Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2016 Jun 1.
Published in final edited form as: J Prim Prev. 2015 Jun;36(3):155–166. doi: 10.1007/s10935-015-0383-6

HIV testing among teens attending therapeutic schools: Having a personal source of information about HIV/AIDS matters!

Rebecca R Swenson 1, Christopher Houck 1, David Sarfati 1, Erin Emerson 2, Geri Donenberg 2, Larry K Brown 1
PMCID: PMC4425569  NIHMSID: NIHMS661807  PMID: 25656380

Abstract

Being informed and using positive coping strategies are associated with engaging in health-promoting behaviors. We assessed whether the type of information source about HIV (personal or impersonal) and coping strategies (optimism, avoidance, or emotion-focused) are associated with HIV testing among adolescents attending therapeutic schools. Participants were 417 adolescents, ages 13 to 19, who attended one of 20 therapeutic day schools for emotionally/behaviorally disordered youth in two U.S. cities (Providence, RI and Chicago, IL) and completed a baseline assessment for an HIV prevention study. Among adolescents in the study, 29% reported having been tested for HIV. Adolescents were more likely to have been tested if they were older, female, Hispanic, identified as non-heterosexual, came from lower SES households, and had recently had unprotected sex. Additionally, youth who endorsed greater use of optimistic thinking and emotion-focused coping, and who reported having been informed about HIV by more personal sources, were also more likely to have been tested for HIV. In a multivariate analysis, having had recent unprotected sex and having more personal sources of information about HIV/AIDS were independently associated with HIV testing. Study findings suggest that, controlling for sociodemographic background, sexual risk behavior, and coping strategy, HIV testing among adolescents with emotional and behavioral problems may be increased when adolescents learn about HIV/AIDS from personal sources such as their healthcare providers, family, and friends.

Keywords: Adolescent, Sexual health, HIV testing, Health promotion, Health information, Coping

The HIV epidemic continues to be a significant public health problem in the United States, with about 50,000 new HIV infections each year since the mid-1990s (Hall et al., 2008). Of the 1.1 million Americans currently living with HIV, nearly one in five (18.1%) are unaware that they are infected (CDC, 2012a). This “hidden” population is important, given estimates that 50–70% of new cases of HIV are spread by people unaware of their infection (Marks, Crepaz, & Janssen, 2006). As such, routine universal HIV testing to allow for early detection and treatment (i.e., the test-and-treat strategy) is an important HIV prevention tool that can prolong the lives of infected individuals and also help to prevent further HIV transmission (Dieffenbach & Fauci, 2009). Individuals who are aware of their infection are able to take antiretroviral medications that reduce their likelihood of transmitting the infection to others and are also more likely to adopt preventive behaviors such as consistent condom use and monogamy.

Yet, the current rate of HIV testing among adolescents falls well below CDC guidelines, which recommend routine opt-out HIV testing for all adolescents ages 13 and older (CDC, 2006). According to data from the Youth Risk Behavior Survey, only 12.9% of high school students had ever been tested for HIV. Even among sexually active youth, less than one-third report having been tested (CDC, 2012b; Swenson, Rizzo, Brown et al., 2009). It is not surprising, then, that youth aged 13–24 are the least likely age group to be aware of their HIV infection, with nearly 60% of HIV positive youth unaware that they are infected (CDC, 2012c).

Adolescents and young adults acquire nearly half of all new sexually transmitted infections (STIs; Weinstock, Berman, & Cates, 2004). Youth with emotional and behavioral problems engage in higher rates of sexual risk behavior than their peers, placing them at an even greater risk for acquiring HIV (Brown, Danovsky, Lourie, et al., 1997; Brown, Hadley, Stewart, et al., 2010). Therefore, while it is important to promote routine universal HIV testing as a prevention strategy among all teens, it is particularly important to understand potentially modifiable factors that are associated with higher rates of HIV testing among teens with mental health problems, so that these may be utilized in the development of effective health promotion interventions for this at-risk population. Two such factors that are particularly relevant to adolescents with mental health problems, for whom healthcare providers and other supportive persons may serve as a point of intervention, are sources of information about HIV (i.e., from whom they learn about prevention) and coping styles (i.e., how they manage stressful events such as a potential exposure to HIV or the decision to be tested).

Information Sources and HIV Testing

Adolescents with mental health problems, if in treatment, have the opportunity to learn about HIV and other sexual health topics from healthcare providers. They may also learn about HIV from family or friends. Other teens may prefer not to discuss sexual health topics with other people and may instead seek out information on the Internet or through other less personal sources. Although studies demonstrate that greater knowledge about HIV and other sexually transmitted infections (STIs) is associated with increased rates of HIV testing (Nyamathi et al., 2000; Swenson et al., 2009), what we have yet to understand is whether the source of knowledge or information about HIV matters. Specifically, with regard to HIV testing, we don’t know whether it is preferable for adolescents to obtain sexual health information from a personal source or if it is sufficient to refer youth to the Internet, printed material, and other forms of media for information about HIV.

Adolescents in mental health treatment may benefit from sexual health discussions with their doctor, therapist, or counselor. Effective patient-provider communication, when it occurs, leads to better compliance with treatment recommendations and improved health outcomes (Beck, Daughtridge, & Sloan, 2002; Stewart, 1995). Adolescents also commonly learn about sexual health topics from their family and friends. Indeed, teens who talk about sex with their parents, relative to their peers who do not, have positive sexual health outcomes including delayed sexual initiation, less engagement in sexual risk behavior, and fewer unexpected pregnancies (Hutchinson & Montgomery, 2007; Lederman et al., 2008). Teens may discuss sexual health topics with their friends but the accuracy of this information is questionable and more likely to focus on positive outcomes than negative consequences (Bleakley et al., 2009; Mosena et al., 2004; Nonoyama et al., 2005).

