Clinical Scholarship

Reconceptualizing Adolescent Sexual Risk

in a Parent-Based Expansion of the Theory
of Planned Behavior
M. Katherine Hutchinson, Elyssa B. Wood

Purpose: To expand the theory of planned behavior (TPB) to explicate the influence of parents
on adolescent behaviors and describe its application to adolescent sexual risk behaviors.
Organizing Construct: Parents have repeatedly been shown to be among the most significant
influences on adolescents’ sexual risk-related attitudes, intentions, and behaviors. However,
many of the leading theoretical frameworks for understanding HIV-related sexual risk
behavior are individual-level models that do not include important influences outside the
individual, such as parents and families.
Findings and Conclusions: The proposed expansion of the TPB indicates the conceptual
underpinnings for the design of family-based prevention programs to reduce HIV-related
risk behaviors among adolescents. Additional research is needed to examine the predictive
validity of the expanded model, and instrument development is needed for many of the
expanded model constructs, most notably the parent constructs.

JOURNAL OF NURSING SCHOLARSHIP, 2007; 39:2, 141-146. 

C 2007 SIGMA THETA TAU INTERNATIONAL.

[Key words: Theory of Planned Behavior, family-based HIV prevention, adolescent sexual
risk, HIV prevention]

* * *

T
he purpose of this article is to propose how one of thereby are a basis for health promotion research, program
the leading theories of health behavior, the theory development, and evaluation of the effectiveness of inter-
of planned behavior (TPB; Ajzen, 1985, 1991), can ventions (Kohler, Grimley, & Reynolds, 1999). HIV-risk re-
be expanded to more explicitly incorporate the influences duction programs that are theory based have been shown to
of parents on adolescent behavior. Although the TPB is be most effective at changing risk behaviors (Fishbein, 2000;
known for its utility and predictive validity in understanding Jemmott, Jemmott, & Hutchinson, 2001). For effectiveness
many health behaviors, the model pertains to the individ- in health-promotion practice, a theoretical framework being
ual level. Influences outside the individual are not included; used must be adequate and able to provide “empirically
rather they are collectively relegated into the global cate- adequate descriptions, explanations, or predictions” of
gory of “external influences.” However, when addressing the phenomena under study (Villarruel, Bishop, Simpson,
issues such as sexual risk behavior among adolescents, the Jemmott, & Fawcett, 2001, p. 158). Two of the most
exclusion of parental influences is a significant omission that commonly used theoretical frameworks for conceptualizing
limits the utility of the TPB. HIV-related risk behavior include the theory of reasoned
In this analysis, TPB is expanded to incorporate a key action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen,
influence from within an adolescent’s most proximal en- 1975; Fishbein & Middlestadt, 1989), and its extension,
vironment: parents. Empirical evidence already exists to
support the expanded model. The proposed expansion of
the TPB indicates the conceptual underpinnings for family- M. Katherine Hutchinson, RN, PhD, Xi, Assistant Professor and Asso-
based prevention programs to reduce HIV-related risk be- ciate Director, Center for Health Disparities Research; Elyssa B. Wood,
haviors among adolescents. RN, MPH, Xi, Doctoral Candidate and Predoctoral Fellow; both at Uni-
versity of Pennsylvania School of Nursing, Philadelphia, PA. Correspon-
Theory of Planned Behavior dence to Dr. Hutchinson, University of Pennsylvania School of Nursing,
231 2L NEB, 420 Guardian Drive, Philadelphia, PA 19104–6096. E-mail:
khutchin@nursing.upenn.edu
Health behavior theories indicate the factors and mech- Accepted for publication December 27, 2006.
anisms that influence various health-related behaviors and

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Patient-Based Expansion of the TPB

