Specific Sexual Risk Behaviors of College Students and the Role of Alcohol Intoxication in the Intention to Participate

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Title:
Specific Sexual Risk Behaviors of College Students and the Role of Alcohol Intoxication in the Intention to Participate
Physical Description:
1 online resource (137 p.)
Language:
english
Creator:
Webb,Monica Cecilia
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University of Florida
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Gainesville, Fla.
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Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Health and Human Performance, Health Education and Behavior
Committee Chair:
Chen, Wei W
Committee Members:
Chaney, Jerry Don
Dodd, Virginia J
Huang, I-Chan
Sanders, Sadie B

Subjects

Subjects / Keywords:
alcohol -- anal -- behavior -- cluster -- college -- instrument -- oral -- risk -- sexual -- vaginal
Health Education and Behavior -- Dissertations, Academic -- UF
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Health and Human Performance thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

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Abstract:
This study explores specific sexual behaviors of college students and the role alcohol intoxication may play in the intention to participate in the behaviors and is presented as three individual manuscripts. A modified version of N. Krause?s instrument development process was applied to create a behavior-specific instrument assessing oral, vaginal, and anal sex behaviors. The process included a review by expert scholars in relevant fields, cognitive interviews with the target population, piloting to assess measurement scales, and a formal investigation. Fifty preliminary measures were developed and assessed during the process, which resulted in 49 final questions. The piloted instrument resulted in a 17.75% response rate. Psychometric testing was conducted and the instrument was edited once more. The formal investigation resulted in a 20.8% response rate. The 3% increase in response rate was attributed to the addition of four $50 gift card incentives. The Theory of Planned Behavior was applied via a path analysis to determine the causal links between the constructs. Three models were developed, one for each sexual behavior: oral, vaginal, and anal. Overall results of all three models indicated Attitude Towards Behavior had the greatest impact on intention. Subjective Norm was also significant, while Perceived Behavioral Control did not significantly impact Intention or Behavior in terms of direct paths. A cluster analytic technique revealed three distinct risk groups. Low-risk members were in an exclusive relationship, reported less condom/barrier or contraceptive usage, and were least likely to be a victim of coercion/abuse. Though the medium-risk group had higher frequencies of sexual activity, it was characterized by more protective behaviors, such as higher proportion of condom/barrier usage. The high-risk group was primarily composed of those casually dating, reporting more sexual partners and less condom/barrier usage. These results indicate an individual?s effort to protect themselves from sexual-risk consequences is attributed to the duration and stability of the relationship. Results have medical screening and policy implications for drinking offenses and sexual assault. They provide a clearer understanding of the relationship between alcohol use and sexual activity and aid in the development of effective public health interventions.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Monica Cecilia Webb.
Thesis:
Thesis (Ph.D.)--University of Florida, 2011.
Local:
Adviser: Chen, Wei W.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2013-08-31

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lcc - LD1780 2011
System ID:
UFE0043339:00001


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1 SPECIFIC SEXUAL RISK BEHAVIORS OF COLLEGE STUDENTS AND THE ROLE OF ALCOHOL INTOXICATION IN THE INTENTION TO PARTICIPATE By MONICA C. WEBB A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2011

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2 2011 Monica C Webb

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3 To my husband without his support, this accomplishment would not have been possible To the Gator Nation

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4 ACKNOWLEDGMENTS The completion of my Ph.D. program at the University of Florida (UF) and the research presented in this dissertation would not have been possible without the love and support of many. I am very fortunate to have had individuals w ho could provide me with the skills necessary to become a successful researcher, educator, and intellectual human being. I thank my committee members, Drs. W. William Chen J. Don Chaney Virginia J. Dodd, Sadie Sanders and I Chan Huang for their patience encouragement, and unwavering support. I appreciate each person for his/her unique gifts and special talents. I am grateful for the attention shown to me, time devoted to me, and sage advice shared with me. I would like to provide a special thanks to Hol ly T. Moses and Dr. Beth Chaney who have lead me with grace and wisdom through the often arduous task of writing a dissertation. Though they may not have served on my committee they were instrumental in helping me plan, implement, and publish this research I would also like to thank my family members and friends who helped support my decision to begin and continue this degree program. T heir love, generosity and encouragement are the reasons you hold this dissertation today. Finally, I would like to acknowledge the myriad of contributions my best friend and husband, John L. Webb I asked him to bear the social, financial and emotional burden of living with a graduate student. In return, he made my life easier and less stressfu l, and made my doctoral program possible. He ha s my love and my deepest thanks

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURES ................................ ................................ ................................ .......... 9 ABSTRACT ................................ ................................ ................................ ................... 10 CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW ................................ ..................... 12 Introduction ................................ ................................ ................................ ............. 12 Research Problem ................................ ................................ ................................ .. 15 Significance ................................ ................................ ................................ ............ 16 Theory of Planned Behavior ................................ ................................ ................... 17 Instru ment Development Process ................................ ................................ ........... 20 Analytic Techniques ................................ ................................ ................................ 25 Research Questions ................................ ................................ ............................... 26 Organization of the Studies ................................ ................................ ..................... 27 Delimitations ................................ ................................ ................................ ........... 29 Limitations ................................ ................................ ................................ ............... 29 Assumptions ................................ ................................ ................................ ........... 30 Definition of Terms ................................ ................................ ................................ .. 30 Summary ................................ ................................ ................................ ................ 32 2 ASSESSING SPECIFIC SEXUAL BEHAVIOR: INSTRUMENT DEVELOPMENT AND VALIDATION TECHNIQUES ................................ ................................ .......... 34 Background ................................ ................................ ................................ ............. 34 Conceptual Framework ................................ ................................ ........................... 36 Classical Te st Theory ................................ ................................ ....................... 36 Theory of Planned Behavior ................................ ................................ ............. 36 Measurements ................................ ................................ ................................ ........ 38 Established Measurements ................................ ................................ .............. 38 Relation ship Status ................................ ................................ .......................... 38 Specific sexual behaviors ................................ ................................ ................. 39 Instrument Development Process ................................ ................................ ........... 40 Development of Preliminary Variables ................................ .............................. 41 Review by Expert Panel ................................ ................................ ................... 42 Cognitive Interviews ................................ ................................ ......................... 43 Pilot Test ................................ ................................ ................................ .......... 45 Formal Investigation ................................ ................................ ......................... 47 Results ................................ ................................ ................................ .................... 47

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6 Discussion ................................ ................................ ................................ .............. 49 Conclusions For C onsideration ................................ ................................ ............... 51 3 SEXUAL RISK TAKING ATTITUDES, PERCEPTIONS, AND PREVALENCE AMONG COLLEGE STUDENTS ................................ ................................ ............ 53 Background ................................ ................................ ................................ ............. 53 Theory of Planned Behavior ................................ ................................ ................... 56 Methodology ................................ ................................ ................................ ........... 58 Participants and Procedures ................................ ................................ ............ 58 Measurements ................................ ................................ ................................ .. 58 Attitudes ................................ ................................ ................................ ..... 59 Subjective Norms ................................ ................................ ....................... 59 Perceived Behavioral Control ................................ ................................ ..... 60 Behavioral Intentions ................................ ................................ ................. 60 Behavior ................................ ................................ ................................ ..... 60 Analysis ................................ ................................ ................................ .................. 61 Results ................................ ................................ ................................ .................... 64 Preliminary Analysis ................................ ................................ ......................... 65 Path Analysi s ................................ ................................ ................................ .... 65 Discussion ................................ ................................ ................................ .............. 68 Conclusions For C onsidertation ................................ ................................ .............. 70 4 IDENTIFYING THE TYPOLOGY OF SEXUAL RISK BEHAVIORS: AN APPLICATION OF A CLUSTER ANALYTIC TECHNIQUE ................................ ..... 77 Background ................................ ................................ ................................ ............. 77 Methodology ................................ ................................ ................................ ........... 78 Participants and Procedures ................................ ................................ ............ 78 Meas urements ................................ ................................ ................................ .. 79 Analysis ................................ ................................ ................................ .................. 81 Results ................................ ................................ ................................ .................... 81 Cluster Analysis ................................ ................................ ................................ 81 Discriminant Analysis ................................ ................................ ....................... 85 Discussion ................................ ................................ ................................ .............. 87 Limitations ................................ ................................ ................................ ............... 89 5 IMPLICATION OF SEXUAL BEHAVIOR RESEARCH ................................ ............ 94 Background ................................ ................................ ................................ ............. 94 Results ................................ ................................ ................................ .................... 95 Limitations ................................ ................................ ................................ ............... 99 Implications ................................ ................................ ................................ ........... 100 Ecological Model ................................ ................................ ............................ 100 Intrapersonal ................................ ................................ ................................ .. 101 Interpersonal ................................ ................................ ................................ .. 102 Organization ................................ ................................ ................................ ... 103

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7 Community ................................ ................................ ................................ ..... 103 Public Policy ................................ ................................ ................................ ... 104 Conclusions ................................ ................................ ................................ .......... 104 APPENDIX A COGNITIVE INTERVIEW CONSENT ................................ ................................ ... 106 B COGNITIVE INTERVIEW QUESTIONS ................................ ............................... 107 C STUDENT EMAIL CONTACT ................................ ................................ ............... 108 Initial Email ................................ ................................ ................................ ........... 108 Reminder Email ................................ ................................ ................................ .... 109 Final Reminder ................................ ................................ ................................ ..... 110 D SURVEY CONSENT ................................ ................................ ............................. 111 E SURVEY INSTRUMENT ................................ ................................ ....................... 112 LIST OF REFE RENCES ................................ ................................ ............................. 127 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 137

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8 LIST OF TABLES Table page 1 1 Cognitive interview probes ................................ ................................ .................. 33 2 1 Study sample comparison to total university population ................................ ..... 52 3 1 TPB attitude toward behavior direct and indirect measures ................................ 71 3 2 TPB subjective norm direct and indirect measures ................................ ............. 72 3 3 TPB perceived behavioral control direct and indirect measures ......................... 73 3 4 sexual behaviors ................................ ................................ ................................ 74 3 5 Correlation matrix for oral sexual behaviors ................................ ....................... 75 3 6 Correlation matrix for vaginal sexual behaviors ................................ .................. 75 3 7 Correlation matrix for anal sexual behaviors ................................ ....................... 75 3 8 Absolute fit indices for each sexual behavior model ................................ ........... 76 4 1 Comparison of study sample and the National College Health Assessment II Sample ................................ ................................ ................................ ............... 91 4 2 Variable profile for three cluster solution ................................ ............................ 92 4 3 Multiple discriminant function analysis of three cluster groups ........................... 93

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9 LIST OF FIGURES Figure page 1 1 Theory of Planned Behavior ................................ ................................ ............... 1 8 1 2 Instrument development process ................................ ................................ ........ 21 1 3 Cluster analytic variables ................................ ................................ .................... 26 3 1 Path diagram for oral sex behavior. ................................ ................................ .... 66 3 2 Path diagram for vaginal sex behavior. ................................ .............................. 67 3 3 Path diagram for anal sex behavior. ................................ ................................ ... 68 5 1 The Ecological Model ................................ ................................ ....................... 101

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10 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy SPECIFIC SEXUAL RISK BEHAVIORS OF COLLEGE STUDENTS AND THE ROLE OF ALCOHOL INTOXICATION IN THE INTENTION TO PARTICIPATE By Monica C. Webb August 2011 Chair: W. William Chen Major: Health and Human Performance This study explores specific sexual behaviors of college students and the role alcohol intoxication may play in the intention to participate in the behaviors and is presented as three individual manuscripts. A development process was applied to create a behavior specific instrument assessing oral, vaginal, and anal sex behaviors. The process include d a review by expert scholars in relevant fields, cognitive interviews with the target population, piloting to assess measurement scal es, and a formal investigation. Fifty preliminary measures were developed and assessed during the process, which resulted in 49 final questions. The piloted instrument resulted in a 17.75% response rate. Psychometric testing was conducted and the instrumen t was edited once more. The formal investigation resulted in a 20.8% response rate. The 3% increase in response rate was attributed to the addition of four $50 gift card incentives. T he Theory of Planned Behavior was applied via a path analysis to determi ne the causal links between the constructs Three models were developed, one for each sexual behavior: oral, vaginal, and anal. Overall results of all three models indicated Attitude Towards Behavior had the greatest impact on intention. Subjective Norm wa s

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11 also significant, while Perceived Behavioral Control did not significantly impact Intention or Behavior in terms of direct paths. A cluster analytic technique revealed three distinct risk groups Low risk members were in an exclusive relationship, repor ted less condom/barrier or contraceptive usage, and were least likely to be a victim of coercion/abuse. Though the medium risk group had higher frequencies of sexual activity, it was characterized by more protective behaviors, such as higher proportion of condom/barrier usage. The high risk group was primarily composed of those casually dating, r eporting more sexual partners and less condom/barrier usage. risk consequences is a ttributed to the duration and stability of the relationship. R esults have medical screening and policy implications for drinking offenses and sexual assault. They provide a clearer understanding of the relationship between alcohol use and sexual activity a nd aid in the development of effective public health interventions

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12 CHAPTER 1 INTRODUCTION AND LIT ERATURE REVIEW Introduction One of the overarching goals of Health People 2020 is the improve ment of reproductive health through promotion of healthy sexual behavior s. Among these o ngoing public health challenges are Sexually Transmitted Infections (STIs) which include more than 25 infectious organisms that are transmitted through various sexual behaviors 1 Though some STIs are treatable, they all cause long term health risks, including increased risk for cancer, and HIV/AIDS 2 Annually, in the U.S., u ntreated infections contribute to infertility in approximately 24,000 women 1 The annual cost of these infections to the U.S. health care system estimated at $15.9 billion 3 The Centers for Disease Control and Prevention (CDC) estimate d approximately 19 million new STI cas es each year 4 Unfortunately this number can only be an estimate due to the lack of proper STI diagnosis and reporting. O nly cases of Chlamydia, gonorrhea, and syphilis are reported to the CDC Some infections are asymptomatic or are never discussed with a physician and thus are undiagnosed. Common viral infections such as Human Papillom avirus (HPV) and genital herpes are not reported as they can be complicated to diagnose due to multiple strains and they have no cure; making it difficult to track the spread of infection T hus public health professionals are left with a fraction of the true scope of the STI probl em probability of acquiring an STI increases with number of sex partners. According to the National College Health Assessment (NCHA) 70% of college students have had at least one sexual partner within the past school year 5 Though total abs tinence is the only way

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13 individuals who are sexually active are unlikely to return to abstinence as a disease protection measure 6 Of those NCHA students who reported being sexually active, only 18% stated they practice d safe sex by always using a condom and 4% reported not using any form of pregnancy protection 5 These risky sexual behaviors l e d to approximately 9 million new STI infections among 15 to 24 year olds as well as increased numbers of unwanted pregnancies 7, 8 Approximately 1 out of 10 women reported an unintended pregnancy with rates highest among women aged 18 24. 9 In addition, a significant percentage of the NCHA college students reported participating in anal sex wh ich if unprotected, is the most efficient route for HIV transmission 10 12 You ng adults aged 15 to 24 account for approximately 12% of newly diagnosed cases of HIV in the United States 4 Alcohol consumption has been linked to risky sexual behavior on college campuses particul arly heavy alcohol consumption. 13 15 Heavy episodic or binge drinking is defined in the literature as the consumption of at least five or more drinks in a row for men (four or more for women) at least once within the past two weeks 16 Depending on the type of school and its location, approximately 20% to 50% of students are likely to be heavy drinkers 17 According to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders nearly o ne third of college students me e t the criteria for the formal diagnosis of alcohol abuse and one in 17 can be classified as alcohol dependent 16 In addition to alcohol abuse and alcohol dependency, heavy alcohol consumption contributes to a variety of other problems. Heavy episodic drinking is consistently associated with serious personal, social, and community consequences which include,

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14 but are not limited to violence, physical injury, property damage, sexually transmitted infections unintended pregnancy, sexual assault, poor acad emic performance, and even death 16, 18 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimates that annually over 1,700 student deaths, 599,000 student injuries, and 696,000 assault s occur and are associated with high risk drinking 19 Heavy alcohol use also impact s academ ics. In their study, Wechsler, Lee, Kuo, and Lee found more than one third of frequent heavy drinkers were behind in schoolwork, and over half reported do ing something they regretted as a result of their alcohol abuse. 15 Forty two percent of college students who drink heavily also engage d in unplanned sex 15 Among college students high risk drinking and sexual risk taking routinely occur simultaneously 7 Inconsistent condom use is also highly correlated with high risk drinking 20, 21 Research i ndicates that women have a one in five chance of being sexually assaulted while enrolled in college 22 The social environment of school with high rates of heavy episodic drinking (5 or more drinks) places students at an increased r isk of sexual assault 23 While rates of sexual assault va ry wi dely due to varying definitions, policies, under reported incidents, and differing data collection methods. One study estimates alcohol involvement in at least 50% of all sexual assaults involving college women. 24 Alcohol use is also associated with an increased likelihood of sexual coercion and sexual assault, along with a greater severity of the latter due to intensified sexual expectations and increased feelings of alcohol induced sexual prowess and aggression among males 25 26 Additionally, some students cite alcohol use as validation for participation in sexual activity a nd high risk behaviors 24

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15 Research Problem Campuses provide an important context in which to study risky sexual behaviors behaviors demonstrate a developmental progression. The percentage of students ever having had sex rises steadily during the college years, peaking at a bout 86% by the senior year 27 While in high school, students who plan to attend college have lower rates of heavy drinking than their non college bound peers. However, a fter high school graduation both groups increase their rates of heavy drinking, with alcohol consumption increasing dramatically and ultimately surpassing their nonstudent peers 28 The difference in level of risk taking is also present within the college student population. Since 2002, data show that young adults enrolled in full time four year ins titutions generally participate in more high risk drinking than those not enrolled full time 29 Additionally, Naimi and fellow researchers report consumption of 5 or more drinks to be most prevalent during the late teens and early to mid twenties. 18 Additional indicators of problem drinking behaviors and sex ual consequences among college students are well documented. In 2006, undergraduate students from 134 colleges across the nation (N=71,189) completed the Core Alcohol and Drug Survey (a standardized instrument specifically aimed at college students). Over 10% of participants reported being taken advantage of sexually and 3.2% reported taking sexual advantage of another person. Additionally, 18.6% of respondents believed alcohol causes women to feel sexier and 18.4% stated the same belief for men. Over half (53.7%) of participants responded in the affirmative when asked if alcohol facilitates sexual opportunities 30 Within the year preceding the study a small percentage of students reported experiencing forced sexual touching (4.9%) and unwanted sexual

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16 intercourse (3.0%), most of these violent acts (69.1% and 82.3%, respectively) o ccurred along with the use of drugs or alcohol. The dangerous interaction s between alcohol use and high risk sexual activities suggest public health prevention efforts attempting to explain the relationship between these two risk factors are needed if effective intervention programs are to be developed Excessive alcohol use results in deleterious sexual health and reproductive consequences for college students. As previously discussed, these risk behaviors are related to one another in complex ways. Ho wever, there is a lack of consensus on the best methodologies for collect ing valid and reliable data on self reported sexual behavior s and alcohol use 31 In addition, while a number of instruments exist to m easure sexual behavior few measure the entire spectrum of behaviors; including digital and oral sex The lack of measurement consistency between studies is problematic making comparisons and generalizations difficult to assess, and possibly resulting in in complete or incorrect public health implications 32 Studies conducted with inappropriate measures or measures lacking sensitivity for certain behavior s may reach inappropriate conclusions Future studies attempt ing to understand individual differences in alcohol use and sexual behaviors are necessary for development of effective interventions 7, 33 Along with increased sensitivity and precision of sexual behavior measurements, assessment of the interaction between alcohol use and participation in sexual activities is warranted Cooper suggests the application of multivariate models embedding alcohol use in the network of these risk behaviors. 7 Significance Sexual beh aviors, especially in combination with alcohol use can cause physical, emotional, and financial burdens. Oftentimes these behaviors result in STIs, a long time