Another source from which adolescents learn about HIV is print and other media such as books, pamphlets, magazines, television, radio, and the Internet. Media sources vary greatly in quality and, though predominantly accurate, research suggests that teens tend to be wary of these impersonal sources (Buhi et al., 2010; Hust et al., 2008; Jones & Biddlecom, 2011). As such, teens may be more likely to trust and act on information about HIV from people with whom they have a relationship. While it is critical to provide adolescents with accurate information about HIV, more needs to be known about what type of information source (personal v. impersonal) most influences HIV testing behavior in order to design effective information campaigns for adolescents to increase testing rates.

Coping and Health Behavior

Another factor that is highly relevant to youth with mental health problems (and amenable to change among those in treatment) is coping. Stress and coping theory (Lazarus & Folkman, 1984) defines ‘coping’ as the thoughts and behaviors used to manage stressful events. Stress can result when a given situation is appraised as having demands that exceed one’s ability to cope. Numerous models of coping abound in the literature and there is a general lack of consensus regarding conceptualization and terminology, particularly with regard to children’s coping mechanisms (Compas, 2001). The present paper adopts the conceptualizations and terminology from the Children’s Coping Strategies Checklist, an empirically-established measure that identifies different strategies children use for coping with stress (Ayers et al., 1996). Optimism, avoidance, and emotion-focused coping are three coping strategies children use that may be particularly relevant to sexual risk and health-promoting behaviors during adolescence.

The first of these, optimism, is an active coping strategy that uses cognitive restructuring to positively reframe a stressful situation. In the case of HIV testing, an adolescent who has had unprotected sex may think, “If I get tested, I’ll know my status and won’t need to worry about it anymore.” Among college students and new mothers, optimism is positively associated with health-promoting behaviors (Gill & Loh, 2010; Mulkana & Hailey, 2001). More optimistic students reported better actual and imagined health habits (i.e., health-promoting behaviors the students imagined they would take if diagnosed with a life-threatening illness). Although it is possible that optimistic thinking may lead some youth to believe they are invulnerable to HIV and, therefore, to believe that HIV testing is unnecessary, the research cited above suggests that optimistic thinking about health encourages youth to adopt better health habits. To this end, preventive screenings such as routine HIV testing constitute a healthy habit that optimistic thinkers may be more inclined to adopt.

Avoidant coping, on the other hand, may involve taking actions to avoid the problem, such as staying away from the doctor or declining an HIV test because of worry that one may test positive for HIV. A recent study found that adolescents with less self-control were more likely to use avoidant coping strategies, which, in turn, was related to poorer physical health outcomes (Boals et al., 2011). Authors posited that teens that used avoidant coping were in poorer health due to less engagement in health-promoting behaviors. In addition, adolescents who reported a greater use of avoidant coping engaged in more risk-taking behavior (Steiner, Erickson, Hernandez, et al., 2002).

Lastly, emotion-focused coping, as defined by Ayers, consists of engaging others to listen to feelings or provide understanding to help one feel less upset. Emotion-focused coping (i.e., emotional expression and processing/understanding) is adaptive and associated with positive health-related outcomes (Austenfeld & Stanton, 2004). For example, among patients with chronic pain, those that reported a positive emotional approach to coping reported less pain and fewer depressive symptoms (Smith, Lumley, & Longo, 2002). Additionally, males with HIV who received more emotional support (e.g., listening, empathy) from a primary support provider also reported greater engagement in health behaviors (Deichert, Fekete, Boarts, Druley, & Delahanty, 2008). With regard to HIV testing, sharing their fears with a doctor or counselor and receiving support for their feelings may help adolescents regulate anxiety about testing positive for HIV.

We are not aware of any current research that has examined the role that coping plays in determining the likelihood of HIV testing among either youth or individuals with emotional and behavioral problems. However, among an at-risk sample of adult women, active coping strategies were associated with increased likelihood of HIV testing (Nyamathi et al., 2000). Adolescents with emotional and behavioral problems may exhibit coping deficits, but they are also in the unique position to be referred for therapeutic interventions to improve their coping skills. As such, it is important to identify coping strategies that are most likely to lead to adolescents’ increased utilization (rather than neglect) of preventive healthcare services and screenings, such as HIV testing.

The Current Study

In the current study, we examined the prevalence and correlates of HIV testing among adolescents who attend therapeutic day schools. These schools serve students with mental health or behavioral difficulties who are unable to benefit from less restrictive academic environments because of their symptoms. Students attending therapeutic schools present with a range of diagnoses, including mood disorders (e.g., Major Depressive Disorder), behavior disorders (e.g., Conduct Disorder), or anxiety disorders (e.g., Generalized Anxiety Disorder). Schools attend to individualized needs of the students with common elements of smaller class sizes, tailored methods of instruction, and supportive services (e.g., individual and/or group psychotherapy) to promote their students’ success. Teens attending therapeutic schools are at high-risk for emotional and behavioral problems, which are linked with higher sex risk behavior (Brown et al., 1997; Brown et al., 2010). Teens with emotional and behavioral problems may also be more likely to have coping deficits. Thus, we first examined the relationship between recent unprotected sex and HIV testing among a high-risk sample of therapeutic school teens. We then examined the relationship between HIV information source, coping strategy, and HIV testing. We expected to find that adolescents who engaged in unprotected sex would be more likely to have been tested for HIV. In addition, we expected that youth who used more optimism and emotion-focused coping (versus avoidant) strategies and those who had sought or received HIV information from more personal (versus impersonal) sources would be more likely to have been tested for HIV.

