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Teresa M. Downing-Matibag
Brandi Geisinger
Iowa State University, Ames, Iowa, USA
Hooking up with friends, strangers, and acquaintances is a popular way for college students to experience sexual
intimacy without investing in relationships. Because hooking up often occurs in situations in which prophylactics
against sexually transmitted infections (STIs) are not available or in which students judgment is impaired, it can
involve risky behaviors that compromise student health. As such, in-depth studies of the factors related to sexual risk
taking during hookups are needed, to advance preventive research and programming. Based on semistructured interviews with 71 college students about their hooking-up experiences, the findings of this study demonstrate that the
Health Belief Model can serve as a useful framework for understanding sexual risk taking during hooking up, and
offers suggestions for sexual risk-prevention programs on college campuses. The results demonstrate why students
assessments of their own and their peers susceptibility to STIs are often misinformed. The findings also show how
situational characteristics, such as spontaneity, undermine students sexual self-efficacy.
Keywords: campus health; health behavior; health education; HIV/AIDS, prevention; intervention programs;
interviews; risk, perceptions; sexual health; sexually transmitted diseases; young adults
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Theory
The HBM is a cognitive model for understanding health risk behavior (Conner & Norman, 1996;
National Cancer Institute, 2005), including sexual
risk behavior among various age (Brown, DiClemente,
& Reynolds, 1991) and cultural (Lin et al., 2005)
groups. Developed in the 1950s by social psychologists working for the U.S. Public Health Services and
since elaborated on (Rosenstock, 1974; Rosenstock
et al., 1988), this model has provided the basis for
prevention-focused interventions and research in
areas such as substance abuse, smoking, obesity,
sexual risk taking, and HIV/AIDS (Conner & Norman,
1996). One of the shortcomings of the current
research is that the general models capacity to lend
insight into the health beliefs of specific populations,
such as college students participating in high-risk
sexual encounters (Zak-Place & Stern, 2004), midlife diabetics struggling with obesity, or even teenagers considering their first cigarette, has not been fully
articulated. Qualitative research that uses the HBM as
a framework for understanding health-related risk
taking among diverse groups and their socio-sexual
environment (Morrison, 2004, p. 328), however,
could inform our understanding of how to better
serve their needs. In a related manner, it could help us
improve the degree to which HBM-related scales
accurately reflect the psychosocial contexts in which
various risk behaviors occur.
The original HBM suggested that whether individuals undertook preventive health behaviors was
contingent on four factors: (a) their perceived susceptibility to an adverse health outcome; (b) their
perceptions of the level of severity of the adverse
health outcome and related consequential outcomes;
(c) their perceptions of the benefits of given preventive behaviors, in terms of helping them avoid the
adverse health outcome; and (d) the perceived barriers to (or costs of) implementing given preventive
behaviors (Rosenstock, 1974). A fifth factor, their
level of perceived self-efficacy (Bandura, 1977) in
implementing preventive behaviors, was later added
to the model (Rosenstock et al., 1988). Self-efficacy
refers to the degree to which individuals believe that
they are capable of implementing preventive actions
(Rosenstock, Strecher, & Becker, 1994). Here, we draw
on the five-factor HBM model to explore college
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Methods
Participants
We completed semistructured interviews with
71 college students at a large midwestern university.
The students were enrolled in an introductory sociology class and had the option of participating in our
research or completing an alternate assignment. The
requirements for participation in the study were
announced during class. Students were told that they
needed to have participated in at least one hookup,
namely a sexual activity (kissing and fondling of the
breasts or genitals, or oral, anal, or vaginal sex) with
someone to whom they had no relational commitments (Flack et al., 2007; Glen & Marquardt, 2001;
Lambert et al., 2003). Interested students were told to
send an e-mail to one of the researchers to schedule
an interview. On arrival at their interviews, students
reestablished their eligibility for participation in the
interviewers. Only one of the participants was ineligible and withdrew from the study.