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17 public health problem of significance, though largely unrecognized by the public, policymakers, and health care professionals 1 Des pite the large amount of research into sexual behavior and alcohol use, a lack of agreement exists as to the best way to measure and validate self reports of sexual behavior and alcohol use 7, 31 In addition, many existing instruments measure sexual behavior but few measure specific sexual behaviors 7 Studies conducted with inappropriate measures or measures lacking sensitivity to specific sexual behavior s can easily reach inappropriate conclusions regarding the risk behavior. Noar, Cole, & Carlyle provide examples of this discrepancy as it related to condom use. 34 They cite surveillance studies assessing the percentage (proportional measure) of condom usage but failing to take into account the frequency of sexual intercourse. This failure results in a lowered risk due to less frequent intercourse, but the pro portional measure of condom usage is not accurately represented A ccurate behavi or measurement is critical for positive impacts on public health and policy. Theo ry of Planned Behavior Planning effective health behavior interventions requires use of a theo retical framework to guide the behavior 35 One of the most widely and effectively used behavioral theor ies in sexual risk research is the Theory of Planned Behavior (TPB) 35 37 The TPB is an extension of the Theory of Reasoned Action (TRA), which posits attitude and perceived tention. Behavioral intention then performing a behavior 36 Ajzen and colleagues expanded the theory by incorporating perceived control over behavior achievement as an additional aggregate of intention. 38 The change allowed researchers

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18 Direct Measures Indirect Measures to take into account factors such as resources and opportunities 39 Refer to Figure 1 1 for the Theory of Planned Behavior Figure 1 1. Theory of Planned Behavior The constructs of the TPB, with the exception of behavior, are psychological and may be measured directly, e.g. asking respondents about their overall attitude towards a behavior, or indirectly, e.g. asking respondents about their beliefs and outcome evalu ations concerning the same behavior. Direct and indirect measurement approaches make different assumptions about the underlying cognitive structures and neither approach is perfect 39 Direct measures are usually more strongly associated with intentions and behaviors than are indirect measures. The association between direct Behavior Intention Attitude Behavioral Beliefs Evaluations of Behavioral Outcomes Subjective Norm Normative Beliefs Motivation to Comply Perceived Control Control Beliefs Perceived Power

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19 measures and intention indicates the relative impo rtance of attitude, subjective norm, and perceived behavioral control in explaining or predicting a behavior. It is critical to demonstrate these associations before analyzing indirect measures. Thus, indirect measures should be strongly associated with di rect measures in order to be certain that appropriate beliefs are included in the indirect measures and that composite beliefs (attitude, norms, and control) are adequate measures of the ir respective TPB constructs. Once this is demonstrated, indirect meas ures are most applicable for intervention and policy development. Thus, experts recommend the inclusion of both measurements in TPB instruments 40 The predictor variable of Attitude is directly measured by asking respondents about their overal l attitude toward a behavior. For example, those who report participation in anal sex while intoxicated is fun and en joyable are more likely to have favorable attitudes in general toward drinking and participating in risky sexual behaviors. Consequently, people who believe participating in anal sex while intoxicated is risky and potentially unhealthy are more likely to h ave unfavorable attitudes toward participating in sexual behaviors while intoxicated. Attitude can also be measured indirectly by inquiring about specific behavioral beliefs and outcome evaluations. Behavioral beliefs wards performing a behavior. Evaluation of behavioral outcomes is the relative value an individual places on possible behavioral outcomes or elements. in their lives (i.e. family, close peers significant others) will approve or disapprove of their behavior and how strongly motivated they are to comply with the expectatio ns of

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20 these influential people I ndirect measures include normative beliefs and motivation to comply. Normative beliefs whether influential people in their life will approve or disapprove of a particular b ehavior. M otivation to comply is influences by whether or not the individual cares what these influential others think. Perceived Behavioral Control (PBC) is the overall assessment of the ir power or control to perform or discontinue a behavi or. Indirect measures include the constructs of control belief, which is an perceived benefits and barr iers to performing the behavior, along with perceived power, which is the evaluation of each condition which makes achieving t he behavior more or less difficult. Cooper and Orcutt conclude that because of the complex relationship between the variables alcohol use and sexual behaviors they are best understood, not in isolation, but in the context of a larger system of interconne cted variables. 33 Thus, selection of the Theory of Planned Behavior (both direct and indir ect measures) to asses these behaviors in relation to college student risk taking seem most advantageous Instrument Development Process The literature contains many articles describing instrument development processes few of the existing methodologies use both qualitative and quantitative methods, and even fewer provide specific methodological detail s. 41 44 Krause effectively described a multi modal technique for developing close ended survey qu estions that effectively bridge the qualitative/quantitative methodological approaches 42 While a full understanding is lacking in regards to the ways multiple risk behaviors interact, s exual activity and related risk behaviors have been widely studied 7, 45 48 T hus development process was slightly adjusted to reflect the current published information

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21 concerning these behaviors (i.e. focus groups, interviews, etc.). F igure 1 2 describes the eight step instrument development process An in depth discussion of each step follows the figure Figure 1 2. Instrument development process Step 1. T he instrument develo pment process requires a thorough review of the literature. When little or no information is known about the behavior of interest, focus groups and in depth interviews are important for filling the void in the literature This study was aided by the pletho ra of published information concerning alcohol and sexual risk b ehaviors among college students. Therefore, a review of the current literature was completed to determine applicable themes, variables and behavioral measures. Step 2. Addressing the propos ed research questions required an instrument using combined measurements consisting of established and validated items, newly 1. Literature Review 2. Identify Concepts & Conceptual Framework 3. Develop Preliminary Measures 4. Review by Expert Panel 5. Cognitive Interviews 6. Pilot Investigation 7. Formal Investigation 8. Psychometric Tests Instrument Development Process [Modified from Krause, 2002]

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22 developed items, and items specifically revised for the purpose of this study. Step 2 involved identifying the appropriate concept s and theoretical frameworks, and culminated in the formal selection of a theoretical or conceptual framework. For this study, the Classical Test Theory was used to guide the development and assessment of all proposed measurements 42, 49 Of equal importance i s acknowledgment of the First, the psychometric properties of this theory are instrument and sample dependent. Also, due to the cross sectional study design the measurement is static 49 A similar theory with increasing use demonstrated in the current literatur e is the Item Response Theory (IRT). However, use of the IRT in this study was precluded by the inability to meet common as sumptions of the theory The present study focuses on behaviors that most likely occur simultaneously a nd, as the Theory of Planned B ehavior posits, influence behavior through intention Thus, the instrument is neither unidimensional nor provides local independence common IRT assumptions In addition, present study methodology required online delivery of the instrument which enabled r espondents to complete it in a private setting The need for respondent anonymity and use of an uncontrolled environment for participant response made it impossible for the researcher to meet the IRT environmental requirement of a non rushed format where t he respondents did not have personal schedule or time restrictions 49 Step 3. Preliminary measures were created by the application of results of the previous steps. For this existing measurements were adapted for use specifically to increase instrument v alidity Items were retrieved from existing instruments including several surveillance and behavioral questions used in the American College Health

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23 NCHA II) 5 Additionally, perceived effects were evaluated using items from the Core Alcohol and Drug Survey. Th e Core su rvey is a nationally validated instrument specifically aimed at evaluating behaviors in college student populations 30 The measurements from the aforementioned instruments were used in their entirety. The third existing instrument was the Worry about Sexual Outcomes (WASO) Scale. This co ncern over sexual risk taking outcomes. The 10 item measurement c ontains two subscales of worry namely STI The WASO was demonstrated to have internal consistency and satisfactory construct validity in a sample of 522 African American female adolescents 44 For this study the pregnancy items were omitted since they exclude male respondents Instead, g end er neutral pregnancy items were developed. The fourth step involved assembling an expert panel to review the proposed instrument. A total of 6 scholars knowledgeable in the areas of alcohol use, sexual behaviors, instrument development and statistical analysis were selected to assess the proposed measures and instrument as a whole. Each expert received for review all student notifications, consent forms and the complete questionnaire. They were asked to evaluate the quality of the conte nt, instrument structure, and the ability of the mea sures to address both the theoretical constructs and the proposed statistical analysis. Following edits based on panel ists cognitive interviews were conducted with the population of interest Th e purpose of the interviews was to assess correct interpretation of the items by participants. Close attention was given to issues arising due to cultural and societal differences between the researchers and the

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24 participants. Eleven interviews were condu cted with college students aged 18 24 years Both genders were sampled and interviews were conducted i n a private, confidential environment. Students were asked to think a loud and hypothetically answer each question. The researcher focus ed on assessing fo ur components : comprehension, information retrieval, judgment, and reporting. Refer to Table 1 1 for a complete list of guiding probes. Careful attention was made to ensure t h at th e context of the recall did not impede the completion of the measurement or the an event. Attention was also given to both the evaluation and presentation of the instrument Step 6. Upon completion of the previous step, a pilot study was conducted o n the edited instrument. The primary purpose of the pilot investigation was to conduct a quality check among the target population. A total of 4,000 students, aged 18 24 were randomly selected by the registrar to participate in the pilot study The selecte d sample consisted of 2,000 students enrolled full time during the Summer A semester and an additional 2,000 participants enrolled full time during the Summer B/C term. This approach allowed the sampling to be reflective of the university population, as op posed to over sampling students who were first semester freshman in the Summer B term. In addition, no one under the age of 18 was allowed to participate in the study. Seven hundred ten students completed t he pilot test r esulting in a 17.75 % response rate The pilot study assessed the length of the survey, frequency of distributions to ensure sufficient variance among the behavioral indicators and performance of exploratory factor analyses to examine the structure and psychometric properties.

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25 Once the pilot instrument was edited the final two step s involved formal investigation and psychometric tests The final instrument was administered to a random sample of 4,000 full time students aged 18 24 years and enrolled during Spring semester The final iteration resulted in 832 respondents for a 20.8% response rate and successful collection data necessary to conduct the required statistical analys es. Of p articular interest ility of sexual risk. Additional psychometric analyses were conducted to continue assessment of the validity and reliability of the final instrument. Analytic Techniques In order to understand the influence of alcohol use and specific sexual behaviors, the following statistical analyses were conducted First, descriptive statistics describe the sample population. Psychometric properties of the instrument were also assessed. S tructural equation modeling was conducted via a path analysis to assess the constru cts of the Theory of Planned Behavior on intention to participate in specific sexual behaviors (oral, vaginal, anal) while intoxicated. Finally, a cluster analytic technique was used to aid in risk identification and assessment. This included a typological grouping followed by a discriminant analysis to differentiate between the groups. Figure 1 3 provides both the cluster and discriminating variable. More information concerning each analysis is included in their respective chapters.

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26 Figure 1 3. Cluster analytic v ariables Research Questions The research questions for the proposed investigations include the following : RQ1: H ow can current sexual risk behavior survey instruments be improved? RQ2: Can an instrument be developed to collect and assess the specific sexual behaviors of college students? RQ3: What is the reliability and validity of the Specific Sexual Behavior instrument? RQ4: What is the prevalence of specific sexual behaviors among college students at a large southeastern university ? RQ5: How much of the sexual behavior while intoxicated variance is accounted for by the Theory of Planned Behavior? Discriminating Variables: race /ethnicity ; age; gender; relationship statu s; history of STI ; unwanted pregnancy (self/partner); coercion or abuse; unprotected sex due to drinking; and sex without giving or rec eiving consent due to drinking (self/partner) Discriminating Variables: race/ethnicity; age; gender; relationship status; history of STI; unwanted pregnancy (self/partner); coercion or abuse; unprotected sex due to drinking; and sex without giving o r receiving consent due to drinking (self/partner) Discriminating Variables: race /ethnicity ; age; gender; relationship statu s; history of STI ; unwanted pregnancy (self/partner); coercion or abuse; unprotected sex due to drinking; and sex without giving or receiving consent due to drinking (self/partner) H H i i g g h h M M o o d d e e r r a a t t e e L L o o w w Clustering Variables : # of times participated in digital, oral, vaginal, & anal sex; # sex partners per sexual activity; alcohol use; heavy episodic drinking (past 2 weeks); frequency of condom or barrier method during oral, vaginal, & anal sex; contraceptive use during oral, vaginal, & anal sex; and frequency of STI testing Proposed Risk Groups

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27 RQ6: Which construct (s) within the Theory of Planned Behavior (Subjective Norm, Attitude Toward the Behavior, Perceived Behavioral Control, and Behavioral Intention) account for the largest proportion of variance when predicting specific sexual behaviors among college students wh ile intoxicated? RQ7: Using constructs from the Theory of Planned Behavior, what are the causal effects in predicting participation in specific sexual behaviors while intoxicated? RQ8: What is the sexual behavior typology of sexually active college student s enrolled full time a t a large southeastern university ? RQ 9: What are the sexual risk taking differences between the observed typology clusters? RQ10: Among the observed clusters, are sexual coercion and abuse, unplanned pregnancy, and sexually transmitted disease more or less prevalent? Organization of the Studies The aim of this study is the examination of specific sexual behaviors and the role of alcohol use intention to participate in these behaviors. The specific purposes were to: 1) develop a survey tool using both qualitative and quantitative methods; 2) apply the Theory of Planned Behavior to assess the perceptions, attitudes, prevalence and intentions of sexual risk taking behaviors among college students; 3) identify the typolo gy of sexual risk taking among college students using a cluster analytic technique. Chapter 2 present s the first manuscript which involves the development and evaluation of the proposed sexual risk taking survey. Due to the sensitive nature of the subject matter the instrument was administered online. Among the college student population, web based surveys are more cost effective and convenient than other modes of survey research 50 Four thousand full time undergraduate students 18 24 were randomly recruited for this investigation. All participants were notified via e mail to complete the online survey.

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28 The survey instrument was developed for this study. Instrument development included: 1) an extensive review of the literature; 2) identifying the concepts and conceptual frameworks commonly associated with alcohol use and sexual behaviors; 3 ) deve lopment of preliminary measures ; 40 4 ) content review by experts in the areas of alcohol use and sexual behaviors instrument development, research and statistical analysis ; 5 ) cognitive interv iews with the target audience of college students ; 6 ) a pilot testing of the proposed instrument ; 7) a formal investigation and 8) continued psychometric test ing Refer to Figure 1 2 for the instrument development frame work Chapters 3 and 4 describe the formal assessment of the instrument. Chapter 3 presents the second manuscript, describing application of the Theory of Planned Behavior to assess sexual risk t aking attitudes, perceptions, and preval ence among college students. This theory was chosen based upon the stated research questions for this study C hapter 3 describes individual motivation factors as behavioral predictors through the relationship between beliefs, norms, attitudes, intentions, and behaviors 39 as they relate to specific sexual activities engaged in while a n individual is intoxicated Chapter 4 presents the cluster analysi s was serving as the focus of the third manuscript In this portion of the study, participants were grouped based on the following sexual risk taking variables: number of times respondents participated in digital sex, oral sex, vaginal sex, and anal sex; number of sex partners in the past 30 days; alcohol use in the past 30 days; heavy episodic drinking in the past 2 weeks; frequency of condom or barrier method use during oral, vaginal, and anal sex in the past 30 days; and frequency of STI testing and contraceptive use. The following consequences were used to discriminate between the cluster groupings: race; age;

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29 gender; relationship status; history of sexually tra nsmitted infections ; unpla nned pregnancy (self or partner); experience with coercion or abuse; experience with unprotected sex due to drinking alcohol ; and sex without giving or receiving consent due to intoxication (self or partn er). Chapter 5 provide s an overall summary of the three papers and a discussion of the results, limitations, implica tions for public health education specialists and recommendations for future research and practice. Delimitations The following delimitations should be considered when interpreting the res ults of this proposed study: Participants in this study include college students, aged 18 to 24, and enrolled full time at the University of Florida. Only students in the specific age range were selected. A random list of survey participants was provided by the UF Registrar. All the member s of the list were sent an email requesting their participation. Respondents in this study agree d to voluntarily participate and may therefore be different from those who chose not to participate Limitations The following limitations should be considered when interpreting the results of this investigation: Data collected from this cross sectional study reflect s responses from participants at a specific point in time. It will not follow respondents longitudina lly to view personally normative behaviors and thus direct causation cannot be established. This study focus es on traditional aged college students who attend a 4 year institution with a robust social environment. Findings from the proposed study cannot be generalized to campuses without a similar environment and social scene.

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30 Demographic variations of the student respondents may influence the results of the study. The self report nature of the data collection limits the ability of the researcher to determ ine the extent of respondents over and under reporting behaviors Assumptions For the purposes of this investigation, the following assumptions were made: Every participant had access to the internet. The university provides internet access to currently enrolled students through various locations on campus. The registrar provide d current and accurate student e mail addresses. Students are assigned a university e mail address bu t they may no longer be enrolled, may have changed their e mail address or their inbox maybe full Thus, the response rate may be influenced by non receipt of survey materials. The students who participate in the study are representative of the overall s tudent population unless otherwise noted. The registrar provide d a completely random list of students to participate in the study. Students who agree d to participate in the study answered survey questions honestly. The consent, instrument, and reminder not ifications assure d participants of their anonymity and encourage d them to answer truthfully. Definition of Terms Anal Sex A sexual position in which the penis is inserted through the 51 Attitude concerning the outcomes or attributes of perfor ming the behavior 39 Behavioral Belief An indirect measure of attitude where individuals assess whether their actions o r potential actions are associated with certain attributes or outcomes 39 Behavioral Intention Perceived likelihood of performing the behavior of interest. 39 College Student Random selection of individuals aged 18 24 who are registered to attend the University of Florida full time Control Beliefs An indirect measure of Perceived Behavioral Control, where individuals assess the presence or absence of facilitat ors and

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31 barriers to behavioral performance 39 Digital Sex Sexual penetration involving one ts; a lso referred to as mutual masturbation or manual sex 52 Drink A standard drink is equal to a 12 oz can or bottle of beer or wine cooler, a 4 oz. glass or whine, or a shot (1 oz.) of liquor straight or in a mixed drink. 16, 53 Drunk Consumption of alcohol to the point of impairment of mental and physical abilities. In the state of Florida legal intoxication or being drunk is defined as blood alcohol level equal to or exceeding 0.08 mg/dl Evaluation of Behavioral Outcomes An indirect measure of attitude, where individuals assess the value attached to a belief or associated with an activity or attribute. 39 Heavy Episodic Drinking This is defined in the literature as five or more drinks for males in one sitting within the past two weeks. The definition for females is four or more drinks in the same time frame. 16 Heterogeneity A statistical measure of diversity that is used as a stopping rule in cluster analysis. A large increase in heterogeneity when two clusters combine indicates a more natural structure exists when the clusters are separate 54 High risk s exual behavior Any sexual behavior that increases the probability of negative consequences such as sexually transmitted infections, number of sexual partner and unplanned pregnancy. The most common form of this behavior is vaginal sex without a condom 55 Hooking up A spectrum of spontaneous sexual behaviors that may include anything from a simple kissing to various forms of intercourse (vaginal, anal, oral) usually la sting only one evening 14 Motivation to Comply An indirect measure of the Subjective Norm where individuals assess their intrinsic drive to act in accordance with what they perceive their key referents deem appropriate concerning the behavior of interest 39 Normative Belief An indirect measure of the Subjective Norm where individuals access the extent to which each referent approves or disapproves of the behavior of interest 39 Oral sex Refers to the sexual activity involving oral (mouth) stimulation of

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32 cunnilingus) 51 Perceived Behavioral Control The degree to which individuals believe they have control over their actions. 39 Perceived Power An indirect measure of Perceived Behavioral Control, where individuals assess the impact of each factor in facilitating or inhabiting the behavior of interest 39 Referent 39 Sexual partner Refers to a person with whom one engages in sexual behavior. This term is not indicative of relationship status. 51 Sexually Transmitted Infection (STI) Also known as Sexually Transmitted Disease; diseases that can be transmitted via sexual interaction 51 Subjective Norm Belief about whether most people approve or disapprove of the behavior. 39 Vaginal sex Refers to penis vagina intercourse. Also known as coitus. 51 Summary The purpose of this study was to assess specific sexual behaviors (digital, oral, vaginal, anal) of college students and the role alcohol intoxication may play in the intention to participat e in these behaviors. This chapter describes the overall focus of this research and includes a description of the research problem, purpose of the study, significance, applicable theories, research questions, statistical analyses delimitations, limitation s, assumptions, and definition of terms. Risky sexual behaviors among college students have serious public health consequences. T he present study provide d a comprehensive description of sexual ly specific behaviors of college students and aid s in addressing gap s in the current knowledge base. The r esults help to provide a clearer understanding of the relationship between alcohol use and specific sexual activity and will aid in the development of effective public health interventions and policies

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33 Table 1 1. Cognitive i nterview p robes Component Guiding Probes Definition of Terms Ensure the terminology is appropriately defined and equally understood by the respondents 1. Define the following in your own words a. One drink of alcohol b. Drunk c. Sexually Transmitted Infection d. Digital sex e. Oral sex f. Vaginal ex g. Anal sex Comprehensions Ascertain what the question is asking and attaching a meaning to the question 1. What do you think the question is asking you? 2. How do you think other students would understand the question? Information Retrieval Recalling relevant information or experience from memory 1. Is it difficult to recall the time frame? 2. Does the context of the question help recall the information? 3. Is the question difficult to distinguish from similar events or inform ation? Judgment Judging sampled experience versus a reference (or an expectation) and formulating answers to a survey question. 1. Does the question ask information you already have? 2. How detailed/complete do you think this information need to be? 3. How accurate do you think this information need to be? Reporting Mapping the judgment onto a response category. 1. Does the design of the response alternatives affect the way you decide to answer? 2. Do you feel the need to edit your answer to satisfy personal and societal pressures?

