Conceptualizing the multidimensional nature of self-efficacy: assessment of situational context and level of behavioral challenge to maintain safer sex. National Institute of Mental Health Multisite HIV Prevention Trial Group.

A. Bandura (1991) argued that self-efficacy measurement should be specific both to the situation in which the behavior occurs and level of challenge in that situation. Measures consistent with the 2 dimensions were developed with graded challenge levels and differing gender-appropriate situations. Participants were 1,496 controls in the National Institute of Mental Health Multisite HIV Prevention Trial recruited from STD clinics and health service centers (925 women and 571 men). The authors tested 4 separate-sex confirmatory factor analysis models as follows: (a) Condom negotiation efficacy as a unitary construct across situations and gradation of difficulty; (b) situation as preeminent, which transfers across skills whatever the gradation of difficulty; (c) skill as predominant, irrespective of situation; and (d) a multidimensional design that simultaneously accounts for both situation and graded difficulty. Consistent with Bandura's theory, the multidimensional model provided the best fit for both samples.

Do parents understand immunizations? A national telephone survey.

BACKGROUND: Immunization may now be undervalued because vaccines have largely eliminated the threat of serious infectious diseases in childhood. As the incidence of vaccine-preventable diseases has declined, concern about vaccine safety has increased. Significant erosion of public confidence in vaccine safety could lead to reduced immunization rates and a resurgence of vaccine-preventable diseases. OBJECTIVE AND METHODS: To assess parents' understanding of vaccine-preventable diseases, vaccines, immunization practices, and policies, we conducted a telephone survey in the United States with a nationally representative sample (n = 1600) of parents with children

A social cognitive-based model for condom use among college students.

BACKGROUND: Social cognitive theory has been used extensively to explain health behaviors. Although the influence of one construct in this model-self-efficacy-has been well established, the role of other social cognitive constructs has not received as much attention in human immunodeficiency virus (HIV) prevention research. More complete understanding of how social cognitive constructs operate together to explain condom use behaviors would be useful in developing HIV and sexually transmitted disease (STD) prevention programs for college students. OBJECTIVE: The primary aim of this study was to test a social cognitive-based model of condom use behaviors among college students. METHODS: Data were collected from a sample of college students attending six different colleges and universities. Participants were 18 to 25 years of age, single, and sexually active. For the sample of 1,380 participants, the mean age was 20.6 years (SD = 1.76). Most participants reported having had vaginal intercourse (95.8%) and oral sex (86.5%); 16% reported anal sex. FINDINGS: Self-efficacy was related directly to condom use behaviors and indirectly through its effect on outcome expectancies. As predicted, self-efficacy was related to anxiety, but anxiety was not related to condom use. Substance use during sexual encounters was related to outcome expectancies but not to condom use as predicted. CONCLUSIONS: Overall, the findings lend support to a condom use model based on social cognitive theory and provide implications for HIV interventions. Interventions that focus on self-efficacy are more likely to reduce anxiety related to condom use, increase positive perceptions about condoms, and increase the likelihood of adopting condom use behaviors.

Planning and initiation of the ONDCP National Youth Anti-Drug Media Campaign.

An alarming upsurge in substance use among American youth in the past decade prompted the Office of National Drug Control Policy (ONDCP) to organize the multifaceted, primary prevention National Youth Anti-Drug Media Campaign. The campaign focuses on adolescents (especially ages 11-13 years), but also targets adolescents' parents and other influential adults. The campaign's main goal is to educate and enable American youth to reject illegal drugs. The purpose of this article is to describe the origin of campaign objectives, processes for the development of specific advertising messages to fulfill these objectives, and how the ONDCP experience could provide a model for other health-oriented media campaigns.

Implications of a health lifestyle and medication analysis for improving hypertension control.

BACKGROUND: National Health and Nutritional Examination surveys have documented poor rates of hypertension treatment and control, leading to preventable morbidity and mortality. OBJECTIVES: To examine covariation in the medication and health lifestyle beliefs and behaviors of persons with hypertension to identify and profile distinct subgroups of patients. METHODS: A sample of 727 patients with hypertension, weighted to match the 1992 National Health Interview Survey age and sex distribution of patients with hypertension, was interviewed by telephone about their beliefs and behaviors regarding hypertension and its management. Cluster analysis of key variables was used to identify 4 patient types. RESULTS: Subgroups differed significantly. Group A members use an effective mix of medication and health lifestyle regimens to control blood pressure. Group B members are most likely to depend on medication and have high adherence rates. Yet they also have high rates of smoking (29%) and alcohol use (average, 104 times per year) and are less likely to exercise regularly. Group C members are most likely to forget to take medication, are likely to be obese, and find it most difficult to comply with lifestyle changes (except for very low rates of smoking and alcohol use). Group D members are least likely to take medication, most likely to change or stop medication without consulting their physician (20%), most likely to smoke (40%), and least likely to control diet (29%). Group A and B members have better health outcomes than group C and D members. CONCLUSIONS: Optimal management strategies are likely to differ for the 4 patient types. Further research should be conducted to validate these findings on a separate sample and to devise and test tailored management algorithms for hypertension compliance and control.

