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AIDS and Adventist Youth
Gary L. Hopkins, Joyce W. Hopp, Helen P. Hopp, Christine Neish, and Gayle Rhoads
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An AIDS risk appraisal of students attending SDA high schools in the United States and Canada
The acquired Immunodeficiency syndrome (AIDS) has become a major global threat. Worldwide, millions of persons have been diagnosed with and died of this dreaded disease. In the United States as of October 1995, a little over one half million persons with AIDS were reported to the Centers for Disease Control and Prevention (CDC)
Clinically, overt AIDS represents only the end-stage manifestation of a prolonged infection with the human immunodeficiency virus (HIV). The CDC(1) reported that 20 percent of the diagnosed cases of AIDS were in the age group of 20-29 years. Since the period from the time of HIV infection to the development of AIDS is generally between eight and 10 years,(2) there is a high likelihood that adolescents are becoming infected with the HIV and are diagnosed with AIDS when they are no longer adolescents.(3)
Currently there is no known cure for AIDS, nor is there a vaccination to prevent HIV infection,(4) although considerable research money has been directed toward this effort. Methods of preventing HIV transmission include abstinence from HIV risk behaviors such as IV drug use and avoidance of HIV-infected body fluids (semen, breast milk, blood, and vaginal fluid). Seventh-day Adventist leaders recommend the maintenance of a monogamous sexual relationship between non-HIV-infected individuals in a marriage relationship as the most effective method for preventing HIV transmission. Until a cure is available, health education targeted at reducing AIDS risk behaviors will be a main method of preventing HIV transmission.
Christian schools typically advocate health standards that include (1) abstinence from dangerous substances, including tobacco, alcohol, and drugs, and (2) abstinence from sexual intercourse until marriage, along with other biblically based principles.
The Seventh-day Adventist Church sponsors 93 four-year high schools (academies) in North America. Four surveys of students in these high schools revealed that some adolescents practice sexual and drug behaviors that place them at risk for contracting or transmitting the HIV.(5) Because of the practice of such HIV risk behaviors, research is needed in the SDA high school population in order to determine the possible points of educational and behavioral intervention to address the potential problem of HIV/AIDS.
In 1995 the authors conducted research to describe the HIV/AIDS risk factors of a sample of students attending SDA high schools throughout the U.S. and Canada. This research was to assess students' AIDS-related attitudes, normative beliefs (perceptions of social pressure), and their perceived control regarding AIDS risk behaviors.
We constructed a questionnaire based on an extensive review of the professional health literature on AIDS and AIDS risk behaviors specific to the adolescent period of development. The purpose of this questionnaire was to measure accurately and identify determinants of behaviors that could place adolescents at risk for transmitting or contracting the HIV. The questionnaire was divided into four sections: (1) demographic characteristics of the respondents. (2) HIV/AIDS-related knowledge. (3) HIV/AIDS minted behaviors, and (4) intentions. attitudes, social pressures, and perceptions of control related to the HIV/AIDS risk behaviors of sexual intercourse and substance use.
Permission for the research was granted by Dr. Gil Plubell, director of the North American Division, Office of Education. The office of education also provided partial funding. Application was then made to the Institutional Review Board (IRB) of Loma Linda University (LLU), under whose authority this research was conducted, for a review and acceptance of the research protocol. The functions of the IRB, as required by federal law, are to protect the subjects of research from emotional and/or physical harm and to assure that ethical research guidelines are followed. The IRB accepted the protocol proposal, but required that before students could answer the questionnaire it was necessary to obtain written consent from their parent(s).
Each of the 93 schools was mailed a box containing parental consent letters equal to its student enrollment. The schools applied mailing labels with the names and addresses of the parents of their high school students. The schools then mailed the letters, a total of 13,368. Parents who chose to allow their children to participate in this research signed and mailed a consent postcard to LLU. A total of 2.834 students were thus enrolled in the study. The students represented 85 of the 93 four-year high schools in the NAD.