Method

Participants

We recruited adolescents, ages 13 to 19, from 20 therapeutic day schools in two U.S. cities (Providence, RI and Chicago, IL) to take part in a larger study of HIV prevention interventions (Donenberg et al., 2012). Inclusion criteria included age and expected attendance at a participating therapeutic school for the duration of the intervention (i.e., students that were being discharged or moving were not invited to participate). Exclusion criteria included inability to speak English fluently, pervasive developmental disability or active psychotic disorder, known HIV infection, history of sexually aggressive behavior, or current pregnancy. Of the 569 adolescents for whom we obtained consent to contact about the study, 417 (73%) were subsequently consented, assessed, and provided data for this study.

Procedures

Institutional review boards at both study sites approved all study protocols. We obtained informed consent either from parents and guardians of youth under the age of 18 or from adult participants. Minor participants also provided written assent. Between 2005 and 2009, we recruited adolescents from therapeutic schools for students with mental health concerns and behavior problems in Providence and Chicago. School staff first identified youth whom they thought were eligible for the project and requested permission by letter or phone from parents or guardians for study staff to contact them regarding the project. After permission was granted, research staff arranged individual meetings with parents (or adolescents 18 years or older) to complete screening procedures, explain the study in detail, and obtain consent.

This current cross-sectional study used baseline data from a larger longitudinal study that were collected via audio computer-assisted self-interviews (ACASI). To assist in behavior recall, study staff prompted participants to generate a list of significant events in the last 90 and 180 days to reference during the assessment. Project staff were present to answer questions as needed; school staff were not present during assessments to ensure the confidentiality of responses. Participants completed the entire assessment via ACASI in one to three sittings, for a total of approximately 75 minutes, and were compensated $25 for their time.

Measures

Computerized Diagnostic Interview Schedule for Children (C-DISC-IV; Shaffer, 2000)

The C-DISC-IV is a structured audio computer-assisted diagnostic interview used to screen for a range of psychiatric diagnoses using DSM-IV criteria. The C-DISC-IV has demonstrated acceptable reliability and validity (Shaffer, 2000). For the current study, we administered modules assessing symptoms of Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Major Depressive Disorder, Mania, Hypomania, Oppositional Defiant Disorder, and Conduct Disorder. We created a dichotomous variable for the analyses to compare youth who met threshold or intermediate criteria for a psychiatric disorder on the C-DISC-IV to those who did not.

Adolescent Risk Behavior Assessment (ARBA; Donenberg, Emerson, Bryant, Wilson, Weber-Shifrin, 2001)

The ARBA is a measure of adolescent-reported sexual and drug use behaviors that uses a skip structure so that adolescents who deny engaging in a given behavior are not asked more detailed questions about it. Relevant to the present analyses, adolescents reported whether they had ever had sex. Sexually active participants provided the number of times they had vaginal or anal sex in the last six months and the number of times they used condoms, which we used to determine each participant’s number of unprotected sexual encounters in the last six months.

The ARBA also assessed HIV testing history. Adolescents were asked “Have you ever been tested for HIV, the virus that causes AIDS?” to which they could reply “yes,” “no,” or “don’t know.” Four participants who responded “don’t know” were excluded from the analyses.

Sources of HIV Information

Participants reported whether they had received information about HIV/AIDS from the following sources: 1) family, 2) friends, 3) doctor, 4) therapist or counselor, 5) TV or radio, 6) books, pamphlets, or magazines, and 7) Internet. For the current analyses, we summed family, friends, doctor, and therapist as “personal” interactions and TV/radio, books/pamphlets/magazines, and Internet as “impersonal” interactions.

Children’s Coping Strategies Checklist (CCSC; Ayers, Sandler, West & Roosa, 1996)

Adolescents completed three subscales of the CCSC. The Support for Feelings (SUPF) subscale consisted of four items (Cronbach’s alpha = .82). A sample item is “You let other people know how you felt.” The Optimism (OPT) subscale included four items (Cronbach’s alpha = .83) that reflect efforts to think about situations more positively, including optimistic thinking (e.g., “You told yourself that it would be okay”). The Avoidant Actions (AVA) subscale included three items from the original subscale (Cronbach’s alpha = .60) that reflect behavioral strategies to avoid the stressor (e.g., “You tried to stay away from things that made you feel upset”).

Data Analysis

We conducted bivariate logistic regressions to determine variables for entry in the final logistic regression models. The potential predictors entered into the bivariate logistic regression models included the hypothesized predictors from demographic, behavioral, and cognitive domains. All predictors that were associated with HIV testing at the bivariate level (p < .10) were simultaneously entered into a multivariate logistic regression model, adjusted for significantly associated demographic variables. We selected simultaneous entry of predictors because there were no specific hypotheses for these exploratory analyses about the relative importance of behavioral and cognitive domains relative to demographics; rather, we were concerned with the context of known variables related to testing. Analyses were performed using SPSS version 18.0.