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34 CHAPTER 2 ASSESSING SPECIFIC S EXUAL BEHAVIOR: INST RUMENT DEVELOPMENT A ND VALIDATION TECHNIQUE S Background One of the overarching goals of Healt hy People 2020 is the improvement of reproductive health through promotion of healthy sexual behaviors. Among these o ngoing public health challenges are sexually transmitted i nfections (STIs) which include more than 25 infectious organisms that are transmitt ed through various sexual behaviors 1 Each year, sexual behavior s lead to approximately 9 million new STI s among 15 to 24 year olds as well as increased rates of unwanted pregnancies 7, 8 Approximately 1 out of 10 women report an unintended pregnancy with rates highest among women aged 18 19 and 20 24 9 In 2007, y ou ng adults aged 15 to 24 accounted for approximately 12% of newly di agnosed cases of HIV in the United States 4 A large focus of HIV/AIDS, STI, and teen pregnancy prevention literature has been on comprehending and promoting safer sexual behavior 12, 27, 34, 56, 57 Though total abstinence is the only way to complet ely eliminate individual risk for HIV and STI transmission, it is not plausible to expect sexually active individuals to use sexual abstinence as a preventive measure for acquiring an STI 6 According to the 2010 National College Health Assessment 70% of students have had at least one sexual partner within the past school year. Th e study goes on to report that of this percentage, 18% practice sa fe sex by always using a condom, while 4% of students reported no use of pregnancy protection 5 Alcohol, readily available in the college environment compounds these issues Alcohol use has been associated with risky sexual behavior on college campuses 13 15, 58 Forty two percent of college students who drink heavily also engage in unplanned

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35 sex 15 C asual sex behaviors of college students combined with high risk drinking influence the simultaneous occurrence of sexual risk taking including inconsistent condom use 7 20, 21 Alcohol use is also associated with the increased likelihood of sexual coercion and increased severity of sexual assault 25 Despite the large amount of research into these risky behaviors there has been a lack of consensus as to the best way to measure and validate self reports of sexual behavior and alcohol use 31, 59 In addition, many instruments have been created to measure sexual behavior but none measure the entire spectrum of behaviors, includin g digital sex, oral sex, and anal sex The lack of measurement consistency between studies is problematic because comparisons and generalizations are difficult to assess, thus leading to serious public health implications 32 Studies conducted with inappropriate measures or measure s that are not sensitive to certain sexual behavior s may reach inappr opriate conclusions regarding the risk behavior s Noar, Cole, & Carlyle provide examples o f this discrepancy as it relates to condom use. 34 They cite a surveillance study conducted using the percentage (proportional measure) of condom usage as not taking into account the frequency of sexual intercourse. Should the comm unity under surveillance reduce frequency of intercourse overall risk would be l ower ed but the outcome would not be portrayed by the proportional measure. Thus accurate behavio r measurement is critical for an accurate description of behaviors and their impacts on public health and policy. The aim of this study was the assessment of s pecific sexual behaviors of college students and the role alcohol intoxication play s in intention to participate in these behaviors. Specifically, the purpose of this study was to develop a survey instrument

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36 and assess measurement properties of the i nstrument using multi modal methods. The following research questions guide the present study : RQ1: H ow can current sexual risk behavior survey instruments be improved? RQ2: Can an instrument be developed to collect and assess the specific sexual behaviors of college students? RQ3: What is the reliability and validity of the Specific Sexual Behavior instrument? Conceptual Framework Classical Test Theory The Classical Test Theory (CTT) guide d the development and assessment of the measurements. It is important to note limitations associated with the use of this theory 49 T he psychometric properties are instrument and sample dependent and cannot be extended to other populations or age groups Also, the measurement is static, not dynami c as it is a cross sectional study design. In order to address the research questions, the instrument was composed of a combination of measure s including established and validated items, newly developed items, and items specifically revised for the purpose of this study. Theory of Planned Behavior The Theory of Planned Behavior (TPB) is a commonly used theory in sexual risk research since it incorporates perceived control over achievement of behavior as an additional aggregate of intention 35 37 The theory focuses on individual motivation factors as behavioral predictors by assessing the relationship between beliefs, norms, attitudes, intentions, and behaviors 39 Cooper and Orcutt conclude that the complex relationship between alcohol use and sexual behaviors req uires the variables to be studie d not in

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37 isolation, but in the context of a larger system of interconnected variables. 33 Thus, the TPB emerged as the best theoretical framework to asses these behaviors as they relate to college student risk taking. The T PB is an extension of the Theory of Reasoned Action (TRA); and incorporates perceived contr ol over behavior achievement as an additional aggregate of intention 36 The TPB focuses on factors of individual motivation as predictors of behavior by asses sing the relationship between beliefs, norms, attitudes, intentions, and behaviors 39 Refer to Figure 1 1 for a graphic representation of the theory. The TPB centers on the following constructs: Behavioral Intention is the perceived likelihood of performing a behavior and is viewed as the most important determinant of behavior. Attitude is the personal evaluation of the b ehavior and impacts behavioral intention. It is shaped by behavioral beliefs and the evaluation of behavioral outcomes. Subjective Norm is the personal beliefs of peer approval or disapproval of the behavior. The construct focuses on behavioral intention a s influenced by the motivation to gain peer approval and assesses normative beliefs and motivation to comply. Perceived Behavioral Control is the construct that was added to the TRA by Azjen and Drive to account for situations in which behavioral intention is influenced by factors perceived to be beyond personal control. It is shaped by control beliefs and perceived power. The TPB assumes all other cultural and environmental factors operate through 39 The TPB is often applied to survey research because it can be used to predict and explain a health behavior in a limited set of constructs 36, 40

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38 Measurements Established Measurements In order to increase instrument validity when possible, existing measurements were used When ex isting measures were not available items were adapted or developed for the purpose s of this study. Existing surveillance and behavioral questions National College Health Assessment II (ACHA NCHA II) 5 Additionally, perceived effects were evaluated using items from the Core Alcohol and Drug Survey. This survey is a nationally validated instrument specifically aimed at evaluating college student behaviors 30 The items from the above named instruments were kept in their entirety. Items from the Worry About Sexual Outcomes (WASO) scale were also used The WASO scale evaluates participant s perceived concern s associated with sexual risk taking o utcomes. The 10 item measure contains two subscales of STI/HIV worry and pregnancy worry and demonstrates internal consistency and satisfactory construct validity 44 Since this study includes male participants, the WASO pregnancy items were omitted and g ender neutral pregnancy items were developed for use in t his study Relationship Status Previous research points to relationship status as strongly affecting sexual risk taking in general 33, 60 62 Surra et al. describe current research focusing on the college population as weak because specific features of relationship status are missing 63 Further research in sexual risk taking needs to include a more thorough assessment s pecific of perceived relationship status. Numerous studi es have included measurements of relationship status and other aspects of sexual risk taking, but none

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39 have analyzed the specific effect of perceived relationship status on alcohol use and sexual acti vity intention 64 6 7 Specific sexual behaviors Digital sex behaviors ar e largely not included in the current literature. Though, p enetration of the vagina, anus, or oral cavity can occur with the penis, foreign objects, or fingers distinction between these behaviors is rarely made 68 Even t he term sexual assault includes both sexual contact (fondling) and sexual penetration (rape). However, when forced digital penetration is the only complaint, a medical legal examination cannot be performed 69, 70 This is based on decades old research identifying rape victims by pregnancy, syphilis or gonorrhea diagnosis, ignoring other physical or psychological trauma. Reports of digital genital contact during sexual as sault range from 26% to 55% 71 74 Rossman and colleagues conducted a retrospective study documenting the frequency and type of genital injuries in women who solely reported forced digital penetration 72 During the 3 year span, 941 sexual assault case f iles were review ed Fifty three cases solely experienced forced digital penetration or manipulation. Of this group, 81% presented genital injuries with a mean of 2.4 injuries per patient. Further research is needed to understand digital behaviors so as to best dictate policy. Little is known about the behavioral norm, such as if it is more likely to occur with other risk behaviors. Even less is known about digital behaviors among college students. Another behavior of interest is oral sex, which refers to s exual activity involving cunnilingus 51 For several reasons, oral sex can be a preferred form of sexual expression for adolescents and young adults. The behavior cannot produce an

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40 unwanted pregnancy, which is often the central focus of their concerns about sexual risks 75 In some situations, oral sex may be preferred because it is perceived to involve less intimacy than intercourse 64 In addition, some studies have found that oral sex is not judged to be a form of sexual activity at all, thus allowing participants to view themselves as not being sexually active 75, 76 Ana l sex is another behavior of interest to this study. I t is a behavior that is not often a ssessed in sexual risk surveys even though it is the most efficient route for HIV transmission 10 Between 20 25% of college aged adults have participated in anal sex behaviors 10 12, 77 Research also suggests those who participate in anal sex are more likely to participate in other risk behaviors 10 Thus further investigation of these specific behaviors is warranted. Instrument Development Process Krause described a multi modal technique for the development of close ended survey que stions that effectively bridges both qualitative and quantitative methodological approaches. 42 Sexual behaviors have been thoroughly researched, thus slightly adjusted to reflect the information already published concerning these behaviors (i.e. focus groups, interviews, etc.). Refer to Figure 1 2 for a graphic of the instrument development process. Instrument measures were guidelines for con structing TPB instruments. 40 Attitude, subjective norm, perceived behavioral control, a nd intention are usually assessed directly by means of standard scaling procedures. When developing the scales, the measure ments must be directly compatible with the behavior in terms of action, target, context, and time elements. Participants may have tro uble understanding questions with negative phrasing, statements containing both subjects

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41 and verbs relating to the behavior, or item responses depending on further information, not specified in the question 78 Thus, it is critical for the spectrum of sexual behaviors to be clarified in the measurements and for each it em to be clear, concise, and completely exhaustive Due to the sensitive nature of the subject matter the instrument was designed in the present study to be administered online. Among college student s web based surveys are more cost effective and conveni ent than other modes of survey research. A meta analysis comparing web and mail surveys among college respondents reported the web survey response rate to be 3% higher 50 The benefits of utilizing web based surveys include reduced implementation costs, faster data collection, improved formatting, elimination of data entry, and reduced processing costs 79, 80 Also, by emphasizing a rate is more likely to be achieved 81 Thus, the present study was administered online, notifying participants via multiple reminders to respond to the one time survey. Participants were told they had the option of discontinuing the survey at any point. In addition, no e mail or IP addresses were collected in order to ensure the anony mity of the subjects. Development of Preliminary Variables P reliminary measures were guidelines for c onstructing a TP B questionnaire 40 Likert type scales provide precise information on respondent s degree of attitudes and provide high reliability 82 Thi s format was used for many of the present survey items. Special attention was given to avoid the use of vague words, technical terms and double negative wording. The instrument defined the s pecific sex ual behaviors

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42 responses In addition, the Flesch Kincaid Readability Score was 8.6, ensuring the material was suitable for college aged students Review by Expert Panel The expert panel consisted of 6 scholars knowledge able in the area of alcohol use, sexual behaviors instrument development and statistical analysis Each panel member received all student notifications, consent forms and the complete preliminary questionnair e. The panel was asked to evaluate the content quality, instrument structure, and ability of the measures to produce data appropriate to answer the stated research questions In addition, the panel received all participant contact emails, consent process and cognitive interview probes. Problems with each measure were identified, discussed, and potential solutions were proposed. The panel judge d important construct and domain themes of the T PB In addition to reviewing questions and response formats, the pa nel was also determine d the order of the questions and content of the email notifications and informed consent. Based upon input from the panel changes were made to the survey instrument, including removal of erotic touch behaviors. These behaviors are d efined as physical acts without penetration, such as massage, groping, and self masturbation Erotic touch was initially included as the researcher sought to assess the entire spectrum of behaviors. However, the panel did not define these behaviors as risk related as rape, STIs, and pregnancy were generally not associated with erotic touch Instead, further information was added clarifying digital sex behaviors and additional questions were suggested concerning the consequences of digital sex (attempted as sault, etc.) Further edits included the clarification of the definition of oral sex to include both giving and receiving the sexual act and the

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43 by expanding them to include specific sexual behaviors. Double barreled items were reworded, skip patterns were applied for conditional questions and the instrument was edited to begin with the least sensitive or personal queries. P articipant notifications were amended to emphasize the topic, clarify the plea for help, include support for school spirit and further discuss the potential impact of the results on the student population. In addition, a graphic was created and used across all materials (par ticip ant notifications, consent and instrument ) to highlight and remind participants of the anonymous nature of the instrument. During the course of the editing process, the researcher turned to the literature to support recommended changes as they applied to p revious qualitative and quantitative studies of sexual behaviors among college students. Cognitive Interviews with members of the target audience were conducted. The purpose of the interv iews was to assess item interpretability by the participants Participants may have trouble understanding questions with negative phrasing, clauses to the behavior, or answers depending on further information, not specified in the question 78 Sometimes issues may arise due to cultural and societal differences between the researchers and the participants Thus, it is critical for the spectrum of sexual behaviors to be clarified in the measurements and for each item to be clear, concise, and completely exhaustive Interviewees were recruited via word of mouth and asked to think a loud while completing the instrument. The cognitive interview focus ed on assessing four components: comprehension, information retrieval, judgment, and reporting via guiding probes Refer to Appendix B for the complete cognitive interview probes. The interviews

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44 assess ed cognitive interpretation of the information required for participants need to answer each question. were captured with Camtasia Studio 6 a screen capture program which is often us ed in distance education development and applied as a tool in the observational analysis of internet use 83, 84 Similarly to the Krause study, the instrument was introduced to participants in a manner intended to increase motivation and commitment during the lengthy interview 42 Student s were provided with an explanation of the time and effort required for instrument development and the importance of their opinions of the current instrument. C ognitive interviews were conducted with 11 students (6 female) The majority of respondents were Caucasian (18% Latino) and the median age was 19. The sample demographics were representative of the overall university. All cognitive interview participants reported their sexuality as heterosexual and 73% reported sexua lly activity within the past 30 days. About a third of the respondents were in a monogamous relationship, another third were dating but not in an exclusive relationship and the final third were neither in a relationship or dating The cognitive intervi ews were analyzed via researcher notes, respondent voice recordings and captured screen movement Findings were used to further edit the instrument. The definition of sexually transmitted infections was clarified, anchors reword ed and the query into sexual partners was expanded to include all sexual behaviors of interest. In addition, great er emphasis was placed on formatting the web survey to include bolded categories, increased spac ing, and larger font size.

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45 Pilot Test After editing the instrument based on the cognitive interviews, a pilot study was conducted. The pilot study served as a quality check among the target population. A total of 4,000 students, aged 18 24 were randomly selected by the registrar to participate in the pilot study Invited participants received one initial contact followed by three additional reminders over the course of two weeks. To ensure anonymity p mails were not collected Respondents were notified of their right to discontinue the questionnaire at any point without retribution. Upon completion of the survey, respondents were directed to an exit page with local alcohol, sexual health, and mental health re sources Zoomerang, a commercial internet survey software program, was used to collect and store the electronic study data. Data was entered in SAS statistic al software package version 9.2 Each question on the survey was coded numerically to facilitate da ta analysis. Response patterns were assessed by age, gender, sexual preference, and relationship status. The distribution and missing responses were analyzed. Due to the sensitive nature of the survey content extra attention was placed on ceiling and floor effects. Data analysis indicated m easure ment s suffer ing from polar weight lacked adequate discriminate capability of high versus low levels of health behavior ; these measures were eliminated A total of 710 students completed the instrument, resulting in a 17.75% response rate. As shown in Table 2 1 comparability of the pilot sample to the entire University population. Survey length, frequency of distributions for sufficient variance, and an exploratory factor analysis was preformed to examine the structure and psychometric properties of the newly developed scales. Particular attention was given to establishing

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46 the reliability and validity of the new instrument. Demographic and prevalence characteristics of the partici pants were calculated through descriptive statistics which included analysis of respondent and nonrespondents characteristics Since bias may were matched to the overall university po pulation ( Table 2 1 ). Content validity was primarily assessed during the qualitative portion of the protocol. The expert panel and cognitive interviews were used to judge important construct and domain themes. Content validity was also asses sed through th e clarity, comprehensiveness, and r edundancy of items and domains. Since the instrument includes both new and edited measures exploratory factor analysis was conducted to i dentify if the derived constructs are the same as those hypothesized. Items were dis carded if they demonstrate d a weak relationship (low factor loading) with the underlying variable V arimax rotation was used to examine the factor loadings. Items were retained on factors if they had high loadings (i.e., saturated or loadings with an absol ute value greater than .40) and were not complex. Cr determined the internal consistency of the scale s and provided evidence for items that might be suppressors. I tems found to be too difficult, too easy, and/or have near zero or negative dis crimination were replaced with more suitable items. M inor revisions were made to the instrument including revisions of response items, elimination of questions with low factor loadings and the revision of the STI testing measure to include both 6 month and 12 month time spans. A total of 49 questions, with multiple sub queries, were retained for the final edition of the i nstrument.