the TPB (Ajzen, 1985, 1991). Both the TRA and the TPB be effective in reducing HIV-related sexual risk behaviors
have been widely and effectively used in studies of HIV risk- (Jemmott et al., 2001).
related behaviors and condom use (Albarracin, Johnson, The TPB does not include many of the variables that
Fishbein, & Muellerleile, 2001; Fishbein, 2000; Hutchinson, have been studied by social scientists in an attempt to un-
Jemmott, Jemmott, Braverman, & Fong, 2003; Jemmott & derstand preventive health behaviors. Instead, behavioral,
Jemmott, 1992; Jemmott, Jemmott, & Fong, 1992, 1998; normative, and control beliefs are the sole determinants of
Villarruel et al., 2001). an individual’s intention, which directly influence behaviors.
The TPB indicates that specific behavioral intentions All other variables outside these three belief systems and
are the direct determinants of behaviors (Ajzen & Fishbein, outside of the individual’s cognitive processes are consid-
1980). For example, using a condom during sexual inter- ered “external” variables (Fishbein, 2000) and are mediated
course (a behavior) is a direct function of a person’s inten- through behavioral, normative, or control beliefs. However,
tion to use a condom during sexual intercourse. Intentions some external variables and influences might be more im-
are determined through the internal psychological process of portant than are others, particularly parental influences.
integrating behavioral beliefs about the consequences of the
behavior (attitudes), normative beliefs referring to the per- Evidence Supporting a Parent-Based Expansion
ceived social pressure to perform or not perform a behavior of the TPB
(subjective norms), and control beliefs about how difficult
or easy performing the behavior would be (perceived be- Parents are the primary socializing agents of their chil-
havioral control; Jemmott et al., 2001). Depending on the dren and, as such, might be the single most important influ-
behavior, the model is adjusted to account for the value indi- ence in the lives of children and adolescents (Pequegnat &
viduals place on the variables (Armitage & Conner, 2001). Szapocznik, 2000). Many studies have shown that parents
Behavioral beliefs are influenced by prevention beliefs, exert significant influence on the sexual risk-related beliefs,
hedonistic beliefs, and partner-reaction beliefs (Jemmott et attitudes, and behaviors of adolescents (DiIorio, Pluhar, &
al., 2001). Normative beliefs reflect individuals’ views of Belcher, 2003; Hutchinson, 2002; Hutchinson et al., 2003;
whether significant people in their lives would approve or Pequegnat & Szapocznik, 2000). Some of the parenting
disapprove of the behavior, and their motivation to comply processes that have been shown to be influential include
with these expectations (Ajzen & Fishbein, 1980). Signifi- parental monitoring (Aronowitz, Rennells, & Todd, 2005;
cant people include peers, parents, and other family mem- Crosby, Diclemente, Wingood, Lang, & Harrington, 2003;
bers. DiClemente et al., 2001), parent-child closeness (Miller,
A third variable, perceived behavioral control (PBC), in- Nortin, Curtis, Hill, & Schaneveldt, 1998), role modeling
dicates that not all health behaviors are within the sole con- and values transmission (Jaccard, Dittus, & Gordon, 1998),
trol of the individual (Ajzen, 1985, 1991). Control beliefs and parent-child communication (DiIorio et al., 2003; Du-
refer to individuals’ beliefs that they possess the necessary tra, Miller, & Forehand, 1999; Hutchinson, 2002; Hutchin-
resources, skills, and opportunities to perform a behavior son & Cooney, 1998). Among these variables, parent-teen
(Madden, Ellen, & Ajzen, 1992), including judgments about sexual risk communication (PTSRC) is thought to be one
whether they have the capabilities to perform the desired be- of the most significant influences of adolescent sexual risk
havior. It is similar to the social cognitive theory construct of beliefs and behaviors (Pequegnat & Szapocznik, 2000).
perceived self-efficacy (Bandura, 1997). The control beliefs Among female adolescents, greater amounts of parent-
that have been identified as salient in relation to condom child sexual communication have been associated with de-
use include (a) beliefs about availability (confidence that an layed onset of initiating sex (Hutchinson, 2002); less sexual
individual can have condoms available when needed), (b) activity (Hutchinson et al., 2003); greater amounts of and
impulse control (confidence that a person can use a condom comfort with sexual risk-related communication with part-
even when sexually excited), (c) negotiation (confidence that ners (Aronowitz et al., 2005; Dutra et al., 1999; Hutchin-
an individual can persuade the partner to agree to condom son & Cooney, 1998; Miller et al., 1998; Whitaker, Miller,
use), and (d) technical skills (confidence than an individ- May, & Levin, 1999); increased condom-use self-efficacy
ual can technically use a condom without ruining the mood; (Hutchinson & Cooney, 1998; Hutchinson et al., 2003);
Jemmott et al., 2001). Control beliefs may exert direct effects and more consistent condom use (Hutchinson et al., 2003;
on behavior, indirect effects mediated through intentions, or Miller, Levin, Whitaker, & Xu, 1998; Miller et al., 1998;
both (Madden et al., 1992). Whitaker et al., 1999).
The inclusion of control beliefs enhances the prediction Hutchinson and associates (2003) recently undertook
of behavioral intention and thus behavior (Jemmott & Jem- a prospective study examining the influence of the base-
mott 1992; Madden et al., 1992). The inclusion of control line levels of mother–daughter sexual risk communication
beliefs also indicates important potential avenues for inter- on the sexual risk behaviors (number of episodes of sex-
vention, e.g., control beliefs can be improved through skill ual intercourse, episodes of unprotected intercourse, sexual
building, practice, positive reinforcement, and role modeling partners) reported by sexually experienced inner-city adoles-
(Jemmott et al., 2001). Interventions to address perceived cent females 3 and 6 months later. The 219 African Ameri-
self-efficacy and safer-sex skill building have been shown to can and Hispanic/Latina female adolescents, aged 12 to 19

