Journal of Psychology & Human Sexuality

ISSN: 0890-7064 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/wzph20

Safer Sex and the Health Belief Model

Tanya L. Boone & Eva S. Lefkowitz

To cite this article: Tanya L. Boone & Eva S. Lefkowitz (2004) Safer Sex and the Health Belief
Model, Journal of Psychology & Human Sexuality, 16:1, 51-68, DOI: 10.1300/J056v16n01_04

To link to this article: http://dx.doi.org/10.1300/J056v16n01_04

Published online: 22 Oct 2008.

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 Safer Sex and the Health Belief Model:
Considering the Contributions
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of Peer Norms and Socialization Factors

Tanya L. Boone
Eva S. Lefkowitz

ABSTRACT. The goal of the present study was to build on the Health
Belief Model (HBM) by adding predictors of late adolescent safer sex
behavior: perceptions of peer norms for sexual behavior, and sexual atti-
tudes that emerge from socialization. Sexually active, late adolescent
college students (N = 154, 62.3% female; mean age 20.8 years, 76% Eu-
ropean American) participated in the study. Predictors from the original
HBM included perceived vulnerability, condom use self-efficacy, and
attitudes about condoms. In addition, peer norms for condom use and
sexual behavior, general sexual attitudes, and endorsement of the sexual
double standard were included as predictors of safer sex behavior. Atti-
tudes about condoms, perceived vulnerability, condom use self-effi-
cacy, and the sexual double standard emerged as significant correlates of
condom use. General sexual attitudes and the sexual double standard
were significantly correlated with alcohol use before or during sex. With

Tanya L. Boone is affiliated with California State University, Bakersfield. Eva S.

Lefkowitz is affiliated with The Pennsylvania State University, University Park.
Address correspondence to: Tanya L. Boone, Psychology Department, 24 DDH, Cal-
ifornia State University, Bakersfield, Bakersfield, CA 93311 (E-mail: tanyab@psu.edu).
The authors are grateful to Meghan Gillen, Shelley Hosterman, Eric Loken, Susan
McHale, Cindy Shearer, and Beth Tempio for their help with study design, data collec-
tion, and statistical analyses.
This work was supported by National Institute of Mental Health Grant #MH63597
to Tanya Boone, and by National Institute of Child Health and Human Development
Grant #R-01 HD 41720 to Eva S. Lefkowitz.
Journal of Psychology & Human Sexuality, Vol. 16(1) 2004
http://www.haworthpress.com/web/JPHS
 2004 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J056v16n01_04 51
 52 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

the addition of these variables, the regression models accounted for 28%
of the variance in condom use, and 14% of the variance in alcohol use be-
fore or during sex. [Article copies available for a fee from The Haworth Docu-
ment Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@
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haworthpress.com> Website: <http://www.HaworthPress.com> © 2004 by The

Haworth Press, Inc. All rights reserved.]

KEYWORDS. Health Belief Model, safer sex, condom use, alcohol use

The late adolescent, college years are some of the riskiest years in individu-
als’ lives. College students take health risks related to poor nutrition, sexually
transmitted infections, unplanned pregnancies, and drug/alcohol abuse (Na-
tional Institute on Alcohol Abuse and Alcoholism [NIAAA], 2002). The
risk-taking behaviors of this age group are related to developmental processes
of late adolescence and emerging adulthood, such as transformations in iden-
tity, changes in social relationships, and new, more independent living situa-
tions (Goldscheider & Davanzo, 1986; Whitbourne & Tesch, 1985). Two
health risks among this age group that have received a great deal of attention
are sexual risk behaviors, and alcohol use and abuse (NIAAA).
Individually and in combination, sexual behavior and alcohol use present
serious potential health risks. Presidents of U.S. colleges have identified binge
drinking as the number one problem on their campuses because of the negative
consequences associated with binge drinking (NIAAA, 2002). These conse-
quences include unplanned pregnancies, sexual violence, and infection with
sexually transmitted diseases. Previous research has demonstrated an associa-
tion between alcohol use and sexual risk taking (Graves, 1995). For example,
roughly half of the college students in one study indicated that they had en-
gaged in vaginal intercourse at least once and up to five times primarily be-
cause they had been drinking (Butcher, Manning, & O’Neal, 1991). A quarter
of those surveyed in another study indicated that they had consumed alcohol
before or during their most recent sexual encounter with a new partner
(MacNair-Semands & Simono, 1996). Further, adolescents who are intoxi-
cated when engaging in sexual activity are more likely to take risks such as not
using a condom (Jemmott & Jemmott, 1993; MacNair-Semands & Simono).
Given the associations between alcohol use and sexual risk taking, safer sex
was conceptualized for the present study as sexual activity in which a condom
was used and alcohol was not consumed before or during the sexual encounter.
Several theories and models have been applied to the alcohol-related and
sexual risk-taking behavior of late adolescents and young adults, including the
Health Belief Model (Brown, DiClemente, & Reynolds, 1991; Mahoney,
1995; Sands, Archer, & Puleo, 1998; Zimmerman & Olson, 1994). This model
predicts behavior and behavior change from individuals’ perceptions of sus-
 Tanya L. Boone and Eva S. Lefkowitz 53

ceptibility to illness, severity of illness, benefits of and barriers to protective

behaviors, and self-efficacy. Although the Health Belief Model has been
somewhat successful in predicting safer sex behavior and behavior change, it
has been criticized for failing to account for substantial variance in behavior
(Brown et al.). It has been suggested that crucial explanatory variables are
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missing from the model, and that inclusion of these variables would enable the
model to explain more variance in adolescent safer sex behaviors (Brown et
al.; Lollis, Johnson, & Antoni, 1997). The goal of the present study was to
build on the Health Belief Model by including two additional predictors of ad-
olescent safer sex behavior: perceptions of peer norms related to sexual behav-
ior, and sexual attitudes that emerge from cultural and gender sexual
socialization.