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47 Formal Investigation 4,000 students for the formal investigation The previously piloted methodology was applied in the formal investigation, with one exception. In order to increase the instrume incentive was offered to the first two and last two participants. On the exit page participants had the option to exit the survey and continue to the incentive form, which required submitting their contact information to be considere d for a $50 gift card. The formal data collection (with incentive) lead to a 20.8% response rate (832 respondents), a 3% increase from the pilot administration. Table 2 1 presents a comparison of the final sample with the university population. Respondent behavioral measures were compared to a national sample (Table 4 1) and were found to be somewhat comparable. The final student notifications, consent information and survey can be found in appendices C, D, and E, respectively. The continued development process of the behavior specific sexual risk survey will be presented in a series of substantive papers exploring the applicability of the Theory of Planned Behavior to predict intention to participate in specific sexual behaviors while intoxicated and the applicability of a risk level typology Results Application of the Krause instrument development process l ead to 50 preliminary measures assessing specific sexual behaviors and the role of alcohol intoxication in the intention to participate. The initial measures included a spectrum of sexual behaviors: erotic touch, digital, oral, vaginal, and anal sex. The expert panel suggested the removal of erotic touch behaviors as they are not risk related, resulting in the deletion of sub

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48 questions from behavior s pecific items. Three additional questions were created to address the consequences of specific sexual behaviors. Definitions were clarified, items reworded, and skip patterns were added. Participant notifications were edited to e mphas ize the topic and the anonymous nature of the study design. Fifty three questions were presented in the student cognitive interviews. Participant comments and screen movements were recorded during the think a loud process. This allowed accurate analysis o f verbal comments and inferences, as well as specific movement over response options and instrument structure. This information led to changes in response options readability, the creation of 3 screening questions and 4 sub questions relating to specific sexual behavior S creen capture software h as previously been used as a methodology assessing internet usage 83, 84 R esults of the present study prove it to be a cost effective, rich data collection technique for instrument development. The piloted instrument contained 56 questions assessing digital, oral, vaginal, and anal sexual behaviors and the role of alcohol intoxication in these behaviors. The factor analysis resulted in the removal of two measures across 3 sexual behaviors (total of six items ) due to poor loadings. es to (oral, vaginal, anal) sex behaviors, how motivated are you to meet the expectations of your from the constructs M otivation to C omply and P erceived B ehavioral C ontrol. Another free a as part of Perceived Power but loaded on Control Beliefs. Exploratory factor loadings

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49 ranged from .56 to 84 Internal consistency was demonstrated for the instrument overa ll ( = 0 .83) and for each factor except Perceived Behavioral Control (oral sex = 0.17, vaginal sex = 0.46 anal sex = 0.31) Factor loadings and estimates of internal consistency are shown in Table 3 4. In addition to the elimination of questions w ith low factor loadings, the item assessing STI testing was revised to include both 6 month and 12 month sub items. During the pilot study, the total numbers of items were reduced from 56 to 49. The formal investigation of the 49 items was conducted with an additional sample 4000 students Survey methodology remained the same except for one notable difference; the use of an incentive. By offering participants the opportunity to receive one of four $50 gift card s the response rate increased 3%. Additional psychometric testing of the instrument is presented in a series of substantive papers (Chapters 3 and 4) Discussion Although the establishment of an instrument is an ongoing task requiring replication across a series of studies, the present study results provide s structured guidelines and encouraging results. To date, concurrent a lcohol use and sexual activity has been difficult to assess T his study contributes to exploratory effort s in this field via development of measures specific to alcohol use and s exual behavior risk. The present instrument development process aids in addressing measurement and validation of self report sexual behavior; which currently lack s consensus in the literatur e 31, 59 In addition, this instrument is the first to assess a spectrum of specific sexual health behavior, including digital, oral, vaginal, a nd anal sex behaviors and how they relate to alcohol intoxication.

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50 The applied eight step instrument development process provided explicit guidelines for mix modal analysis development. By reviewing the literature to identify relevant concepts of sexual be havior and alcohol use, preliminary measures were cultivated These measures where then reviewed by a panel of experts, edited and tested among the target population with cognitive interviews The application of Camtasia Studio in the cognitive interviews, proved to be a cost effective method to web survey. This aspect of the analysis proved fruitful be cause the researcher was able to analyze how the participant interacted with the survey design, response options, length, and overall construction. The web based design of the instrument also proved to be modestly cost effective with a small incentive and provided increase d anonymity for participants. Caution must be applied in generalizing the results of this study to a broader college student sample. The results may not be transferred to campuses without a comparable environment and social scene. In addi tion data collection occurred during a specific time interval and thus does not follow respondents longitudinally to view personally normative behaviors. It is also important to note the mixed methodology of the instrument development process can be costly and labor intensive. However, the present study provide s a comprehensive description of the sexual b ehaviors of college students and aid s in addressing the gap in our knowledge base. Further research should focus on continued development of the measures and specific properties of the 49 item instrument. Further testing with other college student population s is necessary to establish required psychometric measures In addition,

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51 inclusion of additional risk behaviors or measures to better describe these pub lic health perils should be considered C ontinued review of the applied instrument development process is warranted as newer technologies and techniques are developed and assessed. Conclusions For Consideration The lack of measurement consistency between studies evaluating alcohol use and sexual activity is problematic because comparisons and generalizations are difficult to assess 32 The aim of this study was to develop an instrument to assess specific sexual behaviors among college students and the role alcohol intoxication play s in intention to parti cipate in these behaviors. The Classical Test Theory provided the framework for development and assessment of the measurements. In addition, the Theory of Planned Behavior was used to both predict and explain the health behaviors, as well as to guide forma tting and structure of individual items. The instrument development process include d review by an expert panel, cognitive interviews with sample participants, and pilot investigation. Edits and revisions were finalized following pilot testing and the surve y readied for final administration. The applied instrument development process employed screen capture software and web based surveying in a cost effective format suitable for mixed method measurement development The development and application of the ins trument provide s a clearer understanding of the relationship between alcohol use and sexual activity and aid s in the development of effective public health interventions and policies.

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52 Table 2 1 Study sample comparison to total university population Demo graphic University Population Current Study Pilot Study Formal Investigation Gender Male 45 .0 % 39.0% 33 .0 % Female 55 .0 % 61.0% 67 .0 % Race White/Caucasian 60.4% 67.2% 64.6% Black/African American 10.2% 12.5% 7.5% Asian 8.7% 6.4% 5.8% Ethnicity Hispanic 15.4% 18.3% 17.5% Age 18 18.3% 19.9% 14.7% 19 20.2% 20.1% 25.7% 20 21.7% 25.2% 24.0% 21 20.3% 23.1% 22.1% 22 8.9% 7.8% 9.7% 23 3.0% 2.8% 2.4% 24 1.4% 1.0% 1.4%

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53 CHAPTER 3 SEXUAL RISK TAKING ATTITUDES, PE RCEPTIONS, AND PREVALENCE AMONG COLLEGE STUDENTS Background Campuses provide an important context in which to study risky behaviors because plan ning to attend college have lower rat es of heavy drinking than their non college bound peers. After high school graduation both groups increase their rates of heavy peers 28 The difference in level of risk taking is also present in the college student population. Since 2002, data ha ve shown that young adults enrolled in full time 4 year institutions generally participate in more high risk drinking than those not enrolled full time 29 Current literature offers numerous studies describing the d evelopmental progression of 45, 85 87 The percentage of students who have ever had sex rises steadily during the college years, reaching about 86% by the senio r year 27 Among college students high risk drinking and sexual risk taking routinely occur simultaneously 7 The social environment of school with high rates of heavy episodic drinking (5 or more drinks) places students at an increased risk of sexual assault 23 Research indicates that women have a one in five chance of being sexually assaulted while enrolled in college 22 R ates of sexual assault vary wi dely due to varying defi nitions, policies, under reported incidents, and differing data collection methods. One study estimates alcohol involvement in at least 50% of all sexual assaults involving college women. 24 Sexual assault may be greater in severity due to intensified sexual expectations and increased feelings of alcohol induced sexual prowess and aggression

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54 among males. 25 26 Additionally, some students cite alcohol use as validation for participation in sexual activity and high risk behaviors. 24 The term sexual assault includes both sexual contact (fondling) and sexual penetration (rape). However, when forced digital penetration is the onl y complaint, a medical legal examination cannot be performed 69 70 This is based on decades old research identifying rape victims by pregnancy, syphilis or gonorrhea diagnosis, ignoring other physical or psychological trauma. Reports of digital genital contact during sexual assault range d from 26% to 55% 71 74 Rossman and colleagues conducted a retrospective study documenting the frequency and type of genital injuries in women who solely reported forced digital penetration 72 During the 3 year span, 941 sexual assault case files were reviewed. Fifty three cases solely experienced forced digital penetration or manipulation. Of this group, 81% presented genital injuries with a mean of 2.4 injuries per patient. Further research is needed to understand digital sexual behaviors among college students Little is known about the behavioral norm, such as if it is more likely to occur with other risk behaviors. Other sexual behaviors such as oral, vaginal, and anal sex, when combined with alcohol, can result in physical, emotional, and financial burdens. O ral sex re fers to includes both fellatio and cunnilingus 51 For several reasons, oral sex can be a preferred form of sexual expression for adolescents and young adults. The behavior cannot produce an unwanted pregnancy, which is often the central focus of their concerns about sexual r isks 75 In some situations, oral sex may be preferred because it is perceived to involve less intimacy than intercourse 64 In addition, some studies have

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55 found that oral sex is not considered by some to be a form of sexual activity thus allowing participants to view themselves as not sexually active 75, 76 Anal sex is another behavior of interest to this study but one not often assessed in sexual risk surveys. Anal sex is the most efficient route for HIV transmission therefore it is of evident importance 10 Studies indicate that b etween 20 25% of college aged adults have participated in anal sex behaviors 10 12, 77 Research also suggests those who participate in anal sex are more likely to participate in other risk behaviors 10 Thus further investigation of these specific behaviors is warranted. Interventions grounded in theory are considered successful in addressing multiple determinants of risky sexual behaviors 88 To maximize the effectiveness of an intervention it must be tailored to the specific behaviors and culture of the target audience 89 Effective health behavior interventions also apply a theoretical framework so as to behavior 35 Multi ple studies have applied the Theory of Planned Behavior to college student sexual behaviors and alcohol use 88, 90 93 However, most of these studies are specific to condom usage and commonly only evaluate vaginal and/ or anal sex 7 Of necessity to increased understa nding in the field of research is development of instruments with increased sensitivity and precision along with inclusion of items assessing the interaction between alcohol use and participati on in sexual activities. Cooper suggests application of multiv ariate models in whi ch alcohol use is embedded within a network of these risk behaviors. 7 Cooper and Orcutt conclude that the complex relationship between alcohol use and sexual behaviors is best understood in the context

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56 of a larger system of interconnected variables. 33 Application of the Theory of Planned Behavior to a spectrum of specific sexual behaviors can i ncrease understanding of in intention to participate in these behaviors. T his study 1) asses ses the perceptions, attitudes, and prevalence of specific self reported sexual behaviors among college students and 2) examine s the efficien cy of the TPB in explaining intention of engaging in sexual activity while intoxicated. RQ1 : What is the prevalence of specific sexual behaviors among college students at a large southeastern university ? RQ2 : How much of the sexual behavior while intoxicated variance is accounted for by the Theory of Planned Behavior? RQ3 : Which construct (s) within the Theory of Planned Behavior (Subjective Norm, Attitude Toward the Behavior, Perceived Behavioral Control, and Behavioral Intention) account for the largest proportion of variance when predicting specific sexual behaviors among college students while intoxicated? R Q 4 : Using constructs from the Theory of Planned Behavior, what are the causal effects in predicting participatio n in specific sexual behaviors while intoxicated? Theory of Planned Behavior The Theory of Planned Behavior (TPB) focuses on motivation factors of the individual as predictors of behavior 39 The TPB is an expansion of the Theory of Reasoned Action (TRA) which makes the assu mption that attitude (Attitude T oward Behavior) and perceived acceptance of a behavior (Subjective N orm) influence a the behavior. Intention, in turn, is purported to decision to participate in, or abstain from the behavior. TRA was expanded in 1991 to include the additional construct of Perceived Beha vioral Control in order to account for opportunities. The TPB assumes all other cultural and environmental factors operate

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57 94 The following is a brief overview of the TRA/TPB constructs as they relate to the present study. about performing the behavior in question cou pled with the importance or assessment of possible behavioral outcomes. The measures include beliefs about the consequences of the behavior (behavioral beliefs) and the corresponding positive or negative assumptions of each belief (evaluation of the outcom e). perform or not perform the behavior. The measures include beliefs about how influential people would like them to behave (normative beliefs) and how motivated they are to comp ly with what these influential people think (motivation to comply). An influential person can include family members, best friends, or sexual partners. However, college students tend to be most motivated by the support and guidance of their peers on behavi oral decisions 21, 65, 95 perform the behavior and is composed of both internal (e.g., skills, locus of control) and external (e.g., situations, pressures) control factors. The measures of this construct include how much the individual feels they have control over the behavior (control beliefs) and the impact of these factors in facilitating or inhibiting the behavior (perceived power).

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58 The theory posits the most important determinant of behavior is Behavioral behavior and is shaped by attitude, norms, and perceived behavio ral control. Methodology Participants and Procedures A randomly selected sample of 4,000 students, aged 18 24 and enrolled full time in a large southern university, w as provided by the registrar. All participants received email notification to visit the on line survey. Over the course of the study, participants receive d three additional email reminders to log on and complete the survey. Respondents were required to read an informed consent mes sage prior to taking the survey, followed by instructions for comp leting the survey. To ensure anonymity, IP addresses, names and e mails were not collected. The informed consent included a statement informing participants of their right to discontinue the survey at any point without retribution. Upon completion of the s urvey, the exit page offered participants local alcohol, sexual health, and mental health resources In addition the exit page provided participants with the option to exit the survey or to continue to an incentive page where they could submit contact inf ormation and be eligible for a n incentive T he first two and last two participants were selected to receive the incentive as recommended by the Institutional Review Board Measurements The instrument is designed to assess attitudes and behaviors associated with sexual risk taking in the college student population. The survey was formatted using 40 Attitude, subjective norm, perceived behavioral control, and intention were assessed directly by means of

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59 standard scaling procedures. The i nstrument was developed and validated using both qualitative and quantitative methodologies (Chapter 2). Attitudes Attitudes about specific sexual behaviors engaged in while one is intoxicated were assessed across seven items using the following seven poin t sem antic differential scales: good/bad, beneficial/harmful, enjoyable/unenjoyable, healthy/unhealthy, risky/not risky, regretful/ unregretful, and guilt/no guilt To measure b ehavioral beliefs participants reported their likelihood of participating in sex ual behaviors while intoxicated. Each item specific to the sexual behavior, also applies a seven point semantic differential scale (extremely likely/extremely unlikely, strongly agree/strongly disagree). The measures assessed social ease, increased fun, a nd likelihood of participation. Behavioral Outcomes were measured by asking respondents to report the personal value they place on participating in sexual behaviors while intoxicated Respondents were also asked their feelings regarding possible consequenc es that may result from sexual activity under the influence of alcohol For example, feel a greater desire Refer to Table 3 1 for the direct and indirect measures of attitude toward the behavior. Subjective Norm s T he extent to which instrumental people (i.e. family, friends, peers, etc.) in the lives approve and value their participation in sexual behaviors while intoxicated was assessed using the social norms construct of the TPB Once again, seven point semantic differential scale s with the anchors strongly agree/strongly disagree were used as response options To assess Normative Beliefs participants were asked if their close friends, current partner, or ideal future partner (influential

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60 people) would approve of them participating in specific sexual behaviors while intoxicated. Motivation to Comply items asked participants how important it is for them to meet expectations of the influential people in their lives Refer to Table 3 2 for the direct and indirect measures of subjective norm. Perceived Behavioral Control Perceived Behavioral Control was measured using nfidence in the control of the behavior. Control beliefs evaluate how often an individual considers the conseque nces of participating in sexual behavior while intoxicated. Items assessing Perceived Power evaluate the opportunities and barriers influencing the individual participation in sexual activity while intoxicated. Refer to Table 3 3 for the direct and indirec t measures of perceived behavioral control. Behavioral Intentions Behavioral Intentions assess intention to participate in the behavior at the next event or opportunity. Respondents indicated their level of agreement relating to participation in spec ific sexual behaviors while intoxicated namely oral vaginal, and anal sex. Behavior Of great importance to the aims of this study is the assessment of each individual behavior. Past research most often assess es a spectrum of sexu al behaviors, making the inclusion of specific item s relating to participation in each sexual behavior (oral, vaginal, and anal sex) while intoxicated critical Ad ditional behavior items assess participants alcohol use

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61 Analysis A path analysis was conducted to assess the TPB co nstruct relationships, as well as they strength of the se relationships Path analysis is a form of Structural Equation Modeling where simple bivariate correlations are used to estimate relationships 54 In essence, a path analysis ex pands the focus of multiple regression models to include causal relationships In a path analysis independent variables are described as exogenous constructs and dependent variables a s endogenous constructs. Exogenous constructs compose multiple, correla ted variables which are grouped together to create a single variable, whereas endogenous constructs are theoretically determined by factors within the model. Attitude toward the behavior, subjective norm, and perceived behavioral control are the exogenous constructs while the endogenous constructs include intention and behavior. O f note is the inclusion of both direct and indirect measures in exogenous constructs Additionally, d irect and indirect measurement approaches are based on differing assumptions a bout the underlying cognitive structures As a result, disadvantages for each measurement approach exist 39 Direct measu res are usually more strongly associated to intentions and behaviors than indirect measures. The association between direct measures and intention indicates the relative importance of attitude, subjective norm, and perceived behavioral control in explainin g or predicting behavior s It is critical to demonstrate these associations before analyzing indirect measures. Thus, a strong association should exist between indirect and direct measures to be certain of including appropriate beliefs as indirect measures Additionally, the strong association indicates the adequacy of the composite beliefs (attitude, norms, and control) as measures of the respective TPB constructs.

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62 Once this is demonstrated, indirect measures are of most interest for intervention and poli cy development. Attitude toward the behavior (direct measure) is composed of the indirect measures of behavioral belief and evaluation of behavioral outcomes. Subjective norms (direct measure) include the indirect measures of normative belief and motivatio n to comply. The direct measure of perceived behavioral control includes control beliefs and perceived power. To examine the i ndirect measures a composite score was created to rep resent the direct construct, whereas: = Value for the Behavioral B elief question = Value for the Evaluation of Behavioral Outcomes question = Value for the Normative Belief question = Value for the Motivation to Comply question = Value for the Control Belief question = Value for the Perceived Power question Therefore, composite scores of the constructs are as follows: Attitude Towards Behavior: Subjective Norm : Perceived Behavioral Control :

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63 For example, the construct have more fun if I got drunk b efore participating in oral sex to represent the behavioral belief and is which represents the e valuation of the behavioral outcomes. This pairing of variables produces the dependent variable used to describe the TPB construct Attitude Towards Behavior. A path diagram offers a visual representation of the model and the complete set of relationships s information on the pattern of inter correlations among the TPB variables as it relates to participation in sexual behaviors while intoxicated. Construction of the p ath diagrams used the following gu idelines : 54 The path flow must be one way. Connections between exogenous constructs must be two way connections representing the correlation between the variables. A path can go from endogenous construct to another endogenous constr uct, but never from endogenous construct to an exogenous construct. Included in the path diagram for the following regression models are the variances estimated with Mean Squared Residuals, of the respective independent variables : 96 Intention = Behavior = T he endogenous variable is composed of alcohol use before and during sexual activity. The exogenous variables are the composite scores of each of the TPB constructs. To assess internal consistency lpha was cal culated for each of the construct scales. As presented in Table 3 4 the construct of Attitude Toward the Behavior demonstrates the best internal

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64 consistency, across all thre e sexual behaviors. Subjective N orm was fair, with less favorable internal consist ency for P erceived B ehavioral C ontrol items. Since the measures are based upon the theoretical and analytical interests of the research questions all items were retained Sequences of multiple logistic regression analyses were conducted to determine the relationships between the variables in the path model. Goodness of fit was calculated to determine the extent to which the theory explain s the observed covariance matrix among the measured variables Results A total of 832 students responded to the on line survey for a 20.8% response rate A listwise deletion of cases with missing values was performed resulting in 605 useable cases Statistical analyses were conducted with SAS software version 9.2 Similar to the student body profile at the host instit ution respondent mean age was 20 (sd = 1.38) and the majority was female (67.5%) A lso similar to the host institution, a bout 75% of respondents reported their race as white and 8.6% a s African American. Approximately 17.5% of respondents defined their eth nicity as Hispanic. The majority described their sexual orientation as heterosexual (92.1%). Respondents were asked to indicate their current relationship status. Nearly 44 % were in an exclusive, monogamous relationship while 4.1% considered themselves to be in an open or non monogamous relationship, free to see other people Almost 10 % considered themselves openly dating yet not involved in a relationship, and 35.4% reported neither dating nor in a relationship.

