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1 THE MODERATIONAL EFFECTS OF COPING STRATEGIES ON THE ASSOCIATIONS OF STRESS, DEPRESSION, AND PERCEIV ED FAMILY CONFLI CT WITH RISKY SEXUAL BEHAVIOR AMONG ADOLESCENTS LIVING WITH A CHRONIC ILLNESS By PHYLLIS DIANA IVERY A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2009
2 2009 Phyllis Diana Ivery
3 To my Mom and my sister, Phelic ia, for your consistent support
4 ACKNOWLEDGMENTS Special appreciation goes to m y mother and my sister, Phelicia, for your unwavering support and the sacrifices that you made in order that I might accomplish the goal that I set for myself. Thank you to Dr. Tucker for keeping a pr omise and being willing to go through the fire for me. Most importantly, I thank God for always being with me.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ............................................................................................................... 4LIST OF TABLES ...........................................................................................................................7ABSTRACT ...................................................................................................................... ...............8 CHAP TER 1 INTRODUCTION .................................................................................................................. 10Risky Sexual Behavior ...........................................................................................................10Theories of Health Risk Behaviors ......................................................................................... 12Adolescent Depression, Stress, a nd the Family Environment ................................................ 132 REVIEW OF THE LITERATURE ........................................................................................16Health Risk Behaviors in Adolescents ................................................................................... 16Theories of Health-Risk Behaviors ........................................................................................ 19Sexual Risk Behaviors Among Adolescents .......................................................................... 24Influences on Sexual Risk Behavior .......................................................................................26Depression and Stress Among Adolescents ........................................................................... 27Influence of Depression on Sexual Risk Behavior ..........................................................28Influence of Stress on Sexual Risk Behavior .................................................................. 31Family Environment and Sexual Risk Behavior .................................................................... 33Influence of Family Conflict on Sexual Risk Behavior .......................................................... 34Depression, Stress, and Family Conflict Am ong Adolescents with Chronic Illnesses .......... 35Coping .....................................................................................................................................36Coping Strategies .............................................................................................................37Coping in Association with Stress, Depression, and Family Environment ..................... 38Coping in Association with Health-Risk Behaviors ........................................................ 40Coping in Association with Sexual Risk Behavior ......................................................... 41Summary ....................................................................................................................... ..........44Hypotheses and Research Questions ...................................................................................... 453 METHOD ........................................................................................................................ .......47Participants .................................................................................................................. ...........47Instruments ................................................................................................................... ..........47Youth Risk Behavior High School Questionnaire 2003 (YRBS) ...................................48The Life Stressors and Social Resources Inventory Youth Form (LISRES-Y) ........... 48Center for Epidemiologic Studies Scale (CES-D) ........................................................... 49Family Relations Index (FRI) ..........................................................................................50Childrens Coping Strategies Ch ecklistRevision 1 (CCSC-R1) ................................50Marlowe-Crowne Social Desirabili ty Scale-Short Form (MCSD-S) ..............................51
6 Procedure ..................................................................................................................... ...........51Identification and Recruitment of Participants ................................................................ 51Data Collection ................................................................................................................524 RESULTS ....................................................................................................................... ........54Descriptive Data .............................................................................................................. .......54Results from the Analyses to Test Hypotheses 1-5 ................................................................ 54Results from the Analysis to Test the Research Question ...................................................... 575 DISCUSSION .................................................................................................................... .....67Summary and Interpretati ons of the Results ........................................................................... 67Limitations of the Present Study ............................................................................................. 72Directions for Future Research ...............................................................................................73Implications for Counseling Psychologists ............................................................................ 74APPENDIX A YOUTH INFORMATION QUESTIONNAIRE (YIQ) ......................................................... 75B YOUTH RISK BEHAVIOR HIGH SCHOOL QUESTIONNAIRE (YRBS) .......................76C LIFE STRESSORS AND SOCIAL RE SOURC ES INVENTORYYOUTH FORM (LISRES-Y) ............................................................................................................................78D CENTER FOR EPIDEMIOLOGIC STUDIES (CES-D) ....................................................... 83E FAMILY RELATIONS INDEX (FRI) .................................................................................. 85F CHILDRENS COPING STRATEGIES CH ECKLIST REVISION 1 (CCSC-R1) ........... 87G MARLOWE-CROWNE SOCIAL DESI RABILITY SCALE (MCSDS) ..............................91H INVITATION LETTER .........................................................................................................93I PARENTAL INFORMED CONSENT ..................................................................................95J ADOLESCENT ASSENT FORM ........................................................................................ 107K PAYMENT RELEASE FORM ............................................................................................113LIST OF REFERENCES .............................................................................................................114BIOGRAPHICAL SKETCH .......................................................................................................123
7 LIST OF TABLES Table page 3-1 Participant demographic data ............................................................................................. 534-1 Descriptive data for the major variables for all participants ..............................................594-2 Descriptive data for the major variab les for African American participants ..................... 594-3 Descriptive data for the major variab les for non-Hispanic wh ite participants .................. 594-4 Descriptive data for the major va riables for female participants ....................................... 604-5 Descriptive data for the major variables for male participants .......................................... 604-6 Intercorrelations between the major variab les of interest and so cial desirability .............. 614-7 Summary of the multiple regression analys is for the variables predicting sexual risk behavior..............................................................................................................................624 Hierarchical multiple regression models with depression, stress, perceived family conflict, and active coping strategy as pred ictors and sexual risk behavior as the criterion ..................................................................................................................... .........634 Hierarchical multiple regression models with depression, stress, perceived family conflict and avoidance coping strategy as pred ictors and sexual risk behavior as the criterion ..................................................................................................................... .........644 Hierarchical multiple regression models with depression, stress, perceived family conflict, and support seeking coping as predic tors and sexual risk behavior as the criterion ..................................................................................................................... .........654 Hierarchical multiple regression models with depression, stress, perceived family conflict, and distraction coping as predictors and sexual risk behavior as the criterion .... 66
8 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE MODERATIONAL EFFECTS OF COPING STRATEGIES ON THE ASSOCIATIONS OF STRESS, DEPRESSION, AND PERCEIV ED FAMILY CONFLI CT WITH RISKY SEXUAL BEHAVIOR AMONG ADOLESCENTS LIVING WITH A CHRONIC ILLNESS By Phyllis Diana Ivery August 2009 Chair: Carolyn Tucker Major: Counseling Psychology The purpose of the present study was to examine self-reported levels of stress, depression, perceived family conflict, and coping stra tegy (i.e., active, support seeking, di straction, avoidance) as predictors of e ngagement in risky sexual behavior among adolescents living with a chronic illness. The current study proposed that coping strategy serves as a moderator of the relationship between the predictor variables (stres s, depression, and perceived family conflict) and engagement in risky sexual behavior. The cu rrent study also examined the associations of participants age, gender, and ethnicity with th eir self-reported levels of (a) risky sexual behavior, (b) depression, (c) stress and (d) coping strategies. Part icipants in this study included 56 chronically ill adolescents (16 African Amer ican and 40 non-Hispanic White American) ages 12-17. Results of Pearson Product Moment correlations revealed that levels of stress, depression, or perceived family conflict were not significantl y associated with engagement in risky sexual behavior. Multiple regression analyses revealed th at levels of stress, depression, and perceived family conflict were not significant predictors of chronically ill adolescents engagement in risky sexual behavior. Additionally, hierarchical multi ple regression analyses were performed to
9 determine if coping strategy would moderate the relationship between (a) levels of depression, stress, and perceived family conflict and (b) en gagement in risky sexual behavior. The results revealed that active coping was a significant pr edictor of sexual risk behavior, accounting for 39.9% of the variance. A significan t depression x active coping inte raction was found as well as a significant perceived family conflict x active c oping interaction. Finally, a multivariate analysis of covariance was performed to test the associations of participants ag e, gender, or ethnicity with their self-reported levels of (a) risky sexual behavior, (b) depression, (c) stress, and (d) coping strategies. Findings indica ted significant differences in dist raction coping as a function of ethnicity and a significant difference in depres sion as a function of a gender x ethnicity interaction. Results of the present study s uggest that interventions design ed to address risky sexual behavior should incorporate incr easing the use of active coping strategies which would prove particularly relevant in situations where adolescents are depressed and/or are experiencing conflict within their family
10 CHAPTER 1 INTRODUCTION Risky Sexual Behavior Health-risk behaviors among adolescents are a m ajor health concern. Health-risk behaviors are defined as behaviors that occur under ones own volition and that have uncertain and possibly negative health outcomes (Irwin, 1990). Although homicide, suicide, and accidental injury comprise the major causes of all deaths of adolescents, preventabl e health-risk behaviors also make substantial contributi ons to adolescent morbidity rate s (Millstein, Irwin, Adler, Cohn, Kegeles, & Dolcini, 1992). Risky or unsafe sexual activity is one of the primary preventable health-risk behaviors engaged in by adolescents. Risky sexual behavior is any sexual behavior that increases the risk of contracting a sexually transmitted infection (STI ), including the human immunodeficiency virus (HIV), or becoming pregnant (Taylor-Seehafer & Rew, 2000). Sexual risk behaviors, which place adolescents at increased risk for a number of potentially serious health consequences, can include such sexual activity as intercourse at an early age, engaging in unprotected sexual activity, and sexual activity with a number of different partners (Taylor-Seehafer & Rew, 2000). Findings from the 2007 national Youth Risk Behavi or Survey indicated that 48% of U.S. high school students nationwide had ever had sex in their lifetime. Of those who had engaged in sex, 15% had had four or more partners since they had become sexually active (CDC, 2008). National surveys have shown that by as early as eighth grade, up to 30% of adolescents report being sexually active (Johnston, OMalley, & Bachma n, 1998). Meschke, Bartholomae, & Zentall (2001) report that by age 12 approximately 12.1% of males and 3.0% of females have had sexual intercourse. Additionally, African American adolescents are si gnificantly more likely than White
11 adolescents or Hispanic adolesce nts to have engaged in sexual intercourse prior to reaching 13 years of age (Centers fo r Disease Control, 1994). Not only are adolescents engagi ng in sexual activity at an al arming rate, the consequences of sexual risk behavior among adolescents are su bstantial and undesirable. Teenage pregnancy is one of the serious consequences of risky sexual behavior. The teen pregnancy rate in the United States, although on the d ecline, is much higher than the ra tes in other Western industrialized countries, and remains a significant problem (Kirby, 2002). Nearly 900,000 teen pregnancies occur in the United States each year, with eight out of ten of those pregnancies being unintended (Henshaw, 2004). Adolescents are also at a high risk of cont racting sexually transmitted infections, including human immunodeficiency virus (H IV; CDC, 2000). Four million t eens a year acquire an STD, with about half of the new cases of HIV reported each year occurring among those under 25 years of age (CDC, 2004). According to the CDC (2003), between 1985 and 2003, over an estimated 5,000 cases of AIDS were reported among 13 to 19 year olds. Of the over 400 cases reported in 2003 alone, females comprised 46% of the cases (CDC, 2003). Among all of the newly reported cases of HIV infection among wo men, 64 percent of those cases were African American women (CDC, 2001). Give n that there is generally a 10-year incubation period from the time of contraction of HIV to diagnosis, many of these African American women were presumably exposed to the virus during their adolescence. These alarming statistics, coupled with the report that many minorit ies of lower socioeconomic stat us have a greater likelihood of dying from HIV due to disparities in healthcare ( AHRQ, 2004), magnify the need for research to identify the factors that increase or decrease the likelihood that teenager s will engage in risky sexual behavior.
12 Although medical interventions have proven moderately effective in decreasing the number of adolescents who become pregnant or infected with an STI, including AIDS, complete control and prevention cannot be achieved through medical advances alone (Hovell & Hillman, 1994). According to Kirby (2002), it is through the identification of the critical antecedents of sexual behaviors that meaningful interventions can be developed. Identification of these antecedents may also lead to the ability to identif y adolescents who are more likely to engage in risky sexual behaviors. Behavior al science research, which include s research within the field of psychology, provides the best means for identif ying, understanding, and c ontrolling adolescent sexual risk behavior (Kirby, 2002). Theories of Health Risk Behaviors A num ber of biological, psychol ogical, and social variables have been examined as influences on engagement in risky behavi ors among adolescents. A number of different theoretical perspectives and models have been utilized to examine these variables (Pertains, 1995). Theorists have postulated that adolescents engage in ri sky behaviors for a number of reasons, including negative family influences, poor academic performance, negative emotions or affect, peer influences, and sensation seeking (Caffray & Schneider, 2000). A majority of the proposed theories explicitly or implicitly sugge st that adolescents engagement in risky behaviors, including risky sexual be havior, is motivated by a desire to enhance positive affective states or to avoid negative affective stat es (Caffray & Schneider, 2000). Consequently, researchers have suggested that more atten tion should be given to affectively-oriented motivations for behavior when exploring the risky health-rela ted behaviors of adolescents (Brown, DiClemente, & Reynolds, 1991). According to a motivational model based on coping, risky sexual behavior may result from a desire to avoid or minimize nega tive emotions (Cooper, Agocha, & Sheldon, 2000).
13 According to this theory, negative emotionality motivates engagement in problem behaviors as a means of coping. Therefore, adolescents who suffer from negative emotional states may engage in risky sexual behavior to a lleviate negative feelings, such as depression and stress. However, adolescents who possess adaptive coping strategies may be less lik ely to engage in risky sexual behavior, regardless of the pr esence of negative emotional st ates. Thus, coping strategy may serve as a variable that moderates the associa tion between the presence of negative emotional states in adolescents and the adolescents engagement in risky sexual behavior. Adolescent Depression, Stress, and the Family Environment Adolescence is a period of adjustment, tran sition, and change that can potentially be marked by depression and stress. Depression am ong adolescents has been shown to be highly prevalent (Schraedley, Gotlib, & Hayward, 1999). Studies have found that 25% to 40% of adolescent girls and 25% to 35% of adolescent boys experienced symptoms of depression during a six-month period (Compas, Ey, & Grant, 1993). A variety of factors such as family, peer pressure, and academic concerns may be sources of stress for adolescents. Resear ch has indicated that an accumu lation of stressful events and circumstances may occur as a function of the tran sitions and adjustments that are characteristic during adolescence (Rudolph & Hammen, 1999). This accumulation of life stressors places adolescents at increased risk for emotional and behavioral problems (Jackson & Warren, 2000). Results of some studies have s hown a direct relationship between stress and various problem or risk behaviors (Schmeelk-Cone & Zimmerm an, 2003). Sexual beha vior is among those problem/risk behaviors that have been linked to reports of stress (Kirby, 2002). It has been reported that adol escents who are depressed are si gnificantly more likely than a control sample of adolescents to have experien ced stressful events prior to becoming depressed (Williamson, Birmaher, Frank, Anderson, Matty, and Kupfer, 1998). Given that studies have
14 indicated a relationship between depression and risky sexual behavi or, and that stress has been shown to be related to depressi on, it appears that stress may have both a direct and an indirect association with risky sexual behavior in adolescents. Therefore, it stands to reason that both depression and stress are important variables to investigate in asso ciation with adolescents risky sexual behavior. In examining risky sexual behavior, not only are individual variable s important, family environment variables are also worthy of inves tigation because they have also been linked to risky sexual behavior in adol escents (Kirby, 2002). The result s of a review study conducted by Kirby (2002) indicated that the quality of relationships within the fa mily is an antecedent to the initiation of sex, pregnancy, and safe sex prac tices. High levels of warmth and support from parents may reduce an adolescents desire to seek intimacy from alternative relationships (Moore & Chase-Lansdale, 2001). Additionally, results of studies have shown that family environment variables are associated with depression (Lau & Kwok, 2000) a nd stress in adolescents. Although a motivational model of coping with negative emotions such as depression and stress can be used to explain adolescents enga gement in risky sexual behavior, one limitation of the theory is that it neglects to consider the possible influence of the coping strategy of the adolescent on the occurrence of risky sexual behavior. Cooper, Wood, Orcutt, and Albino (2003) state that dysfunctional coping styl es are key risk factors in the promotion of problem behaviors in adolescents. Therefore, it can be extrapolated that if adolescents ar e capable of utilizing adequate coping mechanisms, they will be less like ly to engage in sexual risk behaviors when experiencing stress, depression, or perceived family conflict. Researchers have suggested that more atten tion should be given to affectively-oriented motivations for behavior when exploring the h ealth-related behaviors of adolescents (Brown,
15 DiClemente, & Reynolds, 1991). The present stud y will examine the moderating influence of coping on the associations of st ress, depression, and perceived fa mily conflict with risky sexual behavior among adolescents. Spec ifically, the purpose of the planned study is to examine whether adolescents coping strategies moderate the association between (a) th eir levels of stress, depression, and perceived family conflict and (b) their engagement in risky sexual behaviors.