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Patient-Based Expansion of the TPB

Parent Adolescent

Behavioral Behavioral
beliefs beliefs

External Intentions HIV-r elated

Intentions to
influences to engage sexual
External influence
Normative on adolescent Normative in sexual behaviors
influences adolescent’s (intercourse,
beliefs beliefs risk
on parents sexual condom use)
(Parents’ influence behaviors
behavior
behaviors:
PTSRC,
Control PM)
Control
beliefs beliefs

Note. indicates mediation of parental influences through control belief

indicates possible mediation of parental influences through behavioral and normative beliefs

Figure. Parent-based expansion of the theory of planned behavior.

years, were control-group participants in a randomized con- influenced by other individuals and by the series of nested
trolled trial study of HIV-related sexual risk behaviors. All systems in which they live: the microsystem, exosystem, and
were sexually experienced, nearly 30% reported a history macrosystem. In the proposed PETPB, individual adoles-
of STI, 19% had been pregnant at least once, and more cents are viewed as nested within multilevel systems, in-
than 16% had clinically documented STI at baseline. All cluding the family, community, and larger society. Of these
constructs were assessed with previously published mea- variables, the family is seen as one of the most proximal
sures with known reliability and validity. Outcomes were and important influences of adolescent sexual risk behav-
single-item measures (e.g., “With how many sexual part- iors. More distally, norms and expectations from commu-
ners have you had sex With during the past 3 months?”); nities, schools, and the larger society, and even the his-
mother-daughter sexual communication was measured with torical context, may also exert influence through their ef-
five yes/no items regarding whether the participants and her fects on the beliefs of parents or the adolescents themselves.
mother ever talked about sexual intercourse, birth control, These macrolevel influences are deemed external in the
STDs, HIV, condoms. Scale scores ranged from 0 to 5; the PETPB.
internal reliability of the scale was .86. As shown in the Figure, the traditional TPB is incorpo-
Hutchinson and associates (2003) found that each 1 rated into the expanded model. The right side of the model
point increase in mother-daughter sexual risk communica- is the traditional TPB. It shows that an adolescent’s inten-
tion was associated with an 11% reduction in the number tion is the primary determinant of engaging in sexual-risk-
of sexual episodes and a 19% reduction in the number of related behaviors, such as sexual activity, unprotected inter-
episodes of unprotected sexual intercourse reported at the 3- course, or condom use. Intentions are, in turn, determined by
month follow-up (Hutchinson et al., 2003). No effects were the adolescents’ behavioral, normative, and control beliefs.
found for number of sexual partners. Using the procedures Other influences on adolescents’ sexual-risk-related inten-
outlined by Baron and Kenny (1986), the authors also found tions and behaviors are mediated through their direct effects
evidence that the influence of mother-daughter sexual risk on the adolescents’ beliefs. In the parent-based expansion of
communication on daughters’ number of episodes of un- the TPB, the external influence of greatest interest is parent-
protected intercourse was mediated through their control teen sexual-risk communication (PTSRC), which has repeat-
beliefs, specifically PBC toward condom use (Hutchinson edly been shown to be associated with less risky adolescent
et al., 2003). sexual beliefs and behaviors.
The left side of the model shows that the parenting be-
haviors of interest are themselves primarily determined by
Parent-Based Expansion of the Theory of Planned the parent’s intention to perform those behaviors. In keeping
Behavior with the TPB, a parent’s intention to engage in PTSRC or PM
is determined by behavioral beliefs, normative beliefs, and
The parent-based expansion of the theory of planned be- control beliefs regarding the behaviors. Thus, parents are
havior (PETPB) is based on Bronfenbrenner’s work on the more likely to discuss sexual risk topics with their children
ecology of human development (1989). The core premise if they intend to do so and if they view PTSRC positively,
of Bronfenbrenner’s ecological view is that individuals are believe that important others would approve of doing so,