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65 Preliminary Analysis A preliminary analysis assessed the variance of the combined TPB constructs when predicting intention to participate in specific sexual behaviors while intoxicated. The relationship between the i ndependent variables, intention and behavior required assessm ent prior to the application of multivariate techniques 39 Zero order correlations were computed for each of the TPB con structs and are reported in an inter correlation matrix for each sexual behavior ( Tabl e s 3 5 thru 3 7 ) The correlation analysis revealed strong linear relationships between the constructs Attitudes Toward the Behavior and Social Norms across all three sex ual behaviors. Statistical significance for Perceived Control was present among oral sex behaviors while statistical significance for Intention was significant among both oral and vaginal behaviors. Path Analysis A path analysis was conducted to determine the causal links between study variables. Structural Equation Modeling (SEM) simultaneously examine s a series of interrelated relationships among measured variables and latent constructs 54 A pplication of a multiple logistic regres sion technique determine s the amount of variance accounted for by the theory constructs when predicting participa tion in sexual behaviors while intoxicated. The strength of the association between the dependent variable and the collective set of independen t variables was calculated using the absolute fit indices: Chi square GFI (Goodness of fit Index), and Standardized Root Mean Squ are Residual (SRM S R) The models demonstrated sufficient fit ( Table 3 7 ) Overall path coefficients of the three models (Figu res 3 1 through 3 3) indicated Attitude Towards Behavior as having the greatest impact on Behavioral I ntention. The path coefficient for Subjective Norm was also significant, while the construct Perceived

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66 Behavioral Control did not significantly impact Intention or Behavior in terms of direct paths. Positive correlation coefficients in t he oral sex path diagram (Figure 3 1) between the constructs Attitude, Norms, and Control, positively influence intention to participate in ora l sex while intoxicated and as a result, behavior participation. Twenty seven percent of the intention to participate in oral sex while intoxicated is accounted for by the constructs of A ttitude, N orm, and C ontrol Nine percent of the variance in behavior participation is attributed to both I ntention and the direc t path of P erceived C ontrol to B ehavior. Figure 3 1 Path d iagram for o ral s ex b ehavior Note: indicates statistical significance at the .001 level. The vaginal sex diagram (Figure 3 2) again shows positive correlations between Attitudes, Norms, and Control. However in this model a statistically significant direct path to behavior is represented by Perceived Control. Yet the variance explained by the Attitude Towards Behavior Subjective Norm Perceived Control Intention Behavior 0.36 0.24 0.15 0.42 0.24 0.04 0.05 0.34 r 2 = 0.09 r 2 = 0.27

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67 constructs remained quite low. T wenty eight percent of the variance of I ntention is explained by the constructs of Attitude, Norms and Control. Eleven percent of the variance of B ehavior is explained by Intention and Control directly. Figure 3 2 Path d iagram for v aginal s ex b ehavior Note: indicates statistical significance at the .001 level. Similar to the oral sex model the anal sex model (Figure 3 3) fail to produce statistical significance for the Perceived Control construct In this model t he variance explained by the constructs is lower than the other two mode ls. In the anal sex model 16% of the variance of intention is explained by the constructs of Attitude, Norms, and Control and o nly 1 % of the variance of behavior is explained by intention and the direct path of Control. Attitude Towards Behavior Subjective Norm Perceived Control Intention Behavior 0.35 0.22 0.22 0.44 0.25 0.08 0.02* 0.01 r 2 = 0. 28 r 2 = 0. 11

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68 Figure 3 3 Path diagram for anal sex b ehavior Note: indicates statistical significance at the .001 level. Discussion Alcohol use and sexual activity is difficult to assess, but this study makes an exploratory effort into the co ncomitant behaviors of alcohol intoxication and sexual activity. The present study adds to the literature by addressing measurement and validatio n of self reported sexual behavior 31, 59 In addition, the created instrument assessed intention to participate in oral, vaginal, and anal sex behaviors while intoxicated. T he path analysis found the construct of Perceived Behavioral Control to be a poor predictor of intention and behavior. Several reasons may account for this finding First, the measures well developed as there is high variance among the Control construct Second, constructs contained within the TPB framework lack the predictive ability desired when studying specific sexual behaviors while intox icated. The physiological effects of alcohol may influence physical control over sexual behaviors as Attitude Towards Behavior Subjective Norm Perceived Control Intention Behavior 0.28 0.11 0.03 0.49 0.13 0.01 0.02 0.29 r 2 = 0.16 r 2 = 0. 01

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69 well as perceived control. Thus, future research investigating the predictive ability of the Theory of Reasoned Action is warranted The use of caution is warranted when generalizing study findings to a broader sample of college student s There is an indirect relationship betw een the differences in physical and social environmental characteristics between samples and the transferability of these findings. I n addition the cross sec tional nature of this study should be noted. Future studies employing a longitudinal de sign offer the opportunity to ga recall bias on the data A major criticism of path analysis is its improper use of linear regression to find causal relationships though the main goal of regression is correlation, not causation. In addition, the underlying Theory of Planned Behavior is used to determine the linear combinations of variables that compose the constructs. Thus, path analysis relies h eavily on the underlying theory; if the theory is flawed, the analysis is irrelevant. However, the present study provide s a comprehensive description of the sexual b ehavior s of college students and aid s in addressing the gap the literature by showing attitudes and norms to be better predictors of specific sexual intention and behavior than perceived behavioral control. Overall, perceived control lacks a statistically signifi cant effect on intention, as well as participation in the respective sexual behavior. An exception was present in the model using vaginal sex; perceived behavioral control directly impact ed behavior but not intention to participate in the behavior. Furth er research is needed in the continued development of the measures and investigation into an applicable theory. Perhaps the Theory of Reasoned Action, which

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70 does not include the perceived behavioral control path, would be better suited for these risk behav iors. In addition, further research is needed with other college student populations. C onsideration for greater predictability of the instrument through addition of risk behaviors or other measures is also necessary. Conclusions For Consideration This study assess ed the lack of measurement consistency between studies evaluating alcohol use and sexual activity. Presently, comparisons and generalizations are difficult to conclude with the current behavior al measurements, thus leading to public health impl ications 32 The Theory of Planned Behavior was applied to both predict and explain the health beha viors, as well as to guide the formatting and structure of individual items. T he results showed Perceived Behavioral Control was not a significant predictor of intention to participate in specific sexual behaviors while intoxicated. However, perceived cont rol was found to be statistically significant when predicating vaginal sex behavior directly. This leads the researcher to question the design of the measures or the applicability of the theory. The present exploratory study increases our understand ing of sexual risk behaviors Perceptions, attitudes, and norms were assessed on a sexually specific behavioral level. The information gleaned from this study impacts both future research with this population and developme nt of effective public health interventions and policies.

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71 Table 3 1. TPB attitude toward behavior direct and indirect m easures Construct Item Anchors Attitude Toward Behavior (Direct Measures) Q2 8Stem: Select response that most accurately reflects personal beliefs about your behaviors for each of the following: a. Oral sex while being drunk b. Vaginal sex while being drunk c. Anal sex while being drunk Good Bad Healthy Unhealthy Beneficial Harmful Enjoyable Unenjoyable Risky Not Risky Regretful Unregretful G uilt No Guilt Behavioral Beliefs (Indirect Measures) Q11. I would be more social if I got drunk Q12. I would have more fun if I got drunk before participating in: a. Oral sex b. Vaginal sex c. Anal sex Q13. My chances of participating in ____ would increase if I got drunk. a. Oral sex b. Vaginal sex c. Anal sex Strongly Agree Strongly Disagree Evaluations of Behavioral Outcomes (Indirect Measures) Q31. When I drink I feel a greater desire to participate in: a. Oral sex b. Vaginal sex c. Anal sex participate in: a. Oral sex b. Vaginal sex c. Anal sex Q33. When I drink before having sex a concern of mine is: a. Becoming pregnant or impregnating my partner b. Not being able to perform sexually c. That I may embarrass myself Strongly Agree Strongly Disagree Note: All anchors are on a seven point scale.

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72 Table 3 2 TPB subjective norm direct and indirect m easures Construct Item Anchors Subjective Norm (Direct Measures) Q9. Most people I hang out with would approve of me participating in: a. Oral sex while intoxicated b. Vaginal sex while intoxicated c. Anal sex while intoxicated Q10. The people in my life whom I value encourage me to participate in: a. Oral sex while intoxicated b. Vaginal sex while intoxicated c. Anal sex while intoxicated Strongly Agree Strongly Disagree Normative Beliefs (Indirect Measures) Q35. My close friends would approve of me participating in: a. Oral sex while intoxicated b. Vaginal sex while intoxicated c. Anal sex while intoxicated Q36. My ideal future partner would approve of me participating in: a. Oral sex while intoxicated b. Vaginal sex while intoxicated c. Anal sex while intoxicated Strongly Agree Strongly Disagree Motivation to Comply (Indirect Measures) Q37. When it comes to sexual behaviors while intoxicated, how motivated are you to meet the expectations of your: a. Close friends? b. Current partner? c. Ideal future partner? Strongly Agree Strongly Disagree Note: All anchors are on a seven point scale.

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73 Table 3 3 TP B perceived behavioral control direct and indirect m easures Construct Item Anchors Perceived Behavioral Control (Direct Measures) Q43a. I am confident that I can limit my alcohol consumption. Q43b. I can resist sexual pressures when drunk. when drunk. Strongly Agree Strongly Disagree Control Beliefs (Indirect Measures) Q34. What do you believe is the likelihood of your participations in the following behaviors while being intoxicated: a. Use a condom or other barrier method during vaginal sex. b. Use a condom or other barrier metho d during anal sex. c. Getting tested for sexually transmitted infections. d. Consider your use of contraceptives. e. Consider your chance of contracting a sexually transmitted infection. f. Consider the financial costs associated with an unplanned pregnancy. Extremely Likely Extremely Unlikely Perceived Power (Indirect Measures) Q42a. Availability of free alcoholic drinks influences my decision to get drunk. Q42c. Availability of free alcoholic drinks influences my decision to participate in oral sex. Q42d. Availabi lity of free alcoholic drinks influences my decision to participate in vaginal sex. Q42e. Availability of free alcoholic drinks influences my decision to participate in anal sex. Q42f. The availability of a condom would influence my decision to have sex. Q42g. Pressures from sexual partners would influence my decision to have sex. Extremely Likely Extremely Unlikely Note: All anchors are on a seven point scale.

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74 Table 3 4 Cronbach and factor loading for each TPB construct across the three sexual behaviors Factor and scale Specific Behavior Loadings Oral Vaginal Anal Attitude towards behavior 0.84 0.83 0.82 Personal beliefs of participating in sexual behavior while intoxicated 0.79 0.81 0.77 I would have more fun if I got drunk and participated in the sexual behavior 0.81 0.79 0.82 My chances of participating in the sexual behavior would increase if I got drunk 0.82 0.77 0.84 When I drink I feel a greater desire to participate in the sexual behavior 0.77 0.80 0.79 behavior 0.83 0.84 0.81 Subjective Norm 0.56 0.56 0.54 Most people I hang out with would approve of me participating in the sexual behavior while intoxicated 0.60 0.64 0.67 The people in my life whom I value encourage me to participate in the sexual behavior while intoxicated 0.73 0.66 0.59 My close friends would approve of me participating in the sexual behavior while intoxicated 0.64 0.78 0.76 My ideal partner would approve of me participating in the sexual behavior while intoxicated 0.72 0.83 0.81 When it comes to sexual behaviors while intoxicated, how motivated are you to meet the expectations of your close friends 0.68 0.70 0.65 When it comes to sexual behaviors while intoxicated, how motivated are you to meet the expectations of your current partner 0.70 0.74 0.71 When it comes to sexual behaviors while intoxicated, how motivated are you to meet the expectations of your ideal future partner 0.58 0.63 0.62 Perceived behavioral control 0.17 0.46 0.31 Likelihood of barrier usage while being intoxicated 0.63 0.62 0.69 Consider contraceptive use while intoxicated 0.58 0.60 0.58 Consider STI transmission while intoxicated 0.62 0.62 0.59 Consider financial costs of unplanned pregnancy when intoxicated 0.58 0.56 0.56 Availability of free alcoholic drinks influences decision to participate in sexual behavior 0.56 0.57 0.61 All path variables = 0.83

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75 Table 3 5 Correlation matrix for oral sexual behavior s Constructs Mean SD Range A SN P I B Attitudes (A) 45.43 31.20 1 100 1.00 0.36 0.15 0.51 0.16 Social Norms (SN) 36.86 27.18 1 100 1.00 0.11 0.39 0.13 Perceived Control (P) 21.87 15.53 1 50 1.00 0.04 0.04 Intention (I) 5.51 1.96 1 7 1.00 0.34 Behavior (B) 4.52 8.04 0 60 1.00 Note: p < .01 Table 3 6 Correlation matrix for vaginal sexual behaviors Constructs Mean SD Range A SN P I B Attitudes (A) 44 85 30.91 1 100 1.00 0.35 0.22 0.51 0.16 Social Norms (SN) 3 7.88 27.17 1 100 1.00 0.22 0.39 0.16 Perceived Control (P) 13.44 14.75 1 50 1.00 0.07 0.06 Intention (I) 5.48 2.04 1 7 1.00 0.39 Behavior (B) 5.73 9.71 0 100 1.00 Note: p < .01 Table 3 7 Correlation matrix for anal sexual behaviors Constructs Mean SD Range A SN P I B Attitudes (A) 67.04 31.17 1 100 1.00 0.28 0.03 0.52 0.16 Social Norms (SN) 45.09 27.27 1 100 1.00 0.11 0.27 0.08 ** Perceived Control (P) 15.27 15.76 1 50 1.00 0.03 0.01 Intention (I) 6.49 1.21 1 7 1.00 0.29 Behavior (B) 0.29 2.52 0 50 1.00 Note: p < .01, ** p < .05

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76 Table 3 8 Absolute fit indices for each sexual behavior model 2 df p val ue GFI SRMSR Oral 391.89 10 0.00 1 1.000 0.002 Vaginal 319.55 10 0.001 1.000 0.000 Anal 352.70 6 0.001 1.000 0.002

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77 CHAPTER 4 IDENTIFYING THE TYPO LOGY OF SEXUAL RISK BEHAVIORS: AN APPLIC ATION OF A CLUSTER ANALYTI C TECHNIQUE Background Sexual behaviors and alcohol have a complex rela tionship. Alcohol a ffects cognitive function by impairing distal processing of behavioral consequences therefore an intoxicated individual is more influenced by immediate, and often less deleterious consequences. Thus, sexual activity with a new or casu al partner offers greater opportunities for danger than alcohol induced sexual activity with a steady partner 97 Alcohol can increase risky sexual behaviors in the early stages of a relationship because partner familiarity and contraceptives other than condoms play a larger role as relationships mature 62, 98 Corbin and Fromme found as trust between sexual partners increases the use of alternate forms of pregnancy prevention also increases 62 Sexual partners felt safe within their defined relationship though the majority of participants (66%) had been with their partner for less than 6 months. The majority of sexually active p articipants had never been tested for HIV and only 20% were in a monogamous 62 Numerou s studies have included measurements on relationship status and other aspects of sexual risk taking, but none have analyzed the specific effect of perceived relationship status on alcohol use and sexual activity intention 64 67 These findings have numerous public health implications. G reater attention should be focused on the application of contextual methods in data analysis to supplement contextual ideas (theories, models, and frameworks) to maximize efficiency and efficacy of behavioral interventions Researcher suggest s design interventions take into consideration the variation seen between target groups. 57, 91, 99, 100 Studies assessing

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78 the heterogeneity of sexual risk groups could aid in the design and application of screenin gs and interventions 101, 102 Cluster analysis is an exploratory technique that is useful in revealing unknown subtypes and un derstanding patterns and behavioral context 54 The statistical technique has been used to develop patterns within multivariate data of alcohol use and sexual risk behaviors 102 104 Using a cluster analytic strategy 103 the aim of this exploratory study is to identify the behavior specific typology of sexual risk taking among college s tudents. The researcher was designed to answer the following research questions: RQ1 : What is the sexual behavior typology of sexually active college students enrolled full time at a large southeastern university ? RQ2 : What are the sexual risk taking differences between the observed typology clusters? RQ3 : Among the observed clusters, are sexua l coercion and abuse, unplanned pregnancy, and sexually transmitted disease more or less prevalent? Methodology Participants and Procedures A total of 4 000 participants, aged 18 24 were randomly selected by the registrar and requested by the researcher to participate in the study A total of 832 students participated for a 20.8% response rate. All participants were notified via e mail, to visit the online survey. Over the course of the study, they receive d three additional email reminders to log on and complete the survey. Participants were required to read an informed consent message prior to t aking the survey, whi ch included instructions. Their IP addresses, names and e mails were not collected in order to ensure anonymity. Participants were notified of their right to discontinue the questionnaire at any point without retribution. Upon completion of the survey, the y were directed to an exit page

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79 with local alcohol, sexual health, and mental health resources as well as the option to be re directed to an incentive page. The separate page allowed participants to enter their contact information should they be interested in being considered for the incentive. Only the first two and last two respondents were selected to receive a $50 gift card. Measurements The instrument is designed to assess attitudes and behaviors associated with sexual risk taking in the college stude nt population. It was the aim of the research to assess the spectrum of sexual behaviors, thus each item included the participation of each sexual behavior (digital, oral, vaginal, and anal sex) while intoxicated. Additional behavior items assessed alcohol use, relationship status, and consequences related to sexual activity. Previous research has found relationship status strongly affects sexual risk taking in general 33, 60 62 Surra et al. found most research focusing on the college population did not assess specific features of relationship status. 63 Fur ther research in sexual risk taking needs to include a more thorough assessment specific of perceived relationship status. Numerou s studies have included measurements on relationship status and other aspects of sexual risk taking, but none have analyzed th e specific effect of perceived relationship status on alcohol use and sexual activity intention 64 67 The term sexual assault includes both sexual contact (fondling) and sexual penetration (rape). However, when forced digital penetration is the only complaint, a medical legal examination cannot be performed 69, 70 This is based on decades old research identifying rape victims by pregn ancy, syphilis or gonorrhea diagnosis, ignoring other physical or psychological trauma. Reports of digital genital contact during sexual assault range from 26% to 55% 71 74 Rossman and colleagues conducted a

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80 retrospective study documenting the frequency and type of genital injuries in women who solely reported forced digital penetration 72 During the 3 year span, 941 sexual assault case files were reviewed. Fifty three cases solely experienced forced digital penetration or manipulation. Of this group, 81% pr esented genital injuries with a mean of 2.4 injuries per patient. Further research is needed to understand digital behaviors so as to best dictate policy. Little is known about the behavioral norm, such as if it is more likely to occur with other risk beha viors. Even less is known about digital behaviors among college students. Another behavior of interest is oral sex, which refers to sexual activity involving cunnilingus 51 For several reasons, oral sex can be a preferred form of sexual expression for adolescents and young adults. The behavior cannot produce an unwanted pregnancy, which is often the central focus of their concerns about sexual risks 75 In some situations, oral sex may be preferred because it is perceived to involve less intimacy than intercourse 64 In addition, some studies have found that oral sex is not judged to be a form of sexual activity at all, thus allowing parti cipants to view themselves as not being sexually active 75, 76 Anal sex is another behavior of interest to this study. I t is a behavior that is not often assessed in sexual risk surveys even though it is the most efficient route for HIV transmission 10 Between 20 25% of college aged adults have participated in anal sex behaviors 10 12, 77 Research also suggests those who participate in anal sex are more likely to participate in other risk behaviors 10 Thus further investigation of these specific be haviors is warranted.

