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HIV Prevention for Youths in Foster Care: Understanding Future
Orientation and Intended Risk Behaviors
Michael Polgar a ; Wendy Auslander b
a
Department of Sociology, Pennsylvania State University, Hazleton, Pennsylvania, USA b George
Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA
Online publication date: 10 December 2009
To cite this Article Polgar, Michael and Auslander, Wendy(2009) 'HIV Prevention for Youths in Foster Care:
Understanding Future Orientation and Intended Risk Behaviors', Journal of HIV/AIDS & Social Services, 8: 4, 397 — 413
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Journal of HIV/AIDS & Social Services, 8:397–413, 2009
Copyright # Taylor & Francis Group, LLC
ISSN: 1538-1501 print=1538-151X online
DOI: 10.1080/15381500903417646
HIV Prevention for Youths in Foster Care:
Understanding Future Orientation and
Intended Risk Behaviors
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MICHAEL POLGAR, PhD
Department of Sociology, Pennsylvania State University, Hazleton, Pennsylvania, USA
WENDY AUSLANDER, PhD
George Warren Brown School of Social Work, Washington University in St. Louis,
St. Louis, Missouri, USA
Youths in foster care face challenges, including making healthy
behavioral choices. Empirical data from a sample show how
intentions to engage in HIV-risk behaviors vary among youths in
foster care. Youths who hold safer attitudes about prevention and
those who have fewer peers with behavioral problems more often
intend safer behavior. Among young women, a stronger orientation
toward the future is associated with fewer behavioral intentions
that involve HIV risk. Youths in foster care who are in higher grades,
express greater self-efficacy, or have fewer problems with mental
health or substance abuse express a stronger and more hopeful
orientation toward the future. These research results support the
application of integrated health behavior theory among youths in
foster care, showing that preventive attitudes, well-behaved
peers, and a stronger orientation toward the future are associated
with fewer behavioral intentions that precede HIV risk.
KEYWORDS
adolescents, foster care, HIV prevention, youth
Youths in foster care are more likely to experience a variety of problems that
increase their risk of exposure to HIV, while receiving less social support
(Perry, 2006). These problems include histories of prior abuse and neglect,
This work was funded by The National Institute of Child Health and Human Development
(R01 HD 35445) and by the Annie E. Casey Foundation with grants to the George Warren
Brown School of Social Work at Washington University in St. Louis, Missouri.
Address correspondence to Michael Polgar, Pennsylvania State University, 76 University
Dr., Hazleton, PA 18202, USA. E-mail: mfp11@psu.edu
397

398 M. Polgar and W. Auslander
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family instability and disruption, educational deficits, and mental health
problems (Jonson-Reid & Barth, 2000; Elze, Auslander, Stiffman, & McMillen,
2005; McMillen, Auslander, Elze, White, & Thompson, 2003). Encouraging
youth to adopt precautions against health risks (Weinstein, Sandman, &
Blalock, 2008) and providing these youths with future life options, including
education and support, can improve health outcomes and reduce HIV-risk
behavior in particular (Auslander, Slonim-Nevo, Elze, & Sherraden, 1998).
Previous studies have documented that youths in foster care are at high
HIV risk from sexual and drug-related behaviors. Specifically, youths in foster
care engage in high rates of sexual risk behaviors and substance abuse
(D’Angelo, Brown, English, Mein, & Remafedi, 1994). One study of foster
care youths found that youths engaged in more HIV-risk behaviors when
they experienced mental health problems (Auslander et al., 2002). A related
study also demonstrated that foster care youth who had experienced sexual
abuse engaged in more risky sexual behaviors than their counterparts who
had not been sexually abused (Elze, Auslander, McMillen, Edmond, &
Thompson, 2001). Studies of HIV-risk behaviors among troubled youths
who are demographically similar to the population of foster care youths also
suggest that these adolescents are at a greater risk for contracting HIV.
Studies have found that troubled youth such as runaway and delinquent
adolescents, have engaged in high rates of unsafe sexual behaviors
(Rotheram-Borus and Koopman, 1991; Gillmore, Morrison, Lowery, & Baker,
1994). In general, HIV-risk behaviors among adolescents are partially related
to exposure to adversity and to the extent of available social resources
(Fraser & Terzian, 2005).
The Theory of Reasoned Action (TRA; Fishbein & Middlestadt, 1989)
and the Theory of Planned Behavior (TBP; Ajzen, 1991) have been used
extensively to describe the relationships between individual cognitive factors
and HIV-risk behaviors. Recently, an integrated behavioral model (IBM) that
combines the two theories highlights behavioral intention as the most important
determinant of risk behaviors (Montano & Kasprzyk, 2008). The IBM
predicts that behaviors that carry a health risk are proximately related to individual
intentions and that these intentions are shaped by individual attitudes,
subjective social norms, and perceptions of personal control. Specifically,
behavior-specific knowledge and attitudes, in the context of social norms
and personal control (including self-efficacy), are associated with stronger
intentions to prevent HIV (Montano & Kasprzyk, 2008; Strecher &
Rosenstock, 1997). Peer norms and behaviors provide a particularly influential
context for both behavioral intention and actual HIV-risk behavior
(Wallace, Miller, & Forehand, 2008). A range of experimental research
supports the theory that changing individual intentions has consequences
for a range of health behaviors, while habits, social reactions, and personal
control can moderate the effects of behavioral intentions on risky health
behaviors (Webb & Sheeran, 2006).