16 CHAPTER 2 REVIEW OF THE LITERATURE Health Risk Behaviors in Adolescents Adolescence is a crucial developm ental period. During this developmental stage, adolescents are exposed to a number of challenge s in their lives ranging from academic pressures and social influences to family and relati onship conflict. Given the many challenges that adolescents face, adolescence is a period marked by adjustment in response to these numerous challenges (Spruijt-Metz, 1999). Adolescence is also a period of life in which patterns of behavior are established that have life l ong effects (Spear & Ku lbok, 2001). Health-risk behaviors are among those behaviors that are ofte n established during adol escence. According to Shapiro, Siegel, Scovill and Hays (1998), experiment ation with roles, idea s, styles, as well as risky behaviors, is characteristic of the period of adolescence. Health risk behaviors are de fined as behaviors that are undertaken by ones own volition and that have uncertain and possibly negativ e health outcomes (Irwin, 1990). Health risk behaviors include behaviors that can interfere with healthy liv ing (Zaleski, Levey-Thors, & Schiaffino, 1998). Despite the potential damage to ones he alth and well-being that engagement in health risk behaviors can cause, many theorists and researchers consider participation in health risk behaviors during adolescence to be a normal part of the developmental process (Zweig, Lindberg, & McGinley, 2001). Adolescents often engage in a variety of h ealth-risk behaviors incl uding drug and alcohol use, violence, and risky sexual behaviors (Cen ters for Disease Control, 1998.) Integrative reviews of research focused on adolescent risk behaviors demonstrate the extensiveness and diversity of the existing literature that is focu sed on adolescent risk behaviors (Fahs, Smith, Atav, Britten, Collins, Morgan, & Spencer, 1999) Results of the data from the 2005 national
17 Youth Risk Behavior Survey (YRBS) conducte d by the Centers for Disease Control and Prevention (CDC; 2006) are particularly notewort hy. Specifically, during the 30 days preceding the administration of the YRBS, the following ad olescent health risk behavior reportedly occurred among students in grades 9 12: (a) 43.3% had drunk alcohol; (b) 9.9% had driven a car or other vehicle when they had been drin king alcohol; (c)18.5% ha d carried a weapon; and (d) 20.2% had used marijuana. Additionally, duri ng the 12 months preceding administration of the 2005 YRBS, 35.9% of students in grades 9 12 had been in a physical fight and 8.4% had attempted suicide. Research focusing specifically on sexual risk be havior has also been conducted. Data from a 2002 National Survey of Family Growth, a surv ey which specifically assessed sexual activity, indicated that by 20 years of age, 75% of young respondents had engaged in premarital sex (Finer, 2007). Of high school students who reporte d that they were sexua lly active, 37.2% had not used a condom at last se xual intercourse (CDC, 2006). Of all of the potential health-risk behaviors in which adolescents may engage, risky sexual behavior is a health-risk behavi or that can have particularly detrimental consequences (e.g., pregnancy, sexually transmitted diseases, etc.). In an effort to decrease adolescents engagement in risky sexual behavior, increa sed educational measures have been implemented. Educational programs designed to reduce or delay sexual activity among adolescents have focused on a range of topics from teaching abstinence to pr oviding knowledge about sexual reproduction and contraceptive options to incr easing decision-making skills (Coley and Chase-Lansdale, 1998). For example, Lindberg, Ku, & Sonenstein (2000) found that between 1991 and 1998, the number of states requiring HIV-prevention education in schools increased from 13 to 35. Additionally, there were increases in abstin ence-related education and education about reproductive health.
18 Despite the increases in education provided to adolescents about risky se xual behavior, solely educating adolescents regarding the risk of engaging in variou s health risk behaviors is usually insufficient for resultant changes in behavior (Fahs, Smith, Atav, Britten, Collins, Morgan, & Spencer, 1999). Therefore, research aimed at understanding the potential precipitating variables for engaging in risky sexual behaviors and th e potential protective variables is essential. The scientific study of adolescent developmen t has always had as part of its implicit and explicit agenda the goal of desc ribing, explaining, predicting, and ameliorating problematic behavior (Steinberg & Morris, 2001, p. 85). In efforts to achiev e this goal, there have been numerous studies that have exam ined the factors that serve to increase the likelihood of engaging in risky sexual behaviors or th at serve as protective factors against engaging in risky sexual behaviors. According to Thornberry, Smith, a nd Howard (1997), the identification of risk factors is important for a number of different reasons. First, th e identification of salient risk factors elucidates areas of increased vulnerab ility for at-risk adolescents. Additionally, it provides structure for designing intervention progra ms by identifying particular areas to target for interventions. Finally, the identification of sa lient sexual risk factors assists in determining which adolescents may benefit the most from the interventions targeting t hose risk factors. The identification of sexual risk factors is complex given that adolescents engagement in risk-taking behaviors is neither a simple nor unidimensional concept (Shapiro et al., 1998). Although a number of studies ha ve been conducted with the goa l of identifying sexual risk factors, Bachanas, Morris, Lewis-Gess, Sarett-Cuasay, Sirl, Ries, & Sawyer (2002) point out that a limited number of these studies have been theo retically based. Therefore, there is a need for more studies that identify risk factors for a dolescent engagement in health risk behaviors utilizing a theoretical framework. This need fo r theoretical grounding is particularly relevant
19 when examining factors that contribute to or moderate adolescent engagement in sexual risk behavior. Theories of Health-Risk Behaviors A num ber of theories and models of adolescent engagement in health -risk behaviors have been developed. These theories address a number of factors that may cont ribute to adolescents engagement in health-risk behaviors, including risky sexual behavior. Some of the most popular theories include the Protection Motivation Th eory (Rogers, 1975), the Theory of Reasoned Action (Ajzen & Fishbein, 1980), Social Cogniti ve Theory (Bandura, 1986), the Theory of Planned Behavior (Ajzen, 1987) and Problem Behavior Theory (Jessor & Jessor, 1977). The above mentioned theories are considered to be cognitive or decision-making theories; however, they do include environmental, psychological, and social variables. These cognitive theories or models are focused on determining why a decision is made to engage in risk-taking behaviors rather than focusing on the consequences of the behavior (Shapiro, Siegel, Scovill, & Hays, 1998). In cognitive or decision-making mode ls, an emphasis is placed on an individuals subjective expectation regarding behavior; as such, these models are also known as valueexpectancy models. Thus, according to SpruijtMetz (1999), with value-expectancy models, behavior is viewed as the produc t of a subjective value of an e xpected outcome and a specific expectation that the behavior will lead to the expected outcome. Therefore, it is believed that the motivation for engaging in behaviors is based up on a desire to achieve the expected outcome. One of the earliest proposed value-expectan cy theories was the Protection Motivation Theory (PMT) which was originally developed by Rogers (1975) and later revised to include an emphasis on the cognitive processes that mediat e behavioral change (Rogers, 1983). PMT has four basic tenets: (1) the perc eived severity of the threat or the perception of negative consequences, (2) the individuals vulnerability to the perceived threat or consequences, (3) the
20 perceived efficacy of the protective behavior, an d (4) the individuals perceived self-efficacy. According to PMT, protection motivation arises fr om a process of health threat appraisal and a process of coping appraisal. An individuals apprai sals of the health threat combined with an appraisal of the coping responses result in the individuals intention to perform adaptive responses, which are considered protection motivatio n; alternatively, the appraisals may lead to maladaptive responses, which are responses that place an individual at health risk. Although PMT has been demonstrated to be us eful in predicting and influencing some health-related behaviors, th e theory has received three criticisms. One of these criticisms is that PMT is more useful for predicting intention to perform a behavior rather than predicting actual behavior. Another criticism of PMT is that it does not take environmental influences on health related behavior into considera tion. Finally, PMT theory is crit icized for being largely based upon fear. Researchers have demonstrated that th e use of fear-based interventions to reduce the health risk behavior of adolescents actually incr eased their anxiety levels and failed to decrease engagement in health-risk behaviors (Sherr, 1990 ). Thus, PMT may not be very useful in exploring health-risk behaviors among adolescents. Social cognitive theory (SCT), which wa s developed by Albert Bandura (1986), is a cognitively oriented theory wh ich emphasizes the roles of observational learning, values, and expectancies in determining behavior. A primar y concept in SCT is reciprocal determinism, which is the view that people influence their environment just as their environment also influences them. According to SCT, behavior is a result of a combination of expectations regarding environmental or situational variables (variables that lie outside of the person), selfefficacy expectations (beliefs that one can accomplish certain outcomes), and outcomes.
21 Like Protection Motivation Theory, SCT has also been criticized for being a better predictor of intention than behavi or. Intention to engage in a behavior may not accurately reflect actual engagement in a behavior. Additionally, despite self-efficacys ab ility to consistently predict health-related behavior, in relevant studies, th e predictive power often proves to be quite modest (Ogden, 2003). The Theory of Reasoned Action (TRA), as or iginally developed by Ajzen and Fishbein (1980) is a cognitive theory of health behavior that is built on the premise that all behavior is under volitional control and is determ ined by an individuals inten tions. According to the Theory of Reasoned Action, an individuals intentions are composed of ones attitudes toward a behavior and the prevailing social norms. Social norms are defined as ones percepti ons about the attitudes of other important people about the behavior. Thus according to TRA, behavior can be predicted by ones intention to perform a behavior. However, when predicting an adolescents likeli hood to engage in sexual risk behavior, the adolescents attitude and pr evailing social norms may not hold as much predictive value regarding their intentions. Despite the efforts to educate adolescents about the potentially deleterious consequences of engaging in sexual risk behaviors, their attitudes often remain unchanged. Research has shown that the knowledge of the potential consequences of risky sexual behavior is not enough to deter adolescents from engaging in sexual risk behavior (TaylorSeehafer & Rew, 2000). Additionally, for adolescen ts, the motivation to have sex often appears to be stronger than the social controls hope d to prevent it (Ream & Savin-Williams, 2005). The Theory of Planned Behavior (TPB), as developed by Ajzen (1991), was developed to address the criticized assumpti on made by the Theory of Reasoned Action (TRA) that behavior is always under ones volitional control. According to TPB, as well as TRA, the determinant of
22 volitional behavior is ones in tention to perform that behavior. Intention encompasses ones motivation to engage in the behavior as well as ones attitude toward the behavior and the prevailing social norms regarding the behavior. However, in an e ffort to explain behaviors that are not under volitional control, the concept of perceived behavi oral control was added to TPB According to TPB, perceived behavioral control is the persons perception of the ease or difficulty of performing a behavior (Ajzen, 1991). The TPB has also undergone criticism. The resu lts of a review of 47 empirical articles which was conducted by Ogden (2003) indicated that many studies which utilized the Theory of Planned Behavior (TPB) showed no predictive role for subjective norms, attitudes, or perceived behavioral control. The TPB assu mes that perceived behavioral control is predictive of actual behavior control, which may not be a co rrect assumption (Sharma & Kanekar, 2007). Additionally, Sharma and Kanekar (2007) noted that the TPB, as well as TRA, rely on rational thinking rather than take into account irrational thought processes. Problem Behavior Theory (PBT), by Jesso r and Jessor (1977), was developed for examining problem behaviors among adolescents rath er than health promoting behaviors like the previously mentioned theories. According to PBT, there are three primary systems of importance: the personality system, the perceived environment system, and the behavior system. The relationships between the factors in any of the three systems can lead to a condition of proneness a state in which an individual is more likely to enga ge in health risk behaviors. Jessor and Jessor proposed that health risk behavi ors, along with health pr omoting behaviors, are a part of the adolescent developmental process. As such, health risk behaviors were viewed to be purposeful and goal-oriented. Given that health risk behaviors can be functional and purposeful, Jessor (1991) suggested that the potential benefits of risky behavior, as perceived by the
23 adolescents, should be taken into considerati on when examining adolescents engagement in risky behaviors. According to Problem Behavior Theory, a dolescents who possess fewer adaptive coping strategies are more likely to engage in health risk behaviors. These adolescents may resort to risky behaviors as a means of coping, in par ticular, with stress. Thus, an adolescents engagement in health risk behaviors may be a sign that stress is present in his or her life. Although Problem Behavior Theory posits that adolescents who have inadequate coping skills are more likely to engage in health risk behaviors, the theory does not fully incorporate the influences of negative emotional states on health-ri sk behaviors, nor does it address the role that the lack of adequate coping skills may play in mo tivating engagement in health risk behaviors in an effort to regulate negative emotions. By taking a purely functi onalist perspective of motivation to compensate for the deficits of Problem Behavior Theory, the role of negative emotions and of coping strategies in sexual risk behavior can be assessed. According to a functional pers pective of motivati on for understanding sexual risk taking, behavior is understood in terms of the goal or need that it serves (Cooper, Shapiro, & Powers, 1998). Cooper et al. delineated two common distinctions within motivational theories: appetitive behaviors and aversively motivat ed behaviors. Appetitive behaviors are those which involve seeking pleasurable or positive experiences. Wh ereas, aversively motivated behaviors involve avoiding or escaping from painful or negative emotions. Sexual risk behaviors, like other healthrisk behaviors among adolescents, may function as either appeti tive behaviors or aversively motivated behaviors which serve as a means of he lping adolescents cope with negative emotions when their strategies for coping ar e maladaptive or insufficient.
24 A study by Cooper, Frone, Russell, and Mudar ( 1995) highlights the functional perspective in regards to alcohol consump tion. Cooper et al. (1995) examined the use of alcohol as an aversive motivational process. They hypothesized that adults and adolescents (age 13-19) who rely on maladaptive emotion-focused coping and who hold positive expectancies for the tension reduction effects of alcohol would be more lik ely to use drinking as a coping response. The results of the study supported Cooper et al.s (1995) hypotheses am ong both adults and adolescents by indicating that those who relied on maladaptive coping responses engaged in more alcohol consumption than those who used more adaptive coping responses. Thus it can be extrapolated that the use of adaptive coping mechanisms may modera te the likelihood of engagement in certain health-risk behaviors. The moderating role of potentially protective f actors that are associated with engagement in sexual risk behaviors has rare ly been assessed (Bachanas et al., 2002). As stated by Jessor, Van Den Bos, Vanderryn, Costa, & Turbin (1995), protective factors, such as coping, can serve as moderators when they modify the relationship between the risk factors (i.e., stress, depression, and a negative family environment) and the problem behavior (i.e., sexual risk behavior). The linear and positive relationship between the risk factors and the risk behavior is high in the absence or dearth of the modera ting variable (i.e., coping). Howe ver, if the moderating variable is highly present, the positive relationship between the risk factors and the risk behaviors is likely attenuated. Sexual Risk Behaviors Among Adolescents Sexual risk behavior among adol escents has garnered a lot of attention in th e literature primarily due to the possible dire consequences of engaging in these behaviors. Sexual risk behavior, as defined by Taylor-S eehafer and Rew (2000), is any se xual behavior that potentially increases the risk of becoming preg nant or contracting a sexually transmitted infection, including
25 human immunodeficiency virus (HIV). Examples of sexual risk behaviors include early sexual debut, unprotected sexual activity, inconsistent use of condoms, having multiple partners, and having high-risk partners. Early sexual debut is consider ed a potential health hazard give n the current AIDS epidemic and the increased possibility of contracting other sexually transmitted diseases (Small & Luster, 1994). Early initiation of sexual inte rcourse also increases the time period that adolescents are at risk for teenage pregnancy (Harvey & Spigner, 1995). In addition, early sexual debut may be an indicator of the potential to e ngage in other sexual risk be haviors (McBride, Paikoff, & Holmbeck, 2003). For example, Felton and Bart oces (2002) found that among a group of Black adolescent females and White adolescent females, those who first experienced intercourse at an early age were more than twice as likely not to use a contraceptive during their first sexual experience. The rise in the numbers of teens and young adul ts newly infected with HIV highlights the need for an emphasis on teenage sexual risk behaviors. According to data for 2001 to 2005 from the U.S. Centers for Disease Control and Prev ention (as referenced in Mundell, 2007), the number of newly infected 15-to-19 year olds in the United States increased from 1,010 in 2001 to 1,213 in 2005. Among 20-to-24 year olds, the number of newly in fected individuals rose from 3,184 in 2001 to 3,876 in 2005. In terms of gender, among 13 to 19 year olds, males account for approximately one-third of the adolescents in fected with HIV in this age group; however, females account for nearly two-thirds of thos e infected (Center fo r Disease Control and Prevention, 2000). The increase in the number of AIDS cases among heterosexual women in general, and among African-American women and me n in particular, also speaks to the growing
26 need for interventions aimed at having teens de lay engagement in sexua l intercourse or at increasing their engagement in safer sex practices (Talashek, Norr, & Dancy, 2003). There has also been a recent rise in the teen birth rates. According to statistics compiled by the CDC and referenced by Reinberg (2007) and ba sed on 99 percent of a ll births in 2006, the birth rate for girls aged 15 to 19 rose from 40.5 births per 1,000 in 2005 to 41.9 births per 1,000 in 2006. This represented nearly a 5 percent increas e across a one year period. Black teenage girls experienced the highest increase at 5 percent. In the recent past in an effort to decrease sexual risk behavior among adolescents, there has been an increase in formalized education a bout reproductive health and an increase in abstinence-related education for adolescents (Lin dberg & Sonenstein, 2000). In 1991, according to Lindberg & Sonenstein (2000), 13 states required HIV-preventi on education in schools. By 1998, the number of states requiring HIV-prevention education in schools had increased to 35. The underlying premise of reproductive health and abstinence-related education is that adolescents will use the information that they have learned to make rational decisions to refrain from engaging in sexual risk behavior. Formali zed reproductive health education, particularly abstinence-only education programs, has come under criticism Dworkin & Santelli, 2007). Rather than relying solely on ra tional risk prevention methods wh ich are often presented in HIVprevention education programs and materials, McKirnan, Ostrow, and Hope (1996) advocate for more innovative methods of risk prevention that a ddress the non-rational, affective processes that are often inherent in risk-taki ng behaviors. Thus, research aime d at addressing the influence of affective processes on sexual risk be havior is particularly relevant. Influences on Sexu al Risk Behavior Num erous factors, including developmental, psychological, and environmental factors, have been shown to have an impact on the sexual risk behavior of adolescents. Developmental
27 factors such as biological cha nges and hormonal levels have influential roles in sexual risk behavior. Early pubertal developmen t is a biological factor that has been shown to be directly associated with early sexual debut and ear ly sexual experimentation (Brooks-Gunn, 1988; Resnick et al., 1997). Early sexual debut has been associated with higher pregnancy rates, sexually transmitted diseases, inconsistent contraceptive use, and having multiple sex partners (Coker, Richter, Valois, Mckeown, Garrison, & Vi ncent, 1994; Center for Disease Control and Prevention, 1991). Early pubertal deve lopment has also been associ ated with psychological and emotional consequences that have been linke d to sexual risk behavior. For example, the occurrence of puberty among girls has resulted in decreases in self-esteem and increases in symptoms of depression (Petersen, Compas, Brooks-Gunn, Stemmier, Ey, Grant, 1993). Thus early onset of puberty may have direct and indirect effects on sexua l risk behavior in adolescents. Hormonal influences may also play a role in se xual risk behavior. In a study of Hispanic teenage males conducted by Talashek et al. (199 9, as cited in Talashek, Norr, & Dancy, 2003), testosterone levels were associ ated with early sexual debut. Although the developmental factors of hormonal levels and early pubertal development may impact sexual risk behavior, they are not easily modifiable factors and thus would be of least interest in addressing and reducing sexual risk behaviors among adolescents. Depression and Stre ss Among Adolescents Adolescence is a period of adjustm ent, tran sition, and change that can potentially be marked by stress and depression. Rates of depr essive disorders in adolescents range from approximately .4% to 8.3% (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996). However, depressed mood is a much more common occurrence among adolescents (Steinberg, 1999). Several studies have provided data wh ich indicate that be tween 15% and 60% of adolescents report experiencing an unhappy, sad, or dysphoric mood (Rutter, 1986; Petersen,
28 Sarigiani, & Kennedy, 1991). Studies have also f ound that 25% to 40% of adolescent girls and 25% to 35% of adolescent boys experienced sy mptoms of depression during a six-month period (Compas, Ey, & Grant, 1993; Petersen, Comp as, Brooks-Gunn, Stemmler, Ey, & Grant, 1993). Although symptoms of depressed mood are prev alent among adolescents, 70% to 80% of adolescents with depressed mood do not receive any treatment (Keller, Lavori, Beardslee, Wunder, & Ryan, 1991). Research on the prevalence of the symptoms of depression among adolescents with a chronic illness or multiple chronic illnesses ha s increased over the past several years (Key, Brown, Marsh, Spratt, & Recknor (2001). Key et al. (2000), in a study examining adolescents ranging in age from 13-18 years old, found that in comparison to healthy adolescents, adolescents with chronic illnesses (i.e., cystic fi brosis, spina bifida, diabetes, and asthma) had a higher prevalence of elevated depression scores. Additionally, those adolescents who rated their illnesses as more severe were more likely to endo rse more depressive symptoms than adolescents who rated their illnesses as mild. A higher prevalence of depressive symptoms among adolescents with chronic illnesses places them at higher risk for engaging in sexual risk behaviors. Influence of Depression on Sexual Risk Behavior In clinical assessm ents of depression, decreased libido and sexual desire are considered to be symptoms of depression (K altiala-Heino, Kosunen, & Rimpel a (2003). However, KaltialaHeino et al. maintain that the research on this presumed association between depression and decreased sexual desire is very limited, particularly among adolescents. The limited numbers of studies that have invest igated the associations between depres sion and sexual desire have yielded mixed results.