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81 Analysis Data was entered and analyzed in R statistical software package version 2.9.2 Each survey item was coded numerically to facilitate analysis. Participant demographics were compared to a national sample of college students from the American College National College Health Assessment II (ACHA NCHA II) 5 Among the r espondents, the mean age was 20 (sd = 1.38 ) and a majority were female ( 67.5 %), similar to the student body profile at the host institution. About 75 % described t hemselves as white, 8.6% as African American and 17.5 % defined their ethnicity as Hispanic. The majority described their sexual orientat ion as heterosexual (92.1 %). Study participants were asked to explain their current relationship status. Results indicat ed that 43.7 % were in an exclusive, monogamous relationship and 4.1 % considered themselves to be in an open relationship where they were free to see other people (non monogamous ), 9.5 % considered themselves openly dating yet not in volved in a relationship, and 35.4 % considered themselves neither dating nor in a relationship. Study participants were compared to a national sample of college students from the 2010 National College Health Asse ssment II (Table 3 1) 5 The study sample composition is quite similar to that of the national sample of American college students though s ome risk behaviors seem to be slightly higher among the study sample Results Cluster Analysis Cluster analyses were performed to group participants bas ed on the following sexual risk variables: number of times respondents participated in digital sex, ora l sex, vaginal sex, and anal sex; number of sex partners in the past 30 days; alcohol use in the past 30 days; heavy episodic drinking in the past 2 weeks; frequency of condom or

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82 barrier method used during oral, vaginal, and anal sex; and frequency of STI testi ng and contraceptive use. Using several clustering algorithms means, Expectation Maximization) the Bayesian Information Criterion (BIC) was applied as a clustering criterion to determine the best algorithm and number of clusters The larger the value of the BIC, the stronger the evidence for the model as found in these results (BIC = 20,808) 105 It is important to note that each cluster algorithm produce s different cluster solutions, as found in other research using clustering algorithms across various subject matter s 104, 106, 107 For each analysis the squared Euclidean distance coefficient was used as the measurement of proximity. Th e variables were standardized b y transforming them to Z scores means were each found to produce simple, two cluster solutions between participation in high risk versus low risk sexual behaviors. In contrast, the Expectation Maximization (EM) algorithm distinguished a more sophisticated three group solution. EM is a model based method, where maximum likelihood criterion is used for merging groups 105 It is often used in collaborative filtering for information recommendation systems, such as those employed by websites which provide predictive mu sic or book recommendations based upon user information 108 110 Th e EM clustering algorithm has three main limitations which must be noted and addressed 105 First, the convergence rate can be slow if the variables are not well separated with reasonable values. Second, the algorithm may not be practical for models with very large numbers of components. Finally, t he algorithm will not proceed if clusters contain only a few observations or if the observations they contain are nearly

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83 collinear. Thus, a listwise deletion of cases with missing values was performed resulting in 492 cases in the cluster analysis This i s sufficiently small to avoid the first EM limitation but large enough for statistical power. A total of 2 2 clustering components or variables were used in the study thus avoiding the second limitation of EM In addition, c areful attention was paid to the removal of outliers in order to address the third algorithm limitation Clusters with very few elements were analyzed and those with extreme responses were removed. Upon removal of the outlier, the model based clustering algorithm was re run. The process was repeated until three outliers were removed and cluster groupings stabilized. The results were three distinct cluster solutions, which were then selected for further analysis. Since the clusters were created by maximizing differences between group means, testing for the difference s using ANOVA would be irrelevant. Instead, a permutation test was applied to assess statistical significance via randomization and re evaluation of the Kruskal Wallis (KW) test statistic As the variables had been standard ized via z scores they were uniformly scaled and allowed the permutation of responses per case. In other words, each case included the same responses but they were shuffled to a different variable. The model based clustering algorithm was run again, forcin g a three cluster solution and continued to be permutated and re clustered in order to assess the distribution of all possible 3 cluster solutions for the dataset. A total of 1000 permutations created 1000 KW statistics for each of the 2 2 clustering varia ble questions and compared to the original KW statistic ; resulting in descriptive variable profiles. Refer to table 4 2 for the full list of clustering variable profiles

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84 From the table it can be seen only 14 of the 22 variables were significant at the .0 5 level The only sexual behavior item found to be insignificant was the proportion of times the respondent used a condom during vaginal sex. Upon closer inspection it was revealed there are high levels of condom usage in the low risk group, as it can be e xpected. However, the middle and high risk groups are not clearly delineated on this item, thus it was found to be insignificant. Relationship status may play an important role in vaginal condom usage and should be further explored following the discrimina nt analysis. N either alcohol cons umption, nor the items assessing likelihood of condom usage while intoxicated were found to be significant. A possible explanation may be found investigating the variance. Sexual behavior items included higher variances than the alcohol items and may be due to the difference in scale. The alcohol consumption measures were categorically scaled and the items asse ssing likelihood of condom usage while intoxicated were based on a seven point semantic scale. In contrast, the sexual behavior items allowed the user to enter a numerical response. T he first cluster comprised of 87.6 % of the cases (431 respondents) and w as labeled as low risk takers. This group is characterized by less frequency of sexual activity (digital, oral, vaginal, anal) and fewer sexual partners The second group was identified as medium risk takers (n=42). Distinguishing features of this group in cluded higher frequency of digital, oral, and vaginal sex activity, but with relatively few partners. In addition, this group is characterized by higher contraceptive use during their last sexual experience. The third group was labeled high risk takers (n =19). This group was distinguished from the other two groups by greater numbers of sexual partners, less

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85 condom usage, and greater frequency of anal sex activity, a highly risky sexual behavior 10 Discriminant Analysis A multiple discriminant function analysis was conducted to test the validity of the cluster solution 111 This analysis included variabl es not used in the cluster analyses that best discriminate between the clusters and aid in determining their ability to predict cluster membership 54 The aim was to create linear functions of the discriminating variables that separa te the observations into their respective clusters by comparing between and within group differences The discriminating variables include: race; age; gender; relationship status; history of sexually transmitted infections (self or partner); unwanted preg nancy (self or partner); experience with coercion or abuse; experience with unprotected sex due to drinking; and sex without giving or receiving consent due to drinking (self or partner). The demographic and psychographic variables were chosen due to their practical support as covariates of sexual risk taking consequences. Due to a listwise deletion of 25 cases with missing values, 467 cases were included in the discriminant analysis. Table 4 3 presents the results of the discriminant analysis and show s both discriminant functions were statistically significant ( p < .05). An examination of the group centroids (scatter plot locations representing the typical position of each group not shown here) revealed that Function 1 clearly separated the low risk ta kers from the medium risk takers whereas Function 2 distinguished the high risk takers from the medium risk takers The structure coefficients of the discriminating variables also appear in Table 4 3. On Function 1, sexual penetration without consent (st ructure coefficient = 1.628) was Proposed Risk Groups Proposed Risk Groups

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86 found to be most effective at distinguishing the low risk takers from the medium risk takers, followed by involvement in a physically abusive relationship (structure coefficient = 1.253), participation in sexual activity wh ile intoxicated without giving consent (structure coefficient = 1.030), exclusive relationship status (structure coefficient = 0.993), testing for STIs within the past 12 months (structure coefficient = 0.950) being sexually touched without consent (str ucture coefficient = 0.761), unplanned pregnancy (structure coefficient = 0.749 ), open relationship status (structure coefficient = 0.725), gender (structure coefficient = 0.676), Latino ethnicity (structure coefficient = 0.623), participation in unprote cted sex while intoxicated (structure coefficient = 0.498), victim of attempted sexual penetration (structure coefficient = 0.493) and participation in sexual activity while intoxicated without getting consent from their partner (structure coefficient = 0 .390). The remaining discriminating variables had structure coefficients less than 0.3000, and thus were considered unimportant to the interpretation of Function 1. In order to better under the discriminant analysis, the researcher consulted group means al ong with the structure coefficients to draw final conclusions. Thus, compared to the medium risk takers, the low risk takers were more likely to be in a committed exclusive relationship, more likely to be tested for STIs within the past 12 months, less l ikely to have an unplanned pregnancy, and less likely to be a victim of or participate in coercion and abuse. The low risk group was also more likely to be female, while the medium risk group was more likely to identify their ethnicity as Hispanic. On Func tion 2, participation in sexual activity while intoxicated without getting consent (structure coefficient = 3.096) and without giving consent (structure coefficient = 2.924 ), along with penetration without consent (structure coefficient = 2.521) were

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87 foun d to be most effective at distinguishing the high risk takers from the medium risk takers. This was followed by physically and sexually abusive relationships (structure coefficients 1.293 and 1.241, respectively) unprotected sex while intoxicated (structure coefficient = 1.148), unplanned pregnancy (structure coefficient = 0.925), STI testing within the past 6 months (structure coefficient = 0.896), gender (structure coefficient = 0.871), attempted sexual penet ration (structure coefficient = 0.734), Hispanic (structure coefficient =0.683), and casually dating, but not in an exclusive relationship ( structure coefficient = 0.536) Thus, compared to the medium risk takers, the high risk takers were more likely to participate in sexual activity without giving or getting consent, more likely to be in a physically or sexually abusive relationship, more likely to have unprotected sex while intoxicated and have an unplanned pregnancy but less likely to have been teste d for an STI within the past 6 months or been a victim of attempted sexual penetration. The high risk group was also more likely to be casually dating without exclusivity, of the male gender, and Hispanic, than when being compared to the medium risk group. The classification results of the discriminant analysis also appear in Table 4 3. In classifying these cases, prior probabilities were used to determine group membership. Overall, the 20 discriminating variables correctly classified 87% of the respondents into the three risk groups. The variables were most effective in correctly classifying the low risk takers ( 91.9 %) and least effective in classifying the high risk takers (15.8 %). Discussion Sexual behaviors among college students are multidimensional and may include various co existing factors such as dating behaviors and alcohol intoxication Current research fails to capture the spectrum of specific sexual behaviors (digital, oral, vaginal,

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88 anal) and neglects the association of other behaviors such as a lcohol use and relationship status By understanding the hete rogeneity of sexual risk groups, public health screenings and interventions can be better designed and implemented to fully 101, 102 Using a cluster analytic strategy 103 this exploratory study identified the behavioral heterogeneity of specific sexual behaviors and described ways in which these patterns were associated with sexual risk taking. Cluster analyses revealed 3 distinct groups in the behavior specific typology of sexual risk taking among college stu dents. Members of the low risk group were more likely to b e in an exclusive relationship and thus reported the least number of sexual partners, less frequency of sexual activity, less condom/barrier or contraceptive usage and were least likely t o be a vic tim of coercion/abuse. Though the medium risk group had higher frequencies of sexual activity, it was characteriz ed by more protective behaviors, such as higher proportion of condom/barrier usage and less frequency of partners than the higher risk group. T hey were also more likely to be in an open relationship where they are free to see other people, whereas the high risk group was primarily composed of those casually dating, but not in a relationship. t themselves from sexual risk These exploratory results lend further evidence towards the importance of relationship status in sexual risk taking behaviors. In addition, cheati behavior may provide further dimensionality in relationship status and the sexual risk behaviors of college students. Further consideration of the measure and scope of risk variables are needed in future research.

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89 Hypothetically, results would have implications for surveillance, screening, interventions, and possibly policy development at the local or school level. Interventions to promote risk reduction may need adaptation for those with differing sexual behavior p rofiles. In addition, social norm campaigns aimed at heavy episodic drinking should focus on non monogamous relationships, initial sexual activity and should address the A cluster analytic technique could be applied to screen patients at Student Health Care Centers or provide real time sexual health recommendations, similar to the recommendations when shopping on Amazon. As technology improves, so should applicable statistical techniques and tailored interventions, so as to best reach the target population. Limitations Several limitations of the proposed study limit interpret ation of the possible findings, such as the study relies solely on self report measure ment s However, Hamilton and Morris asses sed the consistency of reported sexual partners and found the mode of survey administration (phone, face to face interviews, self administered questionnaires) did not influence disclosure 112 In addition, the researcher in the present study sought to remind participants at every step their responses were anonymous. Another limitation to note is t he cross sectional study design which prevents conclusions about the causal relationships among the variables and does not follow participants longi tudinally to view personally normative behaviors. T he behavioral measurements were limited to assessing prevalence within the past 30 days As b ehavioral consequences occur infrequently specific experiences may not be captured by the recall questions 59 The results, however, seem to be consistent with studies relying on within subjects analyses of event level and daily report data 47, 62, 113 115

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90 T he results of this study may not be transferred to campuses without a similar environment and social scene. For the development of interventions and application of this data, a more ecological approach will need to be applied to further understand the intr icacies of these behaviors. Though caution must be applied in generalizing the results, the proposed study would provide a comprehensive description of the sexual risk behaviors of college students and aid in addressing the gap o f the knowledge base.

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91 Tabl e 4 1. Comparison of study sample and the National College Health Assessment II Sample Current Study (n = 832) ACHA NCHA II (n = 30,093) Participation at least once within the past 30 days Oral 48.0 % 41.7 % Vaginal 47.6 % 45.4 % Anal 6.3 % 4.7 % Number of drinks consumed 0 23.6 % 32.6 % 1 2 28.0 % 19.6 % 3 4 20.9 % 18.4 % 5 6 15.5 % 13.3 % 7 8 5.5 % 6.8 % 9 or more 6.5 % 9.3 % Consumed 5 or more drinks in a sitting during the last 2 weeks 26.0% 26.8 % None 26.5 % 40.6 % 1 2 times 23.5 % 21.0 % 3 5 times 9.2 % 9.1 % 6 or more times 4.8 % 2.6 % Experienced the following within the past 12 months, as a consequence of their drinking Sex without giving consent 2.9 % 1.5 % Sex without getting consent 1.1 % 0.4 % Unprotected sex 17.5 % 11.6 % Experienced without consent during the past 12 months: Sexually touched 9.9 % 5.9 % Attempted sexual penetration 5.9 % 2.3 % Sexually penetrated 3.3 % 1.5 % Intimate relationship that was (past 12 months) Emotionally abusive 9.8 % 9.8 % Physically abusive 4.4 % 2.4 % Sexually abusive 2.6 % 1.6 % Data from ACHA NCHA II Fall 2010 Report 5

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92 Table 4 2 Variable p rofile for t hree c luster s olution Variable Mean and (Standard Deviation) Low risk takers n = 431 Medium risk takers n = 42 High risk takers n = 19 p value Frequency of digital sex activity 4.02 (6.26) 15.00 (14.63) 7.42 (9.22) 0.000* Frequency of oral sex activity 3.05 (5.05) 13.55 (12.67) 4.16 (3.50) 0.000* Frequency of vaginal sex activity 4.85 (7.07) 19.10 (13.57) 11.32 (13.63) 0.000* Frequency of anal sex activity 0.01 (0.10) 1.98 (4.76) 2.26 (3.54) 0.000* Number of partners digital sex 0.61 (0.64) 1.17 (0.85) 1.58 (1.61) 0.000* Number of partners oral sex 0.54 (0.57) 1.26 (1.04) 1.53 (1.61) 0.000* Number of partners vaginal sex 0.59 (0.62) 1.26 (0.99) 1.21 (1.58) 0.000* Number of partners anal sex 0.01 (0.10) 0.69 (0.52) 1.37 (2.45) 0.047* Proportion of condom/barrier usage digital sex 0.53 (0.50) 0.93 (0.26) 0.74 (0.45) 0.000* Proportion of condom/barrier usage oral sex 0.47 (0.49) 1.00 (0.01) 0.58 (0.51) 0.000* Proportion of condom/barrier usage vaginal sex 0.20 (0.37) 0.61 (0.42) 0.24 (0.38) 0.200 Proportion of condom/barrier usage anal sex 0.00 (0.00) 0.38 (0.48) 0.38 (0.47) 0.000* Contraceptive usage at last experience oral sex (No = 1, Yes = 2, N/A = 3) 1.80 (0.82) 2.45 (0.50) 2.47 (0.84) 0.000* Contraceptive usage at last experience vaginal sex (No = 1, Yes = 2, N/A = 3) 1.64 (0.64) 2.21 (0.42) 1.90 (0.74) 0.000* Contraceptive usage at last experience anal sex (No = 1, Yes = 2, N/A = 3) 1.10 (0.42) 1.88 (0.80) 1.90 (0.94) 0.005* Number of days consumed alcohol during past 30 days (Never =1, Not within past 30 days =2, 1 2days =3, 3 5 days =4, 6 9 days =5, 10 19 days =6, 20 29 days =7, Daily =8) 4.36 (1.12) 5.02 (1.47) 4.58 (1.12) 1.000 Frequency of heavy episodic drinking (Last 2 weeks 5 or more drinks ) (N/A =1, None =2, 1 time =3, 2 times =4, 3 times =5, 4 times =6, 5 times =7, 6 times =8, 7 times =9, 8 times =10, 9 times = 11, 10 or more =12) 3.50 (2.08) 4.07 (2.51) 4.58 (3.22) 1.000 Likelihood of condom/barrier usage while intoxicated during oral sex (Very likely =1 Very unlikely =7) 5.77 (1.83) 6.69 (0.75) 6.47 (1.12) 0.991 Likelihood of condom/barrier usage while intoxicated during vaginal sex (Very likely =1 Very unlikely =7) 2.66 (1.98) 3.95 (2.29) 3.21 (2.04) 1.000 Likelihood of condom/barrier usage while intoxicated during anal sex (Very likely =1 Very unlikely =7) 3.38 (2.48) 4.64 (2.34) 3.79 (2.39) 0.998 Likelihood of considering testing for Sexually Transmitted Infections while intoxicated (Very likely =1 Very unlikely =7) 4.80 (2.17) 4.88 (2.23) 5.21 (1.99) 1.000 Likelihood of considering condom/barrier usage while intoxicated (Very likely =1 Very unlikely =7) 2.85 (2.00) 3.00 (1.99 ) 3.26 (1.73) 1.000 Note: All measures within the past 30 days unless otherwise stated. denotes statistical significance at the .05 level

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93 Table 4 3 Multiple d iscriminant f unction a nalysis of t hree c luster g roups Function Eigenvalue % of Variance Canonical Correlation Lambda Chi Square df p 1 0.15 66.2 0.36 0.81 97.34 40 0.000 2 0.08 33.8 0.27 0.93 33.64 19 0.020 Structure Coefficients Discriminating Variable Function 1 Function 2 Exclusive relationship (no=0, yes =1) 0.993 0.131 Open relationship (no=0, yes =1) 0. 725 0. 062 Dating (no=0, yes =1) 0.165 0. 536 STI testing past 6 months (no=2, yes =1) 0.074 0.896 STI testing past 12 months (no=2, yes =1) 0.950 0.540 STI diagnosis ( 1 = no, 2 = yes for each of 8 common STIs ) 0.021 0.062 Unplanned pregnancy (no=1, yes =2, unsure = 3) 0.749 0.925 Emotionally abusive relationship (no=1, yes =2) 0.021 0.307 Physically abusive relationship (no=1, yes =2) 1.253 1.293 Sexually abusive relationship (no=1, yes =2) 0.068 1.241 Sexually touched without consent (no=1, yes =2) 0.761 0.422 Attempted sexual penetration (no=1, yes =2) 0.493 0.734 Sexually penetrated without consent (no=1, yes =2) 1.628 2.521 Sex while intoxicated without giving consent (no=1, yes=2) 1.030 2.924 Sex while intoxicated without getting consent (no=1, yes=2) 0.390 3.096 Unprotected sex while intoxicated (no=1, yes =2) 0.498 1.148 Age (under 21=1, over 21=2) 0.123 0.172 Gender (male=1, female =2) 0.676 0.871 Race (Caucasian=1, non Caucasian=2) 0.138 0.094 Hispanic/Latino (no=2, yes =1) 0.623 0.683 Classification Results Predicted Group Membership Actual Group Membership n Low risk takers Medium risk takers High risk takers Low risk 431 396 ( 91.9%) 94 (2.1%) 4 (0.9%) Medium risk 42 31 (73.8%) 8 (19.0%) 0 (0%) High risk 19 16 (84.2%) 0 (0%) 3 (15.8%) 87 %