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Patient-Based Expansion of the TPB

and believe that they have the skills necessary to engage in reduction programs are focused on changing parenting be-
PTSRC effectively. haviors that will, in turn, be external influences that lead
An important distinction must be made between the par- to changes in adolescents’ sexual-risk-related beliefs, in-
ent’s sexual-risk communication and the adolescent’s nor- tentions, and behaviors. Family-based interventions would
mative beliefs regarding his or her parents and whether be designed to change adolescent sexual-risk behaviors by
they might approve or disapprove of the adolescent’s en- changing the parenting behaviors of interest (e.g., PTSRC).
gaging in sexual behaviors. The adolescent’s normative be- Parenting behaviors would be modified by intervening to
liefs refer to “intraindividual” psychological processes or change parents’ beliefs about the behaviors and subse-
perceptions about what the parents believe or value. These quently their intentions to engage in the behaviors.
internal beliefs might or might not be similar to what the International studies and projects based on this model
parents actually believe. In contrast, parental behaviors of are currently in progress, including a parent-adolescent
interest (e.g., PTSRC) refer to parental behavioral outcomes, study in South Africa and a collaborative HIV-prevention
actions that parents do or do not perform. This distinction is project with colleagues at the University of the West Indies in
important. Kingston, Jamaica. Recently concluded elicitation research
Another important distinction is that the parenting be- with adolescents, their parents and teachers using the PETPB
liefs of interest (behavioral, normative, control) on the left indicated critical parental influences that were specific to Ja-
side of the model pertain to the parents’ beliefs about their maican culture and will need to be addressed in the design of
performance of parenting behaviors (PTSRC and PM), not HIV-risk-reduction interventions with Jamaican adolescents
the adolescent’s sexual-risk behaviors. Parent’s behavioral (Hutchinson et al., submitted). Culture-specific differences
beliefs about the age-appropriateness of adolescent sexual included: low levels of parent-teen sexual-risk communica-
activity or the effectiveness of condoms might secondarily tion; varying levels of parental monitoring because of high
influence their behavioral beliefs about the utility of engag- rates of single-parent households and transient parenting be-
ing in the parenting behaviors, but the primary focus on the cause of work obligations and work-related travel; parental
left side of the model is the parent’s behavioral, normative, role-modeling of multiple sexual partners among fathers and
and control beliefs and intentions about the parenting be- other males; and adolescent perceptions of father approval
havior of interest, PTSRC. This distinction is important and for adolescent sons initiating sex at young ages and hav-
necessary in order to maintain clear focus when designing ing multiple female sexual partners (Hutchinson et al., sub-
parental interventions. mitted for publication). These family processes indicate the
importance of conducting elicitation research to understand
the family structure, processes, and values that might be
Mediation of Parental Effects
unique in a specific culture; such factors would need to be
Although clear evidence exists that parenting behaviors,
incorporated into the design of any culture-specific family-
particularly PTSRC, are associated with less adolescent sex-
based HIV-risk-reduction intervention for Jamaican youth
ual risk-taking, little is known about how parental processes
(Hutchinson et al., submitted for publication).
influence adolescents’ sexual-risk behaviors. A prospective
study conducted by Hutchinson et al. (2003) provided the
first evidence of mediation of effects. They found that con-
dom use self-efficacy (control beliefs) was a mediator for
the effects of mother-daughter sexual-risk communication
Discussion
on the occurrence of unprotected intercourse among adoles-
The parent-based expansion of the theory of planned
cent daughters (2003). These recent findings are consistent
behavior is an important response to DiClemente and Win-
with those from earlier studies, which showed links between
good’s (2000) call to progress beyond the individual level in
condom use self-efficacy and condom use (Halpern-Felsher,
conceptualization of and interventions to reduce adolescent
Kropp, Boyer, Tschann, & Ellen, 2004; Hutchinson, 2002;
sexual-risk behaviors. The model indicates multiple poten-
Hutchinson & Cooney, 1998). In the proposed expanded
tial targets for HIV-prevention interventions and thus pro-
theory, the mediation of parental influences through control
vides a theoretical basis for the design of family-based pre-
beliefs is indicated by a solid arrow. Less clear is whether
vention programs.
parental influences are mediated through behavioral and
Further, with an emphasis on parents the expanded
normative beliefs, and thus these are indicated on the Figure
model indicates the need to address differences in fami-
with gray dashed lines.
lies’ behaviors, beliefs, and ultimately their values within
their specific cultural context. Just as adolescent risk-related
Parental Interventions sexual behaviors vary across groups, parenting behaviors,
The PETPB explicitly includes parenting influences and including parent-teen sexual communication, vary widely
indicates a conceptual framework for the design of family- across subgroups and are extremely value-laden and culture
based HIV-risk-reduction programs. The model includes the specific. Understanding how these behaviors and the under-
behaviors of both parents and adolescents, and indicates lying beliefs vary across subgroups and cultural contexts is
the relationship between the two. Parent-based HIV-risk- important for tailoring interventions to specific subgroups.

