HHHHI'

WIIH

NIH“
\
! 1:

D
I
\

 

THESIS

EQCCJ

This is to certify that the
thesis entitled
THE RELATIONSHIP BETWEEN THE AGE OF FIRST USE OF ALCOHOL

AND THE AGE OF SEXUAL INITIATION IN RURAL ELEVENTH
GRADE PUBLIC HIGH SCHOOL STUDENTS

presented by

Marguerite Natoli Michels

has been accepted towards fulfillment
of the requirements for

Master of Science degree in Ngrsing

We

Date @074 035619

 

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

 

 

LIBRARY

Michigan State
4 Unlverslty

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11100 W.“

THE RELATIONSHIP BETWEEN THE AGE OF FIRST USE OF ALCOHOL
AND THE AGE OF SEXUAL INITIATION IN RURAL ELEVENTH
GRADE PUBLIC HIGH SCHOOL STUDENTS

BY

Marguerite Natoli Michels

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE IN NURSING
College of Nursing

2000

ABSTRACT
THE RELATIONSHIP BETWEEN THE AGE OF FIRST USE OF ALCOHOL

AND THE AGE OF SEXUAL INITIATION IN RURAL ELEVENTH
GRADE PUBLIC HIGH SCHOOL STUDENTS

BY

Marguerite Natoli Michels

The period of adolescence is marked by rapid physical,
emotional, cognitive and social change. It is a period for
the development of attitudes and behaviors related to sexual
practices and alcohol use. This is a secondary data
analysis of a larger study with a target population of
students attending eleventh grade in a rural high school.
The purpose of this study is to examine if a relationship
exists between the age of first use of alcohol and the age
of sexual initiation in rural eleventh grade high school
students.

The sample size consisted of 51 eleventh grade students
enrolled in a rural northern Michigan high school. The
Youth Risk Behavior Survey was utilized by the original
researcher to obtain the data. The findings suggest that
there is a correlation between the age of onset of alcohol
consumption and the age of sexual initiation in rural

eleventh grade students.

ACKNOWLEDGMENTS

First and foremost I wish to express my love and
gratitude to my family, especially my daughters, Angela and
Lauren. Their sacrifices and encouragement have allowed me
the opportunity to improve myself by continuing my
education. This degree will be as much theirs as it is
mine.

I would also like to thank Dr. Linda Spence for
chairing my committee and my committee members Patty Peek
and Linda Beth Tiedje. I appreciate the direction and
insight that all three have shared with me. This has
allowed me to produce a piece of work that I can be proud
of.

Thank you to my parents and my friends from various
parts of my life that have encouraged and prodded me to
finish. All of their support has assisted me in getting to
this point. I am fortunate to be surrounded by such

wonderful people.

iii

TABLE OF CONTENTS

Page
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . 1
Conceptual Framework . . . . . . . . . . . . . . . . . . 6
Review of Literature . . . . . . . . . . . . . . . . . . 12
Methods . . . . . . . . . . . . . . . . . . . . . . . . . 15
Data Analysis . . . . . . . . . . . . . . . . . . . . . . 19
Results . . . . . . . . . . . . . . . . . . . . . . . . . 22
Discussion . . . . . . . . . . . . . . . . . . . . . . . 26
Summary . . . . . . . . . . . . . . . . . . . . . . . . . 30
LIST OF REFERENCES . . . . . . . . . . . . . . . . . . . 31

APPENDICES . . . . . . . . . . . . . . . . . . . . . . . 33

iv

Figure 1:

Figure 2:

LIST OF FIGURES

Page
Schematization of the relationship between
the three classes of determinants in Triadic
Reciprocal Determinism . . . . . . . . . . . . 9
Operationalization of Bandura's Triadic
Reciprocal Determinism Model . . . . . . . . . 11

Table 1:
Table 2:

Table 3:

LIST OF TABLES

vi

Page
23
23

24

INTRODUCTION

The period of adolescence is marked by rapid physical,
emotional, cognitive and social change. It is a period for
the development of attitudes and behaviors related to diet,
exercise, sexual practices and alcohol use (Guthrie,
Loveland-Cherry, Frey, & Dielman, 1994). Initiation of
certain health behaviors during this time frame, may have
consequences that will alter the rest of an adolescent’s
life. The opportunity for influencing future attitudes and
behaviors during this developmental stage with its rapid
transitions, has tremendous implications for the health care
provider of adolescents. The providers of health care and
the families of adolescents need to address health risk
behaviors that may be related to one another and the
consequences of those behaviors. Alcohol use and initiation
of sexual intercourse are two behaviors that may be related
to each other. The purpose of this study is to examine the
relationship between first use of alcohol and initiation of
sexual intercourse in a group of rural adolescent high
school students.

A Alc 1

Parents often dismiss adolescent alcohol consumption as
benign experimentation because alcohol is legal vs.
marijuana use, which is illegal. Alcohol is socially
acceptable and was readily available in the homes of 25% of
7th-12th grade students who responded to the National
Longitudinal Study of Adolescent Health (ADD). Two—thousand

l

forty-two (17.9%) students report drinking alcohol more than
monthly with 9.97% drinking at least daily. The ADD Health
study is the first nationally representative data set
including longitudinal data on the health status, risk
behaviors, and social contexts of adolescents. A total of
12,118 adolescents in grades 7 through 12 were drawn from an
initial national school survey of 90,118 adolescents from 80
high schools plus feeder middle schools (Resnick, Bearman,
Blum, Bauman, Harris, Jones, Tabor, Beuhring, Sieving, Shew,
Ireland, Bearinger, & Udry, 1997).

In 1993, The National Survey on Drug Use Among
Secondary School Students revealed a large number of 8th
graders already were using alcohol. Almost 70% of 8th
graders, whose age averages 13 years, had tried alcohol,
with 26% reporting having been drunk on at least one
occasion and 14% confirming they had a heavy drinking
episode within two weeks prior to the survey (Johnston,
O’Malley, & Buchman, 1993). The average age of first
alcohol use for male adolescents was 11.9 years and for
female adolescents 12.7 years (Alexander, 1991).

Initiating alcohol use, with peers at such an early age
can have far reaching physical, psychological and
developmental consequences. Studies indicate that quite
often the first drink is taken at home with or without
parental permission. In fact, on many occasions the parents
willingly supplied the alcohol (Vanenaar, 1993). Parental
attitudes of ambivalence or lack of disapproval is part of

the problem.

a 't' '0

There is also a continuing trend toward earlier age of
sexual initiation. By 1988 over one quarter of Afro-
American and Caucasian 15 year old females had experienced
intercourse and by 19 years of age, over four fifths of both
races were sexually active (Cates, 1991). In a study of
1,899 inner city junior high school students, 239
respondents had intercourse before 13 years of age (12.5%)
and 113 respondents reported age of first intercourse
between 13-14 years of age (5.9%) (Durbin, DiClemente,
Siegel, Krasnovsky, Lazarus, & Camacho, 1993). Statistics
indicate that Afro—American boys and girls become sexually
active on the average two years before Caucasians.
Although, racial risk factors are closely tied with
socioeconomic levels, research has been unable to determine
which plays a more important role in early initiation of
intercourse. It is known that chronic disadvantage, bleak
outlook, and hopelessness are associated with earlier
pregnancy and childbearing (Davis, 1989). Approximately 646
(17%) of 7th and 8th graders and nearly half (3,754), of
7,614 9th through 12th graders indicated that they had
sexual intercourse in the ADD Health longitudinal study
(Resnick et al., 1997). As the literature indicates, there
is a difference in the onset of intercourse depending on
race and socioeconomic levels, however, the differences
between rural vs. urban adolescents’ sexual initiation could

not be found in the literature (Davis, 1989).

Initiation of sexual activity at a young age is a
primary risk factor for unintended pregnancies.
Approximately half of all first nonmarital pregnancies occur
in the first six months following the initiation of sexual
intercourse (Davis, 1989). Adolescent pregnancy and child
bearing have lasting social, academic and economic
disadvantages for mother, father and child. Studies
indicate that the children of teenage mothers are at
somewhat greater risk for cognitive and psychological
deficits: the effect of both poor parenting and lower
socioeconomic status (Davis, 1989). The problem of
adolescent pregnancy is that a private event becomes public
and costs society as well as individuals.