Results

Characteristics of the Sample

Demographic Characteristics

The average age of participants was 15.25 (SD = 1.47) years. The majority were male (70%) and heterosexual (77%). With regard to racial/ethnic background, 44% endorsed White, non-Hispanic; 26% Black, non-Hispanic; 7% White, Hispanic; 4% Black, Hispanic; 13% Biracial; 4% Multiracial; and 2% Other. In addition, 52% of the sample reported that they were eligible to receive free or reduced-priced lunch in school.

Psychiatric Disorders

Using the C-DISC-IV, 54% of the sample met threshold or intermediate criteria for at least one of the diagnostic modules assessed and 42% did not meet criteria for any module (for the remaining 4%, presence or absence of a diagnosis could not be determined due to missing data on the clinical report). Among those that met criteria, diagnostic categories were as follows: 9% (n = 37) Internalizing Disorder Only (Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, or Major Depressive Disorder); 25% (n = 106) Externalizing Disorder Only (Oppositional Defiant Disorder or Conduct Disorder); 11% (n = 45) Comorbid Internalizing and Externalizing Disorders but not Manic or Hypomanic Episode; 9% (n = 37) Manic or Hypomanic Episode.

Sexual Behaviors and Health Outcomes

Sixty percent of participants reported having ever had vaginal or anal sex. Among sexually active participants, adolescents reported an average of 1.50 (SD = 1.91) vaginal or anal sex partners and 5.96 unprotected sex acts (SD = 22.09) in the past 6 months. Additionally, 8.1% of the sexually active participants reported having ever been told by a doctor or nurse that they had an STI.

Prevalence and Correlates of HIV Testing Among Adolescents in Therapeutic Schools

In the present sample (N=417), 29% of participants reported that they had been tested for HIV during their lifetime. Among participants who reported a history of vaginal or anal intercourse (n = 243), this increased to 42%. Of those that reported ever having been tested for HIV, many (48%) reported having only been tested once and 60% had been tested recently, within the past 6 months. Meeting criteria for a psychiatric disorder, having had recent unprotected sex, greater use of emotion-focused coping and optimism, and reporting more personal sources of information about HIV/AIDS were positively correlated with having had an HIV test (Table 1).

Table 1.

Associations between HIV testing and main study variables among adolescents attending therapeutic schools (N = 417)

Variables M (SD) or % 1 2 3 4 5 6 7
1. HIV Testing 29% --
2. Psychiatric Disorder 54% .10* --
3. Recent Unprotected Sex 33% .22*** .06 --
4. Support for Feelings (range = 1–4) 2.04 (.78) .15** .04 .15** --
5. Optimism (range = 1–4) 2.13 (.81) .11* .03 .09† .66*** --
6. Avoidant Actions (range = 1–4) 2.25 (.73) .08 .07 .06 .56*** .60*** --
7. Personal Sources (range = 0–4) 1.99 (1.44) .19*** .10* .20*** .16** .10† .08 --
8. Impersonal Sources (range = 0–3) 1.34 (1.16) .09† .03 .14** .17** .14** .14** .52***
Open in a new tab
†

p < .10.

*

p < .05.

**

p < .01.

***

p < .001.

Coping Strategy and HIV Information Source

Means and frequencies of adolescents’ coping strategies and personal and impersonal HIV information sources are reported in Table 1. Coping strategy mean scores ranged from 1 to 4, with higher scores indicating greater use of the coping strategy. Among adolescents attending therapeutic schools, the mean score was 2.04 (SD = .78) for support for feelings, 2.13 (SD = .81) for optimism, and 2.25 (SD = .73) for avoidant actions.

Participants also reported on the sources from which they had received information about HIV/AIDS. With regard to the four personal sources assessed, 62% of adolescents had received information about HIV/AIDS from family, 56% from a doctor, 49% from friends, and 32% from a therapist or counselor. With regard to the three impersonal sources assessed, 48% received information about HIV/AIDS from TV or radio, 44% from books, pamphlets, or magazines, and 43% from the Internet. Eight percent reported that they had not received information about HIV/AIDS from any source.

We also examined the distribution of personal and impersonal sources. Twenty-two percent of adolescents attending therapeutic schools reported no personal sources of HIV information, 20% reported one personal source, 16% reported two personal sources, 23% reported three personal sources, and 20% reported having four personal sources. Thirty-three percent of adolescents reported no impersonal sources of HIV information, 23% reported one impersonal source, 20% reported two impersonal sources, and 23% reported having three impersonal sources.

Bivariate Correlates of HIV Testing

Table 2 contains bivariate associations between HIV testing, demographics, and main study variables. Among the demographic variables, older age, female gender, Hispanic origin, eligibility for free or reduced-price school lunch, and non-heterosexual orientation were significantly associated with increased likelihood of HIV testing. Meeting diagnostic criteria for a psychiatric disorder was significantly associated with increased likelihood of HIV testing at the bivariate level. With regard to sexual risk behavior, having had one or more unprotected sex acts was significantly associated with increased likelihood of HIV testing. For coping strategies, more use of support for feelings and optimism were significantly associated with increased likelihood of HIV testing. Contrary to expectations, use of avoidant actions was unrelated to HIV testing. In addition, the number of participants’ personal sources of HIV information was significantly associated with increased likelihood of HIV testing, whereas having more impersonal information sources was marginally associated with testing.

Table 2.