29 Bachanas, Morris, Lewis-Gess, Sarett-Cuasa y, Sirl, Ries, & Sawyer (2002a) examined depression, conduct problems, drug use, peer no rms, social support, and HIV knowledge as predictors of sexual risk be havior among 158 African-American females ranging in age from 1219. The researchers predicted that higher levels of depression would be associated with engagement in more sexual risk behaviors. Th ey also predicted that those teens who were depressed but who reported higher levels of soci al support or having peer s who were engaging in fewer sexual risk behaviors would engage in fe wer sexual risk behaviors. Contrary to their hypotheses, when controlling for age, Bachanas et al. found that teens self-reported levels of depression were not significantly associated with the their self -reported engagement in risky sexual behavior. Although a signi ficant association between de pressive symptoms and risky sexual behavior was not found, utilization of inte rviews rather than anonymous self-report measures may have contributed to this unexpected finding. In a study similar to the previously men tioned study, Bachanas, Morris, Lewis-Gess, Sarett-Cuasay, Sirl, Ries, & Sawyer (2002b) assessed the associations between psychological adjustment, drug use, coping style, social s upport, HIV knowledge, and risky sexual behavior among a sample of 164 African-American females aged 12-19. They divided the adolescents into two age groups, younger (12-15) and older (1 6-19), and analyzed the data separately for each age group. Bachanas et al. (2002b) found that the younge r adolescents were significantly more depressed than the older adoles cents, and the younger adolescent s who reported more symptoms of depression also reported sexual debut at younger ages. Additionally, among the younger adolescents, reports of higher le vels of psychological distress were associated with sexual debut
30 at younger ages. Among the older adolescents, there were no si gnificant associations found between their psychological functio ning and their sexual behaviors. Research conducted by Hallfors, Waller, Ford, Halpern, Brodish, & Iritani (2004) in which the correlations between drug us e, early sexual intercourse, de pression, suicidal ideation, and previous suicide were examined, revealed result s similar to those of Bachanas et al. (2002b). Hallfors et al. assessed the de gree to which drinking, smoking, and sexual behavior is associated with depression and suicidal ideation among 18,924 primarily white adolescents in grades 7 through 12. Although a causal directi on was not examined, the result s indicated that engagement in any drinking, smoking, and/or sexual behavior was associated with significantly increased odds of depression, suicidal ideation, and suicidal attempts. Girls were found to be at increased risk for exhibiting these associations. The link between depression and sexual activity was also demonstrated in the findings of research conducted by Kaltiala-Heino, Kosunen, & Rimpela (2003). In an examination of the association between pubertal timing, depression, and sexual activ ity in adolescents aged 14-16, depression was associated with the experience of intimate sexual relations (i.e., heavy petting and sexual intercourse) among girls. Among boys, depression was associated with engaging in intercourse. Kosunen, Kaltiala-Heino, Rimpelas, and Laippa la (2003) studied the associations between sexual risk behaviors and self-reported depr ession among 11,793 girls and 10,443 boys in eighth grade and ninth grade in Finla nd. Depression was associated with a number of different sexual risk behaviors. Results of the study indicated that self-reported depression increased in proportion to the number of sexual partners. Self-reported depression was al so associated with
31 the non-use of contraception at the most rece nt intercourse. Additionally, self-reported depression increased in proportion with th e number of reporte d coital experiences. In a study conducted by Harvey and Spigner (1995), 1,206 adolescents in grades 10-12 of which 90% of the adolescents we re Caucasian, the levels of de pression and stress in sexually inexperienced males and females were compared to the levels of depressi on and stress in males and females who reported having engaged in sexual activity. The fi ndings indicated that sexually experienced adolescents reported higher levels of depressive symptomatology and stress than adolescent males and females who were sexually inexperienced. Influence of Stress on S exual Risk Behavior Like depression, an association between st ress and various risk behaviors has been established. For example, Guthrie, Young, Boyd, & Kintner, (2001) examined cigarette use in association with daily life hassles among a sample of 105 African American adolescent girls. Guthrie et al., (2001) divided the adolescents into two groups, those who smoked vs. those who had never smoked. The researchers found that girls who had smoked reported a significantly greater number of daily hassles than the girls who had never sm oked. The increased number of daily hassles was especially prominent within the school and family domains. Orlando, Ellickson, & Jinnett (2001) also found an association between emotional distress and tobacco use in adolescents. In an examinati on of boys and girls in grades 10 through 12, the results of the study indicated that emotional dist ress led to increased tobacco use. Orlando et al. (2001) proposed that emotional distress can lead to initial use and continued, increasing usage of tobacco. Although the link between stress and other risk or problem behaviors has been highly researched, very few studies have been conduc ted which examined the association between stress and risky sexual behavior among adolescents. In one such study, Harvey and Spigner
32 (1995) conducted an examination of factors associated with sexual behaviors among adolescents. The study consisted of 1,026 male and female high school students. Harvey and Spigner found that sexually active males and females reported higher levels of stress than the males and females who had never had sexual intercourse. However, the researchers did note that the research design of the study limited their ability to determine if higher levels stre ss led to engagement in sexual activity or if higher levels of stress resulted from engagement in sexual activity. Given the paucity of research in this area, more studies examining the possible direct association between stress and risky sexual behavior among adolescents are needed. Stress has also been shown to be linked to depression which, as previously mentioned, is directly related to sexual risk behavior in adolescents. Jose & Ratcliffe, (2004) found that in adolescents aged 11-19 stressor fr equency was significantly correlated with level of depression, particularly for the females. Additionally, stre ssor frequency was found to be a strong positive predictor of depression. Findings of a longitudinal study conducted by Waakataar, Borge, Fundingsrud, Christie, & Torgersen, (2004) also support th e link between stress and depr ession. Waakataar et al. (2004) examined the role of stressful life events on the development of depressive symptoms among 163 adolescents. The researchers found a positive rela tionship between the am ount of stressful life events experienced during the adolescents la st year and an outcome of depressive mood. The link between stress and depression is pa rticularly relevant among adolescents with chronic illnesses. In a study conducted by DiGi rolamo, Quittner, Ackerman, & Stevens, (1997), adolescents with chronic illnesses rated their prob lems with clinic and hospital visits as very difficult. They also rated problems in the parent -teen relationship and heal th concerns as highly
33 difficult. Additionally, among the sample, the adolescents who rated their problems as more difficult also endorsed more symptoms of depression. Family Environment and Sexual Risk Behavior Fa mily variables have also been highly studi ed in relation to adol escent sexual behavior. The family is the closest and most important soci al system that affects the development of the adolescent and is considered to wield a potentially prominent influence on adolescent sexual behavior (Perrino, Gonzalez-So ldevilla, Pantin, & Szapoczn ik, 2000). Numerous family environment variables have been implicated in the occurrence of adoles cents engagement in risky sexual behavior. The family variables that have been stud ied include family structure, parenting style, parental monitoring, family communication about sex, and family environment. For instance, Luster and Small (1997) found th at adolescents from families exhibiting poor parental monitoring, low levels of support, low cohesion, and poor communication between the adolescents and their parents were more likely to engage in sexual risk behaviors. Of the numerous family variables that have been examined, family environment appears to have an important association with sexual risk behavior in adolescence. For example, in their examination of maltreat ment, quality of the family relationship, and life stress as predictors of sexual behaviors in adolescents, Fr iedrich, Lysne, Sim, & Shamos (2004) found that the quality of the family relati onship predicted sexual risk taking and deviant behaviors. Results of a study by Deardorff, Gonz ales, & Sandler, (2003) indicated that among a sample of 7th and 8th grade students, family stress, which included extrafamilial difficulties experienced by family members other than the adolescent and intrafamilial problems and conflicts, was associated with their (the adolescents) depressive symptoms. Lau and Kwok (2000) examined the relations hip between three family environment domains (i.e., relationship, personal growth, a nd system maintenance) and depression among a
34 sample of seventh, eighth, and ninth graders. The researchers found th at the adolescents depression was associated with th eir perception of their family environment, particularly the relationship domain of the family environmen t. Although the relationship domain was found to be most influential, Lau and Kwok (2000) did no t independently examine the different subscales of the relationship domain of the family enviro nment (i.e., cohesion, conflict, & expressiveness) in relation to depression. Influence of Family Conflict on Sexual Risk B ehavior The results of prior research ha ve suggested that adolescents perception of conflict within the family may have deleterious effects on the physical and psyc hological well-being of adolescents. The role of family conflict a nd its association with a number of healthcompromising behaviors among adolescents has been highly researched (McBride, Paikoff, & Holmbeck, 2003). For example, in a study of 4th and 5th grade African American students and their families, McBride et al. (2003) found that the adolescents reports of conflict within the family were a significant predictor of an early se xual debut. Interestingly, the parents report of conflict within the family was not found to be a significant predictor. Thus, adolescents perceptions of conflict within the family may provide a more useful variable for predicting adolescents engagement in ris ky sexual behavior. I ndeed, it has been found that adolescents who report having more connected and less conflict -laden relationships with their parents have lower rates of unprotected sex, have fewer sexual partners, are olde r at age of first intercourse, and overall, make safer decisions about sex (Henrich, Brookmeyer, Shrier, & Shahar, 2006). Family conflict may also have an indirect impact on adolescents engagement in sexual risk behaviors by contributing to depression am ong adolescent family members. Constantine (2006) conducted a study examining the mediat ional role of parent al attachment on the relationship between perceived family conflict and depression among African American female
35 adolescents. The results of the study revealed a significant and positive direct relationship between perceived family conflict and depression indicating that higher levels of perceived family conflict resulted in higher levels of depression among the African American female participants. The results also revealed a signi ficant, indirect relati onship between perceived family conflict and depression with parental attachment mediating 28% of the effect. Depression, Stress, and Family Conflict Am ong Adolescents w ith Chronic Illnesses Living with a chronic illness causes both ps ychological and social hardship on an adolescent and the adolescents family Bauma n, Drotar, Leventhal, Perrin, & Pless (1997). Adolescents who have chronic illnesses face uni que challenges and stressors beyond those of adolescents who are not living with chronic illnesse s. Challenges such as disruptions in daily activities due to treatment regimens may lead to increased levels of stress for adolescents living with a chronic illness. Acco rding to Moos (2002), adolescen ts who are living with chronic illnesses and who also face other life stressors are at risk for developing adjustment problems such as stress and depression. Research has demonstrated an increase in depressive symptoms among adolescents who are living with a chronic illness. Findings from a review of 60 studies of depressive symptoms among children and adolescents with chronic illnesses reve aled that adolescents with chronic illnesses may be at a slightly increased risk of reporting symptoms of depression (Bennett, 1994). Seigel, Golden, Gough, Lahley, and Sacker (1990) found that adolescents with asthma reported having more depressive symptoms than adolesce nts without asthma. Additionally, in a similar study which examined the relationship between asthma and psychological distress among adolescents with asthma and adolescents withou t asthma, Gillaspy, Hoff, Mullins, Van Pelt, and Chaney (2002) found that adolescents with asth ma scored significantly higher on measures of depression, anxiety, and global psychological distress. In a study examining psychopathology
36 among adolescents who are obese, the adolescents who are obese scored significantly higher on a depression inventory than adolescents in a norma l weight control group (Erermis, Cetin, Tamar, Bukusoglu, Akdeniz, & Goksen, 2004). Few studies have explored the role of family conflict on th e psychosocial adjustment of adolescents with a chronic illness. A review of the few studies investigating the relationship between family conflict and adjustment of adolescen ts with a chronic illness indicates that family conflict does a play a role in psychological adjustment. Among adolescents with diabetes, the perception of high levels of family conflict was associated with poorer adjustment (Moos, 2002). Results of a study by Reichenberg and Broberg (2005) indicated that family conflict was negatively associated with psychological ad justment among adolescents with asthma. In conclusion, empirical studies have shown that adolescents living with a chronic illness are more likely to experience increased levels of st ress and depression than their healthier peers. Research has also shown that family conflict in the families of adolescents living with a chronic illness is negatively associated with the psycho logical adjustment of the adolescents. The increased likelihood of psychological adjustment problems among chronically ill adolescents may make them more prone to engage in risky se xual behaviors as a means of coping with stress, depression, and family conflict. Coping An adolescents coping strategy may be usef ul in protecting the adolescent during the adolescent period of life (Bachanas et al., 2002). Given that adolescence can be a stressful and difficult time which may draw on all of ones res ources, an adolescents ab ility to cope may be particularly relevant to her or his health (Ste iner, Erickson, Hernandez, & Pavelski, 2002). Thus, adolescents who utilize more adaptive coping stra tegies may be less likely to engage in risky behaviors (Bachanas et al., 2002).
37 According to Compas, Connor-Smith, Salt zman, Thomsen, & Wadsworth (2001) coping consists of a process that involves cognitive, emotional, and behavioral responses aimed at reducing the consequences of st ress. Coping not only involves mana ging a stressful situation, but it also consists of managing the negative emotiona l reactions that arise as a consequence of the stressful situation (Piko, 2001). Addi tionally, a persons ability to cope is influenced by his or her mental and social functioning (Compas et al ., 2001). Thus, individu als who are experiencing stress or depression or problems within their interpersonal relationships, such as familial relationships, may have difficulty coping with life stressors. Coping Strategies Coping appears to be a multidimensional and context driven concept (Ayers, Sandler, Twohey, 1998). Although numerous types or strategies of coping can be utilized, it is important to determine which strategies are useful and which are not (Lewis & Frydenberg, 2002). As such, coping responses can be viewed as be ing either adaptive or maladaptive (Lewis & Frydenberg, 2002). There are a number of different adaptive and maladaptive coping strategies. These strategies have been categorized in numerous ways. One of the methods of categorizing coping strategies is to classify them as either approach coping strategi es or avoidance coping strategies. According to Roth and Cohen (1988), approach c oping involves taking dire ct actions which are aimed at changing or resolving the stressful even t or the consequences of the stressful event. Approach coping arises out of an individual making positive appraisals of the stressful event. Examples of approach coping strategies include direct problem solving, support seeking, and cognitive restructuring.
38 According to Plunkett, Radmacher, and Moll-P hanara (2000) avoidan ce coping strategies refer to attempts to escape or avoid issues or persons that ar e appraised as being stressful. Avoidant strategies may include trying to ignore, forget, or ma nage potentially stressful life events through seeking diversions or distractions. Avoidant strate gies can be either behavioral (e.g., avoiding a stressful situati on) or cognitive (e.g., imagining th at a situation is better). Chapman and Mullis (2000) found that both African-American adolescents and Caucasian adolescents reported using the emotion-focused coping strategy of seeking diversions more frequently than they used any of the other types of coping strategies. Furthermore, of the nine strategies that were reported in the study as most co mmonly used by the participating adolescents, six of them were emotion-focused strategies. Coping in Association with Stress, Depression, and Family Environment An increasing num ber of studies have focused on the utility of understanding adolescent risk for psychopathology as a function of coping with stress (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001). A central tenet of these studies was the assumption that stress increases youths risk for experiencing psyc hopathology symptoms, and that coping helps to weaken the association between stress and psychopathology symptoms (Compas et al., 2001). Results of these studies have varied. In a study conducted by Hampel and Petermann (2006) which examined age and gender effects on perceived interpersonal stress and copi ng with emotional and behavioral problems among 286 junior high school studen ts, the results indicated that emotionfocused coping was negatively correlated with emotional and behavi oral problems including emotional distress, stress, and antisocial behavior am ong girls. It was also found that among the female participants, problem-focused coping was negatively correlated with anger control problems and negative
39 self-image, and maladaptive coping was positively correlated with emotional distress, anger control problems, and negative self-image. For the male participants in the Hampel and Peterman (2006) study, maladaptive coping was positively associated with emotional distress and negative self-image. Problem-focused coping was negatively associated with negative self-image. However, emotion-focused coping was not significantly associated with any of the emotional or behavioral problems being investigated. Overall, the results of the study in dicated that maladaptive coping strategies are positively associated with internalizing and externalizing problems for both female and male adolescents. Tolan, Gorman-Smith, Henry, Chung, and Hunt (2002) conducted a study that examined the developmental-ecological approach to copi ng. This approach places an emphasis on the concepts of developmental timing and context in the understanding of certain coping behaviors. Specifically, the researchers sought to determine what patterns of coping were prevalent among inner-city youth and the relation of these copi ng patterns to the presen ce of internalizing and externalizing symptoms. The participants in the Tolan et al. (2002) study consisted of 372 adolescents ranging from ages 12 to16 who were from lower socioec onomic neighborhoods in two large Midwestern cities. The adolescent participants were administ ered measures to assess coping, social stress, and externalizing and internalizing psychopathol ogy symptoms. Results of the study, which were consistent with those of other studies, include that a relationship existed between emotionfocused coping and symptomatology. Specifically, the findings revealed that adolescents who primarily relied on emotion-focused coping and made relatively little use of other coping strategies reported higher levels of internalizing and externalizing symptoms.
