CLINICAL SCHOLARSHIP
Parental Influences of Sexual Risk Among Urban African American Adolescent Males Allyssa L. Harris, PhD, RN, WHNP-BC1 , Melissa A. Sutherland, PhD, RN, FNP-BC2 , & M. Katherine Hutchinson, PhD, RN, FAAN3 1 Alpha Chi, Assistant Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA 2 Alpha Chi, Assistant Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA 3 Alpha Chi, Associate Dean of Graduate Programs and Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA
Key words Parent child sexual communication, African American male adolescents, sexual risk behaviors Correspondence Dr. Melissa A. Sutherland, William F. Connell School of Nursing, Boston College, 421 Cushing Hall, 140 Commonwealth Avenue, Chestnut Hill, MA 02467. E-mail:
[email protected] Accepted: November 11, 2012 doi: 10.1111/jnu.12016
Abstract Purpose: This study examined the influence of parental marital status, parent-child sexual communication, parent-child closeness on the HIV-related knowledge, safer-sex intentions, and behaviors of late adolescent urban African American males. Design: The study employed a cross-sectional design with retrospective recall of salient parental influences and behaviors. Methods: Data were collected via paper-and-pencil questionnaire from 134 late adolescent African American males, 18 to 22 years of age, recruited from urban communities in and around Boston, Massachusetts. Data were analyzed using bivariate correlations, paired t tests, and regression modeling. Findings: Young men reported greater amounts of sexual communication with mothers than fathers (p < .001). Parent-child closeness was positively correlated with amount of parent-child sexual communication with both mothers and fathers (p < .001 for both). Parent-child closeness was, in turn, associated with greater condom use self-efficacy (p < .01), less permissive sexual attitudes (p < .001), fewer sexual partners (p < .01), and less unprotected sex (p < .01). Greater amounts of parent-child sexual communication were associated with fewer sexual risk behaviors, more consistent condom use, and greater intentions to use condoms in the future. There was evidence that parental influences on sexual risk behaviors and condom use intentions were mediated through young men’s condom use self-efficacy, attitudes, and beliefs. Conclusions: These findings highlight the importance of the parent-child relationship and the role of parent-child communication between parents and sons. Further studies are needed to better understand the nature of father-son communication and develop strategies to help parents communicate effectively with sons. Clinical Relevance: Evidence has shown that African American adolescent males are more likely to engage in high-risk sexual behaviors. Understanding the sexual risk communication between African American adolescent males and their parents is important to developing strategies in reducing sexual risk behavior.
Urban African American (AA) male youth are more likely to initiate sexual activity at younger ages, have multiple partners, acquire a sexually transmitted infection, and father a child compared with White and Journal of Nursing Scholarship, 2013; 45:2, 1–10. C 2013 Sigma Theta Tau International
Hispanic adolescent males (Centers for Disease Control & Prevention [CDC], 2010; The National Campaign, 2008). These sexual risk behaviors also put them at risk for acquiring human immunodeficiency virus and 1
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acquired immunodeficiency syndrome (HIV/AIDS). Parent-adolescent relationships and communication about sexuality and sexual risk have been associated with decreases in adolescent sexual activity and risk behaviors (Hutchinson, Jemmott, Jemmott, Braverman, & Fong, 2003; Hutchinson & Wood, 2007). Although there is a growing body of literature related to AA motherdaughter sexual communication, less is known about fathers’ roles in sexual communication and fathers’ roles in sexual socialization of children more broadly (DiIorio et al., 2006; Hutchinson & Cederbaum, 2011; Hutchinson & Wood, 2007). Therefore, the purpose of this study was to examine the associations between parent-child sexual communication (PCSC), parent-child closeness, and the sexual risk-related beliefs, intentions, and behaviors of urban AA late adolescent males.
