Understanding What Influences Sexual Health Behaviors among Black Males in College

Abstract

Using the Health Belief Model as a guide, focus groups and interviews (n=35) were conducted with Black males at a Historically Black College and University. Findings suggest that norms around the expectations of men and sex relates to their sexual behavior. The study also indicates that while Black college men know they should engage in protected sex (perceived benefits), they are inclined to engage in unprotected sex if their partner is on the pill (cues to action), they don’t believe the consequences are immediate (perceived severity), and they like the feel of not using a condom (perceived barriers).

Introduction

Within the United States, Black males have disproportionately higher rates of sexually transmitted infections (STIs) in comparison to males in other racial groups (CDC, 2019). Because having an STI puts one at greater risk for HIV, it is important to understand what impacts sexual behavior among Black men across the life course. Having a better understanding of sexual behavior among Black men, may help in developing tailored interventions and programs to reduce the disparity burden of STIs and HIV among Black men and the Black population.

Given that the rates of chlamydia, gonorrhea, and primary and secondary syphilis are highest among Black women and men and among those 15–19 and 20–24, Black men in college are an important group to focus on to gain a better understanding of the factors that impact their sexual behavior (CDC, 2019). Although research does exist on the sexual behaviors of young Black men, this research is mainly focused on the sexual behaviors of men in same-sex relationships or men who sleep with both men and women (Cook, Watkins, Calebs, & Wilson, 2016; Nelson et al., 2017; Rutledge, Jemmott, O’Leary, & Icard, 2018). Because engaging in unsafe sexual behavior can impact the health of others, it’s important to have a broad understanding of what impacts sexual behavior among Black men in college regardless of sexual orientation.

Research has reported that the expectation that men should have sex with a lot of women was a deterrent for safe sex practices for Black males (Thompson-Robinson et al., 2007). Additionally, research on gender roles reported that first-year college males who endorsed the idea that men should have more sexual freedom than women had more sexual partners (Lefkowitz et al. 2014). These findings coupled with the notion that college students have a lower perception of their risk for HIV when engaging in risky sexual behavior gives evidence on the need to understand what impacts sexual behavior among college students (Adefuye et al., 2009; Johnson, 2017). Thus, this study seeks to add to the literature by understanding what impacts the sexual behavior of Black men in college. By understanding what impacts the sexual behavior of this group, programs can be developed to include specific elements that influence their sexual behavior to improve the sexual behaviors among this group. Additionally, there is a lack of research on the health behaviors and influences of Black males on Historically Black College and University (HBCU) campuses. Therefore, this study seeks to add to the literature by studying the sexual behavior of Black men in college on an HBCU campus. The following research question guided this study: What factors contribute to the sexual health behaviors of Black men in college?

To understand what contributes to the sexual behaviors in Black college men, the Health Belief Model (HBM) was used to help formulate questions around the different elements that might impact sexual health and sexual behaviors among this group. The HBM suggests that the likelihood of someone engaging in a certain behavior is based on their perceived susceptibility, perceived severity, perceived barriers and benefits, and cues to action (Sharma, 2017). For this study, perceived severity, perceived benefits, perceived barriers, and cues to action were used to develop questions. Perceived severity is one’s belief in how severe a health condition would be if they got it (Sharma, 2017). Perceived benefits are one’s belief in the benefits they will get if they engage in a certain behavior (Sharma, 2017). Perceived barriers are the things one believes are barriers to them engaging in a certain behavior (Sharma, 2017). Cues to action are the factors or elements that push one to engage in a certain behavior (Sharma, 2017). The HBM has been used in research with college students on topics such as weight management and Human Papillomavirus (HPV) knowledge and decision making (Grace-Leitch & Shneyderman, 2016; Das & Evans, 2014; MacArthur, 2017).

Materials and Methods

This study employed a qualitative design with the use of focus groups and in-depth interviews taken from two larger studies that collected data separately from Black male and female students from a HBCU in the southern United States. Inclusion criteria for participation in the study with Black males were: currently enrolled in the university where the study was conducted during the fall 2015 term, self-identify as African American or Black, and male. Inclusion criteria for participation in the study with Black females were: currently enrolled in the university where the study was conducted during the spring 2017 term, self-identify as African American or Black, and self-identify as female.

Recruitment

Because the male population at the HBCU used is much smaller than the female population, participants were recruited using campus email. After receiving IRB approval, a list of emails (without student names) for all Black male students enrolled during the fall 2015 term were obtained. All Black male students received an email informing them that a study addressing health behaviors in Black males needed participants. In this email, participants followed a link that allowed them to select three possible focus group dates. This email was sent out three times a week starting in October 2015 through November 2015. Participants were then emailed letting them know which date they were selected for. Participants were also sent an additional reminder the day before and again several hours before their focus group was to start. To obtain additional participants, two focus groups were held in January and February 2016 with participants recruited through a convenience sample by contacting other faculty and student organizations on campus.