40 In a direct assessment of the possible m oderating affects of coping, Wadsworth and Compas (2002) studied coping as a mediator and a moderator of the influence of family conflict and economic strain on adjustment among a sample of 364 adolescents. Th e results of the study indicated that coping mediated the relationshi p between family conflic t and adjustment. The results did not show support for coping as a mode rator of family conflict or economic strain. Whereas the Wadsworth and Compas (2002) study focused economic strain and family conflict, the present study utilized a broade r conceptualization of stress by assessing various stressors that the adolescents may have encountered. Coping in Association with Health-Risk Behaviors Mixed results have also been obtained rega rding the effects of stress, depression and coping on adolescents engagem ent in health-risk behaviors. Piko (2001) examined the relationships between psychologica l well-being, health-re lated variables, h ealth-risk behaviors and ways of coping among students 14-19 year s old. Piko found that passive coping (i.e., wishing that the situation woul d go away, tendency to criticize oneself, or praying) and risky coping factors (i.e., drinking, eating, smoking, usi ng drugs or medication, or taking it out on other people) were negatively associated with psychological well-being; whereas, the coping strategies of problem-analyzing (i.e., problem solving, being optimistic, and looking on the bright side of things) and support-seeking (i.e., accepting sympathy or understanding from someone) were positively associated with psycho logical well-being. Thes e findings suggest that maladaptive coping, specifically passive coping and risky coping, coupled with psychosocial health problems might result in a cycle in whic h risk-taking becomes a primary way of coping among adolescents. Hansell and White (1991) conducted a study that investigated the interrelationships among psychological distress, drug use, and physical symptoms. They pr oposed that higher levels of
41 distress would lead to increased drug use. Th ey also hypothesized that the presence of more physical symptoms would contribute to greater drug use. Adolescen ts were interviewed in three waves (12, 15, and 18 years of age) Contrary to the hypotheses, drug use did not increase with higher reported levels of distress or physical symptoms. Galaif, Sussman, Chou, & Wills (2003) examin ed relationships among stress, depression, adaptive coping (i.e., seeking social support), and maladaptive coping (i.e., anger coping and substance use) in a sample of 646 adolescents who were 14-19 years old. The study consisted of a longitudinal design in which the adolescents were administered a pre-test and a 1-year followup post-test. The study found that depression predicted perceived stress, but not substance use. However, anger coping behaviors increased hard drug use. Coping in Association with Sexual Risk Behavior Cohen (1995) asserts that adol escents m ay engage in sexual risk behaviors for reasons other than sexual fulfillment. Cohen proposes a number of nonsexual needs which may stem from underlying emotional dissatisfaction that adolescents may fulfill by engaging in sexual activity. According to Wills and Hirky (1996), an adolescents decision to engage or not to engage in health-risk behaviors may be an indicat ion of the adolescents ability to successfully cope with distress. As such, adolescents may e ngage in sexual risk be haviors as a result of having insufficient coping strategies to deal with emotional factors such as stress or depression or environmental factors su ch as family conflict. McKirnan, Ostrow, & Hope (1996) developed the cognitive escape model in examining HIV risk behaviors among gay and bisexual men. According to McKirnan et al., for some people, sexual behaviors arise out of a need to cognitively disengage from their awareness of societal norms and standards and from nega tive emotional states. Thus, this cognitive disengagement may make individuals more prone to engage in ris ky sexual behavior.
42 Cooper, Shapiro, and Powers (1998) utilized a functionalist perspec tive of health-risk behaviors to examine adolescents motivations for engaging in se xual behaviors. The researchers combined two dimensions that are commonly used in motivational theories and are relevant to understanding human behavior: 1) the distinction between whether a behavior is driven by the pursuit of pleasure or the avoidance of pain, and 2) the distinction between whether a behavior is self-focused and internally driv en or other-focused and externa lly driven. Cooper et al. (1998) crossed these two dimensions to de rive four types of motives for adolescents sexual behaviors: 1) appetitive self-focused motives 2) aversive self-focused motiv es, 3) appetitive social motives, and 4) aversive social motives. Appetitive self-focused motives (i.e., enhancement motives) are motives aimed at increasing ones own physical or emotional plea sure. For example, one would have sex purely for physical satisfaction. Aversive self-focused motives (i.e., coping motives) are those which work to decrease negative emotions, such as ha ving sex to counteract feelings of depression. Appetitive social motives (i.e., intimacy motives ) involve motives aimed at gaining interaction with another person. Having sex in order to achieve intimacy is an example of an appetitive social motive. Aversive social motives (i.e., approval motives) are motives whose purposes are to avoid negative social conseque nces. Having sex to avoid the di sapproval of a partner is an example of an aversive so cial motive for having sex. In the first study conducted by Cooper et al. ( 1998), they sought to determine whether students self-generated motives fo r engaging in sex were similar to the researchers theoretically derived motive categories. The researchers as ked 178 college students aged 17 to 21 to provide an open-ended response to a question about their reason for deciding to have sex at a time when they had an opportunity to do so. Qualitative analysis of the 335 responses revealed that 212 of
43 the responses were able to be assigned to one of the four motive categ ories, lending support to the four-category motive typology. Of the 212 res ponses, the majority of the responses (105) were categorized as enhancement motives and a la rge number (91) were categorized as intimacy motives. The remaining responses (16) were ca tegorized as either coping motives or approval motives. In an additional study, Cooper et al. (1998) examined the premise that sexual motives would be differentially associated with risky sexual behavior. Specifi cally, they hypothesized that engaging in sex due to av ersive motives, such as having se x to decrease negative emotions, would be associated with risky sexual behavior. Cooper et al.s hypothesis was based on a theory proposed by Baumeister and Scher (1988) which suggested that indi viduals seeking to gain quick and easy relief from negative emotional states may be more likely to engage in self-destructive behaviors to obtain relief. Add itionally, the need for immediate relief through sexual means may be more prominent than the possible future consequences of engaging in risky sexual behavior. To test their hypothesis based on Baumeister and Schers ( 1988) theory, Cooper et al. (1998) conducted a study using a sample of 1,666 adolescents and young adults who were sexually experienced. The results of the study provided some support of the hypothesis that individuals who used sex as a means of coping with aversive negative emotional states would engage in more risky sexual behavior. Coping motives for engaging in sexual behavior were associated with having multiple sexual partners and engaging in risky sexual practices which were defined as those that are considered to be high risk for contracting the HIV virus. Therefore, the results of Cooper et al.s study su ggest that sex may serve as a coping strategy for some adolescents and that a coping motive for enga gement in sexual behavior is associated with riskier sexual practices.
44 In a longitudinal study of college freshmen, Za leski et al. (1998) found that students who were unable to cope effectively were more likely to engage in higher leve ls of sexual behavior under conditions of higher stress. However, B achanas et al. (2002) found no associations between coping style and engagement in sexual risk behaviors among a group of adolescent females. Stein and Nyamathi (1999) examined gender differences among 205 impoverished minority females and males in the associations among stress, self-esteem avoidant and active coping strategies, and health outcomes of depre ssion, drug use, and sexual risk behaviors. The results indicated a large and si gnificant relationship between st ress and sexual risk behaviors among women, but this association was not found among the men. Women also reported significantly more stress, depression, and avoidant coping styles than men. Additionally, greater stress and less use of active coping strategies predicted more sexual ri sk behaviors for women, but not for men. These findings are significant in demonstrati ng links among stress, depression, coping strategies, and sexual risk behaviors. Although these findings ar e significant, the study participants were adults rather than adoles cents. Thus, the associa tions between stress, depression, coping, and sexual ri sk behaviors among adolescents were not examined. Summary Risky sexual behavio rs place adolescents at increased risk for a number of potentially serious health consequences. A review of the exis ting literature suggests that a number of factors affect the potential of adolescen ts to engage in risky sexual be havior. Factors associated with these sexual behaviors among adol escents need to be further examined in order to develop effective interventions to address decreasing these behaviors. Depression, stress, family conflict and coping ha ve all been implicated as important factors in association with adolescents engagement in risky sexual behaviors. However, there has been
45 limited research aimed at examining the associations of the above mentioned variables within one study, particularly among adolescents with chr onic illnesses and are thus more likely to be experiencing depression, stress, and conflict within the family. Thus, the purpose of present study is to inve stigate the association of depression, stress, and conflict in the family among adolescents with a chronic illness. The influence of coping strategies on risky sexual behavior will also be investigated. Specifically, the present study will empirically examine whether or not adolescent s who experience more depressive symptoms, higher levels of stress, and/or hi gher levels of conflic t in the family engage in more sexual risk behaviors, and if so, whether or not the presence of more effective coping strategies by the adolescents moderates the influenc e of depression, stress and family conflict on engagement in risky sexual behavior. Hypotheses and Research Questions The following hypothes es will be investigated: 1. Among adolescents, level of depression (as measured by the Center for Epidemiologic Studies Depression Scale) will have a significant positive association with engagement in risky sexual behavior (as m easured by the Youth Risk Be havior High School Questionnaire 2003). 2. Among adolescents, stress level (as measured by the Life Stressors and Social Resources Inventory Youth Form) will have a significan t positive association with engagement in risky sexual behavior. 3. Among adolescents, level of perceived fam ily conflict (as measured by the Conflict subscale of the Family Relations Index) will have a significant positive association with engagement in risky sexual behavior. 4. Among adolescents, levels of depression, stre ss, perceived family conflict, and coping strategy (as measured by the Childrens Coping Strategies Checklist Revision 1) will be significant predictors of engageme nt in risky sexual behavior 5. Among adolescents, coping strategy will moderate the relationship between (a) levels of depression, stress, and perceived family c onflict and (b) engagement in risky sexual behavior.
46 The following research questi on will also be explored: Among adolescents, are there any significant age, gender, or et hnicity differences in engagement in risky sexual behavior and in levels of depression, stress, and coping strategy?
47 CHAPTER 3 METHOD Participants Participan ts in this study in cluded 56 adolescents (24 male s and 32 females) between the ages of 12 and 17 who were outpati ents recruited from primary he alth care clinics associated with the Childrens Medical Services (CMS) Network. The CMS Network is a health care program specifically designed for children with a chronic illness who thus have special health care needs. This population of adolescents wa s chosen due to the probability of these adolescents suffering from more negative emotional states as well as increased family stress due to their chronic health problems. These adolescents were recruite d for this study as part of a larger research study examining engagement in health-risk behaviors and health promoting behaviors among adolescents. The de scriptive data for th ese adolescents is pr esented in Table 31. Instruments Each participant was m ailed an Assessment Battery. The adolescent Assessment Battery consisted of a Youth Information Questionna ire (YIQ, see Appendix A), the Youth Risk Behavior High School Questionnaire 2003 (YRBS, see Appendix B), The Life Stressors and Social Resources Inventory Youth Form (L ISRES-Y, see Appendix C), the Center for Epidemiologic Studies Depression Scale (CES-D, see Appendix D), the Family Relations Index (FRI, see Appendix E), the Childrens Coping Stra tegies Checklist Revision 1 (CCSC-R1, see Appendix F), and the Marlowe-Crowne Social Desirability Scale, short-form (MCSDS, see Appendix G ).
48 Youth Risk Behavior High Sc hool Questionnaire 2003 (YRBS) The YRBS, which was developed by the Cent ers for Disease Control and Prevention (2003), was used to determine participants engage ment in various sexual behaviors. The YRBS is a 56-item self-report measure th at assesses behaviors such as tobacco use, alcohol use, drug use, and engagement in sexual behaviors. A comp osite score was created consisting of the eight items on the YRBS that address sexual beha vior. The composite score was derived using a method similar to the method utilized by Bachanas, Morris, Lewis-Gess, Sarett-Causay, Sirl, Ries, and Sawyer (2002), which involved assigni ng a numeric value of 1 to responses which were indicative of engagement in a risky sexual behavior. Possible scor es ranged from 0 to 33. Higher scores indicate higher levels of sexual risk behavior. Respondents rated items based upon their experience. Examples of items from th e YRBS include: Have you ever had sexual intercourse (0 = No; 1=Yes), Did you drink or use drugs before you ha d sexual intercourse the last time (0 = Never had intercourse; 1 = Yes; 2 = No), and The last time you had sexual intercourse, did you or your part ner use a condom. (0 = Never had intercourse; 1 = Yes; 2 = No). The Life Stressors and Social Resources Inventory Youth Form (LISRES-Y) The LISRES-Y, developed by Moos & Moos (1990) was used to measure the life stressors of the adolescents within the past twelve months. The LISR ES-Y measures the relationship between stable life stressors a nd social resources and the effect s of these two variables on the health and well-being of adoles cents 12 to 18 years old. The LISRES-Y consists of 230 items comprising 16 subscales. Only the Negative Life Events Subscale of the LISRES-Y was used in the present study. The Negative Life Events Subscale is composed of 73 stressful events within 8 domains that may have occurred within the past year. The 8 domains include physical health,
49 home and money, school, relationshi ps with parents, relationships with siblings, relationships with extended family members, relationships with friends, and relati onship with boyfriend or girlfriend. The inventory assesses whether or not the respondent has experienced each of the items on the Negative Life Events Subscale that are listed based on their responses to these items. Examples of such items are as follows : Frequent headache or dizziness, Did you move to a new home, and Has your relationship with your mother or stepmother changed for the worse. Inventory item response choices are either yes or no. The domain subscale scores are calculated by summing the yes responses. The overall subscale score is the sum of the eight domain subscores. Higher sub-scale scores i ndicate a higher level of stressful life events. The eight domain subscales of the Negative Life Events Subscale of the LISRES-Y have been reported to have moderate to high inte rnal consistency with Cronbachs alphas ranging from .66 to .92 (Moos & Moos, 1990). According to Moos & Moos (1990), seven of the eight domain subscales were found to have significant positive correlations ranging from .14 to .29 with an assessment of behavior problems (i.e ., the Deviant Behavior Scale by Jessor & Jessor ) The health subscale was the only domain subscale score th at was not correlated with behavior problems. Five of the eight domain subscale scores (health, home and money, parents, siblings, school, & friends) had significant pos itive associations with depression, with the correlations ranging from .13 to .29. Center for Epidemiologic Studies Scale (CES-D) The CES-D, by Radloff (1977) is a 20-item self-report inventor y that was used to measure respondents levels of symptoms of depression. An example of an item on the CES-D is I felt hopeless about the future. Responses to the item s are Rarely or none of the time (< 1 day), Some or a little of the time (1-2 days), Occas ionally or a moderate amount of the time (3-4 days), and Most or all of the tim e (5-7 days). The responses are scored from 0 to 3 based on
50 the frequency of the occurrence of the symptom. Item scores are summed to obtain a total score ranging from 0-60, with higher scores indicating greater symptomatology. The CES-D has demonstrated high internal consistency with Cronbachs alphas ranging from .85 in the general population to .90 in a pa tient sample. The CES-D correlated moderately and in the appropriate direction with similar scales designed to measure symptoms of depression such as the Lubin and the Bradbur n Negative Affect scale. The CES-D also has been show to possess good discriminate validity in research th at tested its ability to discriminate between psychiatric inpatient and general population samples (Radloff, 1977). Family Relations Index (FRI) The FRI, constructed by Moos and Moos (1986 ), was used to assess the quality of the relationships within participating adolescents fa milies as perceived by the adolescents. The FRI measures the level of cohesion, expressiveness, and conflict within the family. The scale is composed of 3 subscales consisting of nine true -false items each. Examples items from the FRI include: We fight a lot in our family, We te ll each other about our personal problems, and We really get along well with each other. The three subscales have demonstrated moderate internal consistencies ranging from .61 to .78. Childrens Coping Strategies Ch ecklistRevision 1 (CCSC-R1) The CCSC-R1, by Ayers, Sandler, West, and Roosa (1996), is a 54-item scale that was used to assess the coping strategies that ar e used by the adolescents. The CCSC-R1 assesses active coping strategies, dist raction strategies, avoidance strategies, and support seeking strategies of coping. Examples of items from the scale are as follows: You tried to ignore it, and You tried to make things better by changing what you did. Each item is rated on a fourpoint Likert scale with response categories of Never, Sometimes Often, and Most of the
51 time. The CCSC-R1 was not designed to produce a full scale score. Therefore, a full scale score was not utilized in the current study. Scores for each of the four subscales of the CCSC-R1 were calculated. The subscales of the CCSC-R1 ha ve demonstrated moderate to high internal consistency with Cronbachs alphas ranging from .46 to .72. Marlowe-Crowne Social Desirab ility Scale-Short Form (MCSD-S) The MCSD-S, created by Strahan and Gerbasi (1 972), is a 20-item scale that was used to determine the degree to which th e adolescents responded to the m easures in order to present themselves in a socially desirable manner. An example item on the MCSD-S is At times, I have really insisted on having things my way. Respons es to the scale items ar e indicated by marking True or False. Responses that indicate so cial desirability are given a score of 1 and responses that are not in dicative of social desira bility are given a scor e of 0. Possible scores range from 0 to 20 with higher scores indica ting that a participant may be responding in a socially desirable manner. The 20-item version of the MCSD-S was derive d from the original 33-item measure which was developed by Crowne and Marlowe (1960). The alpha coefficient of the 20-item version of the MCSD-S was reported to be .82. The Kude r Richardson formula 20 (K-R 20) reliability coefficients were .83 for a sample of females and .78 for males (Strahan & Gerbasi, 1972). A Pearson product-moment correla tion between the 20-item version of the scale and the original version was reported to be .97, indicating that the 20-item scale has high construct validity (Fraboni & Cooper, 1989). Procedure Identification and Recruitment of Participants The potential adolescent participan ts were se lected by the appropriate CMS staff based on the following participant criteria : (a) the adolescent is between the ages of 12 and 17, (b) the
52 adolescent has been a CMS patient for at least one month prior to participating in the study, and (c) the adolescent is able to read, comprehend, and respond independently (i.e., without assistance from anyone) to the research questionnaires. Once lists of potential participants were compiled, the designated CMS staff members mailed each of the primary parent/caregivers of th e potential adolescent participants an Invitation Packet, which was provided by the principle inves tigator and her research team. The Invitation Packet consisted of (a) an i nvitation letter from the research supervisors (see Appendix H), which explained the purpose of the study, (b) two copies of a Parental Informed Consent Form (see Appendix I), (c) two copies of an Adolescent Assent Form (see Appendix J), (d) a Payment Release Form (see Appendix K), and (e) a postage-p aid business reply envel ope addressed to the Primary Investigator. The primary parent/caregivers of the potential adolescent participants who received the Invitation Packet were able to decide if they wanted their children to participate in the study. The primary parent/caregivers who decided to allo w their child to participate returned a signed copy of their Informed Consent Form and Paym ent Release Form. The ad olescent participants returned a signed copy of their Adolescent A ssent Forms and completed Youth Information Questionnaire in the provided pre-addressed envelope. The Principle Investigator and her research team did not have access to the names or personal information of the adolescents or their primary parent/caregivers prior to receiving the reply envelopes with the specified documents. Data Collection Upon receipt of the signed Informed Consent Form and Adolescent Assent Form, the adolescent was mailed an Assessm ent Battery and a postage-paid business reply envelope. The
53 reply envelopes contained a code that was used to calculate the re turn rate of th e study. Of the 135 adolescents who agreed to participate, 83 (6 1%) of the adolescents returned the Assessment Battery. Of those 83 returned Assessment Batte ries, 56 of them were completed Assessment Batteries, which resulted in an overall 41% retu rn rate. Participants were compensated $20 for their research participation. The data collection process occurred across a four-month period. Table 3-1. Participant demographic data N % Gender Male 24 43% Female 32 57% Race Black 16 29% White 40 71% Adolescent gender/race Black male 06 11% Black female 10 18% White male 18 32% White female 22 39% Age Ages 12-14 42 75% Ages 15-17 14 25%
54 CHAPTER 4 RESULTS This chapter will present the resu lts of the analyses to test the hypotheses and research questions set forth in this study. This chapter is di vided into three main sections. The first section contains the descriptive data for all of the major variables of this study. The second section provides descriptions of the results of the st atistical analyses conduc ted to test the five investigated hypotheses. The final section provides descriptions of the results of the statistical analyses conducted to addr ess the research question i nvestigated in this study. Descriptive Data The m ean scores, standard deviations, minimu m scores, and maximum scores for the major variables in this study are pres ented in Table 4-1 through Table 4-5.The variables of interest include risky sexual behavior, depression, stress, perceived fa mily conflict, and the coping strategy variables (active coping, avoidant co ping, support seeking coping, and distraction coping). Results from the Analyses to Test Hypotheses 1-5 Hypotheses 1-3 predicted that stress, depression, and level of perceived fam ily conflict among adolescents would have significant positive associations with their engagement in risky sexual behavior. The hypotheses were tested using a Pearson Product Moment Correlation. The results of this analysis are shown in Table 4-6. Hypothesis 1 states that among adolescents, le vel of depression will have a significant positive association with engagement in ris ky sexual behavior. The results revealed a nonsignificant positive correlation between level of depressive symptoms and risky sexual behavior (r = .14, p = .30) as shown in Table 4.6. This finding failed to support Hypothesis 1.
