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A Health Belief Model-Social Learning Theory Approach to Adolescents' Fertility Control: Findings from a Controlled Field Trial

Original article authored by:
Marvin Eisen, PhD., Gail L. Zellman, PhD, and Alfred L. McAlister, PhD

This research summary is divided into the following sections:

Introduction

The current study is a follow-up to a pilot sexuality education program that combined elements of the Health Belief Model (HBM) and Social Learning Theory (SLT). The promising results of that project led the researchers to conduct this longer-term field trial.

Based upon four major Health Belief Model theoretical constructs, the HBM-SLT curriculum aimed to increase adolescents' awareness of:

  • the probability of becoming pregnant or getting one's partner pregnant;

  • the negative personal consequences of teen pregnancy;

  • the benefits of delaying sexual activity or using protection; and

  • the barriers to abstinence and contraceptive use.

The program's three objectives were to:

  • increase knowledge of and motivation for abstinence or contraceptive use;

  • measure the effect of any change in knowledge and motivation on any change in sexual and contraceptive behavior over the period of one year, and

  • compare the impact of the HBM-SLT curriculum with a range of other community-based programs.

The authors hypothesized that exposure to the HBM-SLT intervention, as opposed to the comparison programs, would lead to fewer transitions to sexual activity and an increase in consistent contraceptive use over the one-year follow-up period.

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Experimental Design and Methods

Agency and Participant Sample
Seven agencies providing family planning services to youth in California and Texas and one Northern Californian school district compared their regular curricula with the HBM-SLT intervention. The agencies served rural to urban low-income youth and recruited participants using their normal methods. The school district selected their eighth- and ninth-grade students for participation.

The 1,444 original participants were 13-19 years of age (mean age=15.5), and 52% were female. Fifty-three percent of participants were Latino, 24% African-American, 15% White, and 8% Asian. Almost two-thirds had had previous sexuality education; 37% had had sexual intercourse. Half of those who had had intercourse reported using contraception at last intercourse, and 74% of those who reported using any contraception at last intercourse used a condom.


Data Collection
Participants were randomly assigned to the comparison or HBM-SLT curriculum at each site. Between June 1986 and August 1987, 1,444 participants were individually interviewed with a questionnaire before the onset of the program (Time 1 data). Of those, 1,328 then participated in part or all of the 12-week HBM-SLT or comparison program and completed the same questionnaire in writing in a group setting (Time 2 data). Between July 1987 and September 1988, 888 participants were re-interviewed with the questionnaire for the 12-month follow-up (Time 3 data).


Programs
Both the HBM-SLT and the Comparison programs were of similar length (up to 12 hours) and covered reproductive biology, contraception, STIs, and sexual decision-making. The HBM-SLT curriculum differed from the other programs in that it emphasized four conceptual components of the HBM model (see Introduction), and in its utilization of role-playing and active student participation as teaching methods. Specific self-efficacy exercises were not included in the program. Educators who delivered the HBM-SLT intervention participated in a two-day training.


Questionnaire
The evaluation instrument assessed beliefs, knowledge, attitudes and behaviors related to sexuality, including abstinence continuation, transition to sexual activity, contraceptive behaviors and pregnancy. It also included items that examined HBM concepts and self-efficacy. The Time 1 interview also included demographic information items.


Analysis
For their analysis, the authors categorized participants by gender and virginity status: female and male Time 1 virgins and female and male Time 1 nonvirgins. Continued abstinence, transition to sexual activity and use of contraception were examined for virgins, and consistent use of contraception was examined for nonvirgins. The authors also examined the incidence of pregnancy and the effects of demographic variables and Time 2 sex knowledge and health beliefs on participants' abstinence maintenance and contraceptive behaviors.

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Results

Female and Male Time 1 Virgins
Seventy percent, or 400 of the 567 Time 1 virgins, remained abstinent throughout the 12-month follow-up period. HBM-SLT females and males were no more likely than comparison participants to remain sexually abstinent or to use contraception if they had become sexually active. In fact, females in the comparison group were better contraceptors at Time 3 than their HBM-SLT counterparts.


Female and Male Time 1 Nonvirgins
Males in both groups showed significant increases in contraceptive use, with the HBM-SLT males reporting greater improvement than comparison counterparts. HBM-SLT females, however, did not exhibit improved contraceptive use over comparison females.


Incidence of Pregnancy
Ten percent (10%) of females and 5% of males reported involvement in a pregnancy. There was no difference here by gender or treatment group.


Sex Knowledge, Health Beliefs and Demographic Variables
At Time 2, HBM-SLT participants exhibited greater sexual knowledge than comparison participants, but the groups were similar in terms of health beliefs. Demographics and Time 2 health beliefs accounted for some of the variation in abstinence maintenance and contraceptive behavior. (In the interest of brevity, these results are not discussed in this summary.)

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Discussion of Outcomes

The authors expected to see a larger proportion of contraceptive behavior to be predicted by exposure to the HBM-SLT curriculum and by students' reported Time 2 health beliefs. The lack of change could be partially due to three factors:

  1. many of the participants were virgins at the onset of the study and remained sexually abstinent throughout the program;

  2. this study compared the HBM-SLT curriculum with other sexuality education programs rather than with a "no treatment" control group; and

  3. the HBM-SLT program was cut to 12 hours maximum whereas many of the comparison programs were actually expanded to 12 hours from their normal length. Thus, the programs' potential impact were virtually equal.

Furthermore, only two-thirds of the original interviewees were available for the Time 3 interview, as many had moved out of the area. Analyses revealed no major differences in terms of sexual or contraceptive behaviors between those who remained and those who moved away, but it is possible that the loss of so many participants affected the final results of the study.

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Study Implications (by the authors of the original article)

  • Intervention programs should be client-group specific — one program may not be equally effective for all participants. The HBM-SLT program appeared to be most effective with sexually experienced males by increasing their consistent use of contraception. It is possible that the use of role-plays and active student participation in the HBM-SLT curriculum increased the males' awareness of pregnancy risk and their sense of responsibility in pregnancy avoidance.

  • For females, the comparison programs appeared more effective. It is possible that many females in this study were already very aware of the risks of pregnancy, especially those who were virgins at the onset of the program. Thus, the impact of the HBM-SLT program was not as great as for males.

  • The success of the HBM-SLT could be improved were its components strengthened and presented in the original 12-15 hours instead of in 8-12 hours, as in the current study.
Eisen, M., PhD, Zellman, G.L., PhD, McAlister, A.L., PhD. (1992) A Health Belief Model-Social Learning Theory Approach to Adolescents' Fertility Control: Findings from a Controlled Field Trial. Health Education Quarterly, 19(2), 249-262.

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