In all recruitment communications, participants followed a link that allowed them to select three possible focus group dates. Participants were then emailed letting them know which date they were selected for. Participants were also sent reminders for their focus group day. To obtain additional participants, three additional focus groups were held during the fall 2017 term with participants recruited in the same manner as 2015.

Procedure

This study was part of a larger study focused on prostate cancer knowledge and risk among Black men in college. Therefore, focus groups were conducted by a Black male faculty member who was a clinical psychologist at the University where participants were recruited from to make participants more comfortable with discussing some of the topics covered. The focus groups lasted no more than 1.5 hours. Because initial recruitment involved participants selecting potential focus group dates, some focus groups didn’t have enough participants show up; thus, some focus groups became in-depth interviews. Having a mix of both methods allowed for assessment of group dynamics with the responses while comparing if responses were based on group dynamics with the in-depth interviews. Focus group questions were guided by the Focus group and interview questions are listed in Table 1.

Table 1.

Focus Group and Interview Questions

How do you believe being a man impacts your health?

How do you believe being a Black man impacts your health?

What health behaviors (good and bad) do you engage in?

Why do you engage in these behaviors?

How does being a man determine if you engage in these behaviors?

How does being a Black man determine if you engage in these behaviors?

Before all focus groups and interviews with the men, informed consent was explained and received. Additionally, all participants completed a brief demographic questionnaire. All focus groups and interviews were recorded and transcribed by the second author and a research assistant. After all focus groups and interviews were conducted, each participant received a $50 Wal-Mart gift card. To make sure that persons would not be coerced into participation because of the incentive, they were unaware of the amount of the gift card and they didn’t receive the gift card until after everyone had participated.

Data Analysis

Thematic analysis was led by the second author with assistance from two research assistants. Because qualitative analysis software was not easily available for the student research assistants, the second author picked an analysis method that was easy to explain and easy for the research assistants to analyze the data they were given. All analysis was conducted by hand using a process of chunking and coding text for themes and sub-themes based on methods used by Griffith and colleagues (Allen et al., 2013; Griffith, Allen, & Gunter, 2011; Griffith, Ellis, & Allen, 2012; Griffith, Ellis, & Allen, 2013; Griffith, King, & Allen, 2013; Griffith, Wooley, & Allen, 2013). In the first step, each research assistant was given a transcript of a focus group or interview and asked to pull out quotes that related to a participant’s reference about sexual health. The chunks of data had to stand on their own without the full transcript so that anyone reviewing the data would understand what the participant was saying and had to explain either of the two areas mentioned above. Additionally, information such as focus group or interview number and transcript page number were also included. For the second step, data from step one was checked by having another research assistant look over the document to make sure no additional data chunks were missed. The third step involved having one research assistant combine all data chunks from steps 1 and 2 into one document about sexual health. For the final step, both research assistants were given the document and asked to list elements that were similar across all data. After this step, the second author reviewed all documents to look for similar themes.

Findings

There were a total of 35 Black male college students, who participated in focus groups for this study. There were a total of five focus groups and four interviews. The number of focus group participants consisted of one group of four, three groups of six, and one group of eight. Additionally, one interview included two participants. Most participants ranged in age from 18 to 25 years old with one participant being 34 years old (Table 2). Participants included freshmen (24%), sophomores (27%), juniors (15%), seniors (27%), and graduate students (9%). Because undergraduate and graduate participants were mixed within each focus group, it would have been difficult to delineate the qualitative responses of undergraduate and graduate students. Therefore, undergraduate and graduate students were used for this research. While there may be some difference between undergraduate and graduate students, understanding what influences sexual health behaviors are important for both groups.

Table 2.

Demographics and Characteristics of Participants

Demographics and Characteristics		Total(n=34)* n (%)
Age
	18–21	26 (76.5)
	22–34	8 (23.5)
Class Rank
	Freshman	8 (23.5)
	Sophomore	9 (26.5)
	Junior	5 (14.7)
	Senior	9 (26.5)
	Graduate	3 (8.8)

^*There were a total of 35 participants, but demographic information was only available for 34.

Influences on sexual health behaviors

Participants responses on sexual health influences were separated into four constructs of the HBM, perceived benefits, perceived barriers, perceived severity, and cues to action. Overall, these findings suggest that perceived severity, perceived barriers, and cues to action outweigh the perceived benefits to engage in healthy sexual behaviors.