The final sample of 71 respondents reflected the
predominately White, Christian, heterosexual demographics of the midwestern region of the United States,
Data Collection
Four researchers, including one professor and
three students, conducted the interviews. The interviews averaged 45 minutes in length, took place in
two private rooms on campus, and were taperecorded
with the interviewees consent. On arrival, participants filled out a questionnaire requesting their general demographics and sexual orientation. Then the
four-part interview began. Part one of the interview
assessed the students perceptions of sex and dating
norms on campus, and what they thought their peers
and friends believed about the pros, cons, and acceptability of hooking up. Part two assessed the events that
occurred during students most recent hookup, and part
three assessed their evaluations of their hooking-up
experiences as a whole.
Part four of the interview, of greater relevance here,
assessed students perceptions of sexual risk taking
during hooking up, with respect to STIs.1 They were
Data Analysis
We used microanalytic content analysis to identify
the key factors associated with students use of protective barriers against STIs during hooking up, followed by the use of global content analysis to link the
patterns that emerged across the interviews to the key
components of the HBM (Lofland et al., 2005).
Initially, the first and second authors separately analyzed all of data by highlighting and coding examples
of students sexual health-related beliefs. We then
considered whether and how these beliefs corresponded to the components of the HBM. All of the
data was coded, thematically, by hand, and a word
processing search function was also used to identify
key concepts that related to students sexual risk taking. The primary researcher (the first author) reviewed
the second authors coded examples to assure correspondence in the interpretation of the data. In the few
cases where we disagreed as to how an example
should be coded, we discussed the example and eventually achieved consensus. We noted instances in
which the correspondence between our data and the
HBM were not clear, and used them as a basis for
suggesting ways to better ground the HBM within the
situational and phenomenological contingencies of
life on campus.
In short, the analysis involved a thorough reading
of all of the collected and transcribed data and coding
the data within a specific domain of interest. This
approach demanded that we become intimately familiar with all of the data, and allowed us to ask specific
questions about our data. Our primary domain of
interest was sexual risk taking during hooking up,
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Results
The HBM states that for people to take preventive
actions, they must believe that (a) they are susceptible
to an adverse health outcome, (b) the cost of incurring
the adverse health outcome would be severe, (c) the
benefits of protection outweigh the costs, and (d) they
can undertake the necessary actions to protect themselves from the outcome (Brown et al., 1991). Each
of these components was represented in the data, as
well as one self-efficacy-related factor often overlooked in quantitative HBM research: disinhibition.
This concept refers to the idea that people who under
normal circumstances would take the necessary precautions against STIs might make poor judgments
because of high levels of sexual arousal or, more
commonly, alcohol use (Aguinaldo & Myers, 2008).2
Furthermore, our analysis suggested that students
perceptions of their self-efficacy in using protection
against STIs varied across situational contexts, another
issue that is underexplored in quantitative HBM studies of adolescent sexual risk behavior.
Each aspect of the HBM was examined relative to
our findings. Qualitative data analysis was used to
identify the specific factors that underlie each aspect
of the HBM within the context of hooking up among
college students. In a subsequent study, we will draw
on this analysis to recommend adaptations to the scalar measures that are traditionally used in (quantitative) HBM-related research on sexual risk behavior.
We believe that our results can be used to improve the
relevance of the items that are included in such scales
to the actual experiences and perceptions of college
students involved in hooking up.
Perceived Susceptibility
to Adverse Outcomes
Many of the students interviewed were unaware of
their own vulnerability to STIs. Only about 50% of
the students were concerned about contracting an STI
during a hookup that involved sexual intercourse, and
the majority of students were not concerned about
contracting an STI during a hookup that went only as
far as fellatio or cunnilingus. We identified three common reasons students underestimated their vulnerability to STIs: (a) they placed too much trust in their
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Mike explained:
I guess I have never really concerned [myself about]
protected oral sex. I mean, I know you hear about it
but its just, one, I know girls dont like, I know
theres flavored condoms, but I mean I know girls
dont like to do that.
Perceptions of self-efficacy in performing preventive behaviors. The last component of the HBM is
self-efficacy, or individuals perceptions that they can
perform the necessary behaviors to avoid an adverse
health outcome (Rosenstock et al., 1988). A critical
issue among students who failed to use protection
for oral intercourse was a sense of confusion regarding how to obtain or use the necessary materials.