THE HEALTH BELIEF MODEL

The Health Belief Model (HBM) is a value-expectancy model for predict-
ing health behavior and changes in health behavior. According to the model,
individuals must place value on avoiding a particular illness or negative out-
come (Maiman & Becker, 1974). In order for that value to exist, however, in-
dividuals must expect that the behaviors suggested for avoiding the illness will
actually prevent the illness (Maiman & Becker; Strecher, Champion, &
Rosenstock, 1997). In other words, individuals must believe that a particular
behavior will protect them from illness if they are to place value on avoiding
the illness. The HBM posits that self-protective behavior will occur when indi-
viduals feel susceptible to illness, believe that the illness would be severe,
that the benefits of the protective behavior outweigh the barriers to enacting
it, and feel that they are capable of performing the protecting behaviors
(Strecher et al.).
Based on the HBM, late adolescents and emerging adults will be motivated
to avoid risky sexual behaviors when they believe that they are susceptible to
an unplanned pregnancy or a sexually transmitted infection (STI), and when
they believe that the consequences of these would be severe (Brown et al.,
1991). Once individuals are motivated to avoid pregnancy and STIs, the
choices they make regarding practicing risky sex depend on their perceptions
of the benefits and barriers associated with safer sex (Brown et al.). For exam-
ple, if late adolescents and emerging adults believe the benefits of condom use
outweigh the potential barriers to using condoms, they are more likely to adopt
condom use to protect themselves from unplanned pregnancy and STIs. In ad-
dition, individuals’ self-efficacy regarding safer sex behaviors will influence
their enactments of such behaviors. Self-efficacy refers to the belief that one
can successfully enact the behaviors prescribed and that those behaviors will
result in particular outcomes (Strecher, DeVellis, Becker, & Rosenstock,
1986). In other words, when late adolescents and emerging adults believe they
 54 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

can acquire and successfully use condoms, and that condoms will prevent
pregnancy and STIs, they are more likely to use condoms. Lack of self-effi-
cacy may act as a barrier to condom use if feelings of being unable to acquire
and use condoms outweigh the perceived benefits of condom use (Strecher et
al., 1997). In the present study, we assessed all of the components of the HBM
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except perceptions of severity. Late adolescent college students generally ac-

knowledge and understand the severity of unplanned pregnancies and STIs,
including HIV (Smith & Stasson, 2000). In addition, several studies have
demonstrated that perceptions of severity do not predict sexual behaviors
(e.g., Sands et al., 1998). Thus, severity was not assessed in the present study.
Previous research has demonstrated the utility of the HBM for predicting
safer sex behaviors among late adolescents. For example, in a sample of Euro-
pean American college students, the HBM predicted between 13% and 25% of
the variance in sexual behaviors including condom use, number of partners,
and frequency of sex (Steers, Elliott, Nemiro, Ditman, & Oskamp, 1996). In
other research, the model explained 18% of the variance in the number of sex-
ual partners for male university students, and 22% of the variance for female
university students (Lollis et al., 1997). Taken together, these studies suggest
that the components of the HBM account for a substantial portion of the vari-
ance in sexual behaviors among late adolescents and emerging adults. The
model has, however, been criticized for failing to account for more variance in
late adolescent and emerging adult sexual behavior. In particular, the model
has been criticized for not including a number of factors that may play an im-
portant role in predicting sexual behavior among individuals in this age group.

Criticisms of the Model

The first major criticism of the HBM is that it does not include the influence
of peers and peer norms in predicting late adolescent and emerging adult sex-
ual behaviors (Brown et al., 1991). As Brown et al. suggest, the model would
likely predict more variance in sexual risk behaviors if it included peer norms
for sexual behavior and safer sex as predictors. Given the importance of peers
during this developmental period (see, for example, Andrews, Tildesley, Hops, &
Li, 2002; Osgood & Lee, 1993), it is likely that perceptions of peers’ disap-
proval of sexual activity or of condom use will act as a potential barrier to safer
sex behavior. Further, the success of the Theory of Reasoned Action, in which
peer norms are a critical component in predicting safer sex intentions (Mad-
den, Ellen, & Ajzen, 1992), lends support for the inclusion of peer norms in the
HBM. Accordingly, we expected that the addition of perceptions of peer
norms for sexual behavior and for condom use would increase the ability of
the HBM to predict safer sexual behaviors, including condom use, and the ab-
sence of alcohol use before or during intercourse.
The HBM has also been criticized for failing to account for socialization in-
fluences on the sexual behaviors of adolescents (Lollis et al., 1997). Specifi-
 Tanya L. Boone and Eva S. Lefkowitz 55

cally, Lollis and his colleagues suggest that additional variance in sexual
behavior may be explained if additional benefits and barriers to safer sex that
are related to culture and socialization are included. For example, the general
sexual attitudes that individuals hold may act as barriers to safer sex. Previous
research indicates that late adolescents who hold liberal sexual attitudes tend
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to have more sexual partners (Basen-Engquist & Parcel, 1992; Levinson,