HIV Prevention for Youth in Foster Care 399
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In addition to attitudes, norms, and personal control, another cognitive
factor that may be related to behavioral risk intentions is an individual’s
orientation toward the future. Adolescents hold variable and evolving views
of the future. Time horizons or future time perspectives and attitudes about
the future comprise future orientation. Future orientation is a set of expectations
and beliefs about the future which can be measured and evaluated with
standard indices and scales (Trommsdorff, Lamm, & Schmidt, 1979). In
theory, stronger adolescent future orientation can help to improve behavioral
intentions and behaviors by strengthening preventive attitudes, reducing
personal susceptibility, and increasing perceived control through greater
self-efficacy (Montano & Kasprzyk, 2008).
A positive future orientation in adolescents has been shown to be
associated with fewer risky behaviors such as substance abuse, unsafe sex
practices, and status offenses (Herrenkohl, Tajima, Whitney, & Wang, 2005;
Jurich & Hughes, 1991; Peters et al, 2005; Robbins & Bryan, 2004; Somers
& Gizzi, 2001; Wills, Sandy, & Yager, 2001). However, little is known about
future orientation in certain at-risk youths such as adolescents in foster care.
Because adolescents in foster care often lack family and peer support, and
they have other characteristics that place them at high risk for HIV, research
is needed to understand the relationship between future orientation and
behavioral intentions in this population.
Consequently, this research has two purposes. First, this study will
describe the variations in future orientation among youths in foster care.
Second, analyses will estimate and predict variations in HIV-risk behavioral
intentions among youths in foster care, incorporating future orientation and
building upon the Integrated Behavioral Model. It is hypothesized that
youth in foster care who intend to avoid HIV-risk behavioral risk hold
stronger preventive attitudes, experience healthier peer norms, express
more self-efficacy, or have a more positive future orientation. Problems
with mental health and substance abuse, while external to the integrated
behavioral model, have also been shown to be associated with higher rates
of HIV-risk behaviors and behavioral intentions (Auslander et al., 2002;
Thompson & Auslander, 2007). Therefore it is expected that mental health
and substance use will be positively associated with intended HIV-risk
behaviors.
METHODS
Participants
Our sample consisted of 168 youths in foster care (mean age: 16.3 years,
SD ¼ .84). Approximately half of these youths (49%) were female. Fifty-six
percent of these youths identified as African American, 33% as White, 10%
as biracial, and 1% as ‘‘other.’’ Sixty-one percent of the youths lived in a

400 M. Polgar and W. Auslander
family or foster care home situation, while the remaining 39% lived in a
congregate setting.
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Procedures
The participants were recruited from a state child welfare agency as participants
in a life-skills training program. Youths were referred to the program
by child welfare agency social workers and case managers. Youths were
eligible for the study and concurrent life-skills program if they were 15 to
18 years old and were living in an out-of-home placement. Informed consent
was obtained from each adolescent’s legal guardian and assent was given by
each respondent, according to procedures approved by a university research
review board for human subjects. Survey data were collected through
face-to-face interviews conducted by master’s-level social work students.
Data were collected at baseline as part of a larger study to evaluate an
8-month HIV prevention and life skills training program.
Measures
FUTURE ORIENTATION
Adolescent views of their future were indicated by a series of 12 attitude
statements, followed by Likert response scales. The measure consisted of
six items from the Life Orientation Test (Scheier, Carver, & Bridges, 1994)
and six items derived from the Future Time Perspective Inventory (Gjesme,
1979). Responses were coded such that higher index scores reflect a combination
of optimism about the future (hopefulness) and a future time-horizon.
INTENTION TO ENGAGE IN HIV-RISK BEHAVIOR
was also measured using responses from a reliable multi-item index
(Slonim-Nevo, Auslander, & Ozawa, 1995; Slonim-Nevo, Auslander, Ozawa,
& Jung, 1996). This index is based on eight different hypothetical situations
or events, each involving a potential HIV risk from unsafe sex or drug use.
The HIV-risk intention index score is the sum of eight items, with responses
ranging from 0 (would not take risk) and 1 (not sure, might take risk) through
2 (would take risk). The result is a variable with a possible range from 0
through 16, where higher index scores indicate stronger intentions to engage
in HIV-risk behaviors.
KNOWLEDGE AND ATTITUDES ABOUT HIV
To assess basic knowledge about HIV=AIDS prevention, 21 items
were selected from a 52-item true-false knowledge test (Koopman,