Background Interest in reducing adolescent sexual risk behaviors is of global importance. A recent study in Africa found that parental monitoring was higher for unmarried adolescent girls compared to boys and that African parents were less likely to engage in sexual risk communication or provide information about contraception (Biddlecom, AwusaboAsare, & Bankole, 2009). In Ghana, Malawi, and Uganda, only one in three girls and one in five boys reported engaging in sexual risk communication with parents (Biddlecom et al., 2009). Understanding PCSC is imperative for intervention development focused on adolescent sexual risk behaviors. In the United States, AA adolescents are more likely to demonstrate high-risk sexual behaviors than other groups, with 60.0% reporting sexual activity compared with 48.6% of Latino and 44.3% of White high school students (CDC, 2011); rates are even higher among urban youth. Almost 22% of AA male high school students report initiating sexual intercourse prior to 13 years of age, 24.6% report not using a condom during their last sexual intercourse, and 32.6% report having four or more lifetime partners (Bakken & Winter, 2002; CDC, 2011). Furthermore, by engaging in sexual risk behaviors and unprotected sex, AA male youth place female sexual partners at risk for sexually transmitted infections (STIs) and HIV. Parents have been shown to be an important influence of adolescents’ sexual risk behaviors (Bleakley, Hennessy, Fishbein, & Jordan, 2009; Hutchinson et al., 2003; Hutchinson & Wood, 2007). Parent-teen sexual communication is one of the ways in which values, beliefs, culture, and normative community behaviors are transmitted (DiIorio, Hockenberry-Eaton, Maibach, & Miller, 2
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1996). Positive relationship quality and general communication are also important and have been shown to delay sexual debut and reduce high-risk sexual behaviors (Aronowitz, Rennells, & Todd, 2005; DiIorio et al., 2000). Much of our understanding of parental influences has been derived from research with mothers and daughters. In general, mothers are more likely to discuss sexual topics with their children than fathers, and fathers are more likely to discuss sexual topics with sons than daughters (DiIorio et al., 2000; Hutchinson & Montgomery, 2007). Glenn, Demi, and Kimble (2008), in their study on AA fathers and sons, found that sons’ reports of their fathers’ abilities to communicate about sexual behaviors and HIV prevention were associated with sons’ self-efficacy for abstinence. Fathers’ involvement with sons is essential in influencing social behavior, psychological well-being, and economic and educational achievement (Mullen Harris, Furstenberg, & Marmer, 1998). ¨ In contrast, Willis and Clark (2009) found that, among low-income AA male adolescents, the absence of a father figure and lack of paternal caregiving resulted in a habitus that promoted promiscuity and lack of attachment to sexual partners and children. This lack of attachment was then carried forward across generations (Willis & Clark, 2009). AA male adolescents without father figures and paternal attachments are more likely to engage in “street” behavior and assume a masculine identity that emphasizes toughness, sexual conquests, and hustling (Oliver, 2006) and contributes to sexual risk-taking. Although some fathers may not be married or co-reside with their children’s mothers, AA fathers highly value fatherhood and the associated responsibility to sexually educate and socialize their children (DiIorio et al., 2006). Some fathers report anxiety, discomfort, and uncertainty about their ability to serve as effective sexual educators and look favorably on programs that could facilitate this process (DiIorio et al., 2006). Given the evidence that urban AA male youth engage in high-risk sexual behaviors and experience disparities in STIs and HIV, and growing evidence that parents may influence adolescent sexual risk behaviors, it is critical to examine the influence of AA parents on the sexual risk-related beliefs, intentions, and behaviors of urban male youth. The knowledge gained will contribute to the development of culture- and gender-specific family interventions.
Theoretical Model The Parent-Based Expansion of the Theory of Planned Behavior (PBE-TPB) served as the theoretical framework for the study (Hutchinson & Wood, 2007). PBETPB posits that parent-child closeness and PCSC act as Journal of Nursing Scholarship, 2013; 45:2, 1–10. C 2013 Sigma Theta Tau International
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external influences on adolescents’ sexual risk-related behaviors and normative and/or control beliefs, which in turn influence their sexual risk intentions and behaviors (Ajzen, 1991; Hutchinson & Wood, 2007).
Study Design and Method The current study employed a cross-sectional design that included retrospective recall of select predictor variables that occurred during the participant’s earlier adolescent years. This method of data collection is a timeand resource-efficient way to address the research questions of interest while eliminating the need for followup data collection and potential loss of subjects through attrition. Although concerns regarding the accuracy of recall may be raised, memory or recall of events is less problematic when participants are asked to recall salient events and occurrences rather than feelings or emotions (Hutchinson, 2007). Using retrospective recall with late adolescents (>18 years of age) also eliminates the need for parental consent and the potential for sampling bias that can occur when parental consent is required.
Procedures The study received human subjects approval from the institutional review board of Boston College. Participants were recruited through the use of flyers posted throughout the targeted areas, at local community health centers, and via word of mouth. Participants provided written informed consent for their participation. Although potential participants expressed interest, some were hesitant to participate. It was difficult to ascertain whether these young men were mistrustful of the research process or apprehensive about the topic. African Americans are often distrustful of the medical community and the research process, and AA men are more likely to be distrustful of healthcare providers and researchers (Wasserman, Flannery & Clair, 2007). All data were collected by the principal investigator (PI) or trained research assistant at a time and place that was convenient for the participant; data collection was completed between October 2009 and August 2010. Questionnaires were administered via paper and pencil. No literacy issues were noted among the recruited participants. Participants received $20 gift cards to reimburse their time. No names or identifiers were recorded; questionnaires were stored in a locked file.
Sample The study participants were 134 AA males, 18 to 22 years of age, residing in Boston and its surroundJournal of Nursing Scholarship, 2013; 45:2, 1–10. C 2013 Sigma Theta Tau International
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ing neighborhoods. The inclusion criteria were (a) selfidentify as AA; (b) 18 to 22 years of age, inclusive; (c) able to speak and understand English; and (d) resident of Boston, Massachusetts. The sample size was determined using power of 0.8, α = 0.05, and an estimated effect size of 0.3 to 0.4 (based on prior studies with urban AA adolescents; Hutchinson et al., 2003; Hutchinson & Montgomery, 2007).