Questionnaires were mailed to each of the participating schools with a list of the names of the students whose parents had granted consent. Each questionnaire was placed in a manila envelope with a letter to the student advising them as to the sensitive content of the questionnaire and guaranteeing that there would be no attempt to identify students by name.
Response rate. A total of 1,765 completed questionnaires were returned, yielding a response rate of 62.46 percent of the 2,826 parental consents. Sixteen of the 85 schools did not administer a total of 1,061 questionnaires.
Demographics. The majority of the respondents attended boarding schools as compared to day schools (53.7 percent versus 46.3 percent). The median age of the respondents was 17, with an age distribution of between 12 and 19; 56.4 percent of the respondents were female; and 93.3 percent were SDA. The distribution of respondents by year in high school was fairly equal (24.1 percent freshmen, 24.0 percent sophomores, 27.9 percent juniors, and 24.0 percent seniors) with the modal year of enrollment reported as eleventh grade. A comparison of the ethnicity of the respondents with the total student population attending four-year high schools throughout the NAD revealed that in the study sample White students were over-represented (79.3 percent versus 58.0 percent) and all minorities were underrepresented.
Knowledge. Accurate knowledge regarding modes of HIV transmission was high. The average score was 90.92 percent.
Substance use. Regarding the use of substances, Figure 1 demonstrates that non-SDA students who attended SDA high schools were more experienced with the use of all substances. The differences in the rates of use of all of the substances were statistically significant.
Parents' use of substances. In order to determine whether or not an association existed between the students' response of parental substance use and the students' rates of substance use, three questions were designed to measure this relationship. The students were asked if either of their parents or guardians smoked cigarettes, drank alcohol, or used marijuana. Figure 2 shows that when at least one of the parents used either tobacco, alcohol, or marijuana. the rates of the students' use of all of the substances increased.
Sexual intercourse. Of the total sample 16.3 percent reckoned having had sexual intercourse. Female students reported a lower rate of sexual intercourse (14.6 percent, N=144) when compared to males (16.2 percent, N-284). The median age at first sexual intercourse was 15 for both sexes. The mean age at first intercourse was 14.5 for males and 15 for females.
Parental and students' substance use behaviors and students' sexual experience. Substance use by parents and by students appeared to have a relationship with the students' past sexual experience. Students who used substances were shown to be the most sexually experienced (Table I). When students reported that they had a parent who also used a substance, the rate of sexual intercourse increased. The lowest rates of sexual experience were among students who had not previously used substances and whose parents, as reported by the students, also did not use substances.
Homosexual experience. Seventy-nine (4.6 percent, N=79} students reported sexual experience with someone of the same sex. The proportion of students with a history of a homosexual experience was higher in males than in females (5.0 percent, N-41 versus 4.2 percent, N-38).
Intentions to have sexual intercourse before marriage. The respondents were asked, "How likely is it that you will have sexual intercourse before marriage?" This question was followed by a seven-point unlikely/likely scale. The students who demonstrated a greater intention to have sexual intercourse before marriage were those who (1) were already sexually experienced, (2) were experienced with substances (i.e., drugs), (3) had a parent who used either tobacco, alcohol, or marijuana, and (4) were non-SDA.
Attitudes, social pressure, and perception of control toward sexual intercourse before marriage. Three separate questions were designed to measure the students' attitudes, perceptions of social pressure, and control regarding sexual intercourse before marriage. Each question was followed by a seven-point scale. The students who (1) were already sexually experienced, (2) were experienced with substances, (3) had a parent who used either tobacco, alcohol, or marijuana, or (4) were non- SDA demonstrated attitudes and perceptions of social pressure more favorable toward engaging in sexual intercourse before marriage. These same four groups demonstrated a lower perception of control over sex before marriage.