A cluster analysis of alcohol-related attitudes and behaviors in the general population.

OBJECTIVE: Alcohol use typologies have previously focused on chronic alcohol abusers and alcohol-dependent populations. This empirical typology was created to profile lifestyle patterns associated with nonclinical patterns of alcohol use. METHOD: This study used two surveys sent to a commercial mailback panel, sampled to construct a study population demographically representative of the general U.S. population (N = 2,910). A K-means cluster analysis of alcohol use predictor variables and alcohol use generated the typology. RESULTS: The results suggest five distinct psychobehavioral clusters, referred to by the modal patterns of alcohol use for each cluster: nondrinkers, light drinkers, moderate drinkers, episodic drinkers and regular heavy drinkers. These clusters were found to have predictive validity using related health behaviors, psychosocial variables, personality self-descriptors, and media use as criteria. In particular, moderate drinkers had double the income of any other cluster and showed consistently healthy exercise, cigarette use, and diet patterns as well as a relatively high ranking of health as a personal value. Episodic drinkers had the highest levels of sensation-seeking and drug use and were not health oriented in values and behaviors, although their total weekly consumption was only marginally greater than the moderate drinkers. CONCLUSIONS: The profile of the moderate drinker cluster is consistent with concerns about lifestyle confounds in the relationship between moderate alcohol consumption and cardiovascular health. The episodic drinker profile is consistent with relatively high risk behaviors; this cluster may be a good target for harm-reduction education and intervention efforts.

Why Americans eat what they do: taste, nutrition, cost, convenience, and weight control concerns as influences on food consumption.

OBJECTIVE: To examine the self-reported importance of taste, nutrition, cost, convenience, and weight control on personal dietary choices and whether these factors vary across demographic groups, are associated with lifestyle choices related to health (termed health lifestyle), and actually predict eating behavior. DESIGN: Data are based on responses to 2 self-administered cross-sectional surveys. The main outcomes measured were consumption of fruits and vegetables, fast foods, cheese, and breakfast cereals, which were determined on the basis of responses to questions about usual and recent consumption and a food diary. SUBJECTS/SETTING: Respondents were a national sample of 2,967 adults. Response rates were 71% to the first survey and 77% to the second survey (which was sent to people who completed the first survey). STATISTICAL ANALYSES: Univariate analyses were used to describe importance ratings, bivariate analyses (correlations and t tests) were used to examine demographic and lifestyle differences on importance measures, and multivariate analyses (general linear models) were used to predict lifestyle cluster membership and food consumption. RESULTS: Respondents reported that taste is the most important influence on their food choices, followed by cost. Demographic and health lifestyle differences were evident across all 5 importance measures. The importance of nutrition and the importance of weight control were predicted best by subject's membership in a particular health lifestyle cluster. When eating behaviors were examined, demographic measures and membership in a health lifestyle cluster predicted consumption of fruits and vegetables, fast foods, cheese, and breakfast cereal. The importance placed on taste, nutrition, cost, convenience, and weight control also predicted types of foods consumed. APPLICATIONS: Our results suggest that nutritional concerns, per sc, are of less relevance to most people than taste and cost. One implication is that nutrition education programs should attempt to design and promote nutritious diets as being tasty and inexpensive.

Marketing HMOs to Medicare beneficiaries.

Medicare health maintenance organizations (HMOs) market extensively to attract beneficiaries. To assess the dynamics of this marketing, this paper examines newspaper and television ads and materials from marketing seminars that are illustrative of Medicare HMOs' marketing activities in four major media markets. Lower costs and better benefits are pitched in the majority of the ads. Image and content analyses suggest that, in general, HMO ads appear to market to healthy seniors and not to the sick or to disabled persons under age sixty-five. Important plan information often appears in fine print. The study raises questions about the impact of marketing on beneficiaries' insurance choices and the challenges facing the Health Care Financing Administration (HCFA) in establishing and enforcing marketing guidelines.

Effects of an HIV risk reduction project on sexual risk behavior of low-income STD patients.

A 10-hour small-group informational and skill-building intervention was tested among patients (N = 472) attending publicly funded sexually transmitted disease clinics in Maryland, Georgia, and New Jersey. After completing a 90-minute interview concerning HIV risk behaviors, condom use self-efficacy and condom outcome expectancies, participants were randomized to either an intervention or a control condition. Participants in both conditions displayed significant reductions in unprotected encounters and number of partners and increases in condom use. No differences between treatment conditions were observed, indicating that the motivational effects of the interview may have been stronger than the effects of the intervention in this population.