The increasing number of teenagers having sex at
earlier ages also means they have a greater number of sexual
partners on average. This puts adolescents at greater risk
for obtaining sexually transmitted diseases (Cates, 1991).
Contracting sexually transmitted diseases can have a number
of consequences including infertility and cancer, and in
some cases death, if HIV is contracted.

c ' u 1

It would be beneficial to investigate if there is a
relationship between alcohol misuse and sexually initiation
because adolescents are experimenting at earlier ages.
Although the initiation of alcohol consumption during
adolescent years is not viewed by some parents as alarming,
perhaps the realization that this relatively'“acceptable”
risk behavior may be related to the initiation of other risk

4

behaviors, that have serious life altering consequences will
alter parental views. Adolescents who reported misusing
alcohol had 6.1 to 23 times higher odds of early onset
sexual activity, multiple partners and unprotected
intercourse than those of young people who did not misuse
alcohol (Fergusson et al., 1996). More research is needed
to investigate the relationship between the initiation of
alcohol use and the initiation of sexual intercourse in all
types of adolescents, regardless of their demographics.

The information obtained in the present research will
be beneficial to the health care providers in rural
communities, who are providing care to adolescents and their
families. These data can be used to develop and initiate
screening tools to identify adolescents at risk for engaging
in unsafe health behaviors. If the two variables are
positively correlated, then adolescents willing to take
risks in one area may do so in another. Educational
programs could be designed for parents of adolescents and
for adolescents themselves that expounds on the information
that the initiation of health risks behaviors are related
and that encouraging the delay of one will have a domino
effect on the others.

S m h P ble

The purpose of this study is to answer the question:

Is there a relationship between the age of first use of
alcohol and the age of sexual initiation in rural eleventh

grade public high school students?

Conceptual Framework
Conceptual Definitien 9f the Variables

The precise boundaries of adolescence are difficult to
define. One way to understand it is to divide it into three
psychosocial development phases; early, 11 to 14 years or
junior high school; middle, 15 to 17 years or high school;
and late, 18 to 21 years or college or work.

Each phase is characterized by certain behaviors.
Within each developmental phase, adolescents deal with
issues of autonomy, body image, peer group involvement and
identity development.

Early adolescence (11 to 14 years), are not quite part
of the adolescent subculture, yet they have moved away from
the childhood culture. During this phase, adolescents
become extremely conscious of their bodies as the onset of
secondary sex characteristics develop. Time spent with
peers increases and less time is spent with their families,
sexual feeling emerge and varying degrees of sexual
experimentation may begin.

Middle adolescence (15 to 17 years) is the essence of
adolescents. They stand out as they develop their own dress
code, code of conduct and communication style. This phase
includes feelings of invulnerability, immortality and risk
taking and behavioral experimentation intensifies. Physical
urges precede emotional maturity and social pressure to
experiment with sex is great.

Late adolescence (18 to 21 year) is a period when
decisions are being made about how to contribute to society

6

as a responsible adult. Relationships with family members
have been renegotiated to a more adult-adult basis. It is a
time for more committed partner relationships based on
individual preference vs. peer group values (Burns & Barber,
1996).

The actual ages of students answering the questions
related to the present study were 16, 17 and 18 years old
and they were in the eleventh grade. This places them in
the period of middle adolescence. It is this time frame
that established the boundaries of adolescents for this
study.

First use of alcohol was defined as when an adolescent
had their first drink of alcohol other than a few sips and
sexual initiation was defined as the age when an adolescent
first engaged in sexual intercourse.

We;

The theoretical model used for this study was Bandura's
Social Cognitive Theory (SCT). SCT is a model of
interpersonal behavior that emphasizes the influence of
social norms and social support. The SCT explains human
behavior in terms of a dynamic, triadic, and reciprocal
model in which behavior, personal factors and environmental
influences interact (Goodson, Evans, Edmundson, 1997). The
initiation of the two specific health risk behaviors in this
study will be considered an interpersonal behavior which may
be understood within the context of dynamic interactions

among multiple and complex factors, therefore the SCT

appears to be an appropriate theoretical model for this
analysis.

The SCT has twelve main constructs and they are as
follows: Biological factors, Environment, Situation,
Behavioral Capability, Expectations, Expectancies, Self
Control, Observational Learning, Reinforcements, Self-
Efficacy, Emotional Responses and Reciprocal Determinism
(Bandura, 1986). Although all twelve constructs could be
applied to this study, reciprocal determinism will be
focused on.

In the social cognitive model of interactive agency,
persons are neither autonomous agents nor mechanical
conveyers of environmental forces. Rather they serve as a
reciprocally contributing influence to their own motivation
and behavior within a system of reciprocal determinism
involving personal determinants, behavior and environmental
factors. These determinants affect each other
bidirectionally rather than unidirectionally (Bandura,
1986) .

The influence exerted by the three interacting factors
will vary for different activities, different individuals
and different circumstances. When environmental conditions
exercise powerful constraints on behavior, they emerge as
overriding determinants. When environmental constraints are
weak, personal factors serve as predominant influences in
the regulatory system (Bandura, 1986).

The definition of the construct reciprocal determinism
refers to the interaction that exists among the individual,

8

Figure 1.

P
PERSONAL EACTORS

 

 

D'
B E
e
BEHAVIOR EXTERNAL
ENVIRONMENT

Schematization of the relationship between the three classes
of determinants in triadic reciprocal determinism.

Note : B signifies behavior; P the cognitive, biological,
and other internal events that affect perceptions and
action; E the external environment

(Bandura, 1986)

his/her behavior and his/her environment (Bandura, 1986).
In the model of reciprocal determinism, which is summarized
schematically in Figure 1, behavior, cognition and other
personal factors and environmental influences all operate
interactively as determinants of each other.

In figure 2, the Operationalization of Bandura’s model
for this analysis includes; health behaviors such as alcohol
consumption and sexual intercourse; personal factors such as
family structure and religious beliefs; the external
environment which includes peers and school involvement.

People's cognitions about themselves and the nature of
things are developed and verified through four different
processes: direct experience of the effects produced by
their actions, vicarious experience of the effects produced
by somebody else’s actions, judgments voiced by others, and
derivation of further knowledge from what they already know
by using rules of inference (Bandura, 1986).

Cognitions govern behavior, the conceptions themselves
are partly fashioned from direct or socially mediated
transactions with the environment. The personal factors and
environment factors convey norms about under age alcohol
consumption and sexual behavior and about what is
permissible and what exceeds socially acceptable boundaries.

In this study, one environmental variable (E) could be
delinquent peers. In SCT this environmental influence may
have a strong effect on an individual or depending on the
specific individual and their beliefs (B) and depending on
personal factors (P), may have little effect. This study

10

Figure 2.

P
PERSONAL FACTORS
ENMLLY STRUCTURE & RELIGIOUS BELIEFS
PERSONALITY 8 DEVELOPMENTAL LEVEL

 

 

D’
B E
‘4
HEALTH RISK BEHAVIOR EXTERNAL ENVIRONMENT
ALCOHOL CONSUMPTION PEERS 8 SCHOOL
8 SEXUAL INITIATION COMMUNITY STANDARDS

Determinism Model

Note: B signifies the individual behavior including health
behaviors of alcohol consumption and sexual intercourse; P
signifies the personal factors such as family structure and
religious beliefs, maturation, cognition

E signifies the external environment, including peers and

school involvement

11

only looks at two variables and their possible relationship
to each other, however if the variables are related, other
aspects to explore would be family structure, religious
beliefs and school connectedness of the student.
Review of Literature

Much has been written on adolescents and health risk
behaviors. Many researchers have attempted to determine the
ages at which people initiate alcohol use, cigarette smoking
and sexual intercourse (Jessor, Costa, Jessor, & Donovan,
1983; Loda, Speizer, Martin, Skatrud, & Bennett, 1997;
Warren, Kann, Small, Santelli, Collins, & Kolbe, 1997).
Researchers are beginning to look at variables, such as
influence of family, school connectedness and peer factors
and if they relate to the age of initiation of risk
behaviors (Fergusson & Lynskey, 1996; Resnick et al., 1997).
This literature review will examine the present research on:
1) Alcohol misuse in adolescents; 2) Sexual initiation in
adolescents.
E] 1 J I . . . . ,2 J

A nationally representative sample drawn from more that
50,000 students in more than 400 schools showed almost 70%
of eighth graders, whose age averaged 13 years, had tried
alcohol, 26% reported having been drunk on at least one
occasion (Alexander & Gwyther, 1995). This survey focused
on drug use and did not incorporate other risk behaviors.
Morrison, Rogers, and Thomas (1995), found the average age
of first alcohol use for males was 11.9 years and for
females 12.7 years. Warren et al. (1997) reported the

12

”in?

median age of first alcohol use for males was 13.9 years and
for females 14.4 years in both 1991 and 1993.

