarding type of user (light, moderate, heavy) were crossed tabbed with educational levels, years of smokeless tobacco use, age the habit was initiated, perception of harm and whether habit forming, and reason for using smokeless tobacco.