PIP: Sexually transmitted disease (STD) treatment services in low-income communities offer an effective arena for accessing those at greatest risk for HIV infection. This study evaluated an intensive HIV risk reduction program implemented in publicly funded STD clinics in Maryland, Georgia, and New Jersey (US). After completion of a 90-minute interview on HIV risk behaviors, condom use self-efficacy, and condom outcome expectancies, the 472 study participants were randomly assigned to either a 10-hour behavioral intervention designed to increase condom use self-efficacy through modeling and skill building or routine brief counseling. The average age of respondents was 30.1 years; they reported an average of 3.2 lifetime STDs. Participants in both the intervention and control groups reported significant reductions in the number of sexual partners and unprotected sexual encounters and significant increases in condom use at the 90-day follow-up interview, with no significant differences between groups. Four possible moderators of behavior change--gender, crack or heroin use, alcohol problems, and child sex abuse--were not significant. The possibility that the baseline interview, not the intervention, motivated the observed changes in sexual behavior merits consideration.

The value and impact of the Cancer Information Service telephone service. Part 4.

The Cancer Information Service (CIS) of the National Cancer Institute (NCI) is a health communications program that disseminates information through two channels: to individuals through a toll-free telephone service and to organizations (serving primarily underserved populations) through an outreach program. People call the 1-800-4-CANCER line to meet a variety of information needs. The information specialists who respond to these calls are prepared to answer questions ranging from cancer prevention to early detection, treatment, and survivorship. In a 1996 random sample survey, 2,489 callers were asked why they called, how they valued the information, and what health-related actions they took or decisions they made since their call. Results show the CIS is highly valued by its users, with satisfaction high across gender, age, education, and racial/ethnic groups. While differences in satisfaction were observed by caller type and subject of inquiry, nearly all respondents reported that contact with the CIS increased knowledge, provided reassurance, and influenced decisionmaking and health behavior. Overall, 95% were satisfied with CIS information, 98% trusted the information, 92% reported an increase in knowledge, 69% felt reassured, and 73% said the information helped them to better cope with their concerns. Eight out of 10 callers reported the information they received had a positive impact, with 56% reporting taking a positive health action. Results demonstrate that health communications programs like the CIS can fill information gaps consumers must bridge to make informed health care decisions and can play an important public health role in motivating people to take actions to reduce risks and/or make decisions that lead to improved health status.

Promoting cancer prevention and screening: the impact of the Cancer Information Service. Part 7.

Cancer Information Service (CIS) inquiries about cancer prevention and screening are an important opportunity to educate callers about primary or secondary cancer prevention, facilitate their decision-making, and, where appropriate, encourage action. An evaluation was conducted to assess whether these callers' information needs are being satisfied and to determine if the information provided facilitates decisionmaking and subsequent risk reduction actions. A random sample of 2,489 callers was surveyed during a 5-week period, 3 to 6 weeks after their initial call to CIS; prevention or screening was stated as the main reason for calling by 331 respondents. A series of questions was asked regarding level of satisfaction with CIS's performance and how helpful the information provided was in terms of feeling more knowledgeable, making decisions, and taking action. The vast majority of respondents were satisfied with the information received, found it to be helpful, felt more knowledgeable as a result, and would call CIS again with subsequent questions. Although demand characteristics are a possible source of bias, nearly three-quarters of the respondents reported subsequently discussing the information provided with someone else, and almost half sought additional information recommended by CIS. Nearly two-thirds of primary prevention respondents and about half of secondary prevention respondents indicated that they had taken some risk-reducing action subsequent to their interaction with CIS. The CIS is effectively satisfying the information needs of prevention and screening callers; information it is providing is effectively facilitating decisionmaking and stimulating callers to take action.

Relative risk in the news media: a quantification of misrepresentation.

OBJECTIVES: This study quantifies the representativeness with which the print news media depict mortality. METHODS: The proportion of mortality-related copy in samples of national print media was compared with the proportion of actual deaths attributable to the leading causes of US mortality over a 1-year period. RESULTS: For every tested cause of death, a significant disproportion was found between amount of text devoted to the cause and the actual number of attributable deaths. Underrepresented causes included tobacco use (23% of expected copy) and heart disease (33%); overrepresented causes included illicit use of drugs (1740%), motor vehicles (1280%), and toxic agents (1070%). CONCLUSIONS: The news media significantly misrepresent the prevalence of leading causes of death and their risk factors. This misrepresentation may contribute to the public's distorted perceptions of health threats.

The relationship of sexual abuse and HIV risk behaviors among heterosexual adult female STD patients.