55 Hypothesis 2 states that among adolescents, their stress level will have a significant positive association with engagement in risky sexual behavior. The results of the Pearson Product Moment Correlation revealed a non-sign ificant positive corre lation between selfreported stress and risky sexual behavior (r = .05, p = .70) as shown in Table 4-6. This finding failed to support Hypothesis 2. Hypothesis 3 states that among adolescents, level of perceived family conflict will have a significant positive association with engagement in risky sexual behavior. The results revealed a non-significant positive correlation between level of perceived fa mily conflict and risky sexual behavior (r = .23, p = .09) as shown in Table 4-6. This finding failed to support Hypothesis 3. Hypothesis 4 states that among adolescents, levels of depression, stress, perceived family conflict, and coping strategy will be significant predictors of engagement in risky sexual behavior. A multiple regression was performed to test hypothesis 4. The predictor variables were levels of depression, stress, perceived family conflict, and coping strategies. The criterion variable was self-reported level of engagement in risky sexual behavior. The predictor variables were simultaneously entered into the model. Regression diagnostics revealed no significant concerns regarding multicollinearity (VIF ra nged from 1.19 to 2.82; Tolerance ranged from 0.35 to 0.84). The model containing all of the pr edictor variables wa s not significant (R2 = .210, F(7, 55) = 1.81, p = .105). These results fail to provide support for Hypothesis 4. Thus it is concluded that the level of depression, leve l of stress, level of family c onflict and coping strategy do not uniquely explain a significant amount of the va riance in the risky sexual behaviors of the adolescents in this study. Th e results of this regressi on are shown in Table 4-7. Hypothesis 5 states that among adolescents, c oping strategy will moderate the relationship between (a) levels of depressi on, stress, and perceived family conflict and (b) engagement in
56 risky sexual behavior. To test the hypothesis, four separate hierarchical multiple regression analyses were performed with sexual risk behavior as the criterion using the following steps: (1) depression, stress, and family conflict were ente red as predictor variables in each of the hierarchical regressions; (2) each of the four coping strategi es (i.e., active, avoidance, support seeking, and distraction) were i ndividually added into one of the four separate hierarchical regressions to determine if there was a significant reduction in any of the predictors from Step 1; and (3) all of the interaction te rms between the first block of predictor variables (i.e., depression, stress, and perceived family conflict) and each of the coping strategy vari ables were separately entered into each of the regressions. To address problems with multicollinearity the predictor variables were centered by subtracting the mean of the predictor variables from each of the adolescents scores on the predictor vari ables (Cohen, Cohen, West & Aiken, 2003; Keith, 2006). The results of the first step of the hierarchical multiple regressions, which was the same for all four multiple regressions, indicated that neither depression, nor stress, nor perceived family conflict predicted engagement in risky sexual behavior. In the fi rst hierarchical regression, the incremental increase in R2 with the addition of active coping to the model was significant ( R2 = .140, F [4, 55] = 3.04, p = .025). Active coping was a significant predictor of sexual risk behavior and accounted for 39.9% of the variance. A significant depression x active coping interaction ( R2 = .002, F [5, 55] = 2.42, p = .048) was found; however, it explained less than 1% of the variance. Additionally, a significant perceived family conflict x active coping ( R2 = .056, F [7, 55] = 2.32, p = .040) interaction was found, which accounted for 5.6% of the total variance. Table 4-8 shows the results of this regression.
57 In the second hierarchical regres sion, the incremental increase in R2 with the addition of avoidance coping to the m odel was not significant ( R2 = .005, F [4, 55] = .782, p = .542). None of the interaction terms were f ound to be significant predictors of sexual risk behavior. The results of this regression are shown in Table 4-9. With the third hierarchical regression, the increase in R2 with the addition of support seeking coping to the model was not significant ( R2 = .085, F [4, 55] = 2.03, p = .105). All of the interaction terms were non-significant. The resu lts of this regression ar e shown in Table 4-10. In the fourth and final hierarch ical regression, the increase in R2 with the addition of distraction coping to the model was not significant ( R2 = .033, F [4, 55] = 1.19, p = .329). None of the interaction terms were f ound to be significant. The results of this regression are shown in Table 4-11. Results from the Analysis to Test the Research Question A multivariate analysis of covariance (MANCOVA) was performed to test the research question. This research question is as follows : Among adolescents, are there any significant age, gender, or ethnicity differences in engagement in risky sexual beha vior and in levels of stress, depression, and coping strategy? The independent variables were ag e, gender, and ethnicity. The dependent variables were level of risky sexual be havior, level of stress, level of depression, and levels of each of the differen t coping strategies (active, avoidant, support seeking, and distraction). Due to significant corr elations between level of social desirability and some of the variables of interest, social desirability was entered as a covariate. Results of the MANCOVA indicated significan t differences in dist raction coping as a function of ethnicity (F [1, 55] = 6.38, p = .015). There was also a significant difference in depression as a function of a ge nder x ethnicity interaction ( F [1, 55] = 5.58, p = .022). Follow-up post-hoc analysis revealed that African American adolescents scor ed significantly higher than
58 the Non-Hispanic White American adolescents on the Center for Epidemiologic Studies Depression Scale (CES-D). There we re no other differences indicated as a result of age, gender, ethnicity, or other interactions be tween the independent variables.
59 Table 4-1. Descriptive data for the major variables for all participants Variables N Min Max M SD Norm M Sex risk 56 .00 8.00 .45 1.70 N/A Stress 56 2.00 23.00 10.78 5.15 N/A Depression 56 .00 46.00 10.92 11.71 N/A Family con 56 .00 9.00 3.10 2.14 4.30 AC-cope 56 1.36 3.63 2.40 .51 2.30 D-cope 56 1.00 3.35 2.30 .57 2.21 S-cope 56 1.00 3.68 2.25 .64 2.20 AV-cope 56 1.33 3.17 2.42 .43 2.45 Note: Sex risk = sexual risk behavior; Stress = perceived stress; Family con = perceived family conflict; AC-cope = active coping strategies; D-c ope = distraction coping strategies; S-cope = support seeking coping strategies; AV-c ope = avoidance coping strategies Table 4-2. Descriptive data for the major va riables for African American participants Variables N Min Max M SD Norm M Sex risk 16 .00 7.23 .51 1.81 N/A Stress 16 3.00 21.00 11.31 4.67 N/A Depression 16 .00 38.60 9.72 9.69 N/A Family con 16 .00 6.00 2.35 1.71 4.30 AC-cope 16 1.58 3.50 2.52 .54 2.30 D-cope 16 2.08 3.35 2.64 .40 2.21 S-cope 16 1.10 3.60 2.42 .63 2.20 AV-cope 16 1.42 3.08 2.43 .45 2.45 Note: Sex risk = sexual risk behavior; Stress = perceived stress; Family con = perceived family conflict; AC-cope = active coping strategies; D-c ope = distraction coping strategies; S-cope = support seeking coping strategies; AV-c ope = avoidance coping strategies Table 4-3. Descriptive data for the major va riables for non-Hispanic white participants Variables N Min Max M SD Norm M Sex risk 40 .00 8.00 .43 1.68 N/A Stress 40 2.00 23.00 10.55 5.37 N/A Depression 40 .00 46.00 11.41 12.50 N/A Family con 40 .00 9.00 3.39 2.24 4.30 AC-cope 40 1.36 3.63 2.35 .49 2.30 D-cope 40 1.00 3.03 2.16 .57 2.21 S-cope 40 1.00 3.68 2.19 .64 2.20 AV-cope 40 1.33 3.17 2.41 .44 2.45 Note: Sex risk = sexual risk behavior; Stress = perceived stress; Family con = perceived family conflict; AC-cope = active coping strategies; D-c ope = distraction coping strategies; S-cope = support seeking coping strategies; AV-c ope = avoidance coping strategies
60 Table 4-4. Descriptive data for the ma jor variables for female participants Variables N Min Max M SD Norm M Sex risk 32 .00 8.00 .48 1.88 N/A Stress 32 2.00 21.00 11.13 5.45 N/A Depression 32 .00 46.00 12.36 13.32 N/A Family con 32 .00 9.00 2.86 2.08 4.30 AC-cope 32 1.36 3.63 2.45 .56 2.30 D-cope 32 1.00 3.35 2.30 .61 2.21 S-cope 32 1.20 3.68 2.39 .64 2.20 AV-cope 32 1.75 3.17 2.45 .41 2.45 Note: Sex risk = sexual risk behavior; Stress = perceived stress; Family con = perceived family conflict; AC-cope = active coping strategies; D-c ope = distraction coping strategies; S-cope = support seeking coping strategies; AV-c ope = avoidance coping strategies Table 4-5. Descriptive data for the ma jor variables for male participants Variables N Min Max M SD Norm M Sex risk 24 .00 7.00 .42 1.47 N/A Stress 24 2.00 23.00 10.29 4.80 N/A Depression 24 .00 38.60 9.00 9.05 N/A Family con 24 .00 8.00 3.42 2.22 4.30 AC-cope 24 1.67 3.38 2.33 .44 2.30 D-cope 24 1.50 3.00 2.29 .51 2.21 S-cope 24 1.00 3.13 2.08 .61 2.20 AV-cope 24 1.33 3.17 2.36 .47 2.45 Note: Sex risk = sexual risk behavior; Stress = perceived stress; Family con = perceived family conflict; AC-cope = active coping strategies; D-c ope = distraction coping strategies; S-cope = support seeking coping strategies; AV-c ope = avoidance coping strategies
61 Table 4-6. Intercorrelations betw een the major variables of interest and social desirability Variables 1 2 3 4 5 6 7 8 9 1. Sexual Behavior 1.00 2. Depression .142 1.00 3. Stress .052 .302* 1.00 4. Family Conflict .226 .504** .198 1.00 5. Active Coping .310* -.109 .242 -.179 1.00 6. Avoidance Coping .069 .110 .077 -.040 .419** 1.00 7. Support Seeking Coping .242 -.129 .164 -.158 .751** .277* 1.00 8. Distraction Coping .147 -.028 -.008 -.147 .324* .315* .237 1.00 9. Social Desirability -.164 -.412** -.098 -.527** .243 .007 .187 .013 1.00 *p <.05, two-tailed. ** p < .01, two-tailed.
62 Table 4-7. Summary of the multiple regression analysis for the variables predicting sexual risk behavior R2 F df B SE B Model .210 1.82 7,55 Depression 0.00 .023 .101 Stress 0.00 .047 -.127 Family Conflict .228 .121 .287 Active Coping 1.34 .720 .401 Avoidance Coping -.498 .576 -.127 Support Seeking Coping 0.00 .520 .033 Distraction Coping .280 .420 .093 *p <.05, two-tailed. ** p < .01, two-tailed.
63 Table 4. Hierarchical multiple regression models with depression, stress, perceived family conflict, and active coping strat egy as predictors and sexual risk be havior as the criterion Measure Variable R2 F Df B SE B t Sexual Risk Behavior Constant .052 .957 3,55 .451 .227 Active Coping 1.34 .449 .399 2.98** Depression x Active Coping -1.02 .027 -.052 -.386 Stress x Active Coping -3.331 .1.01 -.047 -.330 Family conflict x Active Coping .521 .275 .332 1.90 Note The full models included depression, stre ss, perceived family conflict, active co ping, depression x active coping, stress x a ctive coping, and perceived family conflict x active coping. *p < .05, two-tailed. ** p < .01, two-tailed.
64 Table 4. Hierarchical multiple regression models with depression, stress, perceived family conflict and avoidance coping strategy as predictors and sexual risk behavior as the criterion Measure Variable R2 F Df B SE B t Sexual Risk Behavior Constant .052 .957 3,55 .451 .227 Avoidance Coping .293 .539 .075 .544 Depression x Avoidance Coping -2.93 .048 -.092 -.612 Stress x Avoidance Coping 7.49 .121 .094 .619 Family Conflict x Avoidance Coping .150 .314 .078 .634 Note The full models included depression, stre ss, perceived family conflict, avoidanc e coping, depression x avoidance coping, stre ss x avoidance coping, and perceived fa mily conflict x avoidance coping. *p < .05, two-tailed. ** p < .01, two-tailed.
65 Table 4. Hierarchical multiple regression models with depression, stress, perceived family conflict, and support seeking co ping as predictors and sexual risk beha vior as the criterion Measure Variable R2 F Df B SE B t Sexual Risk Behavior Constant .052 .957 3,55 .451 .227 Support Seeking .807 .361 .303 2.238* Depression x Support Seeking Coping -9.96 .030 -.047 -.336 Stress x Support Seeking Coping -3.18 .080 -.058 -.399 Family Conflict x Support Seeking Coping 7.99 .212 .058 .377 Note The full models included depression, stre ss, perceived family conflict, support seeking coping, depression x support seeking coping, stress x support seeking, and perceived family conflict x support seeking coping. *p < .05, two-tailed. ** p < .01, two-tailed
66 Table 4. Hierarchical multiple regression models with depre ssion, stress, perceived family c onflict, and distraction coping as predictors and sexual risk be havior as the criterion Measure Variable R2 F Df B SE B t Sexual Risk Behavior Constant .052 .957 3,55 .451 .227 Distraction Coping .549 .407 .183 1.35 Depression x Distraction Coping 4.81 .033 .199 1.47 Stress x Distraction Coping -6.28 .080 -.113 -.782 Family Conflict x Distraction Coping .279 .218 .020 1.28 Note The full models included depression, stre ss, perceived family conflict, distrac tion coping, depression x distraction coping, stress x distraction coping, and perceived fam ily conflict x distraction coping. *p < .05, two-tailed. ** p < .01, two-tailed.