Perceived Severity

While participants understood that they should engage in protected sex, they didn’t see the consequences of unprotected sex as something to push them to engage in protected sex because the consequences weren’t immediate.

So I know like consequences of using condom or whatever it may not be as apparent because you not just gonna have a child just boom right after you do it. but STIs are still real, like you know that something that you have to be careful about and that’s the boundaries that you set.

In general, participants felt a sense of not being impacted by what goes on around them. As indicated by two participants:

So you know I guess something about it you just feel like as a black man I don’t have to worry about these things. It’s not gonna affect me, um, especially with the young and ignorant mentality so that might be part of it.

Men we think that we’re invincible so whatever we put into our body or whatever we do with our body, we feel that ‘man nothing ain’t gone happen to me. I’mma survive this.

These statements suggest that young Black men may not perceive the actions they engage in as being detrimental to their immediate health. Because they don’t perceive that their health is at risk, they may be less inclined to not engage in this behavior because the consequences may not be immediate.

Perceived Benefits

Participants mentioned that they know they should engage in protected sex to prevent the spread of sexually transmitted infections and to protect against pregnancy. One student offered:

As a dude if you don’t do anything else right as a male. You need to protect yourself and other people. You don’t know, you mighta trust the last person you was with unprotected but you owe the person that you dealing with next to at least protect them if you don’t want to protect yourself like that’s crazy.

Another participant indicated:

you gotta, you know … get your levels checked … You never know what other people have so know for yourself

Another participant talked about realizing he needed to engage in protected sex:

when I was younger, I had a lot of unprotected sex and I knew better too but like now I think you grow up and you just start wearing condoms.

These statements suggest that young Black men know the benefits of engaging in protected sex and understand the consequences of not engage in protected sex. While they understand the benefits of protected sex, this may not determine if they engage in protected sex.

Cues to Action

Participants mentioned that liking the feel of not using condoms was a deterrent for using them especially if the female was on the pill or if she was someone they felt comfortable (e.g. they didn’t have to worry about getting a sexually transmitted infection) not using a condom with based on who she was or how long they had known her as stated by two focus group participants. Because it is feasible to assume that improving the feel of a condom by using a different brand and being involved with a female who demands a condom be used or who is someone they wouldn’t have unprotected sex with, these elements serve as barriers to healthy sexual behavior, but they could also serve as cues to action to engage in healthy sexual behavior if adequately addressed. One student mentioned:

It was like in high school, yeah, I was a condom dude ‘til the day I die. My momma not gone kill me. You get here and it’s just like, you got the pill and then you just realize it just, it feels way better when you not wearing a condom.

A second student said:

Am I going to be the type of person who is just gonna you know take the condom off for any girl type of thing. It doesn’t necessarily have to be that you don’t, you know, not have safe sex. You get what I’m trying to say, like you could do that but it’s about that boundary that you set like what type of girl meets that criteria where the precautions that we taking outside of that, that make sure this is the safest situation for us.

Some participants also mentioned not having condoms available as their reason for not using them. As mentioned by one interview participant, “… as the unprotected sex I know it’s not the right thing to do but sometimes you just don’t have none.” If one is able to remove the barrier of not having condoms, one could assume that having condoms available would be a cue to action to use condoms.

An additional theme emerged from the data collected that focused on how some Black male college students construct masculinity and how it may influence sexual decision-making. The next section addresses this phenomenon.

Masculinity

One element that cut across all influences of sexual health behaviors was the idea of being a man. Participants mentioned how the expectations of being a man could impact the type of sexual behavior they engaged in. Because these expectations could impact how Black males perceive benefits; barriers; severity; and cues to action, they are mentioned first.

Some participants mentioned that there was an expectation that men are to engage in risky sexual behavior:

Dudes back at high school talking ‘bout ‘man I be hitting girls raw I don’t care’. Like just being reckless sexually and that just like with that ego they’re perpetuating something that’s masculine like this the route to take.

Another participant suggested:

Not like you don’t see, like not but like expected to be with like a bunch of different girls or whatever … I think you’d be respected still if you … didn’t have sex. But it’s like still like engrained in us that like you gotta do that to be a man. I don’t know it’s just almost like a stigma at this point.

Another participant mentioned the idea of masculinity and how it may impact their health:

You’re automatically presented with certain characteristics that people assume you have whether it be violent, disrespectful, and along with those characteristics come the you know whether they be the aggressive nature or just eating and drinking whatever, not really caring, getting checked out and the certain ignorance’s … that people place upon us. I think that just factors into the kind of conditioning that we’ve been placed under.