Jaccard, & Beamer, 1995). Further, they may also be more likely to engage in
riskier sexual behaviors (Basen-Engquist & Parcel; Levinson et al.). These
sexual attitudes–whether they are liberal or conservative–can be thought of as
the result of socialization. Individuals are socialized around sexuality by their
families, organizations such as churches, and the larger culture or society. We
expected that adding sexual attitudes to the model would improve its ability to
predict safer sex behaviors among late adolescents.
Another sexual attitude that is directly related to both socialization and
safer sex behaviors is the sexual double standard. The sexual double standard
is the notion that sexual activity is acceptable for males but not for females
(Muehlenhard & Quackenbush, 1996). As with general sexual attitudes, the
sexual double standard is a belief that can be attributed to the influences of so-
ciety. Previous research suggests that the sexual double standard influences atti-
tudes and beliefs about condom use (Hynie & Lydon, 1995; Muehlenhard &
Quackenbush). When presented with hypothetical scenarios in which a
woman either provided a condom in a sexual situation or did not, women rated
the imaginary woman more negatively when she was described as having pro-
vided a condom (Hynie & Lydon). These women also assumed that the male
partner in the sexual situation felt less positive about the imaginary woman
when she was described as having provided a condom. In another study,
women who had sexual intercourse without suggesting, providing or using a
condom believed that their partners endorsed the sexual double standard more
strongly than did those women who did use condoms (Muehlenhard &
Quackenbush). Clearly, the sexual double standard relates to attitudes about
condom use. It is not clear, however, how individuals’ endorsement of the sex-
ual double standard relates to their sexual behavior. To our knowledge, no re-
search has employed the sexual double standard as a predictor of sexual
behaviors, such as condom use. Given that the sexual double standard influ-
ences beliefs about condoms, we expected that adding it to the HBM would
improve the ability of the model to predict safer sexual behaviors, including
condom use and the avoidance of alcohol use.
In summary, we hypothesized that safer sex behaviors, specifically condom
use during intercourse and the absence of alcohol use in conjunction with sex-
ual intercourse, would be predicted by peer norms and sexual socialization in
addition to the original variables included in the HBM. We expected that the
model would predict more variance in safer sex behaviors when peer norms
and sexual socialization were included in the model.
 56 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

METHOD

Participants
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Participants were recruited as part of a study examining college student atti-

tudes about sex at a large university. Flyers were distributed in required and
general education summer session classes and at high-traffic areas on campus.
Participants attended group administrations of the survey. Informed consent
was obtained from each participant at the beginning of the session. Each par-
ticipant received $10 upon completion of the survey.
Two hundred and twenty individuals completed the survey. Of these, 15
were excluded because they did not meet predetermined inclusion criteria
(e.g., they were graduate students or did not meet age criteria). For the present
study, only those students who reported that they had ever had sexual inter-
course were included. The total sample for this study consisted of 154 students
(62.3% female).
The sample ranged in age from 18 to 25 (M = 20.8, SD = 1.7). They were
predominantly European American (76%), with 11% African American, 9%
Asian American, 1% Latino American, and 3% of mixed ethnicity. Forty per-
cent of the sample identified themselves as Catholic, 33% Protestant, 5% Jew-
ish, 3% Hindu, 2% Muslim, 1% Buddhist, 1% other, and 15% identified
themselves as having no religion or as agnostic. Ninety-three percent of the
sample self-identified as heterosexual. Of the remaining 7%, 3% identified as
bisexual, 2% as homosexual, and 2% as other.
Seventy-one percent of participants’ biological parents were still married.
Participants’ socioeconomic status–as indexed by parents’ education–was
varied. Thirty percent of mothers and 21% of fathers had a high school educa-
tion or less. Fifty percent of mothers and 47% of fathers had some college or a
college degree, and 21% of mothers and 33% of fathers had a graduate or pro-
fessional degree.

Measures
Perceived vulnerability to AIDS. The 6-item Fear of AIDS subscale of the
Multidimensional AIDS Anxiety Questionnaire (Snell & Finney, 1996) was
used to assess the extent to which participants experience fear or concern in re-
gard to AIDS (e.g., “I feel scared when I think about catching AIDS from a
sexual partner”). Respondents rated their agreement with each item on a
5-point scale ranging from “strongly disagree” to “strongly agree.” This
measure has demonstrated good reliability in previous research (α = .85-.94;
Snell & Finney) and in the current study (α = .90). Our measure of perceived
vulnerability to AIDS assesses the susceptibility construct of the HBM.
Condom use self-efficacy. The Condom Use Self-Efficacy Scale was used
to assess participants’ self-efficacy for condom use (Basen-Engquist et al.,
 Tanya L. Boone and Eva S. Lefkowitz 57

1996). The scale consists of three subscales (3 items each) that assess self-effi-
cacy for communication about condom use (e.g., “. . . how sure are you that
you could tell your partner that you want to start using condoms?”), self-effi-
cacy for buying and using condoms (e.g., “If you wanted to get a condom, how
sure are you that you could go to the store and buy one?”), and barriers to con-
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dom use (e.g., “I would feel uncomfortable carrying condoms with me”). For
the communication and buying/using subscales, respondents rated their ability
to enact the behavior on a 3-point scale, from “not at all sure” to “totally sure.”
For the barriers subscale, respondents rated their agreement with each state-
ment on a 5-point scale, from “strongly disagree” to “strongly agree.” Higher
scores on the communication and buying/using subscales indicate high
self-efficacy, and higher scores on the barriers subscale reflect lower self-effi-
cacy. For this study, all three subscales were combined to create a total condom
use self-efficacy measure. Basen-Engquist et al. (1996) reported adequate reli-
ability (α = .66-.73). In the current sample, reliability for the overall measure
was also adequate (α = .65). Our measure of condom use self-efficacy assesses
the self-efficacy construct of the HBM.
Outcome expectancies for condom use. The Outcome Expectancies for
Condom Use Scale (Jemmott & Jemmott, 1992) was used to measure partici-
pant attitudes about condoms. The first subscale of the measure consists of
three items and assesses preventive expectancies, or the extent to which partic-
ipants believe that condoms can protect them from pregnancy and STDs in-
cluding AIDS (e.g., “Condoms can prevent sexually transmitted diseases”).
The second subscale of the measure consists of five items that assess hedonis-
tic expectancies, or the extent to which participants hold positive or negative
attitudes about condoms (e.g., “Sex feels good when a condom is used”). Par-
ticipants rated their agreement with the statements in each subscale on a
5-point scale ranging from “strongly disagree” to “strongly agree.” Jemmott
and Jemmott reported adequate reliability for this scale (α = .50-.73). In the
current sample, reliability was good (α = .83 for prevention, α = .76 for hedo-
nistic). These measures represent the benefits construct of the HBM, and can
also be viewed as measures of the absence of barriers to condom use.
Peer norms for sexual behavior. To assess perceptions of their peers’ norms
for sexual behavior, participants were asked to respond to an 8-item measure
that assesses peer approval of specific sexual behaviors at four levels of rela-
tionship involvement (Treboux & Busch-Rossnagel, 1995). For example, par-
ticipants indicated the extent to which their peers would approve of behaviors
such as “Sexual intercourse with someone you have gone out with once or
twice.” Participants rated their peers’ approval on a 4-point scale ranging from
“would strongly disapprove” to “would strongly approve.” As with previous
research (α = .90; Treboux & Busch-Rossnagel), this measure demonstrated
good reliability with the current sample (α = .80).
Peer norms for condom use. The Peer Norms for Condom Use (Gomez &
Marin, 1996) scale asks participants to rate the condom use behaviors of their
 58 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