67 CHAPTER 5 DISCUSSION The purpose of the present study was to em pirically examine depression, stress, perceived family conflict, and coping strategy as predictors of engagement in ri sky sexual behavior among adolescents with chronic illnesses. Specificall y, the study examined whether coping strategies moderate the relationship between (a) depression, stress, and perceived family conflict and (b) risky sexual behavior. This chap ter presents a summary and interpretation of the results of the present study, limitations of the study, and clinical im plications and directions for future research. Summary and Interpretations of the Results Results from this study did not support Hypot hesis 1, which stated that am ong adolescents, level of depression will have a significant positive association with engagement in risky sexual behavior. Although the Pearson Product Moment Correlations revealed a positive correlation between level of depression and risky sexual behavior, the correlation was not found to be significant. The results of the present study regarding H ypothesis 1 differ from those of previous studies in which significant positive associatio ns between depression a nd risky sexual behavior have been found (Hallfors, Waller, Ford, Halp ern, Brodish, & Iritani, 2004; Kosunen, KaltialaHeino, Rimpelas, & Laippala, 2003; Harvey & Spi gner, 1995). However, these previous studies were conducted utilizing very large sample sizes ranging fr om 1,206 participants to 18,924 participants. The use of large sample sizes in creases the like lihood of detecting significant associations. Additionally, given the large sample sizes utilized in the above cited research, the researchers were able to only include participants who had m oderate to high scores on the measures used to detect depr essive symptomatology in their respective studies. The analyses
68 conducted in the present research used the data from all of the particip ants regardless of the participants scores on the measures. Also of note was the low mean score for the le vel of engagement in risky sexual behavior for the sample. The highest possible score that could be obtained on the YRBS was 33. However, the mean score for the participants was .45, whic h indicates that there was minimal engagement in risky sexual behavior by the participants in the study. The low mean level of engagement in risky sexual behavior and the la ck of variance in the scores likely affected the ability to accurately determine if there we re associations between risky sexual behaviors and the other variables of interest in the study (i.e., depression, stress, pe rceived family conflict, and coping style). The results of this study also failed to support Hypothesis 2, which stated that, among adolescents, stress level will have a significant positive association with engagement in risky sexual behavior. Analyses revealed a small posit ive correlation between stress and engagement in risky sexual behavior; however, th e correlation was not significant. The results of the present study regarding Hypo thesis 2 differ from the results obtained by Harvey and Spigner (1995). Results from the Ha rvey and Spigner study i ndicated an association between stress and sexual behavior among adoles cents. However, the study conducted by Harvey and Spigner is one of the few studi es that have examined a direct association between stress and sexual behavior. Also of note, Harvey and Sp igners study did not explicitly examine risky sexual behavior but merely l ooked at adolescents engageme nt in sexual intercourse. Results from the present study did not s upport Hypothesis 3, which stated that, among adolescents, level of perceived family conflict wi ll have a significant positive association with engagement in risky sexual behavior. Results of the present study i ndicated a positive but non-
69 significant relationship between le vel of perceived family conflict and engagement in risky sexual behavior. The results of the present study regarding Hypoth esis 3 are not consiste nt with the findings of McBride, Paikoff, and Holmbeck (2003) who found that adolescents re port of conflict in the family was associated with early sexual debut. Similar findings were achieved by Henrich, Brookmeyer, Shrier, and Shahar (2006) who foun d that less conflict-laden relationships between teens and their parents resulted in the teens engaging in fewer se xual risk behaviors. However, it is of note that the mean score on the Conflict subscale of the Family Relationship Index for the adolescents in the present study was lo wer than the reported normative mean. Results from the study also failed to support hypothesis 4. Hypothesi s 4 stated that among adolescents, levels of depressi on, stress, perceived family conflict, and coping strategy will be significant predictors of engagement in ris ky sexual behavior. The overall model was not significant. The findings from the present study regarding Hypothesis 4 were contrary to the findings of other studies which have found depression (Smith, 1997; Kos unen, Kaltiala-Heino, Rimpela, and Laippala, 2003) and family conflict (McB ride, Paikoff, & Holmbeck, 2003; Henrich, Brookmeyer, Shrier, & Shahar, 2006) to be predic tors of engagement in various risky sexual behaviors. The adolescents in the present study exhibited low scores on the depression measure and the measure of perceived family conflict. Th e low levels of depressive symptomatology and perceived family conflict reported by the adolesce nts likely hindered the ability to detect any associations between these variab les and engagement in risky se xual behaviors. The results of the present study also revealed that the adolescents utilized the four coping strategies to the same degree as indicated by the similar mean scores and standard deviations.
70 The results of the present study provided pa rtial support for Hypothesis 5, which stated that, among adolescents, coping strategy will mode rate the relationship between (a) levels of depression, stress, and perceived family conflict and (b) engagement in risky sexual behavior. Four hierarchical regres sions were conducted to test Hypothesis 5. In the first regression, active coping was the only individual variable found to be a significant predic tor of risky sexual behavior. The interaction terms of depression x active coping and perceived family conflict x active coping were also found to be significant predictors. However, the stress x active coping interaction was not found to be significant. The finding that the stress x active coping inte raction was not a significant predictor of engagement in risky sexual beha vior among the adolescents in this study is a surprising one. One possible explanation for this findi ng is that active coping may not be associated with the number and types of stressful events to which an adolescent may be exposed, which were assessed in the present study. Therefore, the in teraction between active coping and stress, as stress was measured in the present study, may not impact adolescents engagement in sexual behavior; whereas, the interaction between ac tive coping and an adolescents perceived level of stress may have revealed different results. None of the other types of coping (i.e., avoidance coping, support seeking coping, or distraction coping) were found to be significant predictors of engagement in risky sexual behaviors among the adolescents in the present study. In addition, none of the interaction terms (i.e., depression x avoidance c oping, stress x avoidance copin g, perceived family conflict x avoidance coping, depression x support seeking coping, stress x support seeking coping, perceived family conflict x support seeking co ping, depression x distr action coping, stress x distraction coping, perceived family conflict x di straction coping) were found to be significant
71 predictors. These findings suggest that of the four types of coping examined in this study, active coping is the only type of coping that moderates the relationships between (a) depression, stress, and perceived family conflict and en gagement in risky sexual behavior. Results from the examination of the resear ch question presented in the present study revealed that the Non-Hispanic White American adolescents reported sign ificantly higher levels of depression than the African American adolescents. Mixed result s have been obtained regarding differences in the levels of depres sion between African American adolescents and Non-Hispanic White American adolescents (Shaffer, Forehand, Kotchik and The Family Health Project Research Group, 2002). Given the mixed result s that have been obtained, further research is necessary to determine whether differences in the levels of depression between African American adolescents and Non-Hispanic White American adolescents do indeed exist. Results of the present study revealed no other significant differences in levels of depression, levels of stress, levels of perceived family conflict, and the four coping strategies among the adolescents in associatio n with age, gender, or ethnicit y. These findings were contrary to the results of other studies which have found significant differences in levels of depression and levels of stress due to demographic variab les such as age and gender (e.g., Bachanas et al., 2002; McCarthy & Brack, 1996; Galambos, L eadbeter, & Barker, 2004). Although the differences in the present study were not significant, the Africa n American participants had higher mean scores for risky sexual behavior, stress, and for all four of the coping strategies (i.e., active distraction, support seeking, and avoidance) than the non-Hi spanic White participants. The females in the study had higher mean scores th an males for risky sexual behavior, stress, depression, and all four of the coping strategies. Males only ha d higher mean scores than the females for perceived family conflict.
72 Limitations of the Present Study The results of the present study should be interpreted with cau tion due to several lim itations of the study. The use of self-report measures may have affected the results of the study. Adolescents were asked to respond to questi ons about their engagement in sexual activity. The use of self-report measures to assess such se nsitive data allowed for the possibility that the adolescents may have responded in a socially desirable manner. The lack of a correlation between the adolescents scores on the Youth Risk Behavior Sc ale and their scores on the Marlowe-Crowne Social Desirabili ty Scale does not indicate with certainty that the adolescents were not responding without bias. Another limitation is the small sample size of the current study. The small sample size limits the generalizability of its findings. Additio nally, the sample size may have affected the power of the analyses that were conducted th us limiting the ability to find the hypothesized associations among the i nvestigated variables. Other limitations involve the use of the Yout h Risk Behavior Surveillance and the Life Stressors and Social Resources Inventory as meas ures of risky sexual be havior and levels of stress, respectively. The Youth Risk Behavior Surveillance (YRBS) was de signed to be a survey inventory and was not developed to yield a scale score. As such, a scoring protocol was developed for the present study. Th erefore, the YRBS may not have been a reliable measure of risky sexual behavior in the present study. The Negative Life Events Subscale of the Life Stressors and Social Resources InventoryYouth Form (LISRES-Y) was used to determine th e adolescents level of stress. However, as designed, the Negative Life Events Subscale of the LISRES-Y dire cts respondents to indicate if they have experienced a series of stressful events that may have occurred within the past year. Whether or not an adolescent has experienced any of the stressful events listed on this subscale
73 does not provide a clear assessment of the adolescents perception of the level of stress that they have experienced. Therefore, it is not apparent whether scores on the LISRES-Y in the present study reflected the perceived stress levels of the participating adolescents. Directions for Future Research Future research should be conducted that is si m ilar to the research conducted in the present study in which the affects of stress, depression, family conflict, and coping on engagement in risky sexual behavior is examin ed. Researchers have suggested that more attention should be given to affectively-oriented motivations fo r behavior when explor ing the health-related behaviors of adolescents (Brown, DiClemente, & Reynolds, 1991). However, this future research should utilize larger sample sizes than that of the present stud y which would increase statistical power and may increase the variance among the inve stigated variables. Al so, different measures should be used to assess risky sexual behavior and le vels of stress. Another important issue to consider for fu ture research on risky sexual behavior among adolescents with a chronic illness is the inclus ion of Hispanic/Latino participants. Given the differences in mean scores that were found in the investigated variab les of the present study between the African American a dolescents and the non-Hispanic Wh ite adolescents, it is likely that Hispanic/Latino adolescents with chronic i llnesses may also differ from the participants of this study in the levels of the investigated variables. The inclusi on of Hispanic/Latino adolescents is also warranted because of the increased risk of engagement in risky sexual behavior by this group of adolescents. Finally, future research should be directed at determining othe r variables that are affecting adolescents engagement in ri sky sexual behavior. Particular emphasis should be placed on examining the role of negative emotional states in the occurrence of risky sexual behavior among adolescents. Additionally, this research should in clude an examination of the variables that may
74 moderate the impact that negative emotional states may have on an adolescents engagement in risky sexual behavior. Implications for Counseling Psychologists Keeping in m ind the previously mentione d limitations, the pres ent study does however have some important clinical implications. The association found be tween active coping and risky sexual behavior suggests that interventions designed to address risky sexual behavior should incorporate methods (eg., role plays, pare ntal modeling) for incr easing the use of active coping strategies. The use of active coping strategies would be particularly relevant in situations where adolescents are depressed an d/or are experiencing conflict within the family. In addition, non-Hispanic White American adolescents may es pecially benefit from adopting a more active coping style given the higher le vel of depressive symptoms that was exhibited by the nonHispanic White American adolescents in comparis on to the African American adolescents in this study. The incorporation of a focus on active c oping strategies into sexual education programming is consistent with a holistic type of programming. A holis tic approach to sexual education programming has been found to be eff ective in reducing sexual risk behavior (Kirby, 2003). The addition of a component that addre sses active coping strate gies may improve the effectiveness of existing programs.
75 APPENDIX A YOUTH INFORMATION QUESTIONNAIRE (YIQ) Please prov ide the requested inform ation by shading in your answer. It should look like this: 1. What is your age? 12 13 14 15 16 17 2. What is your gender? Male Female 3. Your Race/Ethnicity: Cuban/Cuban-American Dominican Republican Mexican/Mexican-American/Chicano(a) Puerto Rican Other Hispanic/Latino (please specify: _____________________) Caucasian/White/European-American African-American/Black-American Other (please specify: _____________________) 4. With whom do you live? Both parents Mother only Father only Legal Guardian Other (please specify: _____________________) 5. Highest level of educati on that you have completed : Elementary School Middle/Junior High School High School 6. Do you have children? Yes (How many?:________) No
76 APPENDIX B YOUTH RISK BEHAVIOR HIGH SCHO OL QUESTIONNAIRE (YRB S) Directions : Please give all of your answers by comple tely filling in the circle beside your answer. It should look like this: Remember, all of your answer s will be kept strictly private and confidential The next 8 questions ask about sexual behavior. 1. Have you ever had sexual intercourse? O Yes O No 2. How old were you when you had sexua l intercourse for the first time? O I have never had sexual intercourse O 14 years old O 11 years old or younger O 15 years old O 12 years old O 16 years old O 13 years old O 17 years old or older 3. During your life, with how many peopl e have you had sexual intercourse? O I have never had sexual intercourse O 4 people O 1 person O 5 people O 2 people O 6 or more people O 3 people 4. During the past 3 months, with how ma ny people did you have sexual intercourse? O I have never had sexual intercourse O I have had sexual intercourse, but not during the past 3 months O 1 person O 2 people O 5 people O 3 people O 6 or more people O 4 people
77 5. Did you drink alcohol or use drug s before you had sexual intercourse the last time? O I have never had sexual intercourse O Yes O No 6. The last time you had sexual intercour se, did you or your partner use a condom? O I have never had sexual intercourse O Yes O No 7. The last time you had sexual interc ourse, what one method did you or your partner use to prevent pregnancy? (Select only one response.) O I have never had sexual intercourse O No method was used to prevent pregnancy O Birth control pills O Condoms O Depo-Provera (injecta ble birth control) O Withdrawal O Some other method O Not sure 8. How many times have you been pre gnant or gotten someone pregnant? O 0 times O 1 time O 2 or more times O Not sure
78 APPENDIX C LIFE STRESSORS AND SOCIAL RESOURCE S INVENTORY YOUTH FORM (LISRES-Y) Directions: Please answer Yes or No to each of the following questions by completely filling in a bubble. It should look like this: Have you had any of these physical problems DURING THE PAST 12 MONTHS? 1. Frequent cramps or pain in the legs 2. Trouble breathing or shortness of breath 3. Pains in the back or spine 4. Frequent pains in the stomach/ indigestion 5. Frequent headaches or dizziness 6. Frequent sore throat s, coughing, or bad colds 7. Stiffness, swelling, or achi ng in any joint or muscle 8. Overweight compared with kids your age 9. Underweight compared with kids your age 10. Problems with acne or pimples 11. Problems with pubertal or body change 12. Eyesight or hearing problems 13. Were you hospitalized for any reason? 14. Did you have a serious accident or injury? Yes No O O O O O O O O O O O O O O O O O O O O O O O O O O O O
79 Have you had any of these medical conditions DURING THE PAST 12 MONTHS ? (Answer Yes only if the condition was diagnosed by a doctor.) 15. Anemia 16. Asthma or allergies 17. Arthritis or rheumatic disease 18. Chronic bronchitis 19. Kidney trouble 20. Serious back trouble 21. Stomach ulcer or duodenal ulcer 22. Eating disorder (anorexia, bulimia) 23. Do you have any other health problems that have not been mentioned so far? (For example, cancer, physical handicaps, epilepsy/seizures, a learning disability such as dyslexia, or AD/HD.) In the past 12 months : 24. Did you move to a new home? (If not, skip to question 26) If Yes, 25. Is it a worse home? In the past 12 months : 26. Has someone new moved into your home? (If not, skip to question 28) If Yes, 27. Has it made things worse? Yes No O O O O O O O O O O O O O O O O O O Yes No O O O O Yes No O O O O O O
80 28. Has someone moved out of your home? (If not, skip to question 30) If Yes, 29. Has it made things worse? In the past 12 months : 30. Were any of your personal belo ngings stolen or damaged? 31. Was your home burglarized? 32. Were you personally attacked (h it, beaten, assaulted, etc.)? In the past 12 months : 33. Have your parents separated? 34. Have your parents divorced? 35. Has your mother or female guardian died? 36. Has your father or male guardian died? 37. Has your mother remarried and it made things worse? 38. Has your father remarried a nd it made things worse? In the past 12 months : 39. Has your relationship with your mother or stepmother changed for the worse? 40. Has your mother or stepmother had a serious accident or injury? 41. Has your mother or stepmother been hospitalized? 42. Has your mother or stepmother lost her job? 43. Has your mother or stepmother developed a new medical condition? 44. Has your mother or stepmother developed a new emotional or behavioral problem? Yes No O O O O O O Yes No O O O O O O O O O O O O Yes No O O O O O O O O O O O O O O O O
81 In the past 12 months : 45. Has your relationship with your father or stepfather changed for the worse? 46. Has your father or stepfather ha d a serious accident or injury? 47. Has your father or stepfather been hospitalized? 48. Has your father or stepfather lost his job? 49. Has your father or stepfather developed a new medical condition? 50. Has your father or stepfather deve loped a new emotional or behavioral problem? In the past 12 months : 51. Has a brother or sister died? 52. Has a sibling developed a new medical condition? 53. Has a sibling developed a new em otional or behavioral problem? 54. Has a relationship with a brother or sister changed for the worse? 55. Has a brother or sister had a serious accident or injury? 56. Has a brother or sist er been hospitalized? In the past 12 months : 57. Has your relationship with a relative changed for the worse? 58. Has a relative had a serious accident or injury? 59. Has a relative become very ill or had medical problems? 60. Has a relative had emotional or mental problems? Yes No O O O O O O O O O O O O Yes No O O O O O O O O O O O O Yes No O O O O O O O O
82 61. Has a relative died in the last year? 62. Has a relative moved far away? In the past 12 months : 63. Have you tried out for a team but did not make it? 64. Have you got into trouble at school? 65. Have you been suspended from school? 66. Have you been held back a year in school? 67. Have you been dropped by friends at school? 68. Have you changed to a worse school? In the past 12 months : 69. Has a friendship changed for the worse? 70. Have you been dropped by a group of friends? 71. Have you tried out for a club or team outside of school, but did not make it? 72. Has a friend died? 73. Has a friend moved away? In the past 12 months : 74. Have you been rejected or turn ed down by someone you really liked? 75. Have you broke up with a boyfriend or girlfriend? 76. Has your relationship with a boyfrie nd or girlfriend changed for the worse? Yes No O O O O O O O O O O O O Yes No O O O O O O O O O O Yes No O O O O O O O O O O
83 APPENDIX D CENTER FOR EPIDEMIOLOGIC STUDIES (CES-D) Directions: For the 20 items listed below, please fi ll in the answer that best describes how you have felt over the last week It should look like this : Rarely or none (<1 day) Some or a little (1-2 days) Occasionally (3-4 days) Most or all of the time (5-7 days) 1. I was bothered by things that usually dont bother me. 2. I did not feel like eating; my appetite was very poor. 3. I felt that I could not shake off the blues even with the help from my family and friends. 4. I felt that I was not as good as other people. 5. I had trouble keeping my mind on what I was doing. 6. I felt depressed. 7. I felt that everything I did was an effort. 8. I felt hopeless about the future. 9. I thought my life had been a failure. 10. I felt fearful. 11. My sleep was restless. 12. I was unhappy. 13. I talked less than usual. 14. I felt lonely. 15. People were unfriendly. 16. I did not enjoy life. 17. I had crying spells.
