Health Education Research, Vol. 16, No. 3, 293-305,
June 2001
© 2001 Oxford University Press
Predicting condom use with casual and steady sex partners among drug users
Departments of Experimental Psychology,
1 Health Education and Promotion, and
2 