friends (e.g., “How many of your peers think using a condom is a good
idea?”). An expanded, 6-item version was developed from the original mea-
sure. Participants indicated their perceptions of their peers’ norms for condom
use on a 5-point scale ranging from “almost none” to “almost all.” This mea-
sure demonstrated adequate reliability in previous studies (α = .64-.73;
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Gomez & Marin) and with this sample (α = .61).

Sexual attitudes. A modified, 21-item version of the Sexual Attitudes Scale
(Hudson, Murphy, & Nurius, 1983) was used to assess the general conservative
sexual attitudes of participants (e.g., “I think there is not enough sexual restraint
among young people”). Respondents were asked to rate their agreement on a
5-point scale, with “strongly disagree” and “strongly agree” as the endpoints. In
previous research, this measure demonstrated good reliability (α = .94; Hudson
et al.). Reliability for the current sample was also good (α = .84).
Sexual double standard. The Sexual Double Standard Scale (Muehlenhard &
Quackenbush, 1996) assesses participants’ gender beliefs specific to sexual
behavior. This 26-item measure assesses the extent to which participants
adhere to the sexual double standard which allows more sexual freedom for
men than for women (e.g., “It’s worse for a woman to sleep around than it is
for a man”). Participants indicated their agreement with each item on a
4-point scale, ranging from “strongly disagree” to “strongly agree.” This
measure has demonstrated good reliability in previous research (α = .76;
Muehlenhard & Quackenbush). For the current sample, reliability was ade-
quate (α = .68).
Condom use. Participants indicated how frequently in their lifetime they
had penetrative sex without a condom. Penetrative sex was defined as sex in
which the penis enters the vagina or anus. Participants reported the frequency
of condom use on a 4-point scale ranging from “never” to “most of the time”
(see Table 1).
Alcohol use. To assess alcohol use as a sexual risk behavior, participants in-
dicated how frequently they had used alcohol before or during sex. Partici-
pants indicated frequency of alcohol use on a 4-point scale that ranged from
“never” to “most of the time.”

RESULTS

Preliminary and Descriptive Analyses

As indicated in Table 1, participants reported fairly high levels of sexual
risk behavior. More than a quarter of respondents indicated that they did not
use a condom on “some” occasions of sexual intercourse. In addition, 22% re-
ported that during most of their sexual intercourse experiences, they did not
use a condom. For ease of interpretation, this variable was reverse scored for
 Tanya L. Boone and Eva S. Lefkowitz 59

TABLE 1. Percent of Participants Having Sex Without Condoms and with Alcohol

Sex Without a Condom Alcohol Use

Lifetime frequency (N = 154)

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Never 17.5 30.1

Once 12.3 7.8
Couple of times 22.1 37.9
Some of the time 26.0 20.3
Most of the time 22.1 3.9

the remainder of the analyses. Accordingly, in the remainder of the analyses,

we report condom use as opposed to sex without a condom. In regard to alco-
hol use during sexual encounters, roughly a quarter of the participants indi-
cated that they used alcohol some or most of the time during their lifetime
sexual encounters (see Table 1).
Correlations were performed to examine the associations among the pre-
dictor variables (see Table 2). Correlations ranged from ⫺.23 to .31. Given
this magnitude of association, it was determined that these measures were in-
dependent predictors of safer sex behaviors. Age and condom use were found
to be related. Older individuals reported more frequent sexual intercourse
without a condom, r(150) = ⫺.26, p < .001. Accordingly, age was included as
a covariate in all analyses. In addition, all of the partial correlations were con-
ducted separately for males and females because there were mean differences
between the groups on several variables.
Partial correlations between the dependent variables, condom use and alco-
hol use, indicated that lifetime condom use and lifetime alcohol use before or
during sex were related for females. Females who reported less frequent alco-
hol use before or during sex reported more frequent condom use, r(90) = ⫺.32,
p < .01. This pattern did not emerge for the males in the sample.