Little research has been done on the health risk
behaviors of rural adolescents. Loda et al. (1997) reported
that rural youth are having sexual intercourse, getting
pregnant, having babies and experiencing negative birth
outcomes at rates comparable to their urban peers. Rural
youth were found to start drinking at earlier ages, with
approximately one—half of rural boys and close to one—third
of urban boys reporting they had their first drink at 6-8
years old. This article does not state how these statistics
were obtained, however the thrust of this article is to
suggest strategies for future programs addressing rural
adolescent’s needs for pregnancy prevention in the
southeastern portion of the United States. In a study of 51
Michigan rural adolescents 17.6% never used alcohol, 11.8%
were 10 or younger, 17.6% were 11-13 years old, 37.3% were
14-15 years old, 15.7% were 16 years old or older when they
had their first drink (Rosi, 1995).

S x ' i ' ' n

Jessor et a1. (1983) designed a longitudinal study that
involved collecting waves of data over a 10 year period:
1969—1979. The average age for first time intercourse in
this sample was 18 years for males and 17.7 years for
females. Questions regarding alcohol use were also
addressed, however a correlation between the initiation of

theses variables was not noted.

13

Warren et al. (1997) used data from the 1991 and 1993
YRBS with a sample size of 12,272 in 1991, 16,296 in 1993
and an overall response rate of 68% in 1991 and 70% in 1993.
This study indicated the median age of first sexual
intercourse in 1991 and in 1993 for females was 16.6 years
and for males 16.3 years. In comparing these two studies,
the age of sexual initiation had decreased by 1.7 years for
males and 1.1 years for females over a twenty year period.

Davis (1989) reported approximately 45% of young women
15—19 years old were sexually active and 36% of them became
pregnant within two years of their initial sexual
experience. More recent research could not be found to see
if that statistic has changed over time.

Approximately 17% (646/3,788) of 7th and 8th graders
and nearly half (3,754/7,614) of 9th through 12th graders
indicated that they had ever had sexual intercourse in the
National Longitudinal Study on Adolescent Health (Resnick et
al., 1997). In a study of 51 rural adolescents 31.4% never
had sexual intercourse, 5.9% were 13 years old or younger,
39.2% were 14-15 years old and 23.5% were 16 years old or
older when they had first time intercourse (Rosi, 1995). As
one compares the data, the age of initiating sexual
intercourse is becoming younger over time.

Summery

More research is needed in comparing the risk behaviors
to each other. The questions unanswered are: Are they
related to each other? Which ones are related? Are urban
and rural youth at the same risk levels? Warren et al.

14

(1997) found a common pattern for both female and male
students: Alcohol use started first, followed 17 or 18
months later by cigarette smoking, then followed by first
sexual intercourse about 10-11 months later. For both male
and female students first alcohol use preceded first sexual
intercourse by more than 2 years. More studies comparing
health risk behaviors and their age of onset are needed so
that prevention programs can be developed, along with
parental education programs.

There is also little data in the literature that
relates specifically to rural youth and their health risk
behaviors. The present study will examine two health risk
behaviors that youth in a rural community in northern
Michigan have demonstrated and examine if age of first
alcohol use and age of first intercourse are related.

Methods
R e r

This is a secondary data analysis of a larger study
(Rosi, 1995) with a target population of all students
attending 11th grade at a rural high school in northern
Michigan. The original study was a nonexperimental
descriptive ex-post facto design. This secondary data
analysis also will use a nonexperimental retrospective
descriptive design.

Sample

The original researcher describes Crawford County in
1995 as a medically undeserved county located in central
northern Michigan with a total population of 12,260, which

15

included 3,201 children under 18. In 1990, there were 1,688
persons living below 100% of poverty, 4,865 persons living
below 200% of poverty, 1,300 uninsured persons, and 2,014
persons eligible for Medicaid. Thirty-four percent of
students attending public school are eligible for free or
reduced lunch (Rosi, 1995).

The target population was a convenience sample of all
students attending the 11th grade at a rural public high
school in northern Michigan. One hundred and thirty-four
students were eligible to participate. Thirty-eight percent
(51) of the 134 eligible students completed the survey. The
original researcher made an attempt to analyze why 24 of the
students who received parental consent did not participate
in the survey. Six students were absent from the building
participating ir1“out of building’.activities, 8 were absent
from school the day the survey was administered, and 10 did
not participate for unknown reasons (Rosi, 1995). The ages
of the students ranged from 16-18 years of age and 27 were
females and 24 were males. The original researcher chose
11th grade students because the majority of students had
taken a required semester health class in their sophomore
year and theoretically had received health instructions
necessary for making decisions regarding behaviors that may
put them at risk for adverse health outcomes.

Qpetetienel Definitions Qf Varieblee

One variable in this study is the age of initiation of
alcohol consumption. It is measured by question number 76
in the Youth Risk Behavior Study (YRBS). Question number 76

16

on the YRBS measures this variable by asking: "How old were
you when you had your first drink of alcohol other than a
few sips? (A) I have never had a drink of alcohol, other
than a few sips (B) 10 years old or younger (C) 11-13 years
old (D) 14-15 years old (E) 16 years old or older."

The second variable is the age of initiation of sexual
intercourse, which is measured by questions 46 and 47 in the
YRBS. Question 46 asks "Have you ever had sexual
intercourse? (A) yes (B) No. Question 47 asks “How old were
you when you had sexual intercourse for the first time? (A)
I have never had sexual intercourse (B) 13 years or younger
(C) 14 or 15 years old (D) 16 years old or older.”

In umen i n

Subjects completed the Youth Risk Behavior Survey
(YRBS) (See Appendix A). In 1988 the Center for Disease
Control (CDC), created a division of adolescent and school
health, with the goal to identify health risks among youth;
monitor prevalence of these risks, support and implement
national programs to prevent these risks; and evaluate the
impact of national programs (Kolb, 1992). To assess the
status of the nation’s adolescents, the CDC began designing
the YRBS in 1988. The first version of the questionnaire
was completed in October 1989. The second version was
completed in November 1989 and was used the following spring
to generate data from national, state and local samples of
students in grades 9-12. The second version of the YRBS was
sent to the Questionnaire Design Research Laboratory for
four waves of laboratory field testing with high school

17

students. The goal of the field testing was to identify
survey conditions that could be expected to encourage
honesty in answering survey questions. In October 1990, the
core questionnaire was complete. The core questionnaire is
self administered and has about a seventh grade reading
level. Establishing criterion related validity for response
to most of the questions may be impractical, if not
impossible (Kann, Warren, Collins, & Kolbe, 1993). The
survey consists of items measuring risk behaviors in six
areas: (1) sexual behaviors (2) tobacco, alcohol & illicit
drug use (3) suicidal ideation & suicide attempts (4)
behaviors related to unintentional injury (5) dietary
patterns and (6) physical activity. The original researcher
added questions related to current health care utilization,
desired health care services and demographic data. The
Center for Disease Control allows the questionnaire to be
copied, modified or administered without permission or cost
(Kolbe, Kann, & Collins, 1993).

The questions were either yes or no responses, such as
“Did you drink alcohol or use drugs before you had sexual
intercourse the last time?” (A) I have never had sexual
intercourse (B) Yes (C) No. The questionnaire also offered
the subject options, such as "During your life, with how
many people have you had sexual intercourse?" (A) I have
never had sexual intercourse (B) 1 person (C) 2 or 3 people
(D) 4 or more people. The YRBS was chosen for this study
because the instrument included questions that the original
researcher was interested in. Parents and school

18

administration were also more likely to support a survey
that had been developed by the Center for Disease Control, a
nationally renowned organization.

Preeederee

The original researcher met with classroom teachers
prior to the survey being administered, to answer questions
about the survey and to provide oral and written
instructions on procedure. Students were required to obtain
written parental consent prior to the survey. Students who
received parental consent reported to the library at a
specific hour on a specific day. Instructions were read to
the students from a prepared script and the students were
instructed not to write their names or other identifying
marks on the questionnaire (See Appendix C). The students
were to place their answers directly on the questionnaire.
When the survey was completed, the students placed the
survey in a sealed "ballot type" box.

For this secondary data analysis, permission was
obtained from both researchers of the original study, to
look at the specific research question of this proposal.