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Patient-Based Expansion of the TPB

The PETPB model also includes multiple other fac- Although the PETPB is diagrammed as a unidirectional
tors within the community and larger social systems that model, that is an oversimplification. Many family processes
might influence parents and individual adolescents, their be- are circuitous, with feedback loops. This commonly encoun-
liefs and intentions, and ultimately their sexual risk-related tered limitation of cross-sectional studies of parental influ-
behaviors. Questions for further study include: How can ences of adolescent sexual risk might account for some of
parent-education programs based on the PETPB be designed the mixed findings in earlier studies. Higher levels of PTSC
to enhance the provision of in-home sex education? Are associated with higher levels of sexual risk-taking in cross-
these types of family-based sex education programs a vi- sectional studies cannot be interpreted as causal direction-
able alternative or supplement when in-school, sexual-risk- ality. For example, parents might increase sexual commu-
reduction education is not a part of the curriculum? nication in response to recognition that their adolescent is
sexually active or engaging in sexual-risk behaviors. The
need for further refinement of the feedback loops and bidi-
Limitations and Areas for Further Study rectional influences within the model indicates the need for
Beyond the features of the model that need further re- further study with longitudinal designs.
search, several broader areas of inquiry are needed. For ex- Instrument development is needed for many of the con-
ample, the TPB is a predictive theory, providing a direct structs in the expanded model. To date, many published
statistical model through which the intention of an individ- and widely cited instruments are available to assess the key
ual to perform a behavior can be measured and evaluated. components of the TPB as they relate to sexual-risk be-
Although the expanded model is deductively derived and in- havior (e.g., frequency of sexual activity, number of sex-
tuitive, and the relationships among many of the constructs ual partners, occurrence of unprotected intercourse, and fre-
have clear empirical support, further empirical evidence of quency of condom use) (Hutchinson et al., 2003; Jaccard et
the model’s predictive validity and mediation processes is al., 1998; Jemmott et al. 1992, 1998; Miller et al., 1998).
needed. Path modeling and statistical analyses are needed Similarly, measures of sexual-risk-related intentions, behav-
to better define the relationships among expanded model ioral beliefs, normative beliefs, and control beliefs have also
constructs. been published (Jemmott & Jemmott, 1992; Jemmott et al.,
Although these studies provide early evidence to sup- 1998). Less common are measures to assess the parental
port the relationships outlined in the PETPB, further work is constructs from the expanded PETPB, although a few mea-
needed to better understand how parenting processes such as sures of the parental behaviors of interest are available.
PTSRC influence adolescent sexual-risk-related behaviors. Several measures of parental monitoring have been pub-
Specifically, further evidence is needed to confirm whether lished (Crosby et al., 2003; DiClemente et al., 2001). Sev-
control beliefs mediate parent-teen sexual communication, eral measures of parent-teen sexual communication are also
to examine whether evidence of this mediation effect is available, including multi-item “yes or no” measures (Du-
found among male adolescents, and to identify whether be- tra et al., 1999) and multi-item quantifying scales (Hutchin-
havioral and normative beliefs mediate the effects of parent- son, 2002). The Parent-Teen Sexual Risk Communication
teen sexual communication on other sexual-risk behaviors, Scale (PTSRC-III; Hutchinson, 2002) has been used with
including sexual initiation and numbers of sexual partners. racially and ethnically diverse U.S. and international sam-
Further study is also needed to understand how normative ples to quantify the amount of sexual-risk communication
beliefs about parents are constructed. Adolescents’ norma- occurring between parents and adolescents. In addition to
tive beliefs or perceptions about their parents’ values are measures of parenting outcome behaviors, instruments are
not always congruent with parents’ actual or reported val- needed to assess parents’ behavioral, normative, and control
ues. A better understanding of how these normative beliefs beliefs and intentions toward parent-teen sexual communi-
are constructed and which parental behaviors influence their cation and parental monitoring.
formation could be used in the design of parent training fo- Finally, further study is needed to understand how well
cused on clarification and transmission of values. the model applies to various family types, cultures, and na-
Many other parenting behaviors require study as po- tionalities. For example, how are the processes similar or dif-
tentially important influences of adolescent sexual-risk be- ferent for mother-son dyads versus father-daughter dyads?
haviors. One of them, parental monitoring or supervision How well does the model apply in other countries, par-
of adolescent activities, has been empirically supported in ticularly in areas with high HIV/AIDS prevalence such as
several studies as an influence on adolescent risk behaviors. Sub-Saharan Africa and the Caribbean. Effective interven-
However, most of this work to date has been limited to cross- tions that are developed based upon the PETPB will need
sectional studies and outcomes examining substance use, not to be adapted for use with different family types and across
sexual-risk behaviors. Another parenting behavior, parental different cultures and nationalities. Culture-specific differ-
role modeling, has also been cited as an important influ- ences must be understood for family-based interventions to
ence on adolescent substance use. Whether parents’ own be both theory-based and culture-specific (Jemmott et al.,
sexual behaviors (e.g., multiple partners, modeling of gen- 2001). Modification to ensure applicability in a particular
der norms, etc.) influence their children’s sexual beliefs and cultural context should be done through pilot testing and
behaviors is yet to be determined. elicitation research before the adaptation of any intervention