HIV Prevention for Youth in Foster Care 401
Rotherman-Borus, Henderson, Bradley, & Hunter, 1990). These items
were combined into an index covering five domains of AIDS-related
knowledge: HIV-risk behavior, transmission, prevention, testing, and
outcomes of HIV infection. A distinct 10-item index measured attitudes
toward HIV-preventive behavior, based on previous work with youths in
residential centers (Slonim-Nevo, Ozawa, & Auslander, 1991). This index
measured agreement with 10 statements either favoring HIV preventing
or avoiding HIV risk. In the integrated behavior model, attitudes and
knowledge about specific behaviors reflect beliefs evaluating outcomes,
the first of three proximate predictors of intention to perform a health
behavior.
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PEER BEHAVIOR
An index of problematic peer behavior covered a range of teenage problems,
including illegal substance abuse, fights, failing grades, problems with legal
authorities, and teen parenting (Stiffman, Dore, Cunningham, & Earls,
1995). The index was generated by taking the average score from a set of
13 questions. Each question evaluated the number of a respondent’s friends
who had specific problems, using a 5-point response, scale ranging from no
peers (0) to half (2) and to all peers (4). A simple, dichotomous variable
reflecting whether a respondent’s peers had low or high rates of problem
behavior was subsequently created by splitting the index of problematic peer
behavior at the mean. This dichotomous variable was used to simplify interpretation
of the logistic regression coefficient in multivariate models below.
Peer behaviors operationalize subjective norms, the second of three proximate
predictors of intention to perform a health behavior in the integrated
behavioral model.
SELF-EFFICACY FOR HIV PREVENTION
Self-efficacy is important in preventing most types of health problems.
Self-efficacy for HIV prevention was measured using an established index
summarizing the degree of agreement with 12 statements about both actual
and predicted safer sex behaviors (Koopman, 1990). This index has been
used with troubled adolescents (Rotheram-Borus, Mahler, & Rosario, 1995).
Those youths who are committed to HIV preventive behaviors, including
safer sex, score high on self-efficacy, while those youths who feel fatalistic
about HIV or uncomfortable with methods of prevention receive lower
scores. A higher total index score on the sum of the 12 items reflects a stronger
sense of self-efficacy in HIV prevention. Self-efficacy measures operationalize
personal agency, a third and direct measure of perceived control in the
integrated health behavior model.

402 M. Polgar and W. Auslander
MENTAL HEALTH
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The Youth Self Report (YSR) version of Achenbach’s child behavior checklist
(Achenbach, 1991) assessed behavioral and mental health problems. This
youth self-report includes the following ‘‘narrow band’’ subscales: withdrawn,
somatic complaints, anxiety=depression, social problems, thought
problems, attention problems, delinquent behavior, and aggressive behavior.
These subscales are further subsumed under two ‘‘broad band’’ subscales:
internalizing problems (withdrawn, somatic complaints, and anxiety=
depression) and externalizing problems (delinquent behavior and aggressive
behavior). The YSR has been extensively tested and validated, and there is
evidence in support of its reliability and validity as a measure of behavioral
and mental health problems across diverse adolescent populations (see
Achenbach, 1991). Higher scores indicate more behavioral and mental health
problems.
SUBSTANCE AND ALCOHOL USE
Substance use, abuse, and dependence were measured using the alcohol and
drug use sections of the Diagnostic Interview Schedule for Children (DISC-R;
Costello, Edelbrock, Dulcan, Kalas, & Klaric, 1984). The DISC-R assesses
a wide range of symptom information in language suitable for use with
children ages 6 to 18. Specific items from this interview were used to indicate
problems related to use of alcohol or illegal drugs. Data analyses use a simple
measure of recent substance use, which indicates if each adolescent (illegally)
used alcohol or marijuana at any time during the 6 months prior to
the interview.
Data Analysis
First, descriptive statistics were calculated for independent and dependent
variables (Table 1). An index measuring future orientation (Y 1 )wascalculated
using the average response scores on 12 items for each respondent.
Intended HIV-risk behaviors were measured using the sum of an eightitem
index. Subsequently, the eight items in variable index were simplified
to create a dichotomy comparing subject intending any HIV risk with subjects
intending no HIV risk at all (Y 2 ). Statistical analyses first examined
patterns of HIV-risk intentions and future orientation among sample adolescents
using bivariate associations, including categorical comparisons
and correlation analysis. The categorical bivariate relationship between
future orientation and HIV risk was elaborated by gender (Table 2).
Finally, multivariate regression models were computed for each of two
dependent variables (Table 3): future orientation (Y 1 ) and intention to

HIV Prevention for Youth in Foster Care 403
TABLE 1 Descriptive Measures of Youth in Foster Care
Variable
Type of
measure
Range
Average
(percent)
Standard
deviation
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Y 1 : Future orientation 12-item index 0–4 2.82 .38
Y 2 : Any intended HIV-risk behavior Dichotomy 0–1 (40%)
Knowledge of HIV risk 21-item index 0–21 18.52 2.52
Attitudes about HIV prevention 10-item index 1–4 3.38 .34
Prevention self-efficacy 12-item index 12–48 40.46 4.86
Mental health (youth self report) Multi-item index 0–2 .70 .88
Recent use of alcohol or marijuana Dichotomy 0–1 (52%) –
Peers with behavior problems 13-item index 0–4 1.64 .62
Peer substance use 2-item average 0–4 1.54 1.08
Secondary educational year Simple indicator 9–12 10.43 .91
Intends HIV-risk behavior in any of
8 hypothetical scenarios (items in Y 2 )
8-item index 0–16 3.12 2.96
Note. Additional information on many of these variables can be found in work by Auslander et al. (1998,
2002) and McMillen et al. (2003).
engage in HIV risk (Y 2 ). The series of bivariate associations (reported in
text) and subsequent multivariate models of HIV-risk intention (Table 3)
test elements of the integrated behavioral model of health risk in the sample
of youths in foster care.
TABLE 2 Gender Elaborates the Relationship Between Intended HIV Risk and Future
Orientation
Less positive
orientation
toward future
More positive
orientation
toward future
Total
n (%)
1. Any intended HIV-risk behavior
in one of eight situations
No 58% 62% 101 (60%)
Yes 43% 38% 67 (40%)
Total (n) 82 86 168
v 2 ¼ .16, p ¼ .683
2. Any intended HIV-risk
behavior (among males)
No 58% 47% 44 (52%)
Yes 42% 53% 41 (48%)
Total (n) 38 47 85
v 2 ¼ 1.03, p ¼ .309
3. Any intended HIV-risk
behavior (among females)
No 59% 79% 57 (69%)
Yes 41% 21% 26 (31%)
Total (n) 44 39 83
v 2 ¼ 4.0, p ¼ .046
Note. Asterisk ( ) indicates significant association (p < .05).