Data Analysis

Correlational analysis was used to determine if there
was a significant relationship between the ages of first use
of alcohol and sexual initiation in rural eleventh grade
public high school students and to examine the direction of

the relationship.

19

Pr h r ' n uman

The original researcher obtained approval from the
University Committee on Research Involving Human Subjects
(UCRIHS) and from the school district (See Appendix D).
Parents were asked for their consent after they received
information explaining the research proposal and explaining
the participation was voluntary (See Appendix B). Students
gave their consent by completing and returning the survey.

For the purposes of this study, the researcher received
the data on a computer disk with no identifying information
and approval was received from UCRIHS (See Appendix E).
W

The original researcher assumed that the opportunity
for participation in the study was offered equally to all
eligible students. It was assumed that the adolescents
answered the survey understanding the questions and answered
them as honestly as possible. It was also assumed that the
survey correctly identifies levels of risk behavior. For
this secondary data analysis, the assumptions were
unchanged.

When certain behaviors can not be directly observed
self-report is an appropriate method for data collection.
Self report instruments can gather retrospective data or
gather projections about behaviors in which subjects plan to
engage. Many times self report yields information that may

be difficult to obtain by any other means (Polit, 1995).

20

Self report has a serious limitation regarding the
validity of the self report. It is difficult to be sure
that the respondents have answered truthfully. This
limitation must be realized and the distortion may involve
both under and over representation of certain behaviors
(Kolbe et al., 1993).

Another limitation of this study design is that
parental consent is required when studying adolescents.
Several studies have shown differences between youths who
were recruited by active versus passive consent procedures.
Active consent requires that parents provide written or
verbal consent for their student to participate. This is
referred to as active consent because the parent must take
some action for their child to be part of the study.

Passive consent requires no action taken by the parents. In
this approach parents are informed that their nonresponse
implies consent for their children to participate (Dent,
Galaif, Sussman, Stacy, Burtun, & Flay, 1993). In studies
requiring active consent there is lower participation of
minorities, children with less educated parents, children
who receive poorer grades in school and relatively more
children who are cigarette or marijuana smokers than those
requiring passive consent (Dent et al., 1993). It would be
tempting for a researcher to use passive consent when
engaging in research concerning adolescents and their health
risk behaviors, because it is most likely this very group
who are at greater risk for participating in health damaging
behaviors. The drawback in attempting to collect data via

21

passive consent would be the strong objections from parents
and school officials, due to the sensitive nature of the
questions.

Due to the small sample size; 51 respondents (38%) out
of a possible 134 eligible students, the results of this
survey can not be applied to the behavior of all
adolescents.

Results
Desetiptien Qf the Sample

Seventy-five of the 134 eligible students attending
11th grade received parental consent to participate in the
survey, however only 51 students completed the survey (Rosi,
1995) .

Thirty-nine percent of the sample were 16 years of age,
57% were 17 years of age, and 4% were 18 years of age (see
Table 1).

W

The research question addressed was “Is there a
relationship between the age of first use of alcohol and the
age of sexual initiation in rural eleventh grade high school
students?”

Spearman Correlation Coefficient and descriptive
statistics were used to examine the data.

A F' r ourse

Sixty-nine percent of the students reported having had
sexual intercourse. Six percent had first intercourse at 13
or younger, 39% at 14-15 years old, and 24% were 16 years of
age or older (see Table 2).

22

Table 1.

 

 

 

 

 

 

ASE
Cum
Age Frequency Percent Percent
16 20 39.2 39.2
17 29 56.9 96.1
18 2 3.9 100.0
Total 51 100.0 100.0
Table 2.
A F'rs Inter urse
Cum
Frequency Percent Percent
Never 16 31.4 31.4
13 or younger 3 5.9 37.3
14-15 20 39.2 76.5
16 or older 12 23.5 100.0
Total 51 100

23

WM

Eighty-two percent of students report having had a
drink of alcohol. Of those students indicating alcohol use,
12% were 10 or younger, 18% were 11 to 13, 37% were 14 to
15, and 16% were 16 or older when they had their first
drink. Thus by 16 years of age, 82% of the students had

their first drink of alcohol (see Table 3).

Table 3.

Age ef Eirst Aleehel

 

 

 

Cum
Frequency Percent Percent
Never used 9 17.6 17.6
10 or younger 6 11.8 29.4
ll-l3 9 17.6 47.1
14—15 19 37.3 84.3
16 or older 8 15.7 100.0
Total 51 100.0 100.0

Out of 51 students 16 (31.4%) never had intercourse and
9 (17.6%) never drank alcohol. Three (5.9%) had intercourse
at the age of 13 or younger and 15 (29.5%) students had used
alcohol in this age group. An increase in both health risk
behaviors occurred in the next age group. In the age group

of 14-15 year old, 20 (39.2%) students had first intercourse

24

and 19 (37.3%) had their first drink. Up to this point 23
(45.1%) students 15 and younger had intercourse and 34
(66.7%) drank alcohol. The final category was 16 and older.
Twelve (23.5%) students had first intercourse and 8 (15.7%)
had alcohol for the first time. By the age of 16 years a
total of 78.6% had first intercourse and 82% had alcohol for
the first time.

An analysis of the above data reveals that
approximately 50% of the adolescents who responded to this
survey, and who were 15 years old were engaging in one or
both of the of specific health risk behaviors that are being
examined in this study.

R ' n ' xua ni iation n F' A o 8

To answer the research question a Spearman correlation
co—efficient was used. The Spearman correlation coefficient
is a commonly used measure of correlation between two
ordinal variables. For most variables of a social or
psychological nature, the correlation’s are typically in the
.10 to .40 range (Polit, 1995). For the purpose of this
study a .05 level of significance was used.

The correlation between age of first alcohol use and
the age of sexual initiation was .35 with a significance of
p g .01. This indicates that there is a positive
relationship between the age of first alcohol use and the
age of sexual initiation in rural eleventh grade public high

school students.

25

Discussion

Di 8' R W' h he r tical Mod

The focus of this study was to determine if there was a
relationship between the age of onset between the two health
risk behaviors of first alcohol use and sexual initiation.
In the Social Cognitive Theory, which emphasizes the
influence of social norms and support, the two health risk
behaviors are considered interpersonal behaviors. The
results of the study indicate that there is a positive
relationship between the age of onset of the two health risk
behaviors. The younger the adolescent is when they start
drinking, the younger they will be when they initiate sexual
intercourse. Bandura’s model of reciprocal determinism
indicates that behavior, cognitive (personal) and
environmental factors operate interactively. The question
then becomes: Can the personal factors or the environmental
factors influence the age of first alcohol consumption?

The literature indicates that personal factors do play
a role in variety of aspects in an adolescent’s life. Some
of the personal factors that are related to this study are
family structure and religious beliefs and external factors
such as school and peers. The conclusion of the ADD Health
design study states that family and school, as well as
individual characteristics are associated with health and
risk behaviors in adolescents (Resnick et al., 1997). In
the Christchurch Health and Development Study common risks
that predisposed adolescents to engaging in health risk
behaviors were: affiliation with delinquent peers, familial

26

factors and novelty seeking (Fergusson & Lynskey, 1996). In
applying this to the Social Cognitive Theory all aspects,
personal, environment and the individual, interact to
determine the behavior of an individual.

I' . E J . I] I'!

The National Longitudinal Study on Adolescent Health
(Resnick et al., 1997) indicates that 17% of 13 year olds or
younger had engaged in sexual intercourse versus the 5.9% of
adolescents who responded in this study. The percentages
for initiating sexual activity in the adolescents in high
school are closer in range, approximately 50% nationally and
63% in this study.

In a different national study 70% of eighth graders (13
year olds) had tried alcohol compared to the 30% of the
adolescents who responded to the survey for this research.

The differences in the national percentages versus the
percentage obtained from this study may be explained by the
small sample size for this study, and the students for this
study were from a specific demographic area. The small size
does not capture enough variance and being specific to a
certain area the percentages may be different because of
variety of influences, such as family involvement, religious
ties and school involvement.
mp_i g.'o; _o ‘ov- ed _ si . '_. ti - :; Primar . -

The Family Nurse Practitioner in a primary care setting
can be influential and impact the health of adolescents. By
using the concept of reciprocal determinism the FNP can
educate the families and communities in the following ways:

27

1. Utilize the teaching role to increase the adolescent's
knowledge regarding the correlation between health risk
behaviors and their consequences.