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94 CHAPTER 5 IMPLICATION OF SEXUAL BEHAVIOR R ESEARCH Background Sexual behaviors, especially in combination with alcohol, can cause physical, emotional, and financial burdens. Oftentimes these behaviors result in Sexually Transmitted Infections (STIs), which remain a significant public health problem though it is largely unrecognized by the public, policymakers, and health care professionals 1 Despite the large amount of research into sexual behavior and alcohol use, there has been a lack of agreement as to the best way to measure and validate self reports of sexual behavior and alcohol use 7, 31 In addition, many instruments have been created to measure sexual behavior but few measure specific behaviors 7 If a study is conducted with inappropriate measure s or measures that are not sensitive to a certain sexual behavior, then such a study may reach inappropriate conclusions regarding the risk behavior. Noar, Cole, & Carlyle provide examples of this discrepancy as it related to condom use. 34 If a surveillance study is conducted assessing the percentage (proportional measure) of condom usage it does not take into account the frequency of sexual interc ourse. If the community under surveillance reduces their frequency of intercourse it may lower risk but the outcome would not be portrayed by the proportional measure. Thus accurate behavior measurement is critical for a positive public health and policy i mpact. The aim of this study was the examination of specific sexual behaviors and the role of alcohol use on the intention to participate in these behaviors. The specific purposes were three fold : 1) to develop a survey instrument using both qualitative and quantitative methods; 2) to apply the Theory of Planned Behavior to assess the

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95 perceptions, attitudes, prevalence and intentions of sexual risk taking behaviors among college students; 3) to identify the typology of sexual risk t aking among college students using a cluster analytic technique. Results Alcohol use and sexual activity is difficult to assess, but this study makes an exploratory effort into the development of measures specific to behavior and risk. The presented instru ment development process aids in addressing measurement and validation of self reported sexual behavior, which currently suffers from a lack of consensus in the literature 31, 59 In addition, the created instrument is the first to assess a spectrum of specific sexual health behavior, including digital, oral, vaginal, and anal sex b ehaviors and how they relate to alcohol intoxication. The applied eight step instrument development process provided explicit guidelines for mix modal analysis development. By reviewing the literature to identify relevant concepts of sexual behavior and alcohol use, 50 preliminary measures were cultivated to assess the specific sexual behaviors of erotic touch, digital, oral, vaginal, and anal sex These measures where then reviewed by a panel of experts, who recommended the removal of erotic touch behaviors as they were not risk related, resulting in the dele tion of sub questions from the behavior specific items. Three additional questions were created to address the consequences of specific sexual behaviors. Definitions were clarified, items reworded and skip patterns added. Fifty three questions were presen ted to the target population during the cognitive interviews. This information led to changes in response options readability, the creation of 3 screening questions and 4 sub questions relating to specific sexual behavior. Screen capture software has prev iously been used as a methodology assessing

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96 internet usage. 83, 84 Results of the present study prove it to be a cost effective, rich data collection technique for instrument development. The piloted instrument contained 56 questions assessing digital, oral, vaginal, and anal sexual behaviors and the role of alcohol in toxication in these behaviors. The factor analysis resulted in the removal of two measures across 3 sexual behaviors (total of six vaginal, anal) sex behaviors, how motivated are you to meet the expectations of your from the constructs Motivation to Comply and Perceived Behavioral Control. Another item was removed from further analyses a as part of Perceived Power but loaded on Control Beliefs. Exploratory factor loadings ranged from .56 to .84. Intern al consistency was demonstrated for the instrument overall ( = 0.83) and for each factor except Perceived Behavioral Control (oral sex = 0.17, vaginal sex = 0.46, anal sex = 0.31). Factor loadings and estimates of internal consistency are shown in Table 3 4. In addition to the elimination of questions with low factor loadings, the item assessing STI testing was revised to include both 6 month and 12 month sub items. During the pilot study, the total numbers of items were reduced from 56 to 49. The formal investigation of the 49 items was conducted with an additional sample 4000 students. Survey methodology remained the same except for one notable difference; the use of an incentive. By offering participants the opportunity to receive one of four

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97 $50 gift cards, the response rate increased 3%. Additional psychometric testing of the instrument is presented in a series of substantive papers (Chapters 3 and 4). The Theory of Planned Behavior was applied to both predict and explain the health behaviors, a s well as to guide the formatting and structure of individual items. T he results showed Perceived Behavioral Control was not a significant predictor of intention to participate in specific sexual behaviors while intoxicated. However, perceived control was found to be a statistically significant when predicating vaginal sex behavior directly. A little over a quarter (27%) of the intention to participate in oral sex while intoxicated is accounted for by the constructs of Attitude, Norm, and Control Only 9% o f the variance in oral sex behavior participation while intoxicated is attributed to both Intention and the direct path of Perceived Control to Behavior. The vaginal sex path analysis again showed positive correlations between Attitudes, Norms, and Control However, in this model Perceived Control had a statistically significant direct path to Behavior. Yet the variance explained by the constructs was still quite low. Twenty eight percent of the variance of Intention is explained by the constructs of Attitu de, Norms and Control. Eleven percent of the variance of Behavior is explained by Intention and Control directly. Similarly, the anal sex model failed to find significance concerning the construct of Perceived Control. The variance explained by the constru cts was even lower than the other two models. Sixteen percent of the variance of Intention was explained by the constructs of Attitude, Norms, and Control. Only 1% of the variance of anal sex while intoxicated was explained by Intention and Control.

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98 The results of the path analysis lead the researcher to question the design of the measures or the applicability of the theory. The measures may not be well developed as there is high variance among the Control construct. Also, the TPB may not be a good fit a s the physiological effects of alcohol may influence physical control over sexual behaviors as well as perceived control. The c luster analysis revealed 3 distinct groups in the college student sample behavior specific typology of sexual risk taking among college students. Members of the low risk group were more likely to be in an exclusive relationship and thus reported the least number of sexual partners, less frequency of sexual activity, less condom/barrier or contraceptive usage, and were least likely to be a victim of coercion/abuse. Though the medium risk group had higher frequencies of sexual activity, it was characterized by more protective behaviors, such as higher proportion of condom/barrier usage and less frequency of partners than the higher ri sk group. They were also more likely to be in an open relationship where they are free to see other people, whereas the high risk group was primarily composed of those casually dating, but not in a relationship. Compared to the medium risk takers, the high 0risk takers were more likely to participate in sexual activity without giving or getting consent, more likely to be in a physically or sexually abusive relationship, more likely to have unprotected sex while intoxicated and have an unplanned pregnancy, bu t less likely to have been tested for an STI within the past 6 months or been a victim of attempted sexual penetration. Overall, the variables correctly classified 87% of the respondents into the three risk groups. These results may indicate an individual

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99 exploratory results lend further evidence towards the importance of relationship status in sexual risk taking behaviors. behavior may provide further dimensionality in relationship status and the sexual risk behaviors of college students. Further consideration of the measure and scope of risk variables are needed in future research. Limitations Caution must be applied in generalizing the results of this study to a broader college student sample. The present study focuses on traditional aged college students who attend a 4 year institution. Though the sampled population was similar in demographic nature to the university population (Table 2 1) d emographic variations of the student respondents may have influenced the results of the study. The results may not be transferred to campuses witho ut a similar environment and social scene. The sampled university has a vibrant athletic community and thriving night life close to the campus. The environment students face include close proximity to drinking establishments, regularly occurring drink spec ials, social events, sporting events, and an abundance of house parties. In addition the data collection was conducted during a specific amount of time and thus does not follow respondents longitudinally to view personally normative behaviors. The self re port nature of the data collection limits the ability of the researcher to determine the extent of over and under reporting behaviors A major criticism of path analysis is its improper use of linear regression to find causal relationships t hough the main goal of regression is correlation, not causation. In addition, the underlying Theory of Planned Behavior is used to determine the linear combinations of variables that compose the constructs. Thus, path analysis relies

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100 heavily on the underly ing theory and if the theory is flawed, the analysis is irrelevant. Further investigation must occur on the application of the TPB and the intention to participate in specific sexual behaviors while intoxicated. Implications Public health promotion initia tives are successful when they move beyond knowledge of protective factors. In order for positive behavior changes to occur, multiple efforts need to be made outside of personal behavior and knowledge. This is especially true among the inter dependent beha viors of alcohol use and sexual activity. An ecological perspective emphasizes the interaction between and interdependence of factors within and across all levels of problem behaviors 94 By applying an ecological perspecti socio cultural environments. Ecological Model Intervention points are indentified via two key concepts of the ecological perspective: the interactive behavioral effects of mu ltiple layers of influence and reciprocal causation where the individual both shapes and is shaped by the social environment 39, 94 The concept of multiple layers of influence was identified by McLeroy and colleagues to systematically guide interventions 116 The five levels of inf luence of the Ecological Model are intrapersonal, interpersonal, organization, community and public policy. Figure 5 1 provides a visual representation of the model and influence levels. The following sect ions i dentify levels of analysis within the ecologi cal model, as it applies to specific sexual risk behaviors among college students and the results presented in this study

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101 Figure 5 1. The Ecological Model Intrapersonal Intrapersonal factors are those items relating to the individual, such as demographics and psychological characteristics 39 Health education is a core component of intrapersonal behavior change s. However, for lasting changes to occur, the individual must possess more than just knowledge. They must also possess the skills necessary to amend behavior. The results of this study provided a glimpse into the attitude, perceptions, and beliefs of speci fic sexual behaviors among college students. Special attention was paid to these psychological characteristics while under the influence of alcohol. Future interventions addressing intrapersonal factors of alcohol use and sexual behavior should provide rea l time informati on, tailored to the individual. For example, the development of a college based sexual risk app lication (app) for cell phones or tablets (iPhone A ndroid etc ) w ould allow instant resources to be catered Public Policy Community Organization Interpersonal Intrapersonal

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102 situational ne eds The cluster analytic technique presented in this study may be applied in the development of tailored information as the presented results proved to be applicable and effective in public health issues. The statistical algorithm may be used to quickly a ddress intrapersonal factors such as age and gender, as they relate to risky sexual behaviors, resulting in tailored information and resources. Interpersonal The interpersonal level of the model relates to the physical environment and social network of the individual 39 Sexual behaviors are interpersonal by nature, where relationships, social networks, social identity, support and role definition. friends attitudes and beliefs concerning their participation in specific sexual risk behaviors will help shape their intention and participation in those behaviors. These behaviors often co occur with alcohol intoxication, thus it is important to analyze and address these behaviors as well. Since social norm plays a role in the acceptability of the sexual behaviors, pee r educations programs would be viable intervention options for this level. By providing a safe, confidential environment with trained peers, a college student may be more comfortable to reveal the extent of their risk taking. It is important to note the cr itical importance of including the topic of relationship status within this level of the ecological model. Couples peer counseling, school sponsored safe date nights, and partner communication workshops would all be viable interventions to consider when ad dressing college student romantic relationships.

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103 Organization The organizational level is characterized by commercial organizations, social institutions, associations, and clubs with r ules, regulations, policies, and informal structures 39 Prevention interventions at the university level could include pre enrollment requirement s of educational modules highlighting the conse quences of sexual risk taking behaviors as well as local resources Moving beyond knowledge, we acknowledge r esources in the institutional environment can help or hinder eng agement in sexual behaviors. For example, a university may provide condoms for thei r students but fail to provide adequate access or discussion of contraceptive options. University level policies provide guidance and structure for prevention and guidance of behavior reporting. When assessing sexual risk it is exceptionally important to i nclude interventions targeting co occurring behaviors such as drug and alcohol abuse. Campuses with medical forgiveness policies allow students to feel comfortable in seeking treatment for life threatening consequences of drug and alcohol abuse. Sexual ass ault is often a co occurring behavior and thus specific school policies should be instituted to include follow Community The community is a broader level of the university environment as it also includes surround areas. The community is both physical as well as functional and includes standards among groups and social network norms 39 For example, the social environment of the university lends itself to a their peers as consuming alcohol, drugs and par ticipating in sexual activity. The effective to drink and easier for those under 21. Students then move to area clubs and bars to

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104 possibly meet a romantic partner and continue dri nking Sexual behaviors can range from erotic touch, to digital, oral, vaginal, and anal sex. To address this risk environment the availability and accessibility of resources at the community level becomes critical C ity level policies and resources should be in agreement and provide a unified front to meet the high risk takers in the environment where these behaviors occur. For example, the local student bus system could prevent alcohol related accidents by providing night service between campus, popular s tudent housing, and local drinking establishments. These buses could provide free condoms, information about local resources and social marketing campaigns targeting sexual risk behaviors. Public Policy Local, state, and federal policies and laws encompas s the level of public policy in the ecological model 39 This level can provide greater reach and accessibility to resour ces or the establishment of laws against sexual risk behaviors such as alcohol use and the sexually related consequences of intoxication The term sexual assault includes both sexual contact (fondling) and sexual penetration (rape). However, when forced di gital penetration is the only complaint, a medical legal examination cannot be performed 69, 70 Policy is based on decades old research identifying rape victims by pregnancy, syphilis or gonorrhea diagnosis, ignoring other physical or psychological trauma. Results of the current study provide insight and policy need as digital sex behaviors were more likel y to occur with other risk behaviors such as an increased number of sexual partners and alcohol intoxication Conclusions Oftentimes, it can be challenging to operationalize and apply the ecological model to health behavior change However, the current st udy aids to specifically define the

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105 interacting behaviors in order to better understand intrapersonal, interpersonal, and environmental factors associated with sexual behaviors of college students. Further research should focus on continued development of the measures and specific properties of the 49 item instrument. The exploratory instrument should be applied with other college student populations. In addition, consideration should be placed on the possibility of additional risk behaviors or measures to be added in order to better describe these public health perils. Perhaps the Theory of Reasoned Action, which does not include the perceived behavioral control path, would be better a better suited theory for these risk behaviors. In addition, the explorat ory instrument should be applied with other college student populations. Consideration should also be placed on the possibility of additional risk behaviors or measures to be added in order to better describe these public health perils. The researcher als o suggests continued review into the applied instrument development process as newer technologies and techniques are developed and assessed. For the development of interventions and application of this data, a more ecological approach will need to be appli ed to further understand the intricacies of these behaviors. Though caution must be applied in generalizing the results, the proposed study would provide a comprehensive description of the sexual risk behaviors of college students and aid in addressing the gap o f the knowledge base.

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106 APPENDIX A COGNITIVE INTERVIEW CONSENT Cognitive Interview : Sexuality and Alcohol Survey Consent Purpose of the study: The purpose of this study is to explore behaviors and beliefs related to sexual behavior and alcohol consumption in undergraduate students at UF. Specifically, for this portion we will assess the questionnaire and how the participants will understand the q uestion. What you will be asked to do in the study: If you agree to participate, you will be asked to respond to a 48 item (with multiple sub items) online questionnaire. The one time only survey assesses demographic characteristics such as age, sex, and race/ethnicity as well as behaviors and beliefs regarding sexual behavior and alcohol consumption. You do not have to answer any question you do not wish to answer. You will not be penalized in any way for refusing to respond to the survey. The voice and screen capture program is being used to insure that we fully capture all comments. The recordings will be analyzed and then destroyed; at that point, your responses will be completely anonymous. Time required: Approximately 30 50 minutes (one time only). Incentive: No compensation will be provided for your participation. Risks: There are no anticipated risks for participating in this study. Benefits: You may benefit from learning about sexual risk taking behaviors. In addition, you will be presented wi th local alcohol, sexual health, and mental health resources at the end of the survey. Confidentiality and Anonymity: The recordings will be analyzed and then destroyed; at that point, your responses will be completely anonymous. You will not be asked to provide any information that can identify you. There is no way to connect you to your responses. Your email or IP address will not be collected for any reason. Voluntary participation: Your participation in this study is completely voluntary. You have the right to withdraw from the study at anytime without consequence. You do not have to answer any question you do not wish to answer. Whom to contact if you have questions about the study: Principle Investiga tor: Monica C. Webb, MPH, CHES, Doctoral Candidate Department of Health Education and Behavior, University of Florida, Room 69, Florida Gym, PO Box 118210, Gainesville, FL 32611 8210, (352) 392 0583 ext. 1254, webbm@hhp.ufl.edu Faculty Supervisor: William Chen, PhD, Professor, Department of Health Education and Behavior, University of Florida, Room 6, Florida Gym, PO Box 118210, Gainesville, FL 32611 8210, (352) 392 0583 ext. 1284, chen0724@hhp.ufl.edu Whom to contact about your rights as a researc h participant in the study: UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611 2250; (352) 392 0433 Your consent to participate in this study will be implied by continuing to the next page and completing this survey.

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107 APPENDIX B COGNITIVE INTERVIEW QUESTIONS Hypothetically go through the survey and verbally discuss your thought process when answering the survey questions. Do not provide any identifying information such as your name or email. Do not answer the questions on the survey, instead provide are correct) and answer the questions below. Yo u do not have answer any question you find objectionable and you may leave at any time. Once you are ready to begin, review the following questions and proceed to the provid e YOUR answers to the survey questions but instead focus on the questions below. 1. Do you understand the definitions: a. One drink of alcohol b. drunk c. Sexually Transmitted Disease d. digital sex e. oral sex f. vaginal sex g. anal sex 2. Do you understand what the question is as king? 3. It is easy to recall the behavior in question? 4. It is difficult to recall the information because the behaviors are difficult to distinguish? 5. Does the question clearly describe the format of the answer? 6. Are the answer choices clear? 7. Does the question ask information you already have? 8. Does the design of the response alternatives affect the way you decide to answer? 9. Do you feel you need to edit your answer to satisfy personal and societal pressures?

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108 APPENDIX C STUDENT EMAIL CONTACT Initial Ema il Subject: UF Sex & Alcohol Survey Dear UF Student, I am a UF doctoral student and I am writing to ask for your participation in a Sexuality and Alcohol Survey The purpose of this study is to explore the attitudes and beliefs regarding sexual behavior and alcohol consumption in undergraduate students at UF. This survey is being conducted to better address your health needs. to participate in this survey, your answers will be completely anonymous No personal identification (IP address, names, emails, etc.) will be collected and thus you will not be connected to your answers in any way. The first two and last two participants will each receive a $50 Visa gift card If you wish to be considered for the incentive you will be sent to an additional screen, separate from the survey, where you can enter your contact information. Your information will not be linked to the survey, it is completely separate To receive the gift card you must pick it up in room 6 of the Florida Gym. The survey is only available for two weeks so please act quickly. When you are ready to complete this 30 50 minute survey, please click on the following link: http://www.zoomerang.com/Survey/WEB22BX4H8BXET/ Thank you very much for helping us better understand the sexual behavior and alcohol consumption of UF undergraduates. If you have any questions or comments about this survey, please feel free to contact me at (352) 392 0583 x. 1254 or by replying to this email. If you wish to be removed from future notifications please reply with unsubscribe in the subject line. Thank you for your help and Go Gators! Sincerely, Monica C. Webb Monica C. Webb, MPH, CHES Doctoral Candidate Department of Health Education and Behavior University of Florida P.O. Box 118210, FLG 5 Gainesville, FL 32611 8210 Phone: 352.392.0583 ext. 1254 Fax: 352.392.1909 E mail: webbm@hhp.ufl.edu

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109 Reminder Email Subject: 2 nd Notice: Sex & Alcohol Survey Dear UF Student, Last week, I emaile d you introducing myself and asking for your participation in a Sexuality and Alcohol Survey If you have already completed and returned the questionnaire, please accept my sincere thanks. If not, I urge you to please consider doing so today. Your opinions are very important as it identifies the attitudes and beliefs regarding sexual behavior and alcohol consumption in UF undergraduates. As a fellow UF student I am grateful for your help. If you choose to participate in this survey your answers will be completely anonymous No personal identification (IP address, names, emails, etc.) will be coll ected and thus you will not be connected to your answers in any way. The first two and last two participants will each receive a $50 Visa gift card If you wish to be considered for the incentive you will be sent to an additional screen, separate from the survey, where you can enter your contact information. Your information will not be linked to the survey, it is completely separate To receive the gift card you must pick it up in room 6 of the Florida Gym. When you are ready to complete this 30 50 minute survey, please click on the following link: http://www.zoomerang.com/Survey/WEB22BX 4H8BXET/ The survey is only available for a few more days so please act quickly. If you have any questions or comments about this survey, please feel free to contact me at (352) 392 0583 x. 1254 or by replying to this email. If you wish to be removed fro m future notifications please reply with unsubscribe in the subject line. Once again thank you for your help! Sincerely, Monica C. Webb Monica C. Webb, MPH, CHES Doctoral Candidate Department of Health Education and Behavior University of Florida P.O Box 118210, FLG 5 Gainesville, FL 32611 8210 Phone: 352.392.0583 ext. 1254 Fax: 352.392.1909 E mail: webbm@hhp.ufl.edu