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TABLE 3 Multivariate Models of Future Orientation and HIV Risk
Y 1 : future orientation index Y 2 : intends HIV-risk behavior
Model 1.1 Model 1.2 Model 2.1 Model 2.2
beta (b), s e (p) b, s e (p) b, s e (p) b, s e (p)
Knowledge of HIV risk .01, .01 (.93) – .08, .09 (.35) –
Attitudes about HIV prevention .14, .10 (.94) – 1.9, .75 (.01) 2.20, .57 (.00)
Prevention self-efficacy .02, .01 (.01) .02, .01 (.00) .06, .05 (.27) –
Recent use of alcohol or marijuana .12, .07 (.07) .16, .06 (.01) .15, .45 (.74) –
Secondary educational year .07, .03 (.02) .06, .03 (.05) .01, .24 (.98) –
Peers with behavior problems .05, .08 (.53) – .91, .51 (.07) .99, .37 (.01)
Peer substance use .07, .08 (.30) – .88, .50 (.08) –
Intends HIV risk (index) .01, .01 (.99) – – –
Future orientation index – – .05, .62 (.92) .41, .48 (.38)
Model statistics R 2 ¼ 0.26, n ¼ 133 R 2 ¼ 0.23, n ¼ 135 R 2 ¼ 0.18, n ¼ 133 R 2 ¼ 0.15, n ¼ 167
Constant ¼ 0.8 Constant ¼ 1.3 Constant ¼ 1.4 Constant ¼ 5.2
Note. Statistics for each multivariate model include regression coefficients (beta parameters), the standard errors (s e ) for each estimated coefficient, and p-values in
parentheses. An asterisk ( ) indicates significant (p < .05) multivariate associations.
404

HIV Prevention for Youth in Foster Care 405
RESULTS
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Table 1 summarizes variables used in analyses, beginning with two
dependent variables: a continuous (12-item) index of future orientation
(Y 1 ) and a dichotomous indicator of any HIV-risk intentions (Y 2 ). Descriptive
statistics are also reported for explanatory independent variables,
including HIV-related knowledge, attitudes about HIV prevention, recent
substance use, prevention self-efficacy, educational level, mental health
(YSR total score), and two peer behavior variables: problem behaviors
and substance use. The distribution of the index of future orientation is
approximately normal, with a higher score (maximum ¼ 4) indicating that
youths had a stronger and more hopeful or optimistic view of the future.
Summary of individual items within the index of future orientation also
shows that some respondents had uncertainty about the future. For example,
42% never expected things to go their way, 82% were most concerned
about the present, and 46% reported that the future seemed unclear. Future
orientation items were reliably intercorrelated, based on a Cronbach’s alpha
coefficient of .70.
The internal consistency of eight items measuring HIV-risk intention
was indicated by a Cronbach’s alpha score of .71, affirming that the index
is also reliable in this sample. However this index was slightly skewed
toward lower levels of HIV-risk intentions; therefore, multivariate analyses
use a simpler dichotomous measure of any HIV-risk intention, distinguishing
respondents who reported that they would engage in at least one type of
HIV-risk behavior in a hypothetical situation from those who would not
engage in any type of HIV risk at all. Responding teenage youths in the
sample reported a very low rate of actual HIV-risk behaviors during the
two months prior to the survey, providing limited variation for analysis of
these specific health behaviors.
Most youths reported that they would not engage in any HIV-risk behaviors.
About 40% of youths in the sample (67 of 168 respondents) reported
that they would intend to engage in at least one HIV-risk behaviors in any
of eight hypothetical situations (Table 1). The average and standard deviation
from a more continuous indicator of HIV-risk intention (potentially ranging
from 0 to 16) is strongly skewed toward zero, indicating weak or no intentions
to engage in HIV-risk behaviors. Youths in the sample were quite
knowledgeable about HIV prevention; they correctly answered an average
of 18.5 questions on a 21-item (true–false) HIV knowledge test. Items measuring
knowledge of HIV risk were reliably intercorrelated, based on a
Cronbach’s alpha coefficient (.71). Most held attitudes indicating that they
knew which behaviors prevent HIV risk. The reliability of the HIV preventive
attitudes index was marginally acceptable, with a Cronbach’s alpha coefficient
of .62. We found greater variation in attitudes reflecting personal