A critical issue among students who failed to use
protection for vaginal or anal sexual intercourse was
that although they expressed high levels of perceived
self-efficacy in terms of their knowledge about and
ability to use protection, they demonstrated a lack of
efficacy in terms of their preparedness for the type of
unexpected sexual intercourse that occurs during
hooking up. Furthermore, they portrayed themselves
as inefficacious in terms of their ability to discuss
STIs and the use of protection with their partners.
Finally, regardless of students expressions of confidence in terms of understanding how to protect themselves against STIs during sexual intercourse, their
sexual encounters occurred in situational contexts
which sometimes undermined or facilitated their efficacy levels. We therefore examined how self-efficacy
is affected by situational and social contingencies,
factors often overlooked in HMB research (Boone &
Lefkowitz, 2004).
Efficacy in knowledge. Without exception, students
stated that they knew how to prevent STIs during
sexual intercourse. They knew where they could obtain
or purchase protective barriers, such as condoms, and
understood how to use them. However, students were
often unaware of how they could protect themselves,
or that protection was necessary, during oral sex. As
stated earlier, not one of the students interviewed
reported using a protective barrier during oral sex.
Additionally, only a small minority of students queried were familiar with the possibility of using dental
dams for protection against STIs during cunnilingus.
Adam, for example, was confused about using barrier
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protection for oral sex, and did not feel confident that
he would be able to do so:
I dont even know where the hell to buy a dental dam
or whatever the hell, so I just never really contemplated doing it, it just kind of, I dont know. Maybe
thatll be another lapse of judgment on my part
when, I just Ive never done it, period, even in high
school, doing stuff just. I guess condoms would be
more, I guess, I dont know. I mean I know what
youre talking about with dams and the little, I know
what youre talking about with that, but I just never
seen one or even thought about buying em.
Efficacy in discussion. The final area in which efficacy was problematic was when students needed to
discuss the risk of STIs and the use of protection with
their partners. Many students expressed a lack of efficacy in this area when they assumed or hoped that their
partners would tell them if they had an STI, and were
uncomfortable directly addressing the issue. Only one
student indicated that he was comfortable talking
openly with his partners about STIs and protection use
prior to engaging in sexual behavior. The rest of the
students used clues about their partners and their backgrounds to assess the potential that they could have an
STI. One man stated that he was hopefully assuming
everything was okay with his partner, and that he
didnt talk to her because he was uncomfortable. Many
students alleviated such discomfort by deciding to trust
their partners, and underestimating their susceptibility
to risk, as discussed above. They assumed that their
partners were STI-free because they did not mention
that they were not. In addition to situations in which
students had clearer choices as to whether or not to use
protection against STIs, there were some situations,
involving a loss of control because of sexual coercion
or disinhibition, in which their levels of self-efficacy
did not seem to matter at all.
About the females giving me head without protection, I guess thats just a mental thing, that Im like
you know, you see in any pornos [pornographic
movies], you know stuff like that. Its not the norm
for a guy to use protection or anything like that during that, but I mean even during pornos and stuff like
that, they do wear protection while having sex and
stuff like that, so.
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Discussion
After interviewing just a few students, it was
apparent that there were aspects of hooking up that
had not been addressed in the current literature
(Lambert et al., 2003; Paul, McManus, & Hayes,
2000). Discussing hooking up one-on-one with the
students yielded insight into the phenomenology of
hooking up and the reasons students often fail to protect themselves against STIs (Paul & Hayes, 2002).
This phenomenological perspective gave us insight
into how the cognitive core of the HBM can be contextualized by recognizing the culturally informed
meanings that students bring to their hookup experiences. As recommended by Lin et al. (2005) in their
HBM-based study on HIV risk behaviors among
Taiwanese student immigrants to the United States, it
helped us to understand how the HBM can be adapted
to reflect students culturally relevant health beliefs.
In a related manner, it clarified our understanding of
how the components of the HBM specifically relate
to sexual risk behavior among college students, and
how prevention programs might be adapted to better
address their needs. In the following discussion, we
concurrently address the implications of our findings
for prevention programs and for future research, as
these topics are related.