2. Educating parents that a strong family structure and
family involvement in their adolescents life does
influence their adolescents behavior and choices, even
if adolescents deny that.

3. Facilitate communication between the parent and their
adolescent, as good communication, as well as active
listening and mutual respect play an role in an
adolescents decision making process.

4. Encourage adolescents to participate in extracurricular
activities at school or church. School connectedness
and church ties also influence an adolescent’s decision
making.

5. Provide a comprehensive history taking that examines
various social, individual and familial factors that
may contribute to the individual's susceptibility to
early onset of health risk behaviors.

6. Become involved politically to educate the lawmakers
regarding the influences on adolescents’ health and to
encourage them to support family legislation, in order
to strengthen the family as a unit.

R mm ' f r r h r
Some suggestions for further research are to repeat

this study obtaining a larger sample size and using a sample

of students attending grades 6 through 12. This may
identify when risk behaviors are initiated and examine if

28

there a consistent time interval between one risk behavior
and the next. Also comparing urban vs rural students and
their time of initiation of specific health risk behaviors.
Another recommendation would be to design a study using
a sample of families of elementary school children and
provide them with information regarding the association of
health risk behaviors and the influence they can have as a
family on those behaviors. The intervention could be on-
going support groups between parents. The study could
follow the children of the parents who participated in the
support groups from middle school through high school to

assess their age of initiation of specific health risk

behaviors.
Reeemmendatien fer Fermal Edueetien ef Nursee

A recommendation for the formal education of
undergraduate and graduate nurses would be in course work
that supports and places an emphasis on parent and family
involvement in childrens’ lives. The literature reviews are
beginning to look at family, religion and community and the
strength they have on the formation of choices made by
adolescents. Education on this subject would allow nurses
to apply this to the children and families they encounter in
any type of practice setting. A segment of the clinical
rotations should be in the community speaking to parents in
groups, supporting strong family ties and sharing the
information obtained in this research project and in the

literature.

29

In the clinical settings Nurse Practitioners can use
questionnaires and assessment tools that identify
adolescents at risk for initiating risky health behaviors.
Adolescents should be assessed at every office visit, acute
or well, because they do not appear often to their health
care providers office during this age span.

Summary

The purpose of this study was to determine if there was
a correlation between the age of onset of alcohol
consumption and the age of sexual initiation in rural 11th
grade students. This study had a relatively small sample
size and it was specific to rural youth. The statistical
data does show that there is a significant correlation
between theses two variables. This information is useful to
FNP’s practicing in a rural area in a school setting, clinic
or private office. This data can be applied to the youth
and their families that the FNP will provide care for by
assessing for early initiation of alcohol use and then by
providing education about the risk behaviors that are linked

to it.

30

LIST OF REFERENCES

LIST OF REFERENCES

Alexander, B. (1991). Alcohol abuse in adolescents.

American Family Physieian, 43, 527-532.

Alexander, D., & Gwyther, R. (1995). Alcoholism in
adolescents and their families. Pediattie gljgjgg Q: NQIID
America1_42(1), 217-233.

Bandura, A. (1986). ci und ' n f u
- ia o ni 'v he r . Englewood Cliffs, New
Jersey: Prentice-Hall Inc.

Burns, C., Barber, N., Brady, M., & Dunn, A. (1996).
Peo'at,i Pr'mar ,a -- : .onooo-r _. N s- Pr. T for-
Philadelphia, Pennsylvania: W.B. Saunders Company.

Cates, W. (1991). Teenagers and sexual risk taking. The

best and the worst of times. Journal at Adelescent Health,
12, 84-94.

Davis, S. (1989). Pregnancy in adolescents. Pediatric

Cl iniee 9f Netth Ameriea . 36(3), 665-680.

Dent, C., Galaif, J., Sussman, 8., Stacy, A., Burtun,
D., & Flay, B. (1993). Demographic, psychosocial and
behavioral differences in samples of actively and passively

consented adolescents. Addictive Behaviers, 18, 51-56.

Durbin, M., DiClimement, R., Siegel, D., Krasnovsky,
F., Lazarus, N., & Camacho, T. (1993). Factors associated
with multiple sex partners among junior high school

students. Jenrnal ef Adeleseent Health, 13(3), 202-207.

Fergusson, D., & Lynskey, M. (1996). Alcohol misuse
and adolescent sexual behaviors and risk taking. EBQIBLIICSI
98(1) 91-95.

Goodson, P., Evans, A., & Edmunson, E. (1997). Female
adolescents and onset of sexual intercourse: A theory based
review of research from 1984—1994. Jen;nal_ef_Adeleeeent
Health1_21(3), 147-156.

Guthrie, B., Loveland- Cherry, C., Frey, M., & Dielman,
T. E. (1994). A theoretical approach to studying health
behaviors in adolescents. An at- risk population. Eam ily an nd
omm ' alth 7(3), 35- 48.

Jessor, R., Costa, F. Jessor, L., & Donovan, J. (1983).
Time of first intercourse: A prospective study. Jenrnal ef

Persenality and Secial Psycholegy, 44(3), 608-626.

31

Johnston, L., O’Mally, P., & Bachman, J. (1994). 1993
National survey results on drug use from The Monitoring the
Future Study. Ann Arbor, MI: University of MI News and Info
Services.

Kann, L., Warren, W., Collins, J., Ross, J., Collins,
B., & Kolbe, L. (1993). Results from the national school
based 1991 youth risk behavior survey and progress toward
achieving related health objectives for the nation. Enb1ie

WM), 47- 55.

Kolbe, L. (1992). The role of the federal government in
promoting health through schools: Report from the Division
of Adolescent and School Health Centers for Disease Control.

Jpnrnal pf Sehool Hea1th. 62(4), 135-137.

Kolbe, L., Kann, L., & Collins, J. (1993). Overview of
the Youth Risk Behavior Surveillance System. Pnb11e_fiea1tn

Reports, 108(1), 2-9.

Loda, F., Speizer, I., Martin, K., Skatrud, J., &
Bennett, T. (1997). Programs and services to prevent
pregnancy, childbearing and poor birth outcomes among
adolescents in rural areas of the southeastern United

States. Journal pf Adeleseent Health, 21(3), 157-166.

Morrison, 8., Rogers, P., & Thomas, M. (1995). Alcohol
and adolescents. i ' Clinic of N m ic ,
371-387.

Polit, D., & Hungler, B. (1995). Nursing researeh;
Prineiples and Metheds. Philadelphia, PA: J.B. Lippincott
Co.

Resnick, M., Bearman, P., Blum, R., Bauman, K., Harris,
K., Jones, J., Tabor, J., Beuhring, T. Sieving, R., Shew,
M., Ireland, M. Bearinger, L., & Udry, R. (1997).

Protecting adolescents from harm. he rn h
m ' M ' 27 823-832.
Rosi, M. (1995). l h r' eh v' r am n eleven
a ud ' ural i hi h 1

Unpublished master’s thesis, Michigan State University, East
Lansing, MI.

Vagenaar, A. (1993). Where and how adolescents obtain

alcoholic beverages. Publie Health Reportl 108, 459-464.

Warren, C., Kann, L., Small, M., Santelli, J., Collins,
J., & Kolbe, L. (1997). Age of initiating selected health-
risk behaviors among high school students in the United

States. Journal pf Adeleseent Health, 21(3), 225-231.

32

APPENDICES

APPENDIX A
YOUTH RISK BEHAVIOR SURVEY

1995

YOUTH RISK BEHAVIOR
SURVEY

This survey is about health behavior. It has been developed so you can
tell us what you do that may affect your health. The information you give will
be used to develop better health education for young people like yourself.

DO NOT write your name on this survey. The answers you give will be
kept private. No one will know what you write. Answer the questions based
on what you really do.

Completing the survey is voluntary. You indicate your voluntary
agreement to participate by completing and returning this survey.

The questions that ask about your background will only be used to
describe the types of students completing this survey. The information will not
be used to find out your name. No names will ever be reported.

Try to answer every question. When you are finished, follow the

instructions of the person giving you the survey.

Thank You Very Much For Your Help.

33

10.

ll.

YOUTH RISK BEHAVIOR SURVEY
How old are you?
(a) 15 (b) 16 (c) 17 (d) 13
Sex: (a) Female (b) Male
How important is yottt health?
(a) very important (b) somewhat important (c) not important
How healthy are you?

(a) excellent health (c) fair health
(b) good health (d) poor health

How often do you worry about your personal health?