406 M. Polgar and W. Auslander
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control of HIV prevention, described as prevention self-efficacy. The
self-efficacy index had a reliable alpha coefficient of .73. On average, youths
expressed confidence in their ability to prevent infection.
Many youths indicated that they had engaged in some problematic
behaviors in the past, based on the YSR and on other indicators. Data show
the YSR had reliable internal consistency. Cronbach’s alpha coefficients were
high for both subscales, internalizing problems (.90) and externalizing
problems (.85), and for total behavior problems (.94). In this sample, 52%
had used alcohol or illegal drugs in the 6 months prior to the interview
(Table 1). The moderate mean index score for the peer behavior problem
index reflects the general finding that many youths (51%) had at least some
friends about their age with significant behavioral problems. Data also
showed strong internal reliability for the index of peer problems (alpha ¼
.81). In addition, 40% of the respondents said that more than a few of their
friends used alcohol and 45% said that more than a few of their friends used
drugs. This variation in peer substance use is also indicated by the average
score on the peer substance use index.
Bivariate correlation analyses (reported only in text below) clarify
patterns in both future orientation and HIV-risk intentions. Significant correlation
coefficients show that several independent variables were significantly
associated with future orientation and HIV-risk intentions. In particular, a
significant negative correlation (r ¼ .17, p ¼ .03) shows that youths with
stronger future orientation were significantly less likely to intend to engage
in HIV-risk behavior. Youths with stronger future orientation were more
often in higher grades (r ¼ .21, p ¼ .02) and had fewer problems with their
mental health (r ¼ .32, p ¼ .00). They had a greater sense of self-efficacy
(r ¼ .35, p ¼ .00) and stronger attitudes about HIV prevention (r ¼ .23,
p ¼ .00). In contrast, youths with weaker views of the future were more
likely use alcohol or drugs (r ¼ .15, p ¼ .04), have substance abusing
peers (r ¼ .22, p ¼ .00), and report that their peers had behavior problems
(r ¼ .24, p ¼ .00). Notably, differences in future orientation were not significantly
associated with race or gender in the sample.
Consistent with the integrated behavioral model, youths who reported
more risky intentions had a weaker sense of personal control, expressed
through prevention self-efficacy (r ¼ .24, p ¼ .00) and less often held attitudes
that would help prevent HIV risk (r ¼ .43, p ¼ .00). Correlations also
indicate that youths with stronger intentions to engage in HIV-risk behaviors
were significantly more likely to also engage in HIV-risk behaviors (r ¼ .15,
p ¼ .04), have behavioral problems themselves (r ¼ .26, p ¼ .00), use illegal
substances (r ¼ .22, p ¼ .00), or have peers with problems (r ¼ .35, p ¼ .00),
including illegal substance use (r ¼ .31, p ¼ .00).
These correlations of continuous measures were confirmed by a series
of categorical data analyses performed with pairs of simpler variables
(usually dichotomies), some of which were derived from multi-item indices.

HIV Prevention for Youth in Foster Care 407
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First, analyses examined a categorical variable for future time orientation
(dividing the scale at the mean, creating Y 2 ). Future orientation was significantly
stronger among youths who did not have a recent history of alcohol
or marijuana use [chi-square (v 2 ) ¼ 4.1, p ¼ .04] and youths who reported
low rates of peer substance use (v 2 ¼ 8.6, p ¼ .00). A stronger future orientation
was also significantly associated with fewer total mental health problems
listed in the YSR (t ¼ 2.9, p ¼ .00), a finding that holds for both
internalizing mental health problems (t ¼ 3.1, p ¼ .00) and also externalizing
problems (t ¼ 1.6, p ¼ .05). Living in a group home placement (as opposed
to being with a foster family or biological parent) was not significantly associated
with future orientation, but youths in group homes were significantly
more likely to intend HIV-risk behavior (t ¼ 2.3, p ¼ .01). However, analyses
did not initially find a significant categorical association between
future orientation and HIV-risk intentions in the full sample (Table 2, Box 1).
Multivariate categorical data analyses subsequently used gender to
elaborate the hypothesized association between future orientation and intentions
to engage in HIV-risk behaviors. Results show different patterns for
male and female adolescents in the sample (Table 2, Boxes 2 and 3). Young
women in foster care who had more positive views of the future were significantly
less likely to intend to engage in HIV-risk behavior (v 2 ¼ 4.0, p ¼ .05),
while there was not a significant association between future orientation and
HIV-risk intentions among young men in the sample.
Multivariate regression models estimate the normally distributed variations
in the index of future orientation (Table 3). Results from ordinary least
squares regression show significantly stronger future orientation among
more advanced students, youths in better mental health, respondents who
abstained from illegal substance use, and adolescents who expressed greater
self-efficacy in preventing HIV infection (Table 3, model 1.1). Limiting this
predictive equation to include only the four significant variables (model
1.2) did not significantly reduce the proportion of variance explained, estimated
at 23% of all variations in future orientation. Peer behaviors and
knowledge of HIV risks were not significantly associated with future orientation
in the multivariate model.
The multi-item index of HIV-risk intentions was skewed toward the low
end, indicating that most youths in this sample expected to avoid HIV-risk
behaviors in most or all hypothetical situations. Therefore multivariate
logistic regression analyses were conducted to predict differences in a simple,
dichotomous measure of HIV-risk intention using maximum likelihood
estimation (StataCorp, 2003). In these multivariate models (Table 3, models
2.1 and 2.2), only a few variables within or external to the integrated
behavioral model significantly predicted variation in intention to engage in
HIV-risk behavior. Specifically, a youth’s attitude toward preventing HIV
was negatively related to their behavioral intentions (beta ¼ 2.20, p ¼ .00).
Regression coefficients also show that having peers who engage in