Measures and Instruments Consistent with the TPB (Ajzen, 1991) and the parental expansion of the TPB (Hutchinson & Wood, 2007), independent variables included parental influences (PCSC, parent-child closeness), sons’ HIV-related knowledge, relevant behavioral beliefs, control beliefs, and normative beliefs. Dependent variables included condom use intentions and actual sexual risk behaviors (numbers of partners, episodes of sex, and episodes of unprotected sex during the past 30 days). Demographic control variables included age, education, and parent’s marital status (ever married and currently married).
Parent-child sexual communication. PCSC was measured separately for each parent using the eight-item Parent-Teen Sexual Risk Communication Scale (PTSRCIII; Hutchinson, 2007). Items were worded “Between the ages of 10–18 how much information did your mother or father give you about (a) birth control, (b) STIs, (c) HIV/AIDS, (d) condoms, (e) how to protect yourself from HIV/AIDS, (f) postponing or not having sex, (g) peer pressure to have sex, and (h) how to handle sexual pressure.” Response choices were scored from 1 (none) to 5 (extensive amounts). The PTSRC-III scale has demonstrated reliability and validity with diverse populations, with Cronbach’s α ranging from 0.86 to 0.93 (Hutchinson, 2007; Hutchinson & Montgomery, 2007). Internal reliability in the current study was excellent (α = 0.94 and 0.95 for PCSC with mothers and fathers, respectively). Parent-child relationship. A single-item measure of closeness with parents asking “How would you describe your relationship with your parents?” was included. Response choices ranged from 1 (not at all close) to 4 (extremely close). This single item measure has been highly correlated with longer scales of parent-child relationship quality in previous studies (Hutchinson & Montgomery, 2007). HIV/STI knowledge. HIV/STI knowledge was measured by 16 items from the AIDS Knowledge Scale (Koniak-Griffin, 1997). Items were answered as true (1) or false (0). An example of an item was “you can NOT 3
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have an STI if you feel perfectly fine.” Possible scores ranged from 0 to 16. Coefficient α for the scale has ranged from 0.73 to 0.89. Cronbach’s α was 0.67 for this sample.
Sexual permissiveness. Sexual permissiveness was measured with the 10-item subscale from the Brief Sexual Attitudes Scale (Hendrick, Hendrick, & Reich, 2006). Items included “Casual sex is acceptable” and “I would like to have sex with many partners.” Responses ranged from 1 (strongly disagree) to 5 (strongly agree). Total possible scores ranged from 10 to 50, with higher scores representing greater sexual permissiveness. Previous studies have reported an α coefficient of 0.94 (Hendrick & Hendrick, 1987; Hendrick et al., 2006). For this sample, Cronbach’s α coefficient was 0.83. Beliefs about condom Use. Condom use beliefs were measured with six items (Jemmott & Jemmott, 1991) rated from disagree strongly (1) to agree strongly (7). A typical item was “Sex does not feel as good when you use a condom” (Jemmott & Jemmott, 1991). Cronbach’s α coefficient for this sample was 0.79. Condom use self-efficacy (CUSE). CUSE was measured using the six-item CUSE Scale (Jemmott, Jemmott, Spears, Hewitt, & Cruz-Collins, 1992). A typical item was “I am confident that I know how to use a condom.” Responses were rated from strongly disagree to strongly agree. Cronbach’s α was 0.78 (Jemmott et al., 1992) and 0.83 in the current study. Intention to use condoms. Intention to use condoms was assessed using the single item “How likely is it that you will use condoms every time you have sex in the next 3 months?” Response choices ranged from not at all likely (1) to very likely (4). Higher scores indicated greater intention to use condoms. Intentions have been consistently positively associated with actual condom use (Hutchinson et al., 2003; Hutchinson & Montgomery, 2007). Attitudes toward using condoms. Attitudes toward using condoms during the next 3 months were measured with a single question (Jemmott & Jemmott, 1991). Ratings were on a 7-point scale from very negative to very positive. Higher scores indicated more positive attitudes. Sexual behaviors. Current and past sexual behaviors were assessed using standard measures that are widely used in the published literature (Hutchinson et al., 2003; Jemmott et al., 1992) including age at first intercourse, number of lifetime sexual partners, and sexual 4
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Table 1. Sample characteristics Characteristic
N = 134
Age in years, M (SD) Education Grade school only High school diploma Vocational training or some college College degree or above Parent’s marital status Ever married Currently married Relationship with parents Not close at all Fairly close Close Very close Ever had sexual intercourse Age at first intercourse in years, M (SD)
20.1 (1.5) 0.7% 40.3% 48.5% 10.4% 57.3% 37.1% 9.0% 29.3% 41.4% 20.3% 97.8% 15.3 (2.4)
Note. Values are percentages unless otherwise noted.
activity in the past 30 days (number of partners, sexual acts, acts of unprotected sex).
Data Analysis Data were entered into SPSS version 18.0 for Mac (SPSS Inc., Chicago, IL, USA). Descriptive statistics were computed for all variables, and data were examined for normalcy of distributions, outliers, and missing data. Internal reliability of scales was assessed by computing Cronbach’s α. A correlation matrix was constructed to assess for multicollinearity prior to undertaking regression analyses.