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110 Final Reminder Subject: Last Opportunity: Sex & Alcohol Anonymous Survey Dear UF Student, Previously, I emailed you introducing myself and asking for your participation in a Sexuality and Alcohol Survey I am a doctoral candidate in the College of Health and Human Performance and the anonymous survey is part of my dissertation research. If you have already completed and returned the questionnaire, please accept my sincere thanks If not, I urge you to please consider doing so today. Your opinions are very important as it identifies the attitudes and beliefs regarding sexual behavior and a lcohol consumption in UF undergraduates. As a fellow UF student I am grateful for your help. If you choose to participate in this survey your answers will be completely anonymous No personal identification (IP address, names, emails, etc.) will be collec ted and thus you will not be connected to your answers in any way. The first two and last two participants will each receive a $50 Visa gift card If you wish to be considered for the incentive you will be sent to an additional screen, separate from the survey, where you can enter your contact information. Your information will not be linked to the survey, it is completely separate To receive the gift card you must pick it up in room 6 of the Florida Gym. When you are ready to complete this 30 50 minut e survey, please click on the following link: http://www.zoomerang.com/Survey/WEB22BX4H8BXET/ The survey is only available for a few more days so please act quickly. If you have any questions or comments about this survey, please feel free to contact me at (352) 392 0583 x. 1254 or by replying to this email. If you wish to be removed from future notifications please reply with unsubscribe in the subject line. Once again thank you for your hel p! Sincerely, Monica C. Webb Monica C. Webb, MPH, CHES Doctoral Candidate Department of Health Education and Behavior University of Florida P.O. Box 118210, FLG 5 Gainesville, FL 32611 8210 Phone: 352.392.0583 ext. 1254 Fax: 352.392.1909 E mail: webbm@ hhp.ufl.edu

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111 APPENDIX D SURVEY CONS ENT Sex & Alcohol Survey Consent Purpose of the study: The purpose of this study is to explore behaviors and beliefs related to sexual behavior and alcohol consumption in undergraduate students at UF. What you will be asked to do in the study: If you agree to participate, you will be asked to respond to a 49 item (with multiple sub items) online questionnaire. The one time only survey assesses demographic characteristics such as age, sex, and race/ethnicity as w ell as your behaviors and beliefs regarding sexual behavior and alcohol consumption. You do not have to respond to any question you find offensive. You will not be penalized in any way for refusing to respond to the survey. Your responses to these question s are anonymous. Time required: Approximately 30 50 minutes (one time only). Incentive: The first two and last two participants will each receive a $50 Visa gift card. If you wish to be considered for the incentive you will be sent to an additional scr een, separate from the survey, where you can enter your contact information. Your information will not be linked to the survey, it is completely separate To receive the gift card you must pick it up in room 6 of the Florida Gym. Risks: There are no anticipated risks for participating in this study. Benefits: You may benefit from learning about sexual risk taking behaviors. In addition, you will be presented with local alcohol, sexual health, and mental health resources at the end of t he survey. Confidentiality and Anonymity: This survey is anonymous. This means you will not be asked to provide any information that can identify you. There is no way to connect you to your responses. Your email or IP address will not be collected for any reason. Voluntary participation: Your participation in this study is completely voluntary. You have the right to withdraw from the study at anytime without consequence. You do not have to answer any question you do not wish to answer. Whom to contact i f you have questions about the study: Principle Investigator: Monica C. Webb, MPH, CHES, Doctoral Candidate, Department of Health Education and Behavior, University of Florida, Room 69, Florida Gym, PO Box 118210, Gainesville, FL 32611 8210, (352) 392 05 83 ext. 1254, webbm@hhp.ufl.edu Faculty Supervisor: William Chen, PhD, Professor, Department of Health Education and Behavior, University of Florida, Room 6, Florida Gym, PO Box 118210, Gainesville, FL 32611 8210, (352) 392 0583 ext. 1284, chen0724@hhp.ufl.edu Whom to contact about your rights as a research participant in the study: UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611 2250; (352) 392 0433 Your consent to participate in this study will be implied by continuing to the next page and completing this anonymous survey

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112 APPENDIX E SURVEY INSTRUMENT Final Sex & Alcohol Survey Remember: Your responses to these questions are anonymous This means that you cannot be linked to your responses. Your participation in this study is voluntary. You have the right to withdraw from the study at anytime without consequence. You do not have to answer a question if you find it objectionable. Definitions : For the purpose of this survey you need to be familiar with the foll owing terms One drink of alcohol is defined as a 12 oz. can or bottle of beer or wine cooler, a 4 oz. glass of wine, or a shot of liquor (1 oz.) straight or in a mixed drink. Drunk alc ohol. Sexually Transmitted Infection is also known as Sexually Transmitted Disease. Includes a diagnosis of any of the following: Chlamydia, Syphilis, Gonorrhea, HIV or AIDS, Genital Herpes, Genital Warts, Human Papilloma Virus (HPV), Trichomoniasis Dig ital sex digits. Oral sex is the sexual activity involving oral (mouth) stimulation of one's partner's sex organs (includes both fellatio and cunnilingus). Vaginal sex refers to pen is vagina intercourse. Anal sex anus into the rectum. 1. Do you believe that alcohol has the following effects? No Yes Makes me sexier Facilitates sexual opportunities Makes women sexier Makes men sexier

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113 P lease select the response that most accurately reflects your personal beliefs about your behaviors for each of the following statements. Note the adjective at the top of the columns 2. Oral sex (fellatio, cunnilingus) while being drunk is: Vaginal sex while being drunk is: Anal sex while being drunk is: 3. Oral sex (fellatio, cunnilingus) while being drunk is: Vaginal sex while being drunk is: Good Bad Healthy Unhealthy

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114 Anal sex while being drunk is: 4. Oral sex (fellatio, cunnilingus) while being drunk is: Vaginal sex while being drunk is: Anal sex while being drunk is: 5. Oral sex (fellatio, cunnilingus) while being drunk is: Vaginal sex while being drunk is: Anal sex while being drunk is: Beneficial Harmful Enjoyable Unenjoyable

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115 6. Oral sex (fellatio, cunnilingus) while being drunk is: Vaginal sex while being drunk is: Anal sex while being drunk is: 7. and fingers) while being drunk is: Oral sex (fellatio, cunnilingus) while being drunk is: Vaginal sex while being drunk is: Anal sex while being drunk is: Risky Not Risky Regretful Unregretf ul

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116 8. Oral sex (fellatio, cunnilingus) while being drunk is: Vaginal sex while being drunk is: Anal sex while being drunk is: P lease check the circle that indicates your level of agreement or disagreement with each of the following statements. 9. Most people I hang out with would approve of me participating in: Strongly Agree Strongly Disagree digital sex and fingers) while intoxicated. oral sex (fellatio, cunnilingus) while intoxicated. vaginal sex while intoxicated. anal sex while intoxicated. 10. The people in my life whom I value encourage me to participate in: Strongly Agree Strongly Disagree digital sex and fingers) while intoxicated. oral sex (fellatio, cunnilingus) while intoxicated. vaginal sex while intoxicated. Guilt No Guilt

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117 anal sex while intoxicated. 11. Please check the circle that indicates your level of agreement or disagreement with the following statement: I would be more social if I got drunk. Strongly Agree Strongly Disagree 12. Please check the circle that indicates your level of agreement or disagreement with the following statement: I would have more fun if I got drunk before participating in: Strongly Agree Strongly Disagree digital sex oral sex vaginal sex anal sex. 13. Please check the circle that indicates your level of agreement or disagreement with each of the following statements. Strongly Agree Strongly Disagree My chances of participating in digital sex and fingers) would increase if I got drunk. My chances of participating in oral sex (fellatio, cunnilingus) would increase if I got drunk. My chances of participating in vaginal sex would increase if I got drunk. My chances of participating in anal sex would increase if I got drunk.

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118 14. How would you describe your relationship status within the last 30 days? a. I am in an exclusive relationship b. I am in an open relationship where we are free to see other people c. I am casually dating, but not in a relationship d. I am NOT dating or in a relationship 15. Have you participated in any of the following behaviors within the p ast 30 days? a. Digital Sex yes no b. Oral Sex yes no c. Vaginal Sex yes no d. Anal Sex yes no 16. Within the last 30 days how many times did you participate in: digital sex ? ______ times oral sex (fellatio, cunnilingus) ? ______ times vaginal sex ? ______ times anal sex ? ______ times 17. Within the last 30 days how many sexual partners have you had for each of the following behaviors? digital sex ? ______ partner s oral sex (fellatio, cunnilingus) ? ______ partners vaginal sex ? ______ partners anal sex ? ______ partners 18. How many times did you use a condom or other barrier method during digital, oral, vaginal, or anal sex in the past 30 days ? digital s ex ? ______ times oral sex (fellatio, cunnilingus) ? ______ times vaginal sex ? ______ times anal sex ? ______ times 19. Within the past 30 days have you or your partner used birth control (a contraceptive) when participating in any of the following behaviors? b. Oral Sex yes no not applicable (did not participate) c. Vaginal Sex yes no not applicable (did not participate) d. Anal Sex yes no not applicable (did not participate) 20. Think back to the last time you participated in each of the following behaviors. Did you or your partner use birth control (a contraceptive) when participating in the behavior? b. Oral Sex yes no not applicable (did not participate)

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119 c. Vaginal Sex yes no not applicable (did not participate) d. Anal Sex yes no not applicable (did not participate) 21. Have you or any of your sexual partners ever experienced an unplanned pregnancy? a. Yes b. No c. Unsure 22. Have you been tested for a sexually transmitted infection within the past 6 months? a. Yes b. No 23. Have you been tested for a sexually transmitted infection within the past 12 months? a. Yes b. No 24. Have you ever been told by a doctor or nurse that you had: a. Chlamydia yes no b. Syphilis yes no c. Gonorrhea yes no d. HIV or AIDS yes no e. Genital Herpes yes no f. Genital Warts yes no g. Human Papilloma Virus (HPV) yes no h. Trichomoniasis yes no 25. Within the last 30 days on how many days did you consume alcohol? a. Never used b. Have used, but not in the last 30 days c. 1 2 days d. 3 5 days e. 6 9 days f. 10 19 days g. 20 29 days h. Used daily 26. Think back over the LAST 2 WEEKS How many times have you had FIVE or more drinks in a row? (One drink of alcohol is defined as a 12 oz. can or bottle of beer or wine cooler, a 4 oz. glass of wine, or a shot of liquor (1 oz.) straight or in a mixed drink .) a.

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120 b. None c. 1 time d. 2 times e. 3 times f. 4 times g. 5 times h. 6 times i. 7 times j. 8 times k. 9 times l. 10 or more times 27. On average how many alcoholic drinks does it take for you to become drunk? alcohol. One drink of alcohol is defined as a 12 oz. can or bottle of beer or wine cooler, a 4 oz. glass of wine, or a shot of liquor (1 oz.) straight or in a mixed drink .) a. 0 b. 1 2 c. 3 4 d. 5 6 e. 7 8 f. 9 or more 28. The last time ( One drink of alcohol is defined as a 12 oz. can or bottle of beer or wine cooler, a 4 oz. glass of wine, or a shot of liquor (1 oz.) straight or in a mixed drink. ) a. 0 b. 1 2 c. 3 4 d. 5 6 e. 7 8 f. 9 or more 29. Do you usually drink alcohol before participating in any of the following behaviors? a. Digital Sex yes no b. Oral Sex yes no c. Vaginal Sex yes no d. Anal Sex yes no 30. Do you usually drink alcohol during your participation in any of the following behaviors? a. Digital Sex yes no b. Oral Sex yes no c. Vaginal Sex yes no

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121 d. Anal Sex yes no Please check the circle that indicates your level of agreement or disagreement with each of the following statements. 31. When I drink I feel a greater desire to participate in: Strongly Agree Strongly Disagree digital sex and fingers). oral sex (fellatio, cunnilingus). vaginal sex anal sex. 32. Strongly Agree Strongly Disagree digital sex (sex using your hands and fingers). oral sex (fellatio, cunnilingus). vaginal sex anal sex. 33. Please check the circle that indicates your level of agreement or disagreement with each of the following statements. Strongly Agree Strongly Disagree When I drink before having sex I am concerned of becoming pregnant or impregnating my partner When I drink before having sex a concern of mine is not being able to perform sexually When I drink before having sex I am concerned that I may embarrass myself.

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122 34. What do you believe is the likelihood of your participations in the following behaviors while being intoxicated : Very Likely Very Unlikely Use a condom or other barrier method during oral sex Use a condom or other barrier method during vaginal sex Use a condom or other barrier method during anal sex Getting tested for sexually transmitted infections Consider your use of contraceptives Consider your chance of contracting a sexually transmitted infections Consider the financial costs associated with an unplanned pregnancy Please check the circle that indicates your level of agreement or disagreement with each of the following statements. 35. My close friends would approve of me participating in: Strongly Agree Strongly Disagree digital sex and fingers) while intoxicated. oral sex (fellatio, cunnilingus) while intoxicated. vaginal sex while intoxicated. anal sex while intoxicated. 36. My ideal future partner would approve of me participating in Strongly Agree Strongly Disagree digital sex and fingers) while intoxicated. oral sex (fellatio, cunnilingus) while intoxicated. vaginal sex while intoxicated. anal sex while intoxicated.

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123 37. When it comes to sexual behaviors while intoxicated, how motivated are you to meet the expectations of your: Very Motivated Not motivated at all Close friends? Current partner? Ideal future partner? 38. Within the last 12 months : No Yes Were you sexually touched without your consent? Was sexual penetration attempted (vaginal, anal, oral) without your consent? Were you sexually penetrated (vaginal, anal, oral) without your consent? 39. Within the last 12 months have you been in an intimate (coupled/partnered) relationship that was: No Yes Emotionally abusive? (e.g., called derogatory names, yelled at, ridiculed) Physically abusive? (e.g., kicked, slapped, punched) Sexually abusive? (e.g., forced to have sex when you didn't want it, forced to perform or have an unwanted sexual act performed on you) 40. Within the past 12 months have you experienced any of the following as a consequence of your drinking? No Yes Had sex with someone without giving your consent Had sex with someone without getting their consent Had unprotected sex

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124 41. How often do you worry that: Never Sometimes Often Always You might get HIV or AIDS? You might already have HIV or AIDS? Your partner may get HIV or AIDS? You might get an STD or STI? You might already have an STD or STI? Your partner may already have an STD or STI? 42. P lease check the circle that indicates how likely or unlikely you would be influenced by each of the following scenarios. Extremely Likely Extremely Unlikely Availability of free alcoholic drinks influences my decision to get drunk Availability of free alcoholic drinks influences my decision to participate in digital sex Availability of free alcoholic drinks influences my decision to participate in oral sex Availability of free alcoholic drinks influences my decision to participate in vaginal sex Availability of free alcoholic drinks influences my decision to participate in anal sex The availability of a condom would influence my decision to have sex. Pressures from sexual partners would influence my decision to have sex.

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125 43. Please check the circle that indicates your level of agreement or disagreement with each of the following statements. Strongly Agree Strongly Disagree I am confident that I can limit my alcohol consumption I can resist sexual pressures when drunk advances when drunk 44. Please check the circle that indicates your level of agreement or disagreement with each of the following statements. The next time I get drunk I intend to engage in: Strongly Agree Strongly Disagree digital sex and fingers). oral sex (fellatio, cunnilingus). vaginal sex anal sex 45. How old are you? a. 18 b. 19 c. 20 d. 21 e. 22 f. 23 g. 24 46. What is your gender? a. Male b. Female

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126 47. Please indicate your race: a. White/Caucasian b. Black/African American c. Asian d. Native Hawaiian/Other Pacific Islander e. American Indian/Native Alaskan f. Other 48. Are you Hispanic or Latino? a. Yes b. No 49. Which of the following best describes you? a. Heterosexual b. Gay/Lesbian c. Bisexual d. Other Thank you for your participation in this anonymous survey. Your response is greatly appreciated! If you think you would like to visit with someone regarding concerns about drinking, sexual behaviors, sexual assault, or related issues, a number of agencies in our area would be glad to help you. Here is a listing of pl aces you may wish to contact. Student Mental Health Services 3190 Radio Rd. 352 392 1171 https://www.counseling.ufl.edu/cwc/ UF C.A.R.E. Center for Sexual Abuse/Assault Recovery Education 392 1161 ext. 4362 Alachua County Crisis Center Crisis H otline: 352 264 6789 Alcoholics Anonymous 352.372.8091 http://www.alcoholics anonymous.org FL Recovery Center Vista (Shands) 352.265.5497 http://shands.org/hospitals/vista Meridian Behavioral Healthcare, Inc. 352.374.5600 or 1 800 330 5615 ht tp://www.meridian healthcare.org RAINN Rape, Abuse & Incest National Network 24 hour Hotline: 1 800 656 HOPE

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127 LIST OF REFERENCES [1] U.S. Dept. of Health and Human Services. Sexually Transmitted Diseases. Healthy People 2020 ; 2011. Available at: http://www.healthypeople.gov [2] Cohen MS. Sexually transmitted diseases enhance HIV transmission: no longer a hypothesis. Lancet 1998; 351 (s 3 ) : 5 7. [3] Chesson HW, Blandford JM, Gift TL, Tao G, Irwin KL. The estimated direct medical cost of sexually transmitted diseases among American youth, 2000. Perspectives on Sexual and Reproductive Health 2004; 36(1): 11 19 [4] Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2007. U.S. Dept. of Health and Human Services, Atlanta, GA; 2008. [5] American, College, Health, Association. American College Health Association National College Health Assessment II (ACHA NCHA II) Reference Group Data Report Fall 2010 American College Health Association, Baltimore; 2011. [6] Brckner H, Bearman P. After the promise: The STD consequences of adolescent virginity pledges. Journal of Adolescent Health 2005; 36(4): 271 278. [7] Cooper ML. Alcohol use and risky sexual behavi or among college students and youth: evaluating the evidence. J ournal of Stud ies in Alcohol 2002 ; 14 (s ): 101 117. [8] Weinstock H, Berman S, Cates W, Jr. Sexually Transmitted Diseases among American Youth: Incidence and Prevalence Estimates, 2000. Perspec tives on Sexual and Reproductive Health 2004; 36(1): 6 10. [9] Finer LB, Henshaw SK. Disparities in Rates of Unintended Pregnancy In the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health 2006; 38(2): 90 96. [10] Baldwin JI, Bal dwin JD. Heterosexual Anal Intercourse: An Understudied, High Risk Sexual Behavior. Archives of Sexual Behavior 2000; 29(4): 357 373. [11] Flannery D, Ellingson L, Votaw KS. Anal Intercourse and Sexual Risk Factors Among College Women, 1993 2000. American Journal of Health Behavior 2003; 27(3): 228 235

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137 BIOGRAPHICAL SKETCH Monica C. Webb was born in 1981 in Somerville, New Jersey. She grew up in Miami and graduated high school from Maritime and Science Technology (MAST) Academy in 1999. Monica then attended the University of Florida (UF) as an undergraduate in Health Science Education where her passion for health education and behavior began. She graduated with a Bachelor in Health Science Education with a specialization in School Health in 2003. After graduation, Monica moved to Jacksonville, F lorida and worked as a health educator at Darnell Cookman Middle School. During her tenure at the nationally ranked school she was awarded Teacher of the Year by her peers. Monica also earned a Master of Public Health degree from the University of North F lorida (UNF) while in Jacksonville. In 2006, Monica enrolled in the Ph.D. program in the Department of Health Education and Behavior at UF. During her time at UF as a graduate student she clarified her research focus and developed a line of investigation into the relationship between alcohol and sexual risk taking among emerging adults. s doctoral dissertation included multiple scientific papers based on her research submitted for publ ication to scholarly journals. Monica was granted a Doctor of Ph ilosophy in Health and Human Performance with an emphasis i n Health Behavior in August 2011