408 M. Polgar and W. Auslander
problematic behaviors significantly increased the chance that a youth would
intend to engage in HIV risk (beta ¼ .99, p ¼ .01). Future orientation, while
significant in correlations and cross tabulations for female respondents,
was not statistically significant in these multivariate models, and a fair amount
of variation remains unexplained.
DISCUSSION
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Youths in foster care are vulnerable to a variety of problems, including
health behaviors that carry risk of HIV infection. Previous research shows
that an expanding range of interventions can improve knowledge, attitudes,
and self-efficacy among youths, using life-skills training as part of
a larger education strategy (Rotheram-Borus, Mahler, & Rosario, 2000;
Yankah & Aggleton, 2008). Encouraging youths to adopt precautions
against health risks (Weinstein et al., 2008) and providing these youths
with life options, including education and support, can improve health
outcomes and reduce HIV-risk behavior in particular (Auslander et al.,
1998). Our research examined correlates of HIV-risk intentions among
youths in foster care. Bivariate findings support elements of an integrated
theory of health behavior (Montano & Kasprzyk, 2008), since many elements
of this theory are associated with intended HIV-risk behaviors.
However, empirical support for all aspects of this theory is more limited
in multivariate models, where we find that only preventive attitudes and
positive peer behaviors are significantly associated with an absence of
intended HIV risk.
This article examines how youths in foster care view the future, evaluating
the expectation that more positive and hopeful attitudes promote healthier
intended behaviors that can reduce risk of HIV transmission. We find
that several subgroups of youths in foster care express a significantly more
positive and hopeful orientations toward the future: teens in later stages of
their education, youths with fewer mental health problems, teens who feel
more effective at maintaining good sexual health, and those with peers
who avoid illegal substances. We subsequently find that future orientation
is associated with HIV-risk intentions in bivariate comparisons, and that this
association is statistically significant for young women in particular. However,
this finding is not replicated in multivariate regression models, where
only preventive attitudes and peer behaviors are simultaneously associated
with risky intentions.
Previous research shows that youths can reduce HIV-risk behavior
specifically through prevention education, developing accurate knowledge
and positive attitudes that limit exposure to HIV-risk, by reducing and limiting
risk behaviors, by improving mental health, and by finding support
among well-behaved peers (Holtgrave, McGuire, & Milan, 2007). Our

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findings show significant bivariate associations between future orientation
and behavioral intentions that increase HIV risk, particularly among young
females in the sample. Therefore, we cannot reject the idea that fostering
optimism and hope among youths in foster care can help reduce risky
intentions and ultimately help prevent HIV transmission. Prevention
programs may wish to build on the finding that future orientation is associated
with fewer HIV-risk intentions among young females. Interventions
that give hope and strengthen positive attitudes toward the future may help
prevent intended HIV-risk behavior for young women in particular. This is
a new finding that may be explored in future research and through targeted
health prevention.
These findings are significant but also reflect research within a limited
scope. The sample reflects only one community, one type of health
risk, and one relatively specific group of youth. There are other indicators
of concepts within the integrated behavioral model that are not measured
or considered in these data analyses. Due to the limited scope and distribution
of intended HIV risk, a dichotomous measure of intended HIV risk
wasusedinthemultivariateanalyses, which reduces information about
this variable and limits the potential for explained variation. Nonetheless,
significant predictors of behavioral intentions were identified, and according
to both theory and research, behavioral intentions strongly predict
health risk behaviors (Montano & Kasprzyk, 2008; Webb & Sheeran, 2006).
We find that hope helps adolescent females intend to reduce risk, but
this is not found among young males, raising important questions. Why does
a more positive orientation toward the future specifically help young females
in foster care to live by safer behavioral intentions? More generally, how does
gender elaborate the relationship between hope and risk? Should interventions
that focus on HIV prevention specifically for young women emphasize
empowerment and hopeful views of the future? Should interventions for
both young males and females emphasize developing helpful peers and preventive
attitudes? Future studies using more elaborate theories, incorporating
gender, and collecting data across a variety of health behaviors would help to
explain and apply these findings.
Multivariate data analyses clearly indicate that those foster care youths in
this sample who lack preventive attitudes or associate with problematic peers
are significantly more likely to intend to engage in some type HIV risk. This
finding reinforces the importance of both individual responsibility and peer
behavior. Therefore, interventions and programs can help by working to
reduce use of illegal substances and support healthy peer groups and
relationships.
This article examines HIV prevention among youths in foster care,
expanding our understanding of this population and of the role of future
orientation. While survey data provides a wealth of measures about youths
in one regional foster care system, it is not possible to generalize these

410 M. Polgar and W. Auslander
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findings to all youths, or even to all youths in foster care. These findings are
limited since the data presents a cross-sectional view of youths and the
respondents are not a random sample of youths in foster care. Also, youths’
behaviors, attitudes, and experiences are susceptible to change over time.
Even so, empirical data show the importance of attitudes (particularly
self-efficacy), mental health, and peer behaviors. Additional and future
research is necessary to fully explore the range of experiences among youth,
including youths in foster care.
The challenges of living outside of a biological family create many risks
and concerns. The good news from this research is that many youths in foster
care report that they are resilient in the face of these challenges, limiting their
risk of HIV by staying in good mental health, avoiding substances, keeping
an eye toward the future, and limiting their intended HIV-risk behavior.
Among youths in foster care, safer behavioral intentions are statistically associated
with preventive attitudes and well-behaved peers. Therefore effective
HIV prevention can continue to promote ways for young people to spend
time with well-behaved peers, developing positive attitudes to prevent the
risk and the spread of HIV infection.
For youths in foster care, this research indicates that both strong
attitudes and a healthy social context are associated with safer behavioral
intentions, reducing the risk that people will transmit HIV. Older youths with
greater self-efficacy who avoid substance use are more likely to have a
positive view of the future, and young women with a positive view of the
future are more likely to intend to avoid HIV risk. Youths in foster care, while
at risk of many problems including HIV, are well-educated on HIV risk and
can be bolstered by self-efficacy and well-behaved peers. Prevention
programs can build on these findings in the future.
REFERENCES
Achenbach, T. M. (1991). Manual for the youth self-report and 1991 profile.
Burlington, VT: University of Vermont Department of Psychiatry.
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and
Human Decision Processes, 50, 179–211.
Auslander, W., McMillen, J. C., Elze, D., Thompson, R., Jonson-Reid, M., & Stiffman, A.
(2002). Mental health problems and sexual abuse among youths in foster care:
Relationship to HIV risk behaviors and intentions. AIDS and Behavior, 6, 351–359.
Auslander, W., Slonim-Nevo, V., Elze, D., & Sherraden, M. (1998). HIV prevention
for youths in independent living programs: Expanding life options. Child
Welfare, 77(2), 208–221.
Costello, A. J., Edelbrock, C. S., Dulcan, M. K., Kalas, R., & Klaric, S. H. (1984). Report
on the NIMH diagnostic interview schedule for children (DISC). Washington,
DC: National Institute of Mental Health.

HIV Prevention for Youth in Foster Care 411
Downloaded By: [Washington University in St Louis] At: 22:42 18 December 2009
D’Angelo, L., Brown, R., English, A., Mein, K., & Remafedi, G. (1994). HIV infection
and AIDS in adolescents: A position paper for the society of adolescent
medicine. Journal of Adolescent Health, 15(5), 427–434.
Elze, D. E., Auslander, W. F., McMillen, C., Edmond, T., & Thompson, R. (2001).
Untangling the impact of sexual abuse on HIV risk behaviors among youths
in foster care. AIDS Education and Prevention, 13(4), 377–389.
Elze, D. E., Auslander, W. F., Stiffman, A. R., & McMillen, C. (2005). Educational
needs of youth in foster care. In G. P. Mallon & P. M. Hess (Eds.), Child welfare
for the twenty-first century: A handbook of practices, policies, and programs
(pp. 185–204). New York: Columbia University Press.
Fishbein, M., & Middlestadt, E. E. (1989). Using the theory of reasoned action as a
framework for understanding and changing AIDS-related behaviors. In V. M.
Mays, G. W. Albee, & F. S. Schneider (Eds.), Primary prevention of AIDS:
Psychological approaches. Newbury Park, CA: Sage.
Fraser, M. W., & Terzian, M. A. (2005). Risk and resilience in child development. In
G. P. Mallon & P. M. Hess (Eds.), Child welfare for the 21st century (pp. 55–71).
New York: Columbia University Press.
Gilmore, M. R., Morrison, D. M., Lowery, C., & Baker, S. (1994). Beliefs about
condoms and their associations with intentions to use condoms among youths
in detention. Journal of Adolescent Health, 15(3), 228–237.
Gjesme, T. (1979). Future time orientation as a function of achievement motives,
ability. The Journal of Psychology, 101, 173–188.
Herrenkohl, T., Tajima, E., Whitney, S., & Wang, B. (2005). Protection against
antisocial behavior in children exposed to physically abusive discipline. Journal
of Adolescent Health, 36, 457–465.
Holtgrave, D. R., McGuire, J. F., & Milan, J. (2007). The magnitude of key HIV
prevention challenges in the United States: Implications for a new
national HIV prevention plan. American Journal of Public Health, 97(7),
1163–1167.
Jonson-Reid, M., & Barth, R. (2000). From placement to prison: The path to adolescent
incarceration from child welfare supervised foster or group care. Children
and Youth Services Review, 22, 493–516.
Jurich, J., & Hughes, T. (1991). Predictors of contraceptive use by adolescent
mothers. Lifestyles: Family and Economic Issues, 12(1), 7–21.
Koopman, C., Rotheram-Borus, M. J., Henderson, R., Bradley, J. S., & Hunter, J.
(1990). Assessment of knowledge of AIDS and beliefs about AIDS prevention
among adolescents. AIDS Education and Prevention, 2(1), 58–70.
McMillen, C., Auslander, W., Elze, D., White, T., & Thompson, R. (2003). Educational
experiences and aspirations of older youth in foster care. Child Welfare, 82(4),
475–495.
Montano, D., & Kasprzyk, D. (2008). Theory of reasoned action, theory of planned
behavior, and the integrated behavioral model. In K. Glanz, B. Rimer, &
K. Vizwanath (Eds.), Health behavior and health education: Theory, research,
and pactice (4th ed., pp. 67–96). San Francisco: Jossey-Bass.
Perry, B. L. (2006). Understanding social network disruption: The case of youth in
foster care. Social Problems, 53(2), 371–391.

412 M. Polgar and W. Auslander
Downloaded By: [Washington University in St Louis] At: 22:42 18 December 2009
Peters, R., Tortolero, S., Johnson, R., Addy, R., Markham, C., Escobar-Chaves, L. (2005).
The relationship between future orientation and street substance use among Texas
alternative school students. The American Journal of Addictions, 14, 478–485.
Robbins, R. N., & Bryan, A. (2004). Relationships between future orientation,
impulsive sensation seeking, and risk behavior among adjudicated adolescents.
Journal of Adolescent Research, 19(4), 428–445.
Rotheram-Borus, M., & Koopman, C. (1991). Sexual risk behaviors, AIDS knowledge,
and beliefs about AIDS among runaways. American Journal of Public
Health, 81(2), 208–210.
Rotheram-Borus, M. J., Mahler, K. A., & Rosario, M. (1995). AIDS prevention with
adolescents. AIDS Education & Prevention, 7(3), 320–336.
Rotheram-Borus, M. J., Mahler, K. A., & Rosario, M. (2000). Expanding the range of
interventions to reduce HIV among adolescents. AIDS, 14, S33–S40.
Scheier, M. F., Carver, C. C., & Bridges, M. W. (1994). Distinguishing optimism from
neuroticism: A re-evaluation of the life-orientation test. Journal of Personality
and Social Psychology, 67(6), 1063–1078.
Slonim-Nevo, V., Auslander, W., & Ozawa, M. (1995). Educational options and
AIDS-related behaviors among troubled adolescents. Journal of Pediatric
Psychology, 20, 41–60.
Slonim-Nevo, V., Auslander, W., Ozawa, M., & Jung, K. (1996). The long term impact
of AIDS-preventive interventions for delinquent and abused adolescents.
Adolescence, 31, 409–421.
Slonim-Nevo, V., Ozawa, M., & Auslander, W. (1991). Knowledge, attitudes and
behaviors related to AIDS among youth in residential centers: Results from an
exploratory study. Journal of Adolescence, 14, 17–33.
Somers, C., & Gizzi, T. (2001). Predicting adolescents’ risky behaviors: The influence
of future orientation, school involvement, and school attachment. Adolescent
and Family Health, 2(1), 3–11.
StataCorp. (2003). Stata Statistical Software, Release 8. College Station, TX: Stata
Corporation.
Stiffman, A. R., Dore, P., Cunningham, R., & Earls, F. (1995). Person and environment
in HIV-risk behavior change between adolescence and young adulthood.
Health Education Quarterly, 22, 233–248.
Strecher, V., & Rosenstock, I. (1997). The health belief model. In K. Glanz, F. Lewis,
& B. Rimer (Eds.), Health behavior and health education: Theory, research, and
practice (2nd ed.). San Francisco: Jossey-Bass.
Thompson, J. R. G., & Auslander, W. F. (2007). Risk factors for alcohol and marijuana
use among adolescents in foster care. Journal of Substance Abuse Treatment,
32(1), 61–69.
Trommsdorff, G., Lamm, J., & Schmidt, L. (1979). A longitudinal study of adolescents’
future orientation. Journal of Youth and Adolescence, 8(2), 131–147.
Wallace, S. A., Miller, K. S., & Forehand, R. (2008). Perceived peer norms and sexual
intentions among African American preadolescents. AIDS Education &
Prevention, 20(3), 360–369.
Webb, T., & Sheeran, P. (2006). Does changing behavioral intentions engender
behavior change? A meta-analysis of the experimental evidence. Psychological
Bulletin, 132(2), 249–268.

Downloaded By: [Washington University in St Louis] At: 22:42 18 December 2009
HIV Prevention for Youth in Foster Care 413
Weinstein, N., Sandman, P., & Blalock, S. (2008). The precaution adoption process
model. In K. Glanz, B. Rimer, & K. Vizwanath (Eds.), Health behavior and
health education: Theory, research, and practice (4th ed., pp. 123–148). San
Francisco: Jossey-Bass.
Wills, T., Sandy, J., & Yaeger, A. (2001). Time perspective and early-onset substance
use: A model based on stress-coping theory. Psychology of Addictive Behaviors,
15(2), 118–125.
Yankah, E., & Aggleton, P. (2008). Effects and effectiveness of life skills education
for HIV prevention in young people. AIDS Education and Prevention, 20(6),
465–485.