Correlates of HIV testing among adolescents attending therapeutic schools (N = 417)

Variable HIV Test
na (%)		 Unadjusted
ORb 		p value MLR
ORc (CI)		 p value
Site
 Providence 63/217 (29%) 0
 Chicago 58/194 (30%) 1.042 .848
Age
 13–14 31/137 (23%) 0 0
 15+ 90/274 (33%) 1.673 .033 1.307 (.735–2.323) .362
Gender
 Male 69/287 (24%) 0 0
 Female 52/124 (42%) 2.282 .000 1.493 (.863–2.585) .152
Ethnicity
 Non-Hispanic 90/334 (27%) 0 0
 Hispanic 31/77 (40%) 1.827 .022 1.242 (.664–2.322) .498
Race
 Other 89/305 (29%) 0
 Black 32/106 (30%) 1.049 .844
Free Lunch Status
 No 47/197 (24%) 0 0
 Yes 74/214 (35%) 1.687 .018 1.578 (.947–2.631) .080
Sexual Orientation
 Heterosexual 78/297 (26%) 0 0
 Non-heterosexual 35/90 (39%) 1.787 .022 1.656 (.928–2.957) .088
Psychiatric Disorder
 No 42/173 (24%) 0 0
 Yes 74/222 (33%) 1.560 .051 1.475 (.885–2.457) .136
Recent USAs
 No 60/264 (23%) 0 0
 Yes 57/128 (45%) 2.730 .000 2.328 (1.377–3.936) .002
Support for Feelings 0 0
1.496 .004 1.158 (.757–1.773) .499
Optimism 0 0
1.334 .031 1.067 (.721–1.579) .747
Avoidant Actions 0
1.263 .120
Personal Sources 0 0
1.347 .000 1.256 (1.026–1.536) .027
Impersonal Sources 0 0
1.174 .086 0.956 (.748–1.221) .717
Open in a new tab

OR = Odds Ratios. CI = Confidence Intervals. MLR = Multivariate Logistic Regression. USA = Unprotected Sex Act.

a

n may vary according to random missing data patterns.

b

Unadjusted odds of receiving HIV testing.

c

MLR included all significant bivariate predictors of HIV testing (at p <.10).

Multivariate Correlates of HIV Testing

Controlling for significant demographics, we found that having had unprotected sex in the past six months (OR = 2.33) and having more personal sources of information about HIV/AIDS (OR = 1.26) were independently associated with HIV testing (see Table 2). Adolescents who reported having had unprotected sex were over twice as likely to have been tested for HIV.

Exploratory Analyses: Sexually Active Subset

Because sexual risk behavior emerged as the strongest correlate of HIV testing, we conducted exploratory analyses with the sexually active subset (n = 248). Bivariate correlates of HIV testing among sexually active youth included female gender (unadjusted OR = 2.06), non-heterosexual orientation (unadjusted OR = 2.60), more use of support for feelings (unadjusted OR = 1.49), optimism (Unadjusted OR = 1.42), and avoidant coping (unadjusted OR = 1.55), as well as having more personal sources of HIV information (unadjusted OR = 1.23). However, when entered into a multivariate logistic regression, only non-heterosexual orientation remained significant (OR = 2.47). Of the sexually active subset, a sizeable minority (21%) identified as having a non-heterosexual orientation (19 males and 33 females).

Because sexual orientation was not a main focus of the present paper but accounted for a large proportion of the variance, we conducted the analyses without this variable to determine whether findings differed. Removing sexual orientation among the sexually active subset yielded only a marginally significant finding for female gender (OR = 1.69). Among the full sample, however, findings were similar to those reported in Table 2, with recent unprotected sex acts (OR = 1.97) and personal sources of information (OR = 1.28) emerging as significant correlates of HIV testing. Additionally, two demographic variables, free lunch status (OR = 1.75) and female gender (OR = 1.60), emerged as significant and marginally significant, respectively.

Discussion

This study contributes important information to our understanding of HIV testing, a primary focus of current strategies in the field of HIV prevention. Our study examined relationships between HIV testing, information sources, and coping strategies within a sample of therapeutic school adolescents with emotional and behavioral problems. Within this high-risk subgroup, 29% of youth reported having ever been tested for HIV, and 42% of those with a history of vaginal or anal sex reported testing. While higher than the national rate of 12.9% among high school students (CDC, 2012b), these rates of testing are low considering that these young people had been identified as needing additional services and were part of the health care system by virtue of their enrollment in therapeutic schools. The rates of testing found in the present sample of adolescents attending therapeutic schools were similar to those found among high-risk urban adolescents (Mullins et al., 2010; Swenson et al., 2009), but fall far short of the national goal of having all adolescents tested as part of their routine health care. These numbers suggest that much work remains to be done to promote HIV testing among vulnerable adolescents.

In general, adolescents reported higher rates of receiving information about HIV/AIDS from personal sources, such as doctors, family, and friends, than from impersonal sources, such as television, magazines, or the Internet. The notable exception to this pattern was for information received from therapists and counselors. Less than one-third of students attending these therapeutic schools reported having received information about HIV/AIDS from counselors. Given that mental health counseling is often a key component of programs for youth with mental health problems, this percentage represents a missed opportunity. It is possible that therapists in these schools presume that HIV/AIDS information is taught via health classes or feel that encouraging HIV-prevention behaviors such as routine HIV testing is outside the purview of a therapy session. However, addressing HIV and sexual risk behaviors in a tailored, one-on-one fashion has advantages over classroom-based instruction, particularly for youth with mental health concerns. To the extent that therapists do not feel equipped to discuss risky sexual behaviors and HIV prevention with clients, providing training regarding adolescent sexual risk assessments may better enable therapists to discuss and encourage HIV testing with their teenage clients when appropriate to do so. Furthermore, 8% of participants in the study did not endorse receiving information about HIV/AIDS from any of the sources listed, and 22% did not identify any of the personal sources listed. This is particularly important given the strong relationship between personal sources of information and HIV testing identified in this study.