Results As is shown in Table 1, participants ranged in age from 18 to 22 years, with a mean of 20.1 years. The sample was fairly well educated; nearly all of the participants completed high school, and 10% held college degrees. More than half of all participants reported that their parents had been married; 37.1% reported that their parents were currently married. More than 60% of participants reported that they were close or very close with their parents. Almost all of the participants were sexually experienced; the number of lifetime sexual partners ranged from 1 to 120 (M = 13.4, median = 7.0, SD = 21.7).
Correlations Among Variables Bivariate correlations were examined among variables. As expected, reports of PCSC with mothers and fathers were highly correlated with one another (r = 0.74, Journal of Nursing Scholarship, 2013; 45:2, 1–10. C 2013 Sigma Theta Tau International
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p < .001) and PCSC mothers and PCSC fathers was correlated with parent-child closeness (r = 0.54, p < .001 and r = 0.62, p < .001, respectively). Safer sex and HIV prevention knowledge scores were significantly associated with PCSC with mothers (r = 0.27, p = .003), but only marginally associated with father PCSC (r = 0.15, p < .10). Sexually permissive attitudes of sons were inversely associated with reports of mother PCSC (r = –0.43, p < .001) and father PCSC (r = –0.41, p < .001) and parentchild closeness (r = –0.30, p < .001). Reports of PCSC with mothers were positively correlated with sons’ condom use attitudes (r = 0.25, p = .004), condom use selfefficacy (r = 0.21, p < .02), and condom use intentions (r = 0.32, p < .001). Reports of father PCSC were positively associated with sons’ condom use attitudes (r = 0.22, p = .012) and condom use intentions (r = 0.30, p = .001), and marginally associated with condom use selfefficacy (r = 0.16, p < .08). Condom use self-efficacy was also positively associated with parent-child closeness (r = 0.29, p = .001). Parent-child closeness was inversely associated with sexual risk behaviors: number of sexual partners in the past 30 days (r = –0.23, p < .01) and having unprotected sex in the past 30 days (r = –0.24, p = .01).
Differences in Communication With Fathers and Mothers Paired t tests were used to compare reports of PCSC with mothers and fathers. The hypothesis that adolescent boys would report higher PCSC with mothers compared with fathers was supported. Sons reported greater amounts of PCSC with mothers (M = 25.14, SD = 7.88) than with fathers (M = 23.02, SD = 8.33); using paired t tests, these differences were statistically significant (t = 4.09, df = 127, p < .001).
Influence of PCSC on HIV/STI Knowledge Multivariate linear regression was used to examine the effects of PCSC on HIV/STI knowledge, controlling for age, education, and parent-child closeness. It was hypothesized that mother PCSC and father PCSC would be positively associated with HIV/STI knowledge. Due to concerns about potential multicollinearity, four separate preliminary models were constructed that included each PCSC variable alone, in combination, and totaled. Parentchild closeness and father PCSC were not included in the final model because neither was significantly associated with HIV/STI knowledge scores in bivariate correlations or regression models and both parent-child closeness and father PCSC had moderate to large correlations with mother PCSC (r = 0.54 and 0.74, respectively). The
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final regression model, which included the variables of age, education, and PCSC with mother, was significant (F-statistic = 3.76, p = .01) and explained 9.2% of the variance in HIV/STI knowledge. Mother PCSC was the only significant predictor in the model (B = .077, standard error = .025, t = 3.14, p = .002). In sum, the results supported the hypothesis for mother-son PCSC but not for father-son PCSC.
Parental Influences of Sons’ Sexual Risk Outcomes Three sexual risk behavioral outcomes were examined, including number of sexual partners, number of sex acts, and having any unprotected sex during the past 30 days. Negative binomial regression (NBR) was performed for predicting number of sexual partners because the distribution of the dependent variable was highly positively skewed, and the variable was overdispersed count data. NBR is a generalization of Poisson regression that includes an extra parameter to model the overdispersion (Hutchinson & Holtman, 2005). Number of sex acts was examined using ordinary least squares regression, since the distribution was not highly skewed (M = 10.8; median = 10.0; SD = 9.0). Multiple logistic regression was performed for a dichotomized outcome variable, that is, having any unprotected sex (used condoms always = 0 vs. not always = 1). The last analysis was conducted based only on those who were sexually active in the past 30 days. As mothers’ and fathers’ PCSC scores were highly correlated (r = 0.74), separate analyses were conducted for each of the three dependent variables. Combined PCSC scores or individual parent PCSC scores did not differ based on education.