Determinants of the behavior to have sexual intercourse before marriage. Using appropriate statistical tests, measurements were made to determine whether the students' attitudes, perception of social pressures, or perception of control best predicted their intentions to have sex before marriage. It was found that perceived control was the strongest predictor. Students who (I) were sexually experienced (2) were experienced with substances, (3) had a parent who used either tobacco, alcohol, or marijuana, or (4) were non-SDA demonstrated a lower perception of control over sexual intercourse before marriage than those were otherwise.
Determination of perceived control. The items that best predicted the students' perception of control over sexual intercourse before marriage were encouragement from teachers and spiritual strength.
Substance use. Many students attending SDA four-year high schools across the North American Division practice substance-use behaviors that place them at risk for serious health problems, including transmitting or contracting the HIV. Although rates of substance use in SDA schools are typically lower than those in public schools (Figure 3), students who do use substances (including alcohol, tobacco, cocaine, and other drugs) are more likely to practice AIDS risk behaviors.(6)
Because of the association of substance use with AIDS risk behaviors, it is imperative that schools consider the future role of substance abuse counseling for adolescents.(7) Parents have the most important role in influencing the lives of their children. and hence there is a need to counsel parents regarding their own use of substances. The present research demonstrated that parental use of tobacco, alcohol. or marijuana was significantly associated with their children's (1) use of drugs and (2) rate of sexual intercourse. This research demonstrates that parental use of substances may be a factor in the AIDS risk behaviors of their children. When students reported that their parents did not use tobacco, alcohol, or marijuana, and when the students themselves did not use any substance, the rate of sexual intercourse was only 3.5 percent. One must remember, however, that the parental substance use was reported by the students and not by the parents themselves.
Sexual intercourse, the key AIDS risk behavior, as reported in this research, was found to be moderately prevalent. The rate of intercourse for this sample was 16.4 percent for all students. SDA students were less likely to have been sexually active than non-SDA students (14.6 percent versus 37.1 percent). Though the prevalence of sexual intercourse in this sample of students attending SDA schools is lower than the rate of 53 percent in public schools, the students who begin their sexual experience as adolescents are more likely to have multiple sexual contacts, thereby increasing their likelihood of eventual contact with an individual who is HIV-infected.
SDA educational system
The SDA Church places a strong emphasis on Christian education. The North American Division has 1,050 schools, ranging from kindergarten through high school. Enrollment in the schools totaled 50,988 in the fall of the 1994-1995 school year. SDA schools are typically staffed by teachers who are members of the SDA Church. The SDA Church holds a strong belief in the value of abstinence from premarital sex and from harmful substances including tobacco, alcohol, and addictive drugs. This research demonstrates that the strongest predictors of perceived control relating to sexual intercourse before marriage for those students who responded was spiritual strength and encouragement from teachers.
These findings reaffirm the belief that those who are chosen to teach in the SDA system should be committed to demonstrating Christian values not only in the classroom but also in all interactions with students. Those who work in the SDA school system need to have a sense of accountability regarding the seriousness of their roles in the schools. Administrators and school board members who are responsible for selecting teachers should carefully search for teachers who will make themselves available both in the classroom and outside the classroom to students for encouragement and counseling regarding issues such as substance use and premarital sexual intercourse.
Non-SDA students attending SDA schools
Until the last few years, North American Division policy has limited the number of non-SDA students admitted to the denomination's elementary and secondary schools. Schools serving grades K-6 were allowed 15 percent non-SDA students. Grades 7-12 were restricted to no more than 10 percent non-SDA. Those schools that admitted greater proportions of non-SDA students were designated "mission schools." In recent years local school boards have become increasingly ready to accept more non-SDA students. The driving force behind this philosophical shift seems to be that of financial necessity, although some explain the practice as part of the evangelical mission of the church.
Teachers and administrators quite universally report experiences with outstanding non-SDA students who contribute in a positive way to the Christian environment on campuses. There are undoubtedly outstanding non- SDA Christian young people enrolled in SDA schools. The current research, however, suggests that the church might be well served to review its policies regarding this issue.