Correlates of HIV testing were generally consistent with previous literature (e.g., Johns, Bauermeister, & Zimmerman, 2010; Swenson et al., 2009). Adolescents were more likely to have been tested for HIV if they were older, female, Hispanic, identified as non-heterosexual, came from lower SES households, met criteria for a psychiatric disorder, or had had unprotected sex. We also examined relationships between HIV testing, sources of information, and coping strategies. As expected, significant bivariate relationships indicated more testing among youth who endorsed greater use of emotion-focused coping strategies such as talking to others about one’s feelings, greater use of optimistic thinking, and more personal sources of HIV information. These bivariate relationships supported the hypothesis that youth with more positive coping strategies that might encourage health-seeking behaviors would be more likely to have sought or agreed to HIV testing. Obtaining support from others to maintain health, or thinking optimistically about one’s ability to maintain health, may increase the likelihood of using information to get tested. Young people were also more likely to be tested when that information came from people in their lives, rather than mass media, highlighting the powerful influence of personal interactions.

However, in multivariate models accounting for all of these variables, the two variables that emerged with significant relationships to HIV testing were unprotected sex and personal sources of information. The strong association between personal information sources and increased likelihood of testing, even when we included in the model demographics, unprotected sex (which has consistently been shown to be related to testing), coping, and impersonal sources, suggests that these personal conversations with teens play an important role in health decision-making. It may be that, from a developmental standpoint, a “personal touch” is especially critical for adolescents. In addition, publicly expressing attitudes or beliefs increases the likelihood of changing behavior so that it remains consistent with those beliefs (Dawnay & Shah, 2005). In the case of HIV testing, personal conversations may evoke statements that adolescents later use as evidence to support the decisions they make. While our study was concerned with the source of HIV information rather than the content of these interactions, it would be interesting in future studies to assess the quality, quantity, and accuracy of these communications.

Our findings highlight the importance of finding ways to communicate directly with vulnerable adolescents about HIV prevention. Public health initiatives should focus on encouraging professionals who have relationships with young people to discuss HIV and HIV testing, especially with adolescents who have mental health problems. These data suggest that general coping strategies may not be as relevant to HIV testing as personal messages. Even in bivariate relationships, avoidant coping was not associated with poorer rates of testing, as we had hypothesized. This may be encouraging news for the prevention field, suggesting that adolescents’ coping styles might be sidestepped in the development of informational interventions to promote health behavior.

We note several limitations to our study. Because study participants attended therapeutic schools as a result of emotional or behavioral difficulties, the generalizability of these findings to adolescents without such challenges is unknown. We collected data in two communities in the U.S.; differential availability of HIV testing in other regions may influence the patterns in HIV testing we reported in this study. In addition, the coping measures used in our study were general as opposed to specific; thus, coping strategies specific to HIV testing may affect adolescent testing behavior. Additionally, the content (quality, quantity, and accuracy) of HIV information that adolescents received from these various sources, as well as delivery approach, was not assessed and may confound the outcome of HIV testing. However, at the expense of internal validity that might have been gained by standardizing information content and delivery, the method we described is more reflective of “real world” interactions in that the content and delivery of information is indeed likely to vary across sources. We think it is particularly interesting that, despite real differences in the exact content and delivery of health information that youth reported that they received from various sources, personal sources emerged as having a strong influence on teen testing behavior. The real world implication of this is that face-to-face communications about HIV/AIDS are important and should be encouraged. Other sources of HIV information not included in this study may also serve important functions for youth, such as teachers or clergy. Finally, HIV testing was self-reported, and teens may have overestimated their rates of testing because they were participating in a study of HIV prevention, or data may be subject to recall bias. Some teens in this sample of emotionally and behaviorally disturbed youth may have erroneously perceived that they were tested for HIV if they had their blood drawn in a physician’s office for routine monitoring of psychoactive medications. However, prior research has demonstrated that self-reports of most sexual behavior, including HIV testing, can be assessed reliably among adolescents (Vanable et al., 2009). Additionally, we asked participants to identify memory anchors to improve recall.

Despite these limitations, our study adds to the literature on adolescent HIV testing by highlighting the vital role that personal discussions with healthcare providers, family, and friends about HIV/AIDS can play in adolescent health-seeking behavior. Findings also suggest that therapists working with teens with emotional and behavioral problems can have more of an impact on HIV preventive behavior than they currently do. Given that personal discussions about HIV were associated with HIV testing over and above the influence of both sex risk behavior and coping strategies in this sample of therapeutic school adolescents, our findings suggest that HIV testing may be increased by having personal conversations about HIV with teens. Indeed, prior research has demonstrated that over half of teens who are offered an opportunity for an HIV test are likely to accept (Swenson, Hadley, Houck, et al., 2011). Future research should further examine the content, quantity, quality, and accuracy of communication provided to teens about HIV to determine what components or styles most greatly affect adolescent HIV testing.

Acknowledgments

This research was supported by National Institute of Mental Health grant R01 MH 066641, a collaborative project awarded to participating sites: Rhode Island Hospital and University of Illinois at Chicago.

Footnotes

Conflict of Interest

Authors have no conflicts of interest to report.