Number of sexual partners in the past 30 days. Reported number of sexual partners ranged from 0 to 50 (M = 2.9; median = 2.0; SD = 5.1). As seen in Table 2A (published online), after controlling for other factors (including PCSC with mothers and age), education, condom use self-efficacy, and beliefs about condom use were significantly related to number of sexual partners. Adolescent males who had a higher level of education (B = 0.28, p = .02), those who had a lower self-efficacy (B = –0.63, p < .001), and those who had more negative beliefs about condom use (B = 0.03, p = .01) were more likely than their counterparts to have more sexual partners. After controlling for PCSC with fathers, age, and education, factors significantly related to the dependent variable included condom use self-efficacy (B = –0.44, p = .001) and beliefs about condom use (B = 0.02, p = .03). PCSC with mothers and fathers was not associated with number of sexual partners.
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Number of sex acts in the past 30 days. As seen in Table 2B (published online), PCSC with mothers and PCSC with fathers were not significant factors in predicting number of sex acts. Neither age nor education was significantly related to the dependent variable. However, condom use self-efficacy was a significant factor after controlling for PCSC with mothers and other variables (Beta = –0.25, p = .01), and beliefs about condom use was significantly related to number of sex acts, after controlling for PCSC with fathers and other variables (Beta = –0.24, p = .01). Adolescent males with negative beliefs about condom use were less likely than others to be sexually active. Unprotected sex in the past 30 days. Most of the study participants (90%) were currently sexually active; of those, 41% did not always use condoms. Engaging in any unprotected sex (i.e., inconsistent or no use of condoms) was significantly correlated with PCSC with mothers (r = –0.35, p < .001) and with fathers (r = –0.20, p < .05). Those who had less sexual communication with their parents were more likely to report inconsistent or no condom use. However, after adding condom use selfefficacy and beliefs about condom use into the model, PCSC was no longer significantly related to the outcome variable. This result indicated that the effect of PCSC on condom use behavior was mediated by condom use selfefficacy or condom beliefs and attitudes. As is shown in Table 2C (published online), older age, less condom use self-efficacy, and more negative beliefs about condom use were significantly related to inconsistent or no use of condoms. Other independent variables, including education and ever-married parents, were not significantly related to the outcome. Results were similar between the two models. Condom use intentions in the next 3 months. A fourth sexual risk outcome, condom use intentions, was also examined. Logistic regression was used for the dichotomized outcome variable. Prior to the analysis, condom use intentions were recorded as 0 (not at all likely or somewhat likely) vs. 1 (likely or very likely). As seen in Table 3 (published online), both PCSC with mothers and with fathers, age, education, and parents’ marital status (ever) were not significant factors in predicting the outcome variable. In both models, condom use self-efficacy (adjusted odds ratio = 2.83, p = .01; adjusted odds ratio = 3.18, p = .01) and beliefs about condom use (adjusted odds ratio = 0.82, p < .001; adjusted odds ratio = 0.82, p < .001) were statistically significantly related to adolescents’ condom use intentions. Those who had higher
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condom use self-efficacies and more positive beliefs about condom use were more likely than their counterparts to intend to use condoms in the next 3 months.
Discussion The findings from the current study supported the contention that PCSC and closeness influence the sexual risk behaviors of AA male adolescents. Consistent with earlier studies (Hutchinson & Montgomery, 2007; Tsvakayi Kapungu et al., 2010), mothers were reported to be more likely to communicate about sexual topics than fathers. PCSC with mothers and fathers was associated with sons having less permissive attitudes toward sex, more positive attitudes toward condoms, and greater intentions to use condoms. Moreover, mother-son sexual communication was associated with decreased HIV-related risk behaviors, consistent with previous research with AA families (Hutchinson et al., 2003; Jaccard, Dittus, & Gordon, 2000; Somers & Paulson, 2000; Tsvakayi Kapungu et al., 2010). Mixed results were found in the existing literature regarding the effect of parent-child closeness and relationship quality on adolescent sexual beliefs and behaviors (Miller, Benson, & Galbraith, 2001; Somers & Paulson, 2000). The current study found significant correlations between closeness and sons’ condom use self-efficacy and inverse associations with their sexually permissive attitudes and risk behaviors. These findings were consistent with earlier studies that found that adolescents who feel positively about their parents may be better able to listen, ask questions, and absorb parents’ values and beliefs (Moore & Chase-Lansdale, 2001). An interesting finding was the impact of marriage on AA youths’ condom use and sexual activity. Participants whose parents were ever married were more likely to report that they intended to use condoms in the next 3 months. In addition, young men whose parents were ever married had fewer partners than those whose parents were never married. It is difficult to ascertain the relationship between parental marriage and condom use intentions. One possible explanation is that parents who have been married have somehow communicated the importance of sexual activity within the confines of marriage; it is also possible that parental marriage promoted greater parent-child attachment and parental involvement over the life course. Additional research is needed to explore the relationship, if any, between parental marriage and condom use. This study sought to examine the influence of PCSC and closeness from a theoretical standpoint using the PBE-TPB. Data from this study demonstrated that