(a) a lot (b) sometimes (c) hardly ever
How often do you wony about getting sick?

(a) a lot (b) sometimes (c) hardly ever
When you are sick, how much do you worry about it?

(a) a lot (b) some (c) little to none
How much responsibility do you feel for your health?

(a) a lot (b) some (c) little to none
How often do you do things not good for your health?

(a) a lot (b) sometimes (c) 'hardly ever
How many days are you absent from school in a typical month?

(a) almost never (c) 3-5 days a month
(b) 1-2 days a month (d) 6 or more days a month

When did you last go to a doctor or nurse for aHEALTH check-up or physical when
you were NOT sick?

(a) during last 12 months (c) more than 2 years ago
(b) 1-2 years ago (d) never

34

12.

l3.

14.

15.
l6.
17.
18.
19.
20.
21.
22.
23.
24.
25.

26.

How often do you go to a doctor, nurse, or Emergency Room?

(a) never (c) 3-5 times per year
(b) 1-2 times per year (d) more that 5 times per year

When you are sick, where do you go?

(a) Private doctor’s office

(b) Walk-In Clinic (Quick Care)
(c) Emergency Room

((1) Health Department

(e) Other - Where

 

When you are sick or hurt do you always get medical care when you feel you need it?

(a) Yes (Goto question 26)
(b) No (Go to question 15)

My parent(s) didn’t think I needed to see a doctor ............ (a) yes
It cost too much money ............................ (a) yes
I didn’t know where to go ........................... (a) yes
I didn’t have a way to get there ....................... (a) yes
I could not go during office hours ...................... (a) yes
I had to wait too lOng to get an appointment ................ (a) yes
Ididnotwanttomissschool . . . . . . . . . . . . . . . . . ._. ...... (a)yes
My mother/father could not take time off work .............. (a) yes
I was afraid/embarrassed ........................... (a) yes
My visit would not be secret ......................... (a) yes

Other (a) yes
What kind of health insurance does your family have?

(a) Private (Blue Cross/Blue Shield, AETNA, etc.)

(b) Prepaid health maintenance plan, (Blue Care Network, HMO, Health Plus,
(c) Medicaid

(d) My family pays because we have no insurance

(e) I do not know

(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no

etc .)

HAVE YOU BEEN CHECKED FOR THE FOLLOWING IN THE LAST 2 YEARS?

27.
28.
29.
30.
31.
32.
33.
34.

blood iron (anemia) ..................... (a) yes (b) no (c) don’t know
height and weight ...................... (a) yes (b) no (c) don’t know
blood pressure ........................ (a) yes (b) no (c) don’t know
pregnancy .......................... (a) yes (b) no (c) don’t know
pap smear .......................... (a) yes (b) no (c) don’t know
sexually transmitted disease (STD) ............ (a) yes (b) no (c) don’t know
scoliosis (curved back) ................... (a) yes (b) no (c) don’t know
hearing and vision ..................... (a) yes (b) no (c) don’t know

35

35.

36.

37.

38.

39.

41.

42.

43.

How do you describe your weight?

(a) Very underweight (c) Slightly overweight
(1)) Slightly underweight (d) Very overweight
(c) About the right weight

How do you feel about your weight:

(a) I’m trying to lose weight (c) I want to stay the same
(b) I’m trying to gain weight (d) It doesn’t matter to me

Have you ever done any of the following shortly after eating (Mark only one)?

(a) made yourself throw up (c) both of the above
(b) used remedies such as laxatives (d) neither of the above

During the past 30 days, did you vomit or take laxatives to lose weight or to keep
from gaining weight?

(a) Yes (b) No

How many days a week do you usually eat breakfast?

(a) almost never (d) 5-7 times a week

(b) 1-2 times a week (e) every day

(c) 3-4 times a week

In the past six months, have you had the feeling that life wasn’t worth living?
(a) Yes, often (b) sometimes (c) never

In the past six months, have you been depressed for long periods of time?

(a) yes, but not right now

(b) yes, and I’m having real problems right now

(c) no

During the past 12 months, did you ever seriously consider attempting suicide?

(a) Yes 0;) no

During the past 12 months, did you make a plan about how you would attempt
suicide?

(a) Yes (b) no
During the past 12 months, how many times did you actually attempt suicide?
(a) 0 times (d) 4 or 5 times

(b) 1 time (e) 6 or more times
(c) 2 or 3 times

36

45.

46.

47.

48.

49.

50.

51.

52.

53.

If you attempted suicide during the past 12 months, did any attempt result in an
injury, poisoning, or overdose that had to be treated by a doctor or nurse?

(a) I did not attempt suicide during the past 12 months
(b) Yes

(c) No

Have you ever had sexual intercourse?

(a) Yes (b) No

How old were 'you when you had sexual intercourse for the first time?

(a) I have never. had sexual intercourse (c) 14 or 15 years old
(b) 13 years or younger (d) 16 years old or older

During your life, with how many people have you had sexual intercourse?

(a) I have never had sexual intercourse (c) 2 or 3 people
(b) 1 person (d) 4 or more people

During the past 3 months, with how many people did you have sexual intercourse?
(a) I have never had sexual intercourse (c) 1 person
(b) I have had sexual intercourse, but (d) 2 or 3 people
not during the past 3 months (e) 4 or more people
Did you drink alcohol or use drugs before you had sexual intercourse the last time?
(a) I have never had sexual intercourse
(b) Yes
(c) No
The last time you had sexual intercourse, did you or your partner use a condom?
(a) I have never had sexual intercourse
(b) Yes
(c) No

The last time you had sexual intercourse, what one method did you or your partner
use to prevent pregnancy? (Select only one response.)

(a) I have never had sexual intercourse (d) Condoms

(b) No method was used to prevent (e) Withdrawal
pregnancy (I) Some other method

(c) Birth control pills

How many times have you been pregnant or gotten someone pregnant?

(a) 0 times (c) 2 or more times
(b) 1 times (d) Not sure

37

55.

56.

57.

58.

59.

61.

Do you feel pressure to have sex?

(a) Yes (b) No

If you answered YES to question 63 where does the pressure come from?
(a) boyfriend ((1) adult

(b) girlfriend (e) other

(c) friend(s)

How often do you wear a seat belt when riding in a motor vehicle?

(a) Never ((1) Most of the time

(b) Rarely (e) Always

(c) Sometimes

During the past 12 months, how many times did you ride a motorcycle?

(a) 0 times
(b) l to 10 times ((1) 21 to 39 times
(c) 11-20 times (e) 40 or more times

When you rode a motorcycle during the past 12 months, how often did you wear a
helmet?

(a) i did not ride a motorcycle during ((1) Sometimes wore a helmet
the past 12 months (e) Most of the time wore a helmet

(b) Never wore a helmet (I) Always wore a helmet
(c) Rarely wore a helmet

During the past 12 months, how many times did you ride a snowmobile or ATV?
(a) 0 times (d) 21 to 39 times
(b) l to 10 times (e) 40 or more times

(c) 11-20 times

When you rode a snowmobile or ATV during the past 12 months, how often did you
wear a helmet?

(a) I did not ride a snowmobile or (d) Sometimes wore a helmet
ATV during the past 12 months (e) Most of the time wore a helmet
(b) Never wore a helmet (I) Always wore a helmet

(c) Rarely wore a helmet

During the past 30 days, how many times did you ride in a car or other vehicle
driven by someone who had been drinking alcohol?

(a) 0 times (d) 4 or 5 times

(b) 1 time (c) 6 or more times
(c) 2 or 3 times

38

62.

63.

65.

67.

68.

During the past 30 days, how many times did you drive a car or other vehicle when
you had been drinking alcohol?

(a) 0 times (d) 4 or 5 times
(b) 1 tim3e (e) 6 or more times
(c) 2 or times

During the past 30 days, on how many days did you carry a weapon such as a gun,
knife, or club?

(a) 0 days ((1) 4 or 5 days
(b) 1 day (e) 6 or more days
(c) 2 or 3 days

During the past 30 days, how many days did you not go to school because you felt
you would be unsafe at school or on your way to or from school?

(a) 0 days (d) 4 or 5 days
(b) 1 day (e) 6 or more days
(c) 2 or 3 days

During the past 12 months, how many times has someone threatened or injured you
with a weapon such as a gun, knife, or club?

(a) 0 times ((1) 4 or 5 times
(b) 1 time (c) 6 or more times
(c) 2 or 3 times

During the past 12 months, how many times has someone stolen or deliberately
damaged your property such as your car, clothing, or books?