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Patient-Based Expansion of the TPB

for HIV prevention (Jemmott et al., 1998; Jemmott et al., Dutra, R., Miller, K., & Forehand, R. (1999). The process and content of
sexual communication with adolescents in two-parent families: Associ-
2001; Kohler et al., 1999). This approach is particularly im-
ations with sexual risk-taking behavior. AIDS and Behavior, 3, 59–66.
portant for parent-based interventions because family struc- Fishbein, M. (2000). The role of theory in HIV prevention. AIDS CARE,
tures and processes vary across-cultures (Bray, 2000). 12(3), 273–278.
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior.
Boston: Addison.
Conclusions Fishbein, M., & Middlestadt, S. (1989). Using the theory of reasoned action
as a framework for understanding and changing AIDS-related behaviors.
In V. Mays, G. Albee, & S. Schneider (Eds.), Primary prevention of AIDS:
The parent-based expansion of the TPB is a valuable Psychological approaches (pp. 93–110). Thousand Oaks, CA: Sage.
alternative to the individual-level models that are currently Halpern-Felsher, B., Kropp, R., Boyer, C., Tschann, J., & Ellen, J. (2004).
being used to conceptualize HIV-related risk behaviors. In- Adolescents self-efficacy to communicate about sex: Its role in condom
attitudes, commitment and use. Adolescence, 39, 443–456.
corporation of parental influence is particularly salient when
Hutchinson, M. K. (2002). Sexual risk communication with mothers and
addressing sexual-risk behavior among adolescents. The ex- fathers: Influence on the sexual risk behaviors of adolescent daughters.
panded model is a timely response to calls to progress be- Family Relations, 51, 238–247.
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tant for practice, this model shows the multiple potential G. T. (2003). The role of mother-daughter sexual risk communication
influences of HIV-related sexual risk behaviors that exist in reducing sexual risk behaviors among urban adolescent females: A
prospective study. Journal of Adolescent Health, 33, 98–107.
within adolescents’ proximal and more distal environments Hutchinson, M. K., Jemmott, L. S., Wood, E. B., Hewitt, H., Kahwa, E.,
that also are potential targets for intervention. Waldron, N., et al. (2006). Identifying culture-specific factors that con-
tribute to HIV risk among Jamaican adolescent females. (Submitted for
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