These comments suggest that the stereotypes of being a man and the ideas they have been exposed to about what it means to be a man may impact the type of sexual behaviors they engage in so that they meet the expectations they believe have been placed on them as Black men.

Discussion

This study examined what influences the sexual behaviors of Black males in college. While research exists on sexual behaviors and Black males, most of this research is focused on the sexual behaviors of same-sex or bisexual Black men (Cook et al., 2016; Nelson et al., 2017; Rutledge et al., 2018). Additionally, very little research is focused on the sexual health of Black males in college. Given that the rates of chlamydia and gonorrhea are highest among Black men and that these rates are highest among those 15–19 and 20–24, it’s important to understand what influences the sexual behaviors of Black men and women in college regardless of sexual orientation (CDC, 2019). Understanding what influences the sexual behaviors of all Black men across the lifespan and across groups may be beneficial to reducing the health disparities among Black men as it relates to certain STIs.

Research has reported that cultural influence showing that men should be having sex with a lot of women was a deterrent for Black men to engage in safe sex (Thompson-Robinson et al., 2007). This finding is similar to findings from this study with participants reporting that people expect men to engage in sexual behavior that could be risky. Our research also found that men were expected to engage in potentially risky sexual behavior. This is similar to research reporting that first-year college males, who reported that men should be allowed to have more sexual freedom, had more sexual partners (Lefkowitz et al., 2014).

Participants reported that while engaging in safe sex is what they should do to keep themselves and their partners healthy, the lack of immediate consequences from not having safe sex may stop them from engaging in safe sex. The idea that college students don’t understand the risk of engaging in risky sexual behavior has been reported in previous research with a majority Black sample (Adefuye et al., 2009). This finding suggests that increasing the awareness of Black males about the severity of engaging in risky sexual behavior may increase their likelihood to engage in safe sex practices.

Additionally, participants reported that not having condoms, liking the feeling of not using condoms, and not having the risk of pregnancy due to their partner being on birth control were all reasons for them to not engage in safe sex. The idea of preferring the feel of not using condoms and not having the risk of pregnancy are findings reported in other research as justification for Black males to engage in unprotected sex (Bowleg et al., 2011; Pass et al., 2016; Thompson-Robinson et al., 2007). Research also reported the idea that Black women at HBCUs may be more inclined to leave condom use up to Black men because of the low number of men on campus (Johnson, 2017).

Limitations

While this study highlights elements that influence sexual behavior among Black males in college, limitations to the study must be noted. First, this study took place at a small HBCU which may have accounted for the low participant numbers. However, similar responses from focus groups conducted in different semesters shows that a level of saturation with the data was reached. Because participant numbers were low, findings may not be representative of all Black males at the university or generalizable to a larger group of Black college male students. Additionally, because campus dynamics are variable at different campuses, the findings may have been different if students from other campuses were used in the study.

Second, participants were not asked about their sexual orientation, sexual identity, or sexual experience. Since most research on sexual behavior and Black men is focused on same-sex or bisexual Black men, not asking participants these questions may have caused us to miss areas that could have impacted their statements or beliefs around sexual behavior.

Conclusion

Because STI rates for younger Black men are higher than other racial and ethnic male counterparts, it seems important to understand some of the factors that influence their sexual behaviors across the life course. This understanding may be beneficial towards considering culturally specific programs and interventions that may decrease health disparity burdens experienced by Black men. Having a better understanding of what influences sexual behaviors among Black men of all ages, may help with developing tailored programs and interventions to address the specific areas that may be integral and influential in determining the sexual behaviors Black men in college engage in. Having tailored programs may increase the likelihood of men in this group engaging in less risky sexual behavior which may reduce STI rates among this group.

Implications

This study provides insight into the factors that influence sexual behavior among Black men in college. Findings from this study have implications for college health promotion and wellness programs. College health professionals can use these findings as a possible justification for considering developing programs that work to increase the awareness of students around the consequences and risks of engaging in unprotected sex and how to talk to their partners about safe sex. Additionally, college health professionals at HBCUs should work to ensure that they are making sure students have access to all the elements needed to engage in healthy behaviors. As it relates to sexual behavior, this would include access to condoms, birth control, and testing.

Recommendations

Future research in this area should examine how Black male college students determine their sexual risk and how this perception determines the sexual behavior they engage in. Research should also examine the influence of campus environment (student population demographics, resources, etc.) has on the sexual behaviors of Black males. Because this research was conducted at one HBCU, future research should examine if these concepts are true for Black men on other college campuses.