(a) 0 times (d) 4 or 5 times
(b) 1 time (e) 6 or more times
(c) 2 or 3 times

During the past 12 months, how many times were you in a physical fight?
(a) 0 times ((1) 4 or 5 times
(b) 1 time (e) 6 or more times

(c) 2 or 3 times

During the past 12 months, how many times were you in a physical fight in which
you were injured and had to be treated by a doctor or nurse?

(a) 0 times (d) 4 or 5 times

(b) 1 time (c) 6 or more times
(c) 2 or 3 times

39

69.

70.

’71.

72.

73.

74.

75.

76.

The last time you were in a physical fight, with whom did you fight?

(a) I have never been in a physical -(e) A parent, brother, sister, or other
fight family member

(b) A total stranger (0 Someone not listed above

(c) A friend or someone I know (7) More than one of the persons listed

((1) A boyfriend, girlfriend, or date above

Have you ever tried cigarette smoking, even one or two puffs?

a. Yes
b. No

How old were you when you smoked a whole cigarette for the first time?

(a) I have never smoked a whole ((1) 14 or 15 years old
cigarette (e) 16 years old or older

(b) 10 years old or younger

(c) 11-13 years old

During the past 30 days, on how many days did you smoke cigarettes?
(a) 0 days (d) 6 to 10 days

(b) 1 day (e) 11 or more

(c) 2 to 5 days

During the past 30 days, on the days you smoked, how many cigarettes did you
smoke per day?

(a) I did not smoke cigarettes during (d) 6 to 10 cigarettes per day
. the past 30 days (e) 11 to 20 cigarettes per day
(b) 1 cigarette per day (I) More than 20 cigarettes per day

(c) 2 to 5 cigarettes per day
Have you ever tried to quit smoking cigarettes?
(a) Yes (b) No

During the past 30 days, on how many days did you use chewing tobacco or snuff,
such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?

(a) 0 days (d) 6 to 10 days
(1)) 1 day (e) 11 or more
(c) 2 to 5 days

How old were you when you had your first drink of alcohol other that a few sips?

(a) I have never had a drink of alcohol (d) 14 or 15 years old
other than a few sips (e) 16 years old or older

(b) 10 years old or younger

(c) 11-13 years old

40

77.

78.

79.

81.

82.

83.

During the past 30 days, on how many days did you have at least one drink of
alcohol?

(a) 0 days ((1) 6 to 10 days
(b) 1 day (e) 11 or more
(c) 2 to 5 days

During the past 30 days, on how many days did you have 5 or more drinks of alcohol
in a row, that is, within a couple of hoilrs?

(a) 0 days (d) 6 to 10 days
(b) 1 day (e) 11 or more
(c) 2 to 5 days

'How old were you when you tried marijuana for the first time?

(a) I have never tried marijuana (d) 14 or 15 years old

(b) 10 years old or younger (e) 16 years old or older
(c) 11-13 years old

During the past 30 days, how many times did you use marijuana?

(a) 0 days (d) 6 to 10 days
(b) 1 day (e) 11 or more
(c) 2 to 5 days

How old were you when you tried any form of cocaine, including powder, crack, or
freebase, for the first time?

(a) I have never tried cocaine (d) 14 or 15 years old

(b) 10 years old or younger (e) 16 years old or older
(c) 11-13 years old

During the past 30 days, how many times did you use any form of cocaine, including
powder, crack, or freebase?

(a) 0 days (d) 6 to 10 days
0’) 1 day (e) 11 or more
(c) 2 to 5 days

During your life, how many times have you sniffed glue, or breathed the contents of
aerosol spray cans, or inhaled any paints or sprays to get high?

(a) 0 times (d) 10 to 19 times

(b) l or 2 times (e) 20 or more times
(c) 3 to 9 times

41

85.

86.

87.

88.

89.

91.

During your life, how many times have you taken steroid pills or shots without a
doctor’s prescription?

(a) 0 times (d) 10 to 19 times

(b) 1 or 2 times (e) 20 or more times
(c) 3 to 9 times

During your life, how many times have you used any other type of illegal drug, such
as LSD, PCP, ecstacy, mushrooms, spwd, ice, or heroin?

(a) 0 times ((1) 10 to 19 times
(b) l or 2 times (e) 20 or more times
(c). 3 to 9 times

During your life, how many times have you used a needle to inject any illegal drug
into your body?

(a) 0 times (b) 1 time (c) 2 or more times

During the past 12 months, has anyone offered, sold, or given you an illegal drug on
school property?

(a) Yes (b) No
When did you last go to the dentist?

(a) during last 12 months (c) more than 2 years ago
(b) 1-2 years ago (d) never

How often do you brush your teeth?

(a) I never brush my teeth (c) daily
(b) less than 6 times a week ((1) 2 or more times daily

How often do you floss your teeth?

(a) I never floss my teeth (c) daily
(b) less than 6 times a week ((1) 2 or more times daily

Who do you live with now?
(a) both parents (d) other guardian/adults

(b) 1 parent only (e) no adult
(c) 1 parent and 1 step parent

42

WHAT HELP WOULD YOU WANT FROM YOUR DOCTOR OR OTHER HEALTH

92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.

CARE PROVIDER?

Health check-up ................................. (a) yes
Sports physical ................................. (a) yes
A place to go when I’m sick ......................... (a) yes
Birth control ................................... (a) yes
Counseling for my problem .......................... (a) yes
Dental care .................................... (a) yes
Skin care ..................................... (a) yes
Pregnancy test ................................... (a) yes
Care during pregnancy ............................. (a) yes
AIDS information ................................ (a) yes
Sexually transmitted disease (STD) information .............. (a) yes

43

(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no
(b) no

.(b)no

APPENDIX B
FACT SHEET FOR PARENTS

Fact Sheet for Parents

How will education agencies and schools benefit from
conducting this survey?

Results from this survey can be used to; 1) monitor how
health behaviors among high school students increase,
decrease, or remain the same over time; 2) evaluate the
impact of national, state, and local efforts to prevent
health risk behaviors; and 3) monitor progress in achieving
relevant national health objectives and National Education
goals. Results can be used to help focus programs and
policies for HIV prevention education and school health
education on the behaviors that contribute to the leading
cause or mortality and morbidity.

What is the focus of the Youth Risk Behavior Survey?

This survey focuses on health behaviors established during
youth that result in the most significant mortality and
morbidity during youth and adulthood. These include: 1)
behaviors that result in unintentional and intentional
injuries; 2) Tobacco use; 3) alcohol and other drug use; 4)
sexual behaviors that result in HIV infection and other
sexually transmitted diseases (STDs), and unintended
pregnancies; 5) dietary behaviors; and 6) physical activity.

Why were these behaviors selected?

Among persons aged 5 to 24 years, approximately 72% of all
deaths are due to only four causes: motor vehicle crashes
(30%), other unintentional injuries (12%), homicide (19%),
and suicide (11%). In addition, each year an estimated 1
million teenaged girls become pregnant and 86% of all STD
cases occur among 15 to 29 year olds. One out of every five
persons diagnosed with AIDS in the United States is 20 to 29
years old; and many of these may have become infected as
adolescents.

Among adults aged 25 and over in the U.S., 67% of deaths are
due to only three causes: heart disease (35%), cancer (25%),
and stroke (7%). A number of behaviors, often established
during youth, contribute to these health problems. These
behaviors include the use of tobacco, excessive consumption
of fat, and insufficient physical activity.

44

Who developed the questionnaire?

The questionnaire was developed by representatives from all
state education agencies, 16 local education agencies, and
19 federal agencies including the U.S. Department of
Education, and by the foremost scientists in each
categorical area. These representatives were asked to focus
questions on the leading causes of mortality, morbidity, and
social problems nationwide. Additional questions were added
to the Center for Disease Control survey to reflect local
patterns of health utilization.

Will this survey cause students to initiate or increase risk
behaviors?

Student are exposed regularly to information about tobacco,
alcohol, and other drug use; violence; and sexuality through
the television, friends, and magazines. Exposure to a small
number of questions on any one topic is not likely to cause
a significant change in behavior either good or bad.

How long does it take to fill out the questionnaire? Is
there some sort of physical test?

One class period is needed for administration of the
questionnaire. It will take approximately 10 minutes to
distribute survey materials and read directions to the
students. It will then take approximately 35 minutes for
students to record their responses. No physical test or
exam is involved.