84 18. I felt sad. 19. I felt that people disliked me. 20. I could not get going.
85 APPENDIX E FAMILY RELATIONS INDEX (FRI) Directions : There are 2 7 statements on these pages. They are statements about families. You are to decide which of these statements ar e true of your family and which are false. True Fill in the circle under the True co lumn when you think the statement is True or mostly True of your family. False Fill in the circle under th e False column when you think the statement is False or mostly False of your family. You may feel that some of the statements are true for some members and false for others. Fill in the circle under the True column if the statement is true for most members. Fill in the circle under the False column if the statement is false for most members. If the members are evenly divided, decide what is the stronger ove rall impression and answer accordingly. Remember, we would like to know what your family seems like to you So do not try to figure out how other members see your family, but do give us your general impression of your family for each statement. 1. Family members really help and support one another. 2. Family members often keep their feelings to themselves. 3. We fight a lot in our family. 4. We often seem to be killing time at home. 5. We say anything we want to around home. 6. Family members rarely become openly angry. 7. We put a lot of energy into what we do at home. 8. Its hard to blow off steam at home without upsetting somebody. 9. Family members sometimes get so angry they throw things. 10. There is a feeling of unity and cohesion in our family. 11. We tell each other abou t our personal problems. True False O O O O O O O O O O O O O O O O O O O O O O
86 12. Family members hardly ever lose their tempers. 13. We rarely volunteer when something has to be done at home. 14. If we feel like doing something on the spur of the moment we often just pick up and go. 15. Family members often criticize each other. 16. Family members really back each other up. 17. Someone usually gets upset if you complain in our family. 18. Family members sometimes hit each other. 19. There is very little group spirit in our family. 20. Financial matters are openly discussed in our family. 21. If theres a disagreement in our family, we try hard to smooth things over and keep the peace. 22. We really get along well with each other. 23. We are usually careful about what we say to each other. 24. Family members often try to one-up or out-do each other. 25. There is plenty of time and attention for everyone in our family. 26. There are a lot of spontaneous discussions in our family. 27. In our family, we believe you dont ever get anywhere by raising you voice. True False O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O
87 APPENDIX F CHILDRENS COPING STRATEGIES CH E CKLIST REVISION 1 (CCSC-R1) Never Sometimes Often Most of the time 1. You thought about what you could do before you did something. O O O O 2. You tried to notice or think about only the good things in your life. O O O O 3. You tried to ignore it. O O O O 4. You told people how you felt about the problem. O O O O 5. You tried to stay away from the problem. O O O O 6. You did something to make things better. O O O O 7. You talked to someone who could help you figure out what to do. O O O O 8. You told yourself that things would get better. O O O O 9. You listened to music. O O O O 10. You reminded yourself that you are better off than a lot of other people. O O O O 11. You daydreamed that everything was okay. O O O O 12. You went bicycle riding. O O O O Directions: For each statement, please fill in one circle show ing how much you agree or disagree. Directions: Sometimes people have probl ems or feel upset about things. When this happens, they may do different things to solve the proble m or make themselves feel better. For each item below, choose the answer that BEST desc ribes how often you usually did this to solve your problems or make yourself feel better during the past m onth. There are no right or wrong answers, just indicate how often YOU USUALLY did each thing in order to solve your problems or make yourself feel better during the past month.
88 13. You talked about your f eelings to someone who really understood. O O O O 14. You told other people what you wanted them to do. O O O O 15. You tried to put it out of your mind. O O O O 16. You thought about what would happen before you decided what to do. O O O O 17. You told yourself that it would be OK. O O O O 18. You told other people what made you feel the way you did. O O O O 19. You told yourself that you could handle this problem. O O O O 20. You went for a walk. O O O O 21. You tried to stay away from things that made you feel upset. O O O O 22. You told others how you would like to solve the problem. O O O O 23. You tried to make thi ngs better by changing what you did. O O O O 24. You told yourself you have taken care of things like this before. O O O O 25. You played sports. O O O O 26. You thought about why it happened. O O O O 27. You didnt think about it. O O O O 28. You let other people know how you felt. O O O O 29. You told yourself you could handle whatever happens. O O O O 30. You told other people what you would like to happen. O O O O
89 31. You told yourself that in the long run, things would work out for the best. O O O O 32. You read a book or magazine. O O O O 33. You imagined how youd like things to be. O O O O 34. You reminded yourself that you knew what to do.O O O O 35. You thought about which th ings are best to do to handle the problem. O O O O Never Sometimes OftenMost of the time 36. You just forgot about it. O O O O 37. You told yourself that it would work itself out. O O O O 38. You talked to someone who could help you solve the problem. O O O O 39. You went skateboard ri ding or roller skating. O O O O 40. You avoided the people who made you feel bad. O O O O 41. You reminded yourself that overall things are pretty good for you. O O O O 42. You did something like video games or a hobby. O O O O 43. You did something to solve the problem. O O O O 44. You tried to understand it better by thinking more about it. O O O O 45. You reminded yourself about all of the things you have going for you. O O O O 46. You wished that bad things wouldnt happen. O O O O 47. You thought about what you needed to know so you could solve the problem. O O O O 48. You avoided it by going to your room. O O O O
90 49. You did something in order to get the most you could out of the situation. O O O O 50. You thought about what you could learn from the problem. O O O O 51. You wished that th ings were better. O O O O 52. You watched TV. O O O O 53. You did some exercise. O O O O 54. You tried to figure out why things like this happen. O O O O
91 APPENDIX G MARLOWE-CROWNE SOCIAL DESI RABILITY SCALE (MCSDS) Directions: For each of the following statements, pl ease completely fill in the answer you consider to be True (T) or False (F). True False 1. I never hesitate to go out of my way to help someone in trouble. O O 2. I have never intensely disliked anyone. O O 3. I sometimes feel resentful when I dont get my way. O O 4. I like to gossip at times. O O 5. There have been times when I fe lt like rebelling against people in authority even though I knew they were right. O O 6. I can remember playing sick to get out of something. O O 7. There have been occasions when I took advantage of someone. O O 8. Im always willing to admit it when I make a mistake. O O 9. I always try to practice what I preach. O O 10. I sometimes try to get even, rath er than forgive and forget. O O 11. When I dont know something I dont at all mind admitting it. O O 12. I am always courteous, even to people who are disagreeable. O O 13. At times I have really insisted on having things my way. O O 14. There have been occasions when I fe lt like smashing things. O O 15. I would never think of letting someone else be punished for my wrong-doings. O O 16. I never resent being asked to return a favor. O O 17. I have never been irked when people expressed ideas very different from my own. O O
92 18. There have been times when I was quite jealous of the good fortune of others. O O 19. I am sometimes irritated by people who ask favors of me. O O 20. I have never deliberately said so mething to hurt someones feelings. O O
93 APPENDIX H INVITATION LETTER Dear Patient: Thank you for your sustained interest in our re search project. W e are a Research Team, supervised by Dr. Carolyn M. Tucker, Distingu ished Alumni Professor at the University of Florida. The purpose of this project is to t each young people ways to live more healthy lives. Participation in this study involves you and your adolescent completing a set of questionnaires. Although we do not believe that completing thes e questionnaires will cause you any harm, you do have the right to skip any questions that you find offensive and you have the right to stop completing a questionnaire if it makes you feel uncomfortable. You will be asked to complete these same questionnaires again in approximately five months. If you choose to complete the questionnaires again, you will again receive compensation for your time. Both you and your adolescent will be comp ensated for completing the questionnaires. You may decide later whether or not you would lik e to complete the questionnaires again. Your participation in this resear ch project is voluntary. If you experience any discomforts with completing these questionnaires, you may call Dr Carolyn M. Tucker, at (352) 392-0601 ext. 260, and/or the University of Fl orida Institutional Review Bo ard (IRB) Office at (352) 846-1494 to discuss your concerns. Your information will not be shared with your doctor or other members of the health care staff at your clinic. Also, your name will not be placed on any of the questionnaires that you complete. Instead, the information from you will be assigne d a code number. The list of names that identify these codes will be ke pt in a separate locked locatio n from the information that you provide us with. The questionn aires that you provide us will be destroyed as soon as all information from you and other participants has been gathered. All this information will be locked in file cabinets in Dr. Tucker's lab in the psychology building at the University of Florida. All information from participants will be combin ed so that no one can identify your information. In return for your participation in our study, you will be mailed a payment of $20 within three (3) weeks of when we receive your completed questionnaires and payment release form. Please sign the Informed Consent Form and ha ve your adolescent sign the Adolescent Assent Form.Also, in addition to completing the questionn aires, sign and return the completed Payment Release Form. We need your name, address, and social security number requested on this form so that we can send you a check for $20. Your signed Informed Consent Form and Payment Release Forms will be locked in a separate file cab inet from the locked file cabinet in which your completed questionnaires will be kept. This will be done to further protect your confidentiality. In order to participate, please complete the enclosed que stionnaires and Payment Release Form, then return them by mail in the pre-paid reply envelope provided This should only take about an hour. If you need help comple ting the questionnaires, you may ask a family member or friend to read them to you; howev er, we only want your answers to the questions You may also call Dr. Carolyn M. Tucker at (352) 392-0601, Ext. 260 to set up an appointment
94 to have a Research Assistant read the questionn aires to you at the health care clinic that you attend. If you have any questions about this research pr oject, please call a member of our research team at the (352) 392-0601 ext. 260. We are l ooking forward to yo ur participation. Sincerely, Dr. Carolyn M. Tucker Distinguished Alumni Professor Professor of Psychology Professor of Pediatrics Professor of Community Hea lth and Family Medicine
95 APPENDIX I PARENTAL INFORMED CONSENT UF IRB01 194-2003 RCH S 1266 Informed Consent to Take Part in Research and Authorization for Collection, Use, and Disclosure of Protected Health Information (Parents/Caregivers CMS) You are being asked to take part in a research study. This form provides you with information about the study and seeks your authorization fo r the collection, use and disclosure of your protected health information necessary for the st udy. The Principal Investigator (the person in charge of this research) or a representative of the Principal Investigator will also describe this study to you and answer all of your questions. Be fore you decide whether or not to take part, read the information below and ask questi ons about anything you do not understand. Your participation is entirely voluntary. 1. Name of Parent/Caregiver Participant (please print): _____________________________________________________________ Last name First name Middle name 2. Title of Research Study The Childrens Health Self-Empowerment Project 3a. Principal Investigator and Telephone Number(s): Carolyn M. Tucker, Ph.D. University of Florida Distinguished Alumni Professor Professor of Psychology and Director of Training Professor of Pediatrics Professor of Community Hea lth and Family Medicine 352-392-0601 Ext. 256 3b. Co-Investigator
96 Sharon Surrency, RN, MPH Childrens Medical Services Executive Nursing Director, Gainesville/Ocala/Daytona/Jacksonville 4. Source of Funding or Other Material Support The State of Florida Department of Health, Division of Childrens Medical Services, is funding this research. 5. What is the purpose of this research study? The goal of this project is to teach young people ways to live more healthy lives. The project will involve both teenagers and their parents or guardians. The people who take part in the project will be African American, Hispanic/Latino(a) American and Caucasian American. Teenagers who take part in the study will be patients at Childrens Medical Services (CMS). There will be about 270 teenag ers who will take part in this project. One parent or guardian will take part with each teenager, so there will be about 270 adults taking part in this project. Another goal of this project is to teach ways to live more healthy lives to a group of African American teenagers who took part in a neighborhood after sc hool program. The teenagers parent or guardian will also take part If these teenagers want to take part, they must tell us that they are ove rweight and/or have high blood pressure. They might also say that their parent or guardian is overwe ight and/or has high blood pressure. There will be 25 teenagers and 25 adults in this group. The project will use 3 workshops to teach : 1. ways to eat healthier, ex ercise, and worry less. 2. ways to not fight, not use dr ugs and alcohol, and not have protected or unprotected sex. 3. ways to lose weight if they are overweight. 4. ways to lower their blood pressure if they have high blood pressure. 5. ways to lower their blood sugar levels if they have diabetes. The project will also ask teenagers who have CMS health care providers and their parents or guardians: 1. What behaviors and attitudes of their CMS Nurse Care Coordinators, doctors, nurses, a nd clinic staff can make them feel: a) more comfortable b) more respected c) more trusting 2. how the waiting room and doctors exam room of the clinic can make them feel:
97 a) more comfortable b) more respected c) more trusting 6. What will be done if you take part in this research study? You are being invited to take part in this project because your child: 1. Is 12 to 17 years old. 2. Is a patient of Children s Medical Services (CMS). This project has two parts: Part I and Part II. If you want to take part in this project, you will be chosen for only one of the two parts. Here is what will happen in each of the two parts: Part I. If you are chosen to be in this part of the project, you will be asked to: 1. answer questions about your childs Nurse Care Coor dinator, doctors, nurses, and clinic staff. The questions will ask what these persons can do to make you feel: a) more comfortable b) more respected c) more trusting of them 2. rate how important some behavior s and attitudes are to make you feel : a) more comfortable b) more respected c) more trusting of them 3. answer some true or fa lse questions about yourself It should take about one hour to answer all of these questions. Your name and your childs name will not be put on any of your answers to the questions that you are asked to fill out. Instead of using your na me we will give you a code. We will write this code on all of the research forms to protect your privacy. None of your childs CMS Nurse Care Coordinators, doctors, nurses, or clinic staff will see your answers These persons will also not be told if your family is ta king part in the project. If you are chosen to take part in Part I, you will get a packet in about 3 weeks. You will be asked to fill out the forms and send them back to us in about 2 weeks. We will send the packet after we get your completed and signed Informed Consent Form. Once you finish the packet and send it to th e CHSE research team you should get paid in about 3 weeks (go to item number 10 on page 8 to learn about getting paid for taking part in this research). The total tim e you could be asked to take part in this research is about 3 months. A person from the CHSE research team ma y call you if the packet is not completed and sent back to us in about 2 weeks. This call will be made to make sure that you
98 got the packet. You may also be called after you send your packet to us. A person from the CHSE research team may call you if some of the information is missing. When we call, if you do not want to an swer the questions you do not have to. All information about you will be kept private. All information about you will be given a code to make this information private. Your name will be kept in a locked file cabinet in the Psychology bu ilding at the University of Florida. None of your childs CMS Nurse Care Coordinato rs, doctors, nurses, or clinic staff will be told if you are in this project. Part II: If you are chosen for this part of the project, you will be asked to: 1. take part in 3 health workshops. Each workshop will be about 4 hours long. The health workshops will teach you things like: how to have less family worry and sadness how to make and eat healthier food how to exercise more and worry less the risks of having unprotected a nd protected sex, and so on. You will be asked to take part in all of the workshop activities. You can choose not to take part in any activity that makes you f eel uncomfortable. You can also choose not to finish any activity that you may have started. 2. answer some questions about things like: your health behaviors and beliefs how your family deals with worry and sadness if you have unprotected sex smoking drug use alcohol use violent behaviors if you have tried to kill yourself if you exercise what kinds of foods you eat how motivated you are whether some questions a bout you are true or false If you have problems or need help with th ese things, please talk to your doctor. We will not be able to help you. Your an swers to these questions will be kept private. It should take you about two hours to answer all of the questions. You should take breaks when filling out the forms so that you do not get tired.
99 Please try to work on the forms for only 45 minutes at a time. Then take at least a 2hour break before working some more on finishing the forms. Your name will not be put on any of the questions or forms you fill out Instead of using your name we will give you a code. We will write this code on all of the forms that you fill out to protect you and your childs privacy. None of your childs CMS Nurse Care Coordinators, doctors, nurses, or cl inic staff, will see your answers. They will not be told if your family is ta king part in the project. There will be 2 different groups in Part II. If you are chosen to take part in Part II, you will be put in only one of the groups. Part II Intervention Group o About 3 weeks after we get your co mpleted Informed Consent Form you will get your first packet of questionnaires and forms. o Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks (go to item number 10 on page 8 to learn about getting paid for taki ng part in this research). o About 2 months later you will be asked to take part in the 3 workshops. o The 3 workshops will be about 3 weeks apart. Each workshop will be about 4 hours long. You should get pa id about 3 weeks after you go to the 3rd workshop (go to item number 10 on page 8 to learn about getting paid for taking part in this research). You will need to go to all 3 workshops to get paid. o About 6 months after the 3rd workshop you will get your 2nd packet of questionnaires and forms. o Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks (go to item number 10 on page 8 to learn about getting paid for taki ng part in this research). This means that if you are chosen to be in the Part II Inte rvention Group you would take part for about 9 months Part II Control Group o About 3 weeks after we get your co mpleted Informed Consent Form you will get your first packet of question forms. o Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks (go to item number 10 on page 8 to learn about getting paid for taki ng part in this research). o About 9 months later you will get your 2nd packet of questionnaires and forms. o About 3 weeks later you will be asked to take part in the 3 workshops. o The 3 workshops will be about 3 weeks apart. Each workshop will be about 4 hours long. You should get pa id about 3 weeks after you go to the 3rd workshop (go to item number 10 on page 8 to learn about
100 getting paid for taking part in this research). You will need to go to all 3 workshops to get paid. o About 6 months after the 3rd workshop you will get your 3rd packet of questionnaires and forms. o Once you finish the packet and send it to the CHSE research team you should get paid in about 3 weeks (go to item number 10 on page 8 to learn about getting paid for taki ng part in this research). This means that if you are chosen to be in the Part II Control Group you would take part for about 18 months. A person from the CHSE research team may call you if a packet is not sent back in about 2 weeks. This call will be made to make sure that you got the packet. You may also be called after you send a packet to us. A person from the CHSE research team may call you if some of the information is missing. When we call, if you do not want to answer the questions you do not have to. Lastly, a person from the CHSE research team may call to remind you about upcoming project activities. All information about you will be kept private. All information about you will be given a code. Your name will be kept in a locked file cabinet in the Psychology building at the University of Florida. None of your childs CMS Nurse Care Coordinators, doctors, nurses, or clinic staf f will be told if you are in this project. 7. What are the possible discomforts and risks? If you want to take part in this research, there should be no physical or psychological risks to you. Some of the questions that will be asked may make you feel uncomfortable If you do feel uncomfortable, please feel free to skip th e questions that caused this feeling. During the study we will tell you of any changes in the risk of you taking part in the research. We will also tell you about any information that ma y change your wanting to take part in the study. If you want to talk about the information above or any worries you may have, please call the Principal Investigator of the research, Dr. Carolyn M. Tucker. Dr. Tuckers phone number is (352) 392-0601 Ext. 256. 8a. What are the possible benefits to you? If you are chosen for Part I, there is no instant or direct benefit to you. If you are chosen for Part II, you may gain he lpful ways to make healthy life choices. Your family may gain from learning how to d eal with worries and di sputes better in the health workshops.