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parental influences (communication and closeness) can play a significant role in reducing sexual risk behaviors. Therefore, parents who communicate their attitudes, beliefs, and values about sexual activity can affect their sons’ attitudes, beliefs, and self-efficacy about sexual activity, thereby positively influencing their risk behaviors. From an international perspective, this study adds to the knowledge about the effect parent-child closeness and PCSC have on reducing adolescent sexual risk behaviors. Researchers have studied PCSC and noted the influence cultural traditions have on PCSC (Biddlecom et al., 2009; Phetla et al., 2008; Wamoyi, Fenwick, Urassa, Zaba, & Stones, 2010). For example, in Thailand researchers found that PCSC involved discussions about dating and body changes, but little or no information was discussed on what sexual activity is, the importance of delaying sexual activity, HIV, contraception, or pregnancy (Rhucharoenpornpanich et al., 2012). Results from a study in Singapore found that parents thought that PCSC was important but felt uncomfortable or less confident in their ability to do so; only 50% of parents were actually able to carry out these conversations (Hu et al., 2012). Researchers have noted that gender and cultural norms play a role in determining which parent provides sexual communication and the content of the discussions. Tanzanian parents emphasized societal gender role expectations (Wamoyi et al., 2010); conversations with girls focused on abstinence until marriage, while boys received messages about sexual prowess. PCSC is limited by cultural norms and the family living situations in Ghana (Kumi-Kyeree, Awusabo-Asare, Biddlecom & Tanle, 2007). Ghanaian culture dictates the household structure; therefore, many extended family members are living together. Although biological parents are responsible for PCSC, other family members might be engaging in conversations about sex. With the rates of STIs and HIV/AIDS continuing to rise globally (Kaiser Family Foundation, 2012), the importance of developing interventions for reducing adolescent sexual risk behaviors must be stressed. This study lends support to the growing body of evidence that PCSC can reduce sexual risk behaviors. More culturally and evidence-based programs are needed to assist parents in developing the necessary skills to effectively communicate their attitudes, values, and beliefs about sexual health.
Limitations There are several limitations to this study. The study included a convenience sample of late adolescent males
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who volunteered to participate. The PI was an AA female; recruitment by AA males and the use of audiocomputer-assisted self-interviewing may have enhanced participation rates. In addition, all of the participants were recruited from inner-city neighborhoods in Boston; suburban and rural youth were not represented. The relatively small sample size limits generalizability. Other limitations include the use a of single-item measure to operationalize parent-child closeness. Future studies need to have separate measures for each parent, recognizing that a child may have a closer relationship with one parent than the other. Additionally, using a single-item measure for “intention to use condoms” and “attitudes toward using condoms” may have been a limitation. Further assessment of psychometrics, including the HIV/STI Knowledge Scale, is needed with this population.
Implications for Practice and Future Research The results of this study underscore the potential importance of family-based approaches to reduce adolescent sexual risk behaviors. Sex, sexuality, and sexual behavior are often difficult topics for parents to broach with their children. Nursing has always supported open communication between parents and their children (Wakley, 2011), and nurses are in the position to help facilitate the parent-child communication process. Parents’ educational needs should be assessed during well child visits and anticipatory guidance provided. Interventions that may facilitate effective parenting include sex education classes for parents to enhance knowledge, answer questions, and dispel myths, as well as parenting training that includes role modeling and skill-building in communication, sexual communication, and other important parenting behaviors (e.g., monitoring and supervision). The Strong African American Families (SAAF) program is one such family-based intervention that has demonstrated success in helping parents protect their children from alcohol use and early sexual debut by strengthening parenting skills and enhancing parent-child communication (McBride Murray, Berkel, Brody, Gibbons, & Gibbons, 2007). SAAF participants attend weekly training sessions and receive information on parenting, discipline, family values, racial pride, and community support. Participating children have been more likely to report positive self-esteem, positive racial identity, positive body image, and lowered likelihood to be influenced by peers to engage in sexual activity. The findings from the current study also suggest areas for further investigation. There has been limited research elucidating the content of PCSC between fathers and sons (Hutchinson & Cederbaum, 2011). In addition, little
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is known about how father-son sexual communication content and processes vary depending on the family structure and residential arrangements. Although fathers communicate with their children about sex (Gillmore, Chen, Haas, Kopak, & Robillard, 2011), fathers are less likely to communicate sexual health information and more likely to focus on values transmission and general sexual socialization (Hutchinson & Cederbaum, 2011; Wight, Williamson, & Henderson, 2006). Further research is needed to better understand how the role of fathers differs from that of mothers in the sexual socialization of children and how these processes operate within AA families.
Conclusions Findings from the current study contribute to the body of evidence that positive parent-child relations and sexual communication may reduce adolescent sexual risk behaviors (Epstein & Ward, 2008; Glenn et al., 2008; Hadley et al., 2009). Considering that AA late adolescent males report high levels of closeness to their parents (Smetana, Metzger, & Campione-Barr, 2004), family-based approaches to sexual risk reduction may be particularly useful. Family-based interventions to promote positive parent-son relations and increase PCSC in urban AA families should be developed and rigorously evaluated.
Acknowledgments This research was supported by an American Nurses Foundation–Mary E. Carnegie/Nurses in AIDS Care grant to Allyssa L. Harris.