Is student participation anonymous? How is student privacy
protected?

Survey administration procedures are designed to protect
student privacy and allow for anonymous participation.
Students submit a completed questionnaire containing no
names or personal identifiers.

Are students tracked over time to see how their behavior
changes?

No. Students who participate cannot be tracked because no
identifying information is collected.

‘What is the reading level of the questionnaire?

The reading level is approximately 7th grade.

45

Will students be able to answer these questions?

Yes. Questions have been selected that have been used
successfully in other school based surveys of high school
students. Evidence indicates that high school students can
understand and appropriately respond to the questions.

Do students answer the questions truthfully?

Research indicates data of this nature may be gathered as
reliably from adolescents as from adults. To obtain
truthful answers, students must perceive the survey as
important and know that their privacy and confidentiality is
assured.

Do Youth Risk Behavior Surveys have broad national support?

Yes. The survey is supported by many major national
organizations. The American Association of School
Administrators, American Medical Association, American
School Health Association, Association for the Advancement
of Health Education, Association of State and Territorial
Directors of Health Promotion and Public Health Education,
Association of State and Territorial Health Officials,
Council of Chief State School Officers, National Association
of State Boards of Education, National Education
Association, National Education Goals Panel, National PTA,
National School Boards Association, National School Health
Education Coalition, and the Society of State Directors of
Health, Physical Education and Recreation have prov1ded
letters of support.

This material is adapted from the Center for Disease Cbntrol
Fact Sheet.

46

 

APPENDIX C
SURVEY ADMINISTRATION GUIDELINES

Survey Administration Guidelines

Administering the Survey

In a study of this kind, it is important to have a
standardization format so that procedures are consistent
across the study. Therefore, where oral instructions are
given below, try to give them as written.

Introductory Procedure

As quickly as possible after the class period begins, bring
the class to attention. Students need approximately 30 to
45 minutes to take the survey, plus another 5 minutes for
directions.

Homeroom Teacher Script

“Our school is involved in a very important study on student
health behaviors, health needs, and health care utilization.
The purpose of this study is to help our school better
understand the health issues and problems students face. By
taking this survey seriously, and by being as honest as you
can, you will help to improve our school’s programs.

It is very important that you know that your survey will be
anonymous. Since your name will not be on the survey, no
one will know which survey you completed.

I will now give each of you a survey form and pencil.
Please do not open the survey until I tell you to do so.
Remember: The survey is not a test.”

After distributing the materials, ask the students to follow
along as you read the paragraphs on the front page of the
survey. When done reading the paragraphs, continue.

“When you have finished the survey, raise your hand. I will
come to your desk, and you will place your survey form in
this envelope. After all the surveys are enclosed, I will
seal it. Neither I nor anyone else in this school will open
the envelope or look at the surveys. They will be sent for
processing to Michigan State University graduate students.
Again, no one here at this school will every see your survey
forms. So, please answer the questions honestly.

If you have any questions during the survey, raise your
hand, and I will try to answer them. You have 45 minutes to
do the survey. Make sure you read and try to answer each
question. When you are done, raise your hand, and I will
have you put your survey in this envelope. If you finish
early, remain in your seat and use your time to study. You
may begin.”

47

Concluding Procedure

Announce when there are five minutes remaining. Do not make
special arrangements for students to finish later, or on
their own. The hard and fast rule is to collect all forms
by the end of the period.

At the end of the session” “Thank you very much for your
participation. You may return to your classes now.”

If there is high absenteeism, note it (percentage absent)
and its cause on the envelope. Do not use names.

Additional Directives

If a student does not want to participate, that is his or
her right. Try to encourage participation, but do not
mandate it. Students who do not wish to participate will be
sent to the library.

Should they ask, assure the students that having a sip of an
alcohol beverage (communion wine included) does not
constitute drinking.

Do not include in the sealed envelope any unused surveys.
Return them separately to the survey coordinator.

48

APPENDIX D
CONSENT FORMS

 

Crawford Aub’able School District
403 Michigan Avenue

Grayling, Ml 49738

Phone (517) 348-7641 Kent S. Reynolds, Superintendent
FAX (517) 3486822 Paul B. Lerg, Assistant Superintendent

February 23, 1995
To Whom It May Concern:

The Crawford AuSable School District gives permission for Marilyn Rosi, BSN, RN, to
conduct a research project in cooperation with Michigan State University. The project will
involve a survey of the health behaviors and health care utilization of Grayling High School
eleventh grade students. Participation in the survey is strictly voluntary and individual
responses will be anonymous. The district is beginning a review of health and science
curriculum and the information Ms. Rosi will gather is invaluable to our district team
assigmd to health and science curriculum improvement.

We will administer the survey- instrument according to her design and use her analysis in our
curricular improvement effort.

Sincerely,

Kent S. ey Ids
Superintendent

'QUALH'Y EDUCATION IN THE HEART OF THE NORTH'

49

March, 1995
Dear Parents:

Next month graduate students from Michigan State University
College of Nursing will be conducting a very important study
of the health needs, health behaviors, and health care
utilization of students in grade 11. The Youth Risk
Behavior Survey developed by the Center for Disease Control
will be used for the study. It will take students
approximately 40 minutes to complete the survey. A copy of
the survey, as well as information on it, is available in
the main office at Grayling High School for your review.

This survey is voluntary. Parents and students have a right
to refuse to participate without penalty of any kind. All
information will be collected anonymously with no names or
other identifying marks on the surveys. Michigan State
University College of Nursing graduate students will be
coordinating the survey and analyzing the data. The study
will be conducted in a scientific manner guided by detailed
administrative guidelines. The final data analysis will be
made available to school officials and the Board of
Education.

Please fill out the form below and return it in the
enclosed, pre-addressed and stamped envelope by March __,
1995. If you have any questions about the study, please
contact Mr. Joel Raddatz, the high school principal.

Sincerely,

Mr. Joel Raddatz
High School Principal

 

I hereby give my permission for
(name of student/s) to participate in the Health Survey.

 

 

 

Signature of Parent/Guardian Date

50

APPENDIX E
UCRIHS APPROVAL LETTER

 

onuror
RESEARCH
AND
GNIADUAJE
STUDIES

shyConwmmnoa

(UCRIHS)
ligan State University
mmemmmummmg
ntmuthflhhm

fififldflfi

517A§E¥2180

FAX: 517/432-1171 '

amumflnUWmm
shamMMWMmMM
aumMmHHMn

Banaflmfiwafln
(flanmmWMWMMT

    
  
 
 

g

MICHIGAN STATE

1) II I VI E It S I 1' Y

 

May 14, 1998

TO: Linda S ence
A230 Li e Sciences

RE: IRB#: 98-316
TITLE: THE RELATIONSHIP BETWEEN THE FIRST USE OF
ALCOHOL AND SEXUAL INITIATION IN RURAL ELEVENTH
:> GRADE PUBLIC HIGH SCHOOL STUDENTS
REVISION REQUESTED: N/A
CATEGORY: l-E
APPROVAL DATE: 05/12/98

The university Committee on Research Involving Human Subjects'(UCRIHS)
review Of this prOJect is complete.. I am pleased to adVISe that the
rights and welfare of the human subjects appear to be adequately
rotected and'methods to Obtain informed.consent are appropriate.
hereforet the UCRIHS approved this progect and any rev1sions listed
above. ' . ' - -

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to:_
continue a prOJect beyond one year must_use the green renewal
form (enclosed with t e original agproval letter or when a
prOject is renewed) to seek u date certification. There is a
maximum of four such expedite renewals ssible. Investigators
wishin to continue a prOJect beyond tha time need to submit it
again or complete rev1ew.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the.time o renewal, please use the green renewal form. To
rev18e an approved protocol at an other time during the year,
send your written request to the. CRIHS Chair, requesting rev1sed
approval and referenCing the pronect's IRB # and title. Include
in our request a description of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PROPLHNS/ .

CHANGES: Should.either of the following arise during the course of the
work, investigators must noti UCRIHS romptly: (1) roblems
(unexpected Side effects, comp aints, e c.) involving uman
subjects.or (2).changes in the research environment or new
information indicating greater risk to the human sub ects than
eXisted when the protocol was preViously reviewed an approved.

If we can be of any future hel , please do not hesitate to contact us
at (517)355-2180 or FAX (Sl7)4 2-1171.

Sincerely,
avid E. Wright, Ph

CRIHS Chair

cc: Marguerite I. Michels

51