101 8b. What are the possibl e benefits to others? Your answers to the questions during the st udy will be joined with the answers of the other people in the study. When put together your answers may help other people. They may help teach teenagers and their parents or guardians ways to live healthier lives. Your answers may also help teach CMS Nurse Care Coordinators, doctors, nurses, and clinic staff helpful ways to give better health care to all of their patients. These results may also raise patients liking of the health care that they get. 9. If you choose to take part in this research study, will it cost you anything? No, this research will not cost your family any money. 10. Will you receive compensation for ta king part in this research study? Yes. How much you will get paid depends on the part of the study you take part in. You cannot choose the part of the study that you will take part in. The amount of money that will be paid to you (and your child) for ta king part in the resear ch study is explained below: 1) Each family (you and your child together) in Part I who fill out and send back the question form packet will get a total of $20. 2) Each family (you and your child together) in Part II who is asked to take part in the intervention group and who fill out and send back the question form packet will get $20. Each family is asked to do this 2 times for a total of $40. You will get another $40 for going to all 3 workshops. So, each family in the intervention group will get a total of $80. 3) Each family (you and your child together) in Part II who is asked to take part in the control group and who fill out and send back the question form packet will get $20. Each family is asked to do this 2 times for a total of $40. You will get another $40 for going to all 3 workshops. After the 3 workshops you will be asked to fill out and send back th e question form packet a 3rd time. You will get an extra $10 for doing this. So, each family in the control group will get a total of $90. ***Please Note : You will not get paid for sending us back this Informed Consent Form and the Adult Information Questionnaire. The question forms you will get paid for filling out will be sent to you after you agree to take part in the project. In order to pay you, we will have to give your name and social security number to the people at the University of Florida who write the checks. They will also write down that you have been paid. You will get paid about 3 weeks after we get each of your packets. You will also get paid about 3 w eeks after you go to all 3 workshops. If
102 you stop taking part during the research study, you will only be paid for the parts that you took part in. 11. What if you are injured because of the study? If you get hurt as a direct result of this study, you can be seen by a professional consultant at the University of Florida Health Science Center free of charge. But, hospital bills will have to be paid by you or your insurance provider. No other payment for being injured is offered. 12. What other options or treatments are availa ble if you do not want to be in this study? We do not know of any other options or treatments that are available to you if you do not want to be in this study. 13a. Can you withdraw from this research study? Yes, you may stop taking part in or decide not to take part in this study at any time. If you do choose to stop taking part in the middle of the study, you will not be punished your child will not be punished you will still be paid for the parts that you took part in If you decide to stop taking part in the middle of the study for any reason, you should contact Dr. Tucker, the Principal Inve stigator, at (352) 392-0601 ext. 256. If you have any questions regarding your righ ts as a research subject, you may phone the Institutional Review Board (I RB) office at (352) 846-1494 or the Florida Department of Health Review Council for Human Subjects at (850) 245-4585, or toll free in Florida at (866) 433-2775. 13b. If you withdraw, can information abou t you still be used and/or collected? Yes. Any information collected about you can be used for further research purposes. Any information given directly to us by you can be used for further research purposes. Only information collected before your decision to no l onger take part in this research study will be used. No further information will be collected after you decide to stop taking part in this research study.
103 13c. Can the Principal Investigator withdraw you from this research study? Yes, we may not allow you to stay in the study if: 1) You do not return this Informed Co nsent Form (or contact the principal investigator) within two weeks of getting it. 2) You do not send us the question sheets we send you to fill out within two weeks of getting them. 3) You are sent to jail or prison for more than one month while you are in the study. 4) The Principal Investigator (Dr. Tucke r) gives you a job while you are in the study. 5) You do not meet the rules for taking pa rt in the study. If you are not sure about these rules, please call the Principal Inve stigator (Dr. Tucker) at (352) 392-0601 Ext. 256. 6) The Principal Investigator (Dr. Tucke r) or Co-Investigator (Ms. Surrency) think that you might be hurt if you stay in the study. 7) The study is stopped by the State of Flor ida Department of Health and/or is stopped for other administrative reasons. 14. How will your privacy and the confidential ity of your protected health information be protected? To keep your privacy: your Informed Consent Forms which iden tify you will be separated from your Adult Information Questionnaire both will be locked in separate filing cab inets in the Psychology Building at the University of Florida. a 3-digit number code followed by a P for parent will be placed on your questionnaires in place of your name. the master-list that identifies you will be kept in a separate key-locked filing cabinet in Dr. Tuckers office in the Ps ychology Department at the University of Florida. If you take part in this research, your privat e health information will be collected, used, and shared under the terms specified in sections 15 below. 15. If you agree to participate in this resea rch study, what protected health information about you may be collected, used and disclosed to others? To find out if you can be in the study, the following information may be collected, used, and shared with others: Your name, address, and phone number (which will not be shared with others) Your age and ethnicity Your answers to the questions that you will be asked to complete
104 16. For what study-related purposes will your protected health information be collected, used and disclosed to others? No personal protected health information wi ll be given out. All of your information will be joined with other peoples informati on. Your protected health information will be collected to make a general report. Your protected health information will be used to find out if you are eligible for our study. Your information added to information from others to report how useful the work shops are for helping people (teenagers and parents or guardians) with: o lowering blood pressure o lowering body weight o lowering blood sugar level o lowering drug use, violence, and unprotected sex in teenagers o helping people to exercise, eat healthy foods, and worry less. 17. Who will be authorized to collect, use and disclose to others your protected health information? Your private health information may be co llected, used, and shared with others by: Dr. Carolyn M. Tucker, Ms. Sharon Surre ncy, and Dr. Tuckers research staff (Dr. Frederic Desmond, Dr. Keith Herman, Christopher Mack, Kellie Hyde, Phyllis Ivery, Rachelle Studer, and Cynthia Karlson) Other professionals at the University of Florida or Shands Ho spital that provide study-related treatment or procedures The University of Florida Institutional Review Board The Florida Department of Health Review Council for Human Subjects 18. Once collected or used, whom may your pr otected health information be disclosed to? Your protected health information may be given to: a. The Florida Department of Health Review Council for Human Subjects b. US and foreign governmental agencies w ho are responsible for overseeing research, such as the Food and Drug Administrati on, the Department of Health and Human Services, and the Office of Human Research Protections c. Government agencies who are responsible for overseeing public health concerns such as the Centers for Disease Control and Fede ral, State and local health departments 19. If you agree to participate in this re search, how long will your protected health information be collected used and disclosed?
105 Your private health information may be colle cted, used, and shared until the end of our study. The subject identifiers will be removed at the end of the study and the information will be maintained in a secure database forever. 20. Why are you being asked to authorize the collection, use and disclosure to others of your protected health information? Under a new Federal Law, researchers cannot collect, use or share any of your private health information. Researchers must get you to allow them to do so by having you sign this consent form. 21. Are you required to sign this consent and authorization and allow the researchers to collect, use and disclose (give) to others of your protected health information? No. If you do not want them to get your pr ivate health information, do not sign this consent form. It will not change anything of yours outside of this research study. If you do not sign this consent, you cannot take part in the research study. If you do not send this consent form back to us, you will not be contacted again. 22. Can you review or copy your protected health information collected, used or disclosed under this authorization? Yes. You have the right to look at and copy your private health information. But, you will not be allowed to do so until after the study is done. 23. Is there a risk that your protected health information could be given to others beyond your authorization? Yes. There is a small risk that informati on given to the researchers could be given to others. It would be outside of your control and not covered by the law. 24. Can you revoke (cancel) your authorization for collection, use and disclosure of your protected health information? Yes. You can stop allowing the collection, use, and sharing of your private health information at any time. It could be before, dur ing or after you take part in the research. No new information will be collected about you after you tell us to stop. If information was already collected it may still be used and shared with others. You can tell the researchers to stop collecting information by writing to us and signing your name. 25. How will the researcher(s) benefit from your being in this study? In general, doing research helps the career of a scientist. So, Dr. Carolyn M. Tucker and her research team may benefit. They will be nefit if the results of the study are shown at scientific meetings or in scientific journals.
106 26. Signatures As the Principal Investigator of this study, I have shared with you: the goals the things that you will have to do if you want to take part the possible benefits the risks of this research study the other options to being in the study how your private health information w ill be collected, used, and shared. ______________________________________________ _______ Carolyn M. Tucker, Ph.D. (Principal Investig ator) Date As the person who wants to take part in this study, you agree that you have been told about: the goals the things that you will have to do if you want to take part the possible benefits the risks of this research study the other options to being in the study how your private health information will be collected, used, and shared. You have been given the chance to ask questions before you sign. You have also been told that you can ask other questions at any time. You voluntarily agree to take part in this study. By signing this Form, you are allowing the collection, use, and sharing of your privat e health information. This is described in sections 15-24 above. By signing this Form you are not giving up any of your legal rights. __________________________________________ _________ Parent/Guardian Signature Date
107 APPENDIX J ADOLESCENT ASSENT FORM You are being asked to take part in a research study. The goal of the project is to teach young people ways to live more healthy lives. The proj ect will involve both teenagers and their parents (or guardians). There will be about 270 teenagers w ho will take part in this project. One parent or guardian must take part with each teenager. Most of the te enagers who take part in this project will be patients at Childrens Medical Services To take part in this project you will need to be African American, Caucasian Ameri can, or Hispanic/Latino(a) American. Your parent must give permission for you to be in this study, but you can make up your own mind whether or not you want to take part in it. 1. What is the name of the research project? The name of the project is the Childrens Health Self-Empowerment Project (CHSE). 2. Who is in charge of the project? Dr. Carolyn M. Tucker is in charge of the proj ect. Dr. Tucker works at the University of Florida. A group of university students help Dr. Tucker with the project. 3. Why are you being invited to take part in this project? You are being invited to take pa rt in this project because you: 1. are 12 to 17 years old 2. are a patient of Childrens Medical Services 4. What will you be asked to do if you want to take part in this project? There are two parts of the projec t, Part I and Part II. You w ill be asked to take part in only one of the two parts of the project. You cannot choose which part you want to be in. Part I. If you are chosen to be in this part I of the project, you will be asked to: 2. answer questions about your Nurse Care Coordinator, doctors, nurses, and clinic staff. The questions will ask what they can do to make you feel: d) more comfortable e) more respected f) more trusting of them 3. rate how important some behaviors a nd attitudes are to make you feel: d) more comfortable e) more respected
108 f) more trusting of them 3. answer some true or fa lse questions about yourself If you are chosen to take part in Part I, you will get a packet of question forms in about 3 weeks. We will send the question forms after we get your completed and signed Assent Form. You will be asked to fill out the forms and send them back to us in about 2 weeks. If you are chosen to be in Part I, you w ill be in the project for about 3 months. Part II: If you are chosen for this part of the project: 1. You will be asked to take part in 3 health workshops. Each workshop will be about 4 hours long. The health workshops w ill teach you things like: how to have less family worry and sadness how to make and eat healthier food how to exercise more and worry less the risks of having unprotected sex and protected sex, and so on. You will be asked to take part in all of the workshop activities. You can choose not to take part in any activity that ma kes you feel uncomfortable. You can also choose not to finish any activity that you may have started. 2. You will be asked to answer some questions about things like: your health behaviors and beliefs how your family deals with worry and sadness if you have unprotected sex smoking drug use alcohol use violent behaviors if you have tried to kill yourself if you exercise what kinds of foods you eat how motivated you are whether or not some questions about you are true or false If you have problems or need help with th ese things, please talk to your doctor. We will not be able to help you. Your an swers to these questions will be kept private.
109 There will be 2 different groups in Part II. If you are chosen to take part in Part II, you will be put in only one of the groups. Part II Intervention Group o About 3 weeks after we get your completed Assent Form you will get your first packet of question forms. o About 2 months later you will be asked to take part in the 3 workshops. At the workshops, trained nursing st udents will collect your height, weight, and blood pressure. o Each workshop will be about 4 hours long. o About 6 months after the 3rd workshop you will get your 2nd packet of question forms. o At this time you may be asked to go to your local Health Department or to a central location to have your height, weight, and blood pressure taken. This means that if you are chosen to be in the Part II Inte rvention Group you would take part in the pr oject for about 9 months. Part II Control Group o About 3 weeks after we get your completed Assent Form you will get your first packet of question forms. o At this time you may be asked to go to your local Health Department or to a central location to have your height weight, and blood pressure taken. o About 9 months later you will get your 2nd packet of question forms. o About three weeks later you will be asked to take part in the 3 workshops. At the workshops, trained nursing st udents will collect your height, weight, and blood pressure. o Each workshop will be about 4 hours long. o About 6 months after the 3rd workshop you will get your 3rd packet of question forms. o At this time you may again be as ked to go to your local Health Department or to a central location to have your height, weight, and blood pressure taken. This means that if you are chosen to be in the Part II Control Group you would take part in the project for about 18 months.
110 5. Will you get paid for taking part in this project? Yes. How much you will get paid depends on the part of the study you take part in. You cannot choose the part of the study that you will take part in. The amount of money that will be paid to you and your parent or guardian for taking part in the research study is stated below: 1) Each family (your child and you together) in Part I that fills out and sends back the question forms we send you will get a total of $20. 2) Each family (you and your child together) in the Part II intervention group that fills out and sends back the question fo rms we send you will get $20. Each family is asked to fill out questions forms two times for a total of $40. Each family will get another $40 for going to all 3 workshops. So, each family in the Part II intervention group will get a to tal of $80. 3) Each family (you and your child together) in the Part II control group that fills out and sends back the question forms we send you will get $20. Each family is asked to fill out question forms two times for a total of $40. Each family will get another $40 for going to all 3 workshops. After the 3 workshops each family will be asked to fill out question forms a third time. Each family will get an extra $10 for doing this. So, each family in the Part II control group will get a total of $90. 4) Each child that goes to her or his local Health Department or a central location to have her or his height, weight, and blood pressure taken will be given a gift certificate to a local business ***Please Note : You will not get paid for sending us back this Informed Consent Form and the Adult Information Questionnaire. The question forms you will get paid for filling out will be sent to you after you agree to take part in the project. You will get paid about 3 weeks after we get each of your packets of question forms. You will also get paid about 3 weeks after you go to all 3 workshops. If you stop taking part during the research study, you will only be paid for the parts that you finished. 6. What information will we ask about you? If you are chosen to be in the project, we w ill need to get your grad e point average (GPA). We will get it from the school board where you go to school. By signing this form, you are telling us that it is okay to get your GPA. We will also ask Childrens Medical Services Nurse Care Coordinators to gi ve us the following medical information from your Childrens Medical Services medical chart: medical diagnosis
111 body weight height blood pressure blood sugar level only medications that you are ta king for your medical diagnosis your social security number (to check your grades) the name of your Nurse Care Coordinator. the name of your regular doctors clinic This is the only information about you that our res earch team will get from Childrens Medical Services. This information will be us ed for research reasons only. We will only get this information during the time the research study is going on. By signing this form, you are telling us that it is okay for us to get your medical information. 7. How long will it take to answer the questions in the packets we send to you? Part I: It should take you about one hour to answer all of these questions. Part II: It should take you about two hours to answer all of the questions. You should take breaks when filling out the form s so that you do not get tired. Please try to work on the forms for only 45 minutes at a time Then take at least a 2-hour break before working some more on finishing the forms. You should work on the question forms in a quiet place, away from other people. This is so that no one else will see your answers. That way you will be able to answer the questions honestly. 8. Will we call you during the project? A person from the research team may call you if you do not send a packet back to us within 2 weeks of getting it. This call will be made to make sure that you got the packet. You may also be called after you send a packet to us. A person from the CHSE research team may call you if some of the information is missing. When we call, if you do not want to answer the questions, you do not have to. Lastly, a pers on from the CHSE research team may call to remind you about upcoming project activities. 9. Will all of your information be kept private? Yes All information about you and your parent or guardian will be kept private All information about you will be given a code to make this information private. Your name will
112 be kept in a locked file cabinet in the Psychol ogy Building at the University of Florida. None of your CMS Nurse Care Coordinators, doctors, nurses, or clinic staff will be told if you are in this project. 10. Tell us what you would like to do by putting an X in only one of the boxes below : I agree to take part in this study. I do not want to take part in this study. _________________________________________ __________ Print your name here Date _________________________________________ __________ Sign your name here Date
113 APPENDIX K PAYMENT RELEASE FORM Please g ive us the information below. We will n eed some of the information so we can get in touch with you and mail you your payment for taking part in the research. We need your social security number so you can get paid for taking part in the study. All of this information will be kept private as stated in Section 14 of this Informed Consent Form. Please write large and as neatly as possible Feel free to call Dr. Carolyn M. Tucker at 352-392-0601 Ext. 256, if you feel your information may be hard to read. Primary Parent/Caregivers name (Please Print) __________ _______ __________ Social Security Number of Primary Parent/Caregiver Are you a UF employee? Yes (or) No Phone Number(s): Home: ________________________ Cell: _________________________ (Area code) Number (Area code) Number Other: ________________________ (Area code) Number Your Mailing Address: (Street or Post Office Box) ___________________________________________________ (City) (State) (Zip Code) ________________________________ (Parent or Guardian Signature)
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123 BIOGRAPHICAL SKETCH Phyllis Dian a Ivery is a graduate of the Un iversity of Floridas Counseling Psychology Doctoral Program. She received her undergradu ate degree from Armstrong State College in 1996 with a Bachelors of Science in psychology. Sh e is currently employed as a Coordinator of Clinical Services and therapist at a small liberal arts college in middle Georgia.