Some effects of sexual abuse, for example, heightened sexual activity, are also risk factors for infection with the human immunodeficiency virus (HIV). Moreover, Social Cognitive theory suggests that the reduced self-esteem and increased sexual arousal that can result from abuse might alter self-efficacy for performing a behavior and expected outcomes of the behavior, making adoption of preventive behavior more difficult. Studies in the general population, adolescents, and male clients of sexually transmitted disease (STD) clinics, have found associations between childhood sexual abuse and HIV risk behaviors. This study was designed to measure: (a) whatever the association persists among female STD clinic clients; and (b) whether sexual abuse is associated with self-efficacy for condom use or condom use outcome expectations. Among the 83 female STD clinic clients studied, those sexually abused before age 18 had more sexual partners (p < .05), more positive hedonic outcome expectations for condom use (p < .01), and fewer positive partner-related outcome expectations for condom use (p < .05) than those never forced to have sex against their will. In summary, HIV risk behavior among female STD clients varies with childhood sexual abuse and Social Cognitive Theory suggests future directions for prevention.

Measurement of condom use self-efficacy and outcome expectancies in a geographically diverse group of STD patients.

The aim of this project was to conduct an initial evaluation among sexually transmitted disease (STD) patients of the psychometric properties of two instruments: the National Institute of Mental Health (NIMH) multisite condom use self-efficacy scale and the NIMH multisite condom use outcome expectancy scale. The condom use self-efficacy scale was designed to measure one's degree of confidence in various aspects of condom use, whereas the outcome expectancy scale was designed to measure one's belief about the consequences of using condoms. Using a sample of 641 patients from five geographically diverse STD clinics in the eastern United States, initial reliability coefficients were computed. The alpha coefficient for the self-efficacy scale was .91 and for the outcome expectancy scale .88, indicating high internal consistency for both scales. Both scales were analyzed using common factor analytic procedures. Five factors emerged from the analysis of the self-efficacy scale and six factors from the analysis of the outcome expectancy scale. Reliability coefficients for the individual factors ranged from .76 to .86. Construct validity of each scale was assessed by hypothesis testing. As predicted, participants with higher levels of self-efficacy and more positive outcome expectancies were more likely to use condoms.

Psychological and Behavioral Factors Predicting Attendance at a Community-based HIV Prevention Intervention.

To date, virtualiy no research has addressed individuals' characteristics which influence their participation in prevention interventions targeting the human immunodeficiency virus (HIV). Identification of these characteristics is important, for no intervention is effective if not attended. This study explored stage of condom adoption and selected other psychological and behavioral factors, to determine which of these predicted attendance at a clinic-based HIV intervention. Stage of condom adoption (p = .03) and frequency of drunkenness (p = .05) were significant predictors of attendance for persons with more than one sex partner. For persons with only one sex partner, self-efficacy and outcome expectations were identified. The implications of these findings are discussed.

Mother and adolescent knowledge of sexual development: the effects of gender, age, and sexual experience.

As part of a larger study on the impact of personal and family characteristics on adolescents' HIV risk and risk-reduction behavior, 90 adolescents and 73 mothers were asked to define in their own words seven terms related to sexual development: ejaculation, hormones, menstruation, ovulation, puberty, semen, and wet dreams. Mother and adolescent knowledge of sexual development terms and the effects of age and sexual experience on that knowledge were examined. Results suggest that the mothers were not able to adequately define the sexual development terms and thus may be ill-prepared to teach their children about sex or reinforce information they learn in school. Since adolescent knowledge did not significantly increase with age and sexual experience, the researchers suggest that continuing sex education about normal sexual development is needed.

Self-efficacy in pediatric resuscitation: implications for education and performance.

OBJECTIVE: This article examines the relevance of self-efficacy--a cognitive process indicating people's confidence in their ability to effect a given behavior--to training and performance of pediatric resuscitation. The case is made that self-efficacy is likely to influence the development of and real-time access to cognitive, affective, psychomotor, and social aspects of resuscitation proficiency. METHODS: Comprehensive literature reviews were conducted on relevant topic areas, including self-efficacy theory and empirical investigations of self-efficacy in clinical practice. Three case studies are used to illustrate the influence of self-efficacy on resuscitation practice. RESULTS: The limited empirical evidence on the role of self-efficacy in clinical practice is consistent with self-efficacy theory: clinicians are less likely to initiate and sustain behaviors for which they lack confidence. This performance-based confidence can be distinguished from both knowledge and skills necessary to perform the behavior. CONCLUSIONS: Even clinicians who are knowledgeable and skilled in resuscitation techniques may fail to apply them successfully unless they have an adequately strong belief in their capability. General guidelines for promoting self-efficacy are presented, and specific recommendations are made for enhancing resuscitation self-efficacy during resuscitation training and postresuscitation procedures.