References

  1. Austenfeld JL, Stanton AL. Coping through emotional approach: A new look at emotion, coping, and health-related outcomes. Journal of Personality. 2004;72:1335–1364. doi: 10.1111/j.1467-6494.2004.00299.x. [DOI] [PubMed] [Google Scholar]
  2. Ayers TS, Sandler IN, West SG, Roosa MW. A dispositional and situational assessment of children’s coping: Testing alternative models of coping. Journal of Personality. 1996;64:923–58. doi: 10.1111/j.1467-6494.1996.tb00949.x. [DOI] [PubMed] [Google Scholar]
  3. Beck RS, Daughtridge R, Sloan PD. Physician-patient communication in the primary care office: A systematic review. Journal of the American Board of Family Practice. 2002;15:25–38. [PubMed] [Google Scholar]
  4. Bleakley A, Hennessy M, Fishbein M, Jordan A. How sources of sexual information relate to adolescents’ beliefs about sex. American Journal of Health Behavior. 2009;33:37–48. doi: 10.5993/ajhb.33.1.4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Boals A, vanDellen MR, Banks JB. The relationship between self-control and health: The mediating effect of avoidant coping. Psychology & Health. 2011;26:1049–1062. doi: 10.1080/08870446.2010.529139. [DOI] [PubMed] [Google Scholar]
  6. Brown L, Danovsky M, Lourie K, DiClemente R, Ponton L. Adolescents with psychiatric disorders and their risk for HIV. Journal of the American Academy of Child & Adolescent Psychiatry. 1997;36:1609–1617. doi: 10.1016/S0890-8567(09)66573-4. [DOI] [PubMed] [Google Scholar]
  7. Brown LK, Hadley W, Stewart A, Lescano CM, Whitely L, Donenberg G, DiClemente R Project STYLE Study Group. Psychiatric disorders and sexual risk among adolescents in mental health treatment. Journal of Consulting and Clinical Psychology. 2010;78:590–597. doi: 10.1037/a0019632. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Bruine de Bruin W, Downs JS, Fischhoff B, Palmgren C. Development and evaluation of an HIV/AIDS knowledge measure for adolescents focusing on misconceptions. Journal of HIV/AIDS Prevention in Children & Youth. 2007;8:35–57. [Google Scholar]
  9. Buhi ER, Daley EM, Oberne A, Smith SA, Schneider T, Fuhrmann HJ. Quality and accuracy of sexual health information web sites visited by young people. Journal of Adolescent Health. 2010;47:206–208. doi: 10.1016/j.jadohealth.2010.01.002. [DOI] [PubMed] [Google Scholar]
  10. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;2006:55, 1–17. [PubMed] [Google Scholar]
  11. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data – United States and 6 U.S. dependent areas – 2010. HIV Surveillance Supplemental Report 202. 2012a;17(3 part A) [Google Scholar]
  12. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance, United States – 2011. 2012b;61(MMWR 2012)(SS-4) [Google Scholar]
  13. Centers for Disease Control and Prevention. HIV Surveillance Supplemental Report 2012. 3 part A. Vol. 17. Atlanta, GA: US Department of Health and Human Services, CDC; 2012c. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and six U.S. dependent areas—2010. 2012. [Google Scholar]
  14. Compas BE, Connor-Smith JK, Saltzman H, Thomsen AH, Wadsworth ME. Coping with stress during childhood and adolescence: Problems, progress, and potential in theory and research. Psychological Bulletin. 2001;127:87–127. [PubMed] [Google Scholar]
  15. Dawnay E, Shah H. Behavioral economics: Seven principles for policy makers. London: New Economics Foundation; 2005. [Google Scholar]
  16. Deichert NT, Fekete EM, Boarts JM, Druley JA, Delahanty DL. Emotional support and affect: Associations with health behaviors and active coping efforts in men living with HIV. AIDS and Behavior. 2008;12:139–145. doi: 10.1007/s10461-007-9214-y. [DOI] [PubMed] [Google Scholar]
  17. Dieffenbach CW, Fauci AS. Universal voluntary testing and treatment for prevention of HIV transmission. Journal of the American Medical Association. 2009;301:2380–2382. doi: 10.1001/jama.2009.828. [DOI] [PubMed] [Google Scholar]
  18. Donenberg GR, Emerson E, Bryant FB, Wilson H, Weber-Shifrin E. Understanding AIDS-risk behavior among adolescents in psychiatric care: Links to psychopathology and peer relationships. Journal of the American Academy of Child and Adolescent Psychiatry. 2001;40:642–53. doi: 10.1097/00004583-200106000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Donenberg G, Emerson E, Brown L, Houck C, Mackesy-Amiti ME. Sexual experience among emotionally and behaviorally disordered students in therapeutic day schools: An ecological examination of risk. Journal of Pediatric Psychology. 2012;37:904–913. doi: 10.1093/jpepsy/jss056. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Ebata AT, Moos RH. Coping and adjustment in distressed and healthy adolescents. Journal of Applied Developmental Psychology. 1991;12:33–54. [Google Scholar]
  21. Gill RM, Loh J. The role of optimism in health-promoting behaviors in new primiparous mothers. Nursing Research. 2010;59:348–355. doi: 10.1097/NNR.0b013e3181ed6b11. [DOI] [PubMed] [Google Scholar]