Limitations in external validity
It is important to keep in mind some limitation. of this data set. Although serious attempts were made to secure a representative sample of all students attending four-year SDA high schools throughout the U.S. and Canada, the responses collected represent (1) an overrepresentation of White students, (2) only the responses of students whose parents or guardians consented to their students' participation, (3) a lack of representation of high school-age students who attended junior high schools, and (4) an under-representation of students attending inner-city schools.
The need for continued research
During the process of contacting the 93 four-year high schools in the NAD and arranging the logistics of this research, it was clear that many parents and individuals in school administrative positions were skeptical of how such research could be of value to them. Commonly expressed fears were that reporting simple descriptive statistics regarding rates of sexual intercourse and substance use might place the SDA educational system in a bad light and serve as an embarrassment, while yielding little benefit to the schools and the students.
Useful conclusions drawn from this research were not that a certain proportion of SDA youth engaged in sexual behaviors or substance use, but were rather that SDA youth are not immune or exempt from engaging in behaviors that place them at risk for unintended pregnancy, sexually transmitted diseases including AIDS, and the legal and health consequences of substance use. Educators can now act by creatively designing strategies that, when implemented, may serve to reduce the consequences of the behaviors studied.
-- Gary L. Hopkins, M.D., Dr.P.H., is coordinator of the evaluation research unit, School of Public Health, Loma Linda University, Loma Linda California; Joyce W. Hopp, Ph.D., M.P.H.,R.N., is the dean of the School of Allied Health, Loma Linda University; Helen P. Hopp, PhD., is associate professor in the School of Public Health, Loma Linda University; Christine Neish, PhD, M.P.H., R.N., is chair of the Department of Health Promotion and Education, School of Public Heath Loma Linda University; Gayle Rhoads, Ed.D., is the principal of Loma Linda Academy, Loma Linda, California.
(1) HIV/AIDS Surveillance Report, Part 7, No. (1) (Atlanta: Centers for Disease Control and Prevention, 1995).
(2) V. L. Tucker and C. T. Cho, "AIDS and Adolescents: How Can You Help Them, Reduce Their Risk?" Postgraduate Medicine 89, No.3 (1991): 49-53.
(3} C. Zimet, D. L. Bunch, T. M. Anglin, R. Lazebnik, P. Williams, and D. P. Krowchuk, "Relationship of AIDS-related Attitudes to Sexual Behavior Changes in Adolescents." Journal of Adolescent Health 13, No, 6 (1992): 493-498.
(4) Palacio, "Safer Sex," in P. T. Cohen, M. A. Sande, P. A. Volberding, eds., The AIDS Knowledge Base (Boston: Little, Brown, and Company, 1994).
(5) See G. Ludescher, AID5-related Knowledge, Attitudes, and Behaviors in Adolescents Attending Seventh-day Adventist Schools in California" (doctoral dissertation. Loma Linda University, 1992); P. L. Benson and M. J. Donahue, Valuegenesis: Repot 1: A Study of the Influence of Family, Church, and School on the Faith, Values, and Commitment of Adventist Youth (Minneapolis: Search Institute, 1990): G. L. Hopkins, "AIDS-related Knowledge. Attitudes, and Behaviors of Twelfth-Grade Students at Loma Linda Academy" (unpublished manuscript. 1994); and D. Gray, "Human Immunodeficiency Virus and Acquired Immune Deficiency: Beliefs, Knowledge, and Behaviors of High School Students Attending Seventh-day Adventist Academies" (doctoral dissertation. Andrews University, 1994).
(6) K. R. Miner, "Educating About HIV/AIDS:" in P, Cortese and K. Middleton, eds., The Comprehensive School Health Challenge: Promoting Health Through Education (Santa Cruz, Calif.: ETR Associates, 1994), vol. I, pp. 413-441.
(7) M. Hochhauser, "AIDS and Chemical Dependency: Prevention Needs of Adolescents," Journal of Psychoactive Drugs 21, No.4(1989): 381-385.
This article was published in the July 1996 issue of Ministry