Clinical Resources
r r r
Sexual Risk Behavior Publications and Resources. Centers for Disease Control and Prevention: http:// www.cdc.gov/HealthyYouth/sexualbehaviors/ Office of Adolescent Health: http://www.hhs.gov/ ash/oah/adolescent-health-topics/reproductivehealth/ AIDS.gov: http://www.aids.gov/
References Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior & Human Decision Processes, 50, 179–211.
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Aronowitz, T., Rennells, R., & Todd, E. (2005). Heterosocial behaviors in early adolescent African American girls: The role of mother-daughter relationships. Journal of Family Nursing, 11, 122–139. Bakken, R., & Winter, M. (2002). Family characteristics and sexual risk behaviors among Black men in the United States. Perspectives on Sexual and Reproductive Health, 34, 252–258. Biddlecom, A., Awusabo-Asare, K., & Bankole, A. (2009). Role of parents in adolescent sexual activity and contraceptive use in four African countries. International Perspectives on Sexual and Reproductive Health, 35, 72–81. Bleakley, A., Hennessy, M., Fishbein, M., & Jordan, A. (2009). How sources of sexual information relate to adolescents’ beliefs about sex. American Journal of Health Behaviors, 33, 37–48. Centers for Disease Control & Prevention. (2011). Youth risk behavior surveillance—United States, 2011. Surveillance summaries, June 8, 2012. Morbidity & Mortality Weekly Report, 61, No.SS-4. Retrieved from http://www.cdc.gov/ HealthyYouth/yrbs/index.htm DiIorio, C., Hockenberry-Eaton, M., Maibach, E., & Miller, K. (1996). The content of African American mothers’ discussions with their adolescents about sex. Journal of Family Nursing, 2, 365–382. DiIorio, C., Lehr, S., Wasserman, J.L., Eichler, M., Cherry, C., & Denzmore, P. (2006). Fathers are important people: A study of father-son sexual communication. Journal of HIV/AIDS Prevention in Children & Youth, 7, 55–72. DiIorio, C., Resnicow, K., Dudley, W., Thomas, S., Wang, D. T., Van Marter, D.,. . . Lipana, J. (2000). Social cognitive factors associated with mother-adolescent communication about sex. Journal of Health Communication, 5, 41–51. Epstein, M., & Ward, L. M. (2008). “Always use protection:” Communication boys receive about sex from parents, peers and the media. Journal of Youth & Adolescence, 37, 113–126. Gillmore, M. R., Chen, A. C., Haas, S., Kopak, A., & Robillard, A. (2011). Do family and parenting factors in adolescence influence condom use in early adulthood in a multiethnic sample of young adults? Journal of Youth & Adolescence, 40, 1503–1518. Glenn, B., Demi, A., & Kimble, L. (2008). Father and adolescent son variables related to son’s HIV prevention. Western Journal of Nursing Research, 30, 73–89. Hadley, W., Brown, L., Lescano, C., Kell, H., Spalding, K., DiClemente, R., & Donenberg, G. (2009). Parent–adolescent sexual communication: Associations of condom use with condom discussions. AIDS & Behavior, 13, 997–1004. doi:10.1007/s10461=008-9468-z Hendrick, S. & Hendrick, C. (1987). Multidimensionality of sexual attitudes. The Journal of Sex Research, 23, 502–526. Hendrick, S., Hendrick, C., & Reich, D. (2006). The brief sexual attitudes scale. Journal of Sex Research, 43(1), 76–86.
Journal of Nursing Scholarship, 2013; 45:2, 1–10. C 2013 Sigma Theta Tau International
Harris et al.
Hu, Y., Wong, M.L., Prema, V., Wong, M.L., Fong, N.P., Tsai, F.F., & Vijaya, K. (2012). Do parents talk to their adolescent children about sex? Findings from a community survey in Singapore. Annals of the Academy of Medicine Singapore, 41, 239–246. Hutchinson, M. K. (2007). The parent-teen sexual risk communication scale (PTSRC-III). Nursing Research, 56, 1–8. Hutchinson, M. K., & Cederbaum, J. (2011). Talking to daddy’s little girl about sex: Daughters’ reports of sexual communication and support from fathers. Journal of Family Issues, 32, 550–572. doi:10.1177/0192513×10384222 Hutchinson, M. K., & Holtman, M. (2005). Analysis of count data using Poisson regression. Research in Nursing & Health, 28, 408–418. doi:10.1002/nur.20093 Hutchinson, M. K., Jemmott, J., Jemmott, L., Braverman, P., & Fong, G. (2003). The role of mother-daughter sexual risk communication in reducing sexual risk behaviors among urban adolescent females: A prospective study. Journal of Adolescent Health, 33, 98–107. Hutchinson, M. K., & Montgomery, A. (2007). Parent communication and sexual risk among African Americans. Western Journal of Nursing Research, 29, 691–707. Hutchinson, M. K., & Wood, E. (2007). Reconceptualizing adolescent sexual risk in a parent-based expansion of the theory of planned behavior. Journal of Nursing Scholarship, 39, 141–146. Jaccard, J., Dittus, P., & Gordon, V. (2000). Parent-teen communication about premarital sex: Factors associated with the extent of communication. Journal of Adolescent Research, 15(2), 187–208. doi:10.1177/0743558400152001 Jemmott, J. B., Jemmott, L. S., Spears, H., Hewitt, N., & Cruz-Collins, M. (1992). 