  22. Hall HI, Song R, Rhodes P, Prejean J, An Q, Lee LM, Karon J, Brookmeyer R, Kaplan EH, McKenna MT, Janssen RS. Estimation of HIV incidence in the United States. JAMA. 2008;300:520–29. doi: 10.1001/jama.300.5.520. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hust SJ, Brown JD, L’Engle KL. Boys will be boys and girls better be prepared: An analysis of the rare sexual health messages in young adolescents’ media. Mass Communication & Society. 2008;11:3–23. [Google Scholar]
  24. Hutchinson MK, Montgomery AJ. Parent communication and sexual risk among African Americans. Western Journal of Nursing Research. 2007;29:691–707. doi: 10.1177/0193945906297374. [DOI] [PubMed] [Google Scholar]
  25. Johns MM, Bauermeister JA, Zimmerman MA. Individual and neighborhood correlates of HIV testing among African American youth transitioning from adolescence into young adulthood. AIDS Education and Prevention. 2010;22:509–522. doi: 10.1521/aeap.2010.22.6.509. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Jones RK, Biddlecom AE. Is the Internet filling the sexual health information gap for teens? An exploratory study. Journal of Health Communication. 2011;16:112–123. doi: 10.1080/10810730.2010.535112. [DOI] [PubMed] [Google Scholar]
  27. Lazarus RS, Folkman S. Stress, appraisal, and coping. Springer; New York: 1984. [Google Scholar]
  28. Lederman RP, Chan W, Roberts-Gray C. Parent-Adolescent Relationship Education (PARE): Program delivery to reduce risks for adolescent pregnancy and STDs. Behavioral Medicine. 2008;33:137–143. doi: 10.3200/BMED.33.4.137-144. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447–1450. doi: 10.1097/01.aids.0000233579.79714.8d. [DOI] [PubMed] [Google Scholar]
  30. Mosena PW, Ely J, Ho J, Ruch-Ross HS. Peer advocates for health: A community-based program to improve reproductive health knowledge and lifestyle choices among adolescent males. International Journal of Men’s Health. 2004;3:221–240. [Google Scholar]
  31. Mulkana SS, Hailey BJ. The role of optimism in health-enhancing behaviors. American Journal of Health Behavior. 2001;25:388–395. doi: 10.5993/ajhb.25.4.4. [DOI] [PubMed] [Google Scholar]
  32. Mullins TL, Kollar LM, Lehmann C, Kahn JA. Changes in human immunodeficiency virus testing rates among urban adolescents after introduction of routine and rapid testing. Archives of Pediatrics and Adolescent Medicine. 2010;164:870–874. doi: 10.1001/archpediatrics.2010.161. [DOI] [PubMed] [Google Scholar]
  33. Nonoyama M, Tsurugi Y, Shirai C, Ishikawa Y, Horiguchi M. Influences of sex-related information for STD prevention. Journal of Adolescent Health. 2005;36:442–445. doi: 10.1016/j.jadohealth.2004.01.017. [DOI] [PubMed] [Google Scholar]
  34. Nyamathi AM, Stein JA, Swanson JM. Personal, cognitive, behavioral, and demographic predictors of HIV testing and STDs in homeless women. Journal of Behavioral Medicine. 2000;23:123–147. doi: 10.1023/a:1005461001094. [DOI] [PubMed] [Google Scholar]
  35. Shaffer D. Diagnostic Interview for Children (DISC 4.0) – Child Version. New York, NY: Columbia University; 2000. [Google Scholar]
  36. Smith JA, Lumley MA, Longo DJ. Contrasting emotional approach coping with passive coping for chronic myofascial pain. Annals of Behavioral Medicine. 2002;24:326–335. doi: 10.1207/S15324796ABM2404_09. [DOI] [PubMed] [Google Scholar]
  37. Steiner H, Erickson SJ, Hernandez NL, Pavelski R. Coping styles as correlates of health in high school students. Journal of Adolescent Health. 2002;30:326–335. doi: 10.1016/s1054-139x(01)00326-3. [DOI] [PubMed] [Google Scholar]
  38. Stewart MA. Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal. 1995;152:1423–1433. [PMC free article] [PubMed] [Google Scholar]
  39. Swenson RR, Hadley WS, Houck CD, Dance SK, Brown LK. Who accepts a rapid HIV antibody test? The role of race/ethnicity and HIV risk behavior among community adolescents. Journal of Adolescent Health. 2011;48:527–529. doi: 10.1016/j.jadohealth.2010.08.013. [DOI] [PubMed] [Google Scholar]
  40. Swenson RR, Rizzo CJ, Brown LK, Payne N, DiClemente R, Salazar L, Vanable P, Carey M, Valois R, Romer D, Hennessey M. Prevalence and correlates of HIV testing among sexually active African American adolescents in 4 U.S. cities. Sexually Transmitted Diseases. 2009;36:584–591. doi: 10.1097/OLQ.0b013e3181b4704c. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Swenson RR, Rizzo CJ, Brown LK, Vanable P, Carey M, Valois R, DiClemente R, Romer D. HIV Knowledge and its contribution to sexual health behaviors of low-income African American adolescents. Journal of the National Medical Association. 2010;102:1173–1182. doi: 10.1016/s0027-9684(15)30772-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Vanable, et al. Test–retest reliability of self-reported HIV/STD-related measures among African-American adolescents in four U.S. cities. Journal of Adolescent Health. 2009;44:214–221. doi: 10.1016/j.jadohealth.2008.09.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Weinstock H, Berman S, Cates W., Jr Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health. 2004;36:6–10. doi: 10.1363/psrh.36.6.04. [DOI] [PubMed] [Google Scholar]

RESOURCES