Condom Use
To examine associations between the predictor variables and participants’
lifetime condom use, partial correlations were conducted, controlling for age
(see Table 3). Among the males in the sample, condom use related to per-
ceived vulnerability and to hedonistic outcome expectancies for condom use.
Specifically, more frequent condom use was associated with stronger fears of
AIDS and with more positive hedonistic expectations for condom use. Among
the females in the sample, more frequent condom use related to higher condom
use self-efficacy, positive hedonistic outcome expectancies for condom use,
and endorsement of the sexual double standard.
 60 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

TABLE 2. Correlations Among Predictor Variables

Peer Peer
Condom Outcome Outcome Norms– Norms– Sexual
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Perceived Use Self- Expectancies– Expectancies– Sexual Condom Sexual Double

Vulnerability Efficacy Prevention Hedonistic Behavior Use Attitudes Standard

Perceived -- .03 ⫺.15 .13 ⫺.04 ⫺.05 .17* .08

Vulnerability

Condom Use -- ⫺.05 .17* .12 .13 ⫺.06 .01

Self-Effcacy

Outcome -- .11 .24** .07 ⫺.23** ⫺.03

Expectancies–
Prevention

Outcome -- .15 .27** .09 .04

Expectancies–
Hedonistic

Peer Norms– -- .26*** ⫺.23* ⫺.04

Sexual
Behavior

Peer Norms– -- ⫺.14 .08

Condom Use

Sexual -- .31***
Attitudes

Sexual Double --
Standard

Note. Due to missing data, sample size ranged from N = 152 to 154.
* p < .05; ** p < .01; *** p < .001.

TABLE 3. Partial Correlations Between Condom Use and Predictor Variables

(Controlling for Age)

Lifetime Condom Use Frequency

Males (N = 54) Females (N = 92)
Perceived Vulnerability .27* .08
Condom Use Self-Efficacy ⫺.02 .24*
Outcome Expectancies–Prevention .03 ⫺.13
Outcome Expectancies–Hedonistic .44** .37***
Peer Norms–Sexual Behavior .24 .15
Peer Norms–Condom Use .18 .17
Sexual Attitudes ⫺.05 .04
Sexual Double Standard .08 .38***

* p < .05; ** p < .01; *** p < .001.

 Tanya L. Boone and Eva S. Lefkowitz 61

Next, a hierarchical regression was performed to examine each predictor

within the context of the other predictors and to assess the contribution of the
peer norms and socialization variables beyond that of the original HBM vari-
ables. For the regression, age and gender were entered in the first step, the
original HBM variables were entered in the second step, and the peer norms
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and socialization variables were entered in the third step. Frequency of lifetime
sexual intercourse with a condom was the dependent variable (see Table 4). In step
one, age was negatively associated with frequency of sex with a condom such
that younger participants reported more frequent condom use. In step two, in
addition to age and gender, hedonistic outcome expectancies for condom use
were related to lifetime frequency of condom use during sexual intercourse.
Those participants who reported positive attitudes about condoms reported
more frequent condom use. Finally, in step three, age and hedonistic outcome
expectancies were related to condom use just as in step two. Peer acceptance
of sexual behavior was also marginally associated with more frequent condom
use. In addition, the sexual double standard was associated with frequency of
condom use such that endorsement of the sexual double standard related to

TABLE 4. Regression Model Predicting Condom Use from HBM Variables Plus
Peer Norms and Sexual Socialization Variables (N = 150)

Variable B SE B ␤ R2⌬

Dependent Variable: Lifetime frequency of sex with a condom (R2 = .28)

Step 1 .07**
Age ⫺.20 .06 ⫺.25**
Gender ⫺.27 .23 ⫺.10
Step 2 .17***
Age ⫺.19 .06 ⫺.23**
Gender ⫺.53 .22 ⫺.19*
Perceived Vulnerability .01 .02 .05
Condom Use Self-Efficacy .04 .04 .08
Outcome Expectancies–Prevention ⫺.06 .04 ⫺.12
Outcome Expectancies–Hedonistic .13 .03 .38***
Step 3 .08***
Age ⫺.15 .06 ⫺.19*
Gender ⫺.14 .23 ⫺.05
Perceived Vulnerability .01 .02 .03
Condom Use Self-Efficacy .03 .03 .07
Outcome Expectancies–Prevention ⫺.07 .04 ⫺.14
Outcome Expectancies–Hedonistic .12 .03 .35***
Peer Norms–Sexual Behavior .06 .03 .15^
Peer Norms–Condom Use .01 .03 .01
Sexual Attitudes ⫺.01 .01 ⫺.06
Sexual Double Standard .07 .02 .30***

^ p = .06; * p < .05; ** p < .01; *** p < .001.

 62 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

more frequent condom use. As expected, more variance in lifetime condom

use was explained when the peer norms and sexual socialization variables
were included in the regression model.

Alcohol Use During Sexual Intercourse

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To examine associations between the predictor variables and participants’

lifetime alcohol use in conjunction with sexual intercourse, partial correlations
were conducted controlling for age (see Table 5). For females, alcohol use was
negatively related to both sexual attitudes and the sexual double standard. Fe-
males who used alcohol frequently in conjunction with sex reported more lib-
eral sexual attitudes and less endorsement of the sexual double standard.
Next, a hierarchical regression was performed to examine each predictor
within the context of the other predictors, and to assess the contribution of the
peer norms and sexual socialization variables beyond that of the original HBM
variables. Lifetime frequency of alcohol use before or during intercourse was
the dependent variable (see Table 6). In the first step, neither age nor gender
were significant predictors of alcohol use. Similarly, in the second step, none of
the predictors related significantly to alcohol use. In the third step, sexual atti-
tudes related to alcohol use such that liberal sexual attitudes were associated
with more frequent lifetime alcohol use before or during sexual intercourse. As
expected, the model accounted for more variance in alcohol use when the peer
norm and sexual socialization variables were included as predictors.

DISCUSSION
The present study supports recent contentions that the ability of the Health
Belief Model to predict late adolescent and young adult safer sex behaviors
TABLE 5. Partial Correlations Between Alcohol Use During Sexual Intercourse
and Predictor Variables (Controlling for Age)

Lifetime Alcohol Use Frequency

Males (N = 53) Females (N = 92)
Perceived Vulnerability ⫺.05 ⫺.14
Condom Use Self-Efficacy .09 .01
Outcome Expectancies–Prevention ⫺.01 .16
Outcome Expectancies–Hedonistic ⫺.21 ⫺.01
Peer Norms–Sexual Behavior ⫺.08 .19
Peer Norms–Condom Use .07 .01
Sexual Attitudes ⫺.22 ⫺.37***
Sexual Double Standard ⫺.26 ⫺.20*

* p < .05; *** p < .001.