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, 512–519. Jemmott, L. S., & Jemmott, J. (1991). Applying the theory of reasoned action to AIDS risk behavior: Condom use among Black women. Nursing Research, 40, 228–234. Kaiser Family Foundation. (2012). The global HIV/AIDS epidemic (Report No. 3030–17). Retrieved from http://www.kff.org/hivaids/3030.cfm Koniak-Griffin, D. (1997). AIDS risk behaviors, knowledge, and attitudes among pregnant adolescents and young mothers. Health Education & Behavior, 24, 613–624. Kumi-Kyereme, A., Awusabo-Asare, K., Biddlecom, A., & Tanle, A. (2007). Influence of social connectedness, communication and monitoring on adolescent sexual activity in Ghana. African Journal of Reproductive Health, 11, 133–149. McBride Murry, V., Berkel, C., Brody, G., Gibbons, M., & Gibbons, F. (2007). The Strong African American Families Program: Longitudinal pathways to sexual risk reduction. Journal of Adolescent Health, 41, 333–342. doi:10.1016/j.jadohealth.2007.04.03 Journal of Nursing Scholarship, 2013; 45:2, 1–10. C 2013 Sigma Theta Tau International
Parental Influences of Sexual Risk
Miller, B., Benson, B., & Galbraith, K. (2001). Family relationships and adolescent pregnancy risk: A research synthesis. Developmental Review, 21(1), 1–38. Moore, M., & Chase-Lansdale, L. (2001). Sexual intercourse and pregnancy among African American girls in high-poverty neighborhoods: The role of family and perceived community environment. Journal of Marriage & Family, 63, 1146–1157. Mullen Harris, K., Furstenberg, F., & Marmer, J. (1998). ¨ Parental involvement with adolescents in intact families: The influence of fathers over the life course. Demography, 35, 201–216. The National Campaign. (2008). Fast facts. Men in the United States: Unplanned pregnancy, sexual activity, and contraceptive use. Retrieved from http://www.thenationalcampaign. org/resources/pdf/fast-facts-men-in-the-united-states. pdf Oliver, W. (2006). “The streets” An alternative Black male socialization institution. Journal of Black Studies, 36, 918–937. Phetla, G., Busza, J., Hargreaves, J., Pronyk, P., Kim, J., Morison, L., Watts, C., & Porter, J. (2008). “They have opened our mouths:” Increasing women’s skills and motivation for sexual communication with young people in rural South Africa. AIDS Education & Prevention, 20, 504–518. Rhucharoenpornpanich, O., Chamratrithirong, A., Fongkaew, W., Miller, B., Cup, P., Rosati, M., . . . Chookhare, W. (2012). Parent-teen communication about sex in urban Thai families. Journal of Health Communication: International Perspectives, 17, 380–396. doi: 10.1080/10810730.2011.626668 Smetana, J., Metzger, A., & Campione-Barr, N. (2004). African American late adolescents’ relationships with parents: Developmental transitions and longitudinal patterns. Child Development, 75, 932–947. Somers, C., & Paulson, S. (2000). Students’ perceptions of parent-adolescent closeness and communication about sexuality: Relations with sexual knowledge, attitudes and behaviors. Journal of Adolescence, 23, 629–644. Tsvakayi Kapungu, C., Baptiste, D., Holmbeck, G., McBride, C., Robinson-Brown, M., Sturdivant, A., . . . Paikoff, R. (2010). Beyond the “birds and the bees”: Gender differences in sex-related communication among urban African American adolescents. Family Process, 49, 251–264. doi:10.1111/j.1545–5300.2010.01321.x Wakley, G. (2011). Helping parents with sex education. Journal of Family Health Care, 21, 30–33. Wamoyi, J., Fenwick, A., Urassa, M., Zaba, B., & Stones, W. (2010). Parent-child communication about sexual and reproductive health in rural Tanzania: Implications for young people’s sexual health interventions. Reproductive Health, 7, 1–18. Wasserman, J., Flannery, M.A., & Clair, J.M. (2007). Raising the ivory tower: The production of knowledge and distrust 9
Parental Influences of Sexual Risk
of medicine among African Americans. Journal of Medical Ethics, 33, 177–180. Wight, D., Williamson, L., & Henderson, M. (2006). Parental influences on young people’s sexual behavior: A longitudinal analysis. Journal of Adolescence, 29, 473–494. doi:10.1016/j.adolescence.2005.08.007 Willis, L., & Clark, L. (2009). Papa was a rolling stone and I am too: Paternal caregiving and its influence on the sexual behavior of low-income African American men. Journal of Black Studies, 39, 548–599.
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Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web site: Table 2. Regression Models for Predicting Sexual behaviors in the past 30 days. Table 3. Logistic regression Model Predicting Condom Use Intentions.
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