The HBM poses that for individuals to engage in
preventive behaviors, they must perceive that they are
susceptible to an adverse health outcome (Rosenstock
et al., 1988). Therefore, survey-based studies of sexual
risk behavior that rely on the HBM model generally
include a number of items regarding respondents perceptions of their own susceptibility (Lin et al., 2005).
Our findings suggest, however, that such studies would
be improved by taking into account not only students
estimates of their own susceptibility, but also the criteria they use to assess their partners susceptibility. This
is because students who did not use protection often
trusted that their hookup partners were STI-free based
on appearance or informal character assessments.
They also tended to rationalize that because there
were low rates of HIV/AIDS in the region where they
lived, they did not have to protect themselves against
it. Finally, they underestimated their susceptibility to
STIs because of not knowing that their partners could
transmit STIs to them via oral intercourse. Students
failure to accurately assess their own or their partners
susceptibility to STIs, then, was largely because the
vast majority had serious, if not predictable, gaps in
their knowledge of sexual health. These gaps need to
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Future research could address the issue of the limited sample that was used in our study in several
ways. First, it could involve studies of hooking up
among college students from diverse racial, ethnic, or
religious groups, or with nonheterosexual orientations. Winfield and Whaleys (2002) research on
whether the HBM predicts condom use among
African American college students is a good example
of how to incorporate diversity into our research.
Future research could also examine hooking up at
various types of colleges and universities located
within specific regions of the country, or in urban or
rural communities. Research across diverse populations and contexts can yield insight into the complexities of human health and well-being (Morse,
2002). Understanding such complexities is necessary
to better inform our efforts to prevent STIs, and we
recommend that multiple methodologies, including
qualitative and mixed-methods approaches, be used
for identifying the nuances of sexual risk taking during hooking up among specific subpopulations.
We also recommend that future research examine
whether our findings are supported by quantitative
surveys of larger, more representative samples. We
strongly recommend, however, that the scale items
utilized in such research be adapted to better reflect
the realities of hooking up on campus. As discussed
previously, scale items must account for the fact that
students decisions regarding sexual intimacy are
based on the culturally informed beliefs they bring to
their understanding of sexual risk and by situational
characteristics that are not currently accounted for by
the HBM. For example, the current HBM does not
account for the fact that students evaluations of their
risks of contracting an STI are informed by their
evaluations of whether or not any given partner has an
STI, not merely by a generalized estimation of their
personal vulnerability. It also does not account for the
roles of alcohol, sexual coercion, or condom accessibility in students ability to translate their sense of
self-efficacy in using condoms into protective behaviors. We have offered suggestions for addressing these
and other limitations in future research.
To conclude, we emphasize the importance of
studying hooking up as a unique phenomenon that is
different from what we have traditionally called
casual sex. Hooking up is a cultural phenomenon
that is legitimizing relationship-free sexual intimacy among many adolescents and young adults,
and it is taking the hush out of surreptitious sexual
encounters with relative strangers, classmates, online
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Notes
1. When we refer to STIs, we include HIV/AIDS, and we
emphasized this during the student interviews.
2. Again, in the Neff and Crawford (1998) study, individuals
expectations that the disinhibitory effects of alcohol would prevent them from practicing safe sex were conceptualized as a barrier to using protection against STIs, within the five-factor HBM.
Even though we agree that individuals alcohol-related expectations are important to address, we propose that the direct impact
of alcohol on individuals decision-making capacities, not to
mention the direct impact of sexual arousal itself on such capacities, is not fully accounted for by the HBM.
3. According to Ajzen (2002), perceived behavioral control
can serve as a proxy for actual behavioral control, and is thus
predictive of whether or not individuals will implement intended
behaviors. Although we did not measure perceived or actual
behavioral control in this study, the data suggest that women in
situations that involve having sexual intercourse against their will
believe they have no choice regarding the use of protection
against STIs.
References
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Teresa M. Downing-Matibag, PhD, is an assistant professor in
the Department of Sociology at Iowa State University in Ames,
Iowa, USA.
Brandi Geisinger, BS, is a recent graduate from the Iowa State
University Department of Psychology in Ames, Iowa, USA.
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