 Tanya L. Boone and Eva S. Lefkowitz 63

TABLE 6. Regression Model Predicting Alcohol Use During Sexual Intercourse

from HBM Variables Plus Peer Norms and Sexual Socialization Variables
(N = 150)
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R⌬
2
Variable B SE B ß
2
Dependent Variable: Lifetime alcohol use during sexual intercourse (R = .14)
Step 1 .02
Age .09 .06 .12
Gender ⫺.08 .21 ⫺.03
Step 2 .03
Age .08 .06 .12
Gender .08 .22 .03
Perceived Vulnerability ⫺.01 .02 ⫺.07
Condom Use Self-Efficacy .02 .03 .06
Outcome Expectancies–Prevention .05 .04 .12
Outcome Expectancies–Hedonistic ⫺.04 .03 ⫺.12
Step 3 .10**
Age .10 .06 .15
Gender ⫺.08 .23 ⫺.03
Perceived Vulnerability .00 .02 .00
Condom Use Self-Efficacy .01 .03 .03
Outcome Expectancies–Prevention .02 .04 .05
Outcome Expectancies–Hedonistic ⫺.05 .03 ⫺.15
Peer Norms–Sexual Behavior ⫺.05 .03 ⫺.01
Peer Norms–Condom Use .02 .03 .05
Sexual Attitudes ⫺.03 .01 ⫺.28**
Sexual Double Standard ⫺.02 .02 ⫺.12

* p < .05; ** p < .01; *** p < .001.

can be enhanced by including peer norms and sexual socialization variables as

predictors. In previous research, the model has explained between 13% and
22% of the variance in condom use (Lollis et al., 1997; Steers et al., 1996). In the
current study, we were able to improve on this by including peer norms and
sexual socialization as predictor variables. Specifically, the expanded
model accounted for 28% of the variance in lifetime condom use and 14%
of the variance in lifetime alcohol use before or during sexual intercourse.
Further, substantially more variance was explained when the additional
variables were included as compared to when only the original HBM vari-
ables were included. We can conclude from this that the expanded model is
successful in predicting safer sex behaviors, at least for this age group.
In addition to explaining a substantial portion of the variance in safer sex
behaviors, several variables emerged as significant predictors of sexual be-
haviors. Several of the original HBM predictors emerged as significant cor-
relates of safer sex behaviors. In addition, the peer norms and sexual
socialization variables predicted lifetime condom use and alcohol use.
 64 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

Health Belief Model Predictors

Individuals with positive attitudes about condoms reported more condom
use over their lifetimes. It appears that this belief may represent a benefit or
“absence of barrier” in the HBM. Specifically, participants who believe that
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sex is still pleasurable with condoms are more likely to use condoms. Impor-
tant for prevention and intervention planners is the consistent connection be-
tween the belief that sex is pleasurable when condoms are used and the use of
condoms. This finding suggests that a continued focus on condoms as protec-
tive as well as natural, and not an impediment to sexual pleasure, will encour-
age condom use among this age group.
It is important to note that positive attitudes about condoms were associated
with condom use but not with alcohol use before or during sex. This is not sur-
prising given that this variable specifically addresses sexual behavior. This
finding does, however, suggest important questions related to attitudes and ex-
pectations for sexual behavior when drinking. For this age group, it may be
important to understand attitudes about condom use specifically in situations
in which individuals have been drinking. For example, do individuals have
positive attitudes about using condoms in situations in which they have been
drinking? LaBrie, Schiffman, and Earleywine (2002) addressed a similar
question and found that among college men, alcohol use was associated with
the expectation that such alcohol use would impair decision-making abilities
and condom use skills. In turn, those expectancies related to a decreased inten-
tion to use condoms when drinking. Future efforts at predicting actual condom
use from condom use attitudes and expectancies when alcohol is involved will
be important for understanding the associations between condom attitudes and
condom use.
Perceived vulnerability to AIDS, one of the central predictors of the HBM
(Strecher et al., 1997), was only related to condom use for males. Males who
reported higher fear of AIDS reported more frequent lifetime condom use.
Fear of AIDS was not, however, related to lifetime condom use for females.
Although perceived vulnerability to AIDS was related to males’ condom use
in the partial correlations, it did not emerge as a significant predictor of con-
dom use in the regression. This finding suggests that among college students,
perceived vulnerability may not be as critical in predicting condom use as the
HBM posits. As suggested by others (Boone et al., 2003), the role of perceived
vulnerability in the HBM may need to be reconsidered in models predicting
sexual behaviors.
Condom use self-efficacy, another central variable in the HBM, also
emerged as a correlate of condom use, but only for females. As predicted by
the HBM (Strecher et al., 1997), self-efficacy in acquiring, communicating
about, and using condoms was positively associated in the present study with
lifetime condom use. Although self-efficacy was related to condom use in the
partial correlations, it was not a significant predictor of condom use in the re-
 Tanya L. Boone and Eva S. Lefkowitz 65

gression. This finding suggests that at least for college students, condom use
self-efficacy may not contribute much to the prediction of actual condom use.
It is possible that as a result of receiving education and information about con-
doms, the individuals in this age group have such strong feelings of condom
use self-efficacy that self-efficacy does not distinguish the condom users from
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the nonusers. In fact, examination of the distribution of scores suggested high

levels of condom use self-efficacy among the majority of participants.

Peer Norms and Sexual Socialization Predictors

Peer norms emerged as a marginally significant predictor of condom use,
but not of alcohol use before or during sex. Individuals who believe their peers
would approve of their sexual behavior reported more frequent lifetime con-
dom use. These findings indicate that perceptions of peer norms are important
in predicting condom use and that including them in the HBM bolsters its abil-
ity to understand and predict the sexual behaviors of this age group. Given the
specific relevance of peer norms to sexual behavior and condom use, it is not
surprising that these variables were not significant predictors of alcohol use in
conjunction with sex. The co-occurrence of alcohol use and sex in this age
group (Butcher et al., 1991; Graves, 1995; MacNair-Semands & Simono,
1996), however, indicates that it will be important in the future to understand
the role of peer norms regarding drinking alcohol specifically when engaging
in sex.
The sexual double standard emerged as a significant predictor of lifetime
condom use, but not of alcohol use. Individuals who reported more frequent
lifetime condom use endorsed the sexual double standard more strongly. In
other words, individuals who believe that the rules for sexual behavior are dif-
ferent for men and women are less likely to engage in risky sexual behaviors.
This is somewhat contrary to what we had expected. Previous research sug-
gests that women who endorse the sexual double standard may be prevented
from providing condoms and negotiating condom use by the belief that
women who are sexually active are less desirable (Hynie & Lydon, 1995;
Muehlenhard & Quackenbush, 1996). This previous research, however, asked
participants about hypothetical situations (Muehlenhard & Quackenbush) or
about their perceptions of their partners’ endorsement of the sexual double
standard (Hynie & Lydon). In contrast, the present study directly assessed re-
spondents’ endorsement of the sexual double standard and their past sexual
behavior. Perhaps the construct is viewed differently when it is personal and
can be related to one’s own sexual behavior. Specifically, if men and women
endorse the sexual double standard, then they may assume that the man in a
sexual encounter has had many previous sexual encounters. Awareness of this
behavior, which would be expected given endorsement of the sexual double
standard, may raise awareness of sexual risk. Men who have had many sexual
partners may be more aware of their risk of having and passing on a STI.
 66 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

Women who endorse the sexual double standard, and therefore expect this be-
havior from their sexual partners, may be highly cognizant of the possibility of
being infected by their partners. To avoid these risks, these individuals who
endorse the sexual double standard may be more likely to use condoms. It is
clear that more research will be required to fully understand this association.
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Global sexual attitudes were related to alcohol use before or during sex, but
not to condom use. It is somewhat puzzling that sexual attitudes related to al-
cohol use but not to condom use. One possible explanation for this pattern is
the degree to which alcohol use and condom use are viewed as risky among
this age group. It appears that most college students view using condoms as ef-
fective risk prevention (Holtzman, Bland, Lansky, & Mack, 2001). In con-
trast, there is less evidence that the majority of college students recognize the
risks associated with using alcohol. Therefore, among those individuals who
are sexually active, their level of sexual conservatism may not be associated
with the choice to use condoms, in that most students perceive condoms as
protective. In contrast, more sexually conservative youth may refrain from al-
cohol use because they fear the loss of control, whereas more sexually liberal
youth may not have the same concerns, and therefore may use alcohol more
freely. Future research aimed at understanding the nuances of the associations
between sexual attitudes, alcohol use, and condom use will be helpful for un-
derstanding sexual risk in this age group, and for informing future interven-
tions.
It is important to note a number of limitations in this study. First, the use of
a college sample prevents us from generalizing these findings to individuals of
the same age who are not in college. For example, it is possible that non-col-
lege individuals are less influenced by peer norms. Second, our sample was
predominantly European American. Accordingly, we must be careful in
generalizing our findings to members of other ethnic groups. Finally, the
cross-sectional nature of our design prevents us from drawing any conclusions
about causality. We cannot conclude, for example, that outcome expectancies
for condom use, sexual attitudes, the sexual double standard, and peer norms
caused the individuals in our study to use or not use condoms or alcohol. As
Brunswick and Banaszak-Holl (1996) suggest, it is just as possible that the risk
behaviors are causing the attitudes and beliefs included in our model.
Despite these limitations, several important findings emerged from this
study. Although the Health Belief Model has been somewhat successful in pre-
dicting safer sex behaviors among late adolescents and emerging adults, it can
be improved upon. We have demonstrated that including peer norms and sexual
socialization variables improves the predictive ability of the model. Peer norms
for sexual behavior and condom use, sexual attitudes, and the sexual double
standard help us to understand late adolescent and emerging adult sexual behav-
ior within the context of the variables outlined in the Health Belief Model. In the
future, it will be important to examine these additional variables further to more
fully understand their contribution to the Health Belief Model.
 Tanya L. Boone and Eva S. Lefkowitz 67

REFERENCES
Andrews, J. A., Tildesley, E., Hops, H., & Li, F. (2002). The influence of peers on
young adult substance use. Health Psychology, 21, 349-357.
Basen-Engquist, K., Masse, L., Coyle, K., Parcel, G. S., Banspach, S., Kirby, D., &
Downloaded by [Athabasca University] at 04:19 20 June 2016

Nodora, J. (1996). Validity of scales measuring the psychosocial determinants of

HIV/STD-related risk behavior in adolescents. Unpublished manuscript.
Basen-Engquist, K., & Parcel, G. S. (1992). Attitudes, norms, and self-efficacy: A
model of adolescents’ HIV-related sexual risk behavior. Health Education Quar-
terly, 19, 263-277.
Boone, T. L., Lefkowitz, E. S., Romo, L., Corona, R., Sigman, M., & Au, T. K. (2003).
Mothers’ perceptions of AIDS vulnerability and adolescents’ AIDS perceptions.
International Journal of Behavioral Development, 27, 347-354.
Brown, L. K., DiClemente, R. J., & Reynolds, L. A. (1991). HIV prevention for adoles-
cents: Utility of the Health Belief Model. AIDS Education and Prevention, 3, 50-59.
Brunswick, A. F., & Banaszak-Holl, J. (1996). HIV risk behavior and the Health Belief
Model: An empirical test in an African American community sample. Journal of
Community Psychology, 24, 44-65.
Butcher, A. H., Manning, D. T., & O’Neal, E. C. (1991). HIV-related sexual behaviors
of college students. Journal of American College Health, 40, 115-118.
Goldscheider, F., & Davanzo, J. (1986). Semiautonomy and leaving home during early
adulthood. Social Forces, 65, 187-201.
Gomez, C. A., & Marin, B. V. (1996). Gender, culture, and power: Barriers to
HIV-prevention strategies for women. The Journal of Sex Research, 33, 355-362.
Graves, K. L. (1995). Risky sexual behavior and alcohol use among young adults.
American Journal of Health Promotion, 10, 27-36.
Holtzman, D., Bland, S. D., Lansky, A., & Mack, K. A. (2001). HIV-related behaviors
and perceptions among adults in 25 states: 1997 behavioral risk factor surveillance
system. American Journal of Public Health, 91, 1882-1888.
Hudson, W. W., Murphy, G. J., & Nurius, P. S. (1983). A short-form scale to measure
liberal vs. conservative orientations toward human sexual expression. Journal of
Research on Adolescence, 19, 258-272.
Hynie, M., & Lydon, J. E. (1995). Women’s perceptions of female contraceptive be-
havior: Experimental evidence of the sexual double standard. Psychology of
Women Quarterly, 19, 563-581.
Jemmott, J. B., & Jemmott, L. S. (1993). Alcohol and drug use during sexual activity:
Predicting the HIV-risk-related behaviors of inner-city Black male adolescents.
Journal of Adolescent Research, 8, 41-57.
Jemmott, L. S., & Jemmott, J. B. (1992). Increasing condom-use intentions among sex-
ually active Black adolescent women. Nursing Research, 41, 273-279.
LaBrie, J. W., Schiffman, J., & Earleywine, M. (2002). Expectancies specific to con-
dom use mediate the alcohol and sexual risk relationship. The Journal of Sex Re-
search, 39, 145-152.
Levinson, R. A., Jaccard, J., & Beamer, L. (1995). Older adolescents’ engagement in
casual sex: Impact of risk perception and psychosocial motivations. Journal of
Youth and Adolescence, 24, 349-364.
 68 JOURNAL OF PSYCHOLOGY & HUMAN SEXUALITY

Lollis, C. M., Johnson, E. H., & Antoni, M. H. (1997). The efficacy of the Health Belief
Model for predicting condom usage and risky sexual practices in university stu-
dents. AIDS Education and Prevention, 9, 551-563.
MacNair-Semands, R. R., & Simono, R. B. (1996). College student risk behaviors: Im-
plications for the HIV-AIDS pandemic. Journal of College Student Development,
Downloaded by [Athabasca University] at 04:19 20 June 2016

37, 574-583.
Madden, T. J., Ellen, P. S., & Ajzen, I. (1992). A comparison of the Theory of Planned
Behavior and the Theory of Reasoned Action. Personality and Social Psychology
Bulletin, 18, 3-9.
Mahoney, C. A. (1995). The role of cues, self-efficacy, level of worry, and high-risk
behaviors in college student condom use. Journal of Sex Education and Therapy,
21, 103-116.
Maiman, L. A., & Becker, M. H. (1974). The Health Belief Model: Origins and corre-
lates in psychological theory. In M. H. Becker (Ed.), The Health Belief Model and
personal health behavior. Thorofare, NJ: Charles B. Slack, Inc.
Muehlenhard, C. L., & Quackenbush, D. M. (1996). The social meaning of women’s
condom use: The sexual double standard and women’s beliefs about the meaning
ascribed to condom use. Unpublished manuscript.
National Institute on Alcohol Abuse and Alcoholism (2002). College drinking: Chang-
ing the culture.
Osgood, D. W., & Lee, H. (1993). Leisure activities, age, and adult roles across the life
span. Society and Leisure, 16, 181-208.
Sands, T., Archer, J., Jr., & Puleo, S. (1998). Prevention of health-risk behaviors in col-
lege students: Evaluation seven variables. Journal of College Student Development,
38, 331-342.
Smith, B. N., & Stasson, M. F. (2000). A comparison of health behavior constructs: So-
cial psychological predictors of AIDS-preventive behavioral intentions. Journal of
Applied Social Psychology, 30, 443-462.
Snell, W. E., Jr., & Finney, P. (1996). The Multidimensional AIDS Anxiety Question-
naire. Unpublished manuscript.
Steers, W. N., Elliott, E., Nemiro, J., Ditman, D., & Oskamp, S. (1996). Health beliefs
as predictors of HIV-preventive behavior and ethnic differences in prediction. The
Journal of Social Psychology, 136, 99-110.
Strecher, V. J., Champion, V. L., & Rosenstock, I. M. (1997). The Health Belief Model
and health behavior. In D. S. Gochman (Ed.), Handbook of health behavior re-
search I: Personal and social determinants (pp. 71-91). New York: Plenum Press.
Strecher, V. J., DeVellis, B. M., Becker, M. H., & Rosenstock, I. M. (1986). The role of
self-efficacy in achieving health behavior change. Health Education Quarterly, 13,
73-92.
Treboux, D., & Busch-Rossnagel, N. A. (1995). Age differences in parent and peer influ-
ences on female sexual behavior. Journal of Research on Adolescence, 5, 469-487.
Whitbourne, S. K., & Tesch, S. A. (1985). A comparison of identity and intimacy sta-
tuses in college students and alumni. Developmental Psychology, 21, 1039-1044.
Zimmerman, R. S., & Olson, K. (1994). AIDS-related risk behavior and behavior
change in a sexually active, heterosexual sample: A test of three models of preven-
tion. AIDS Education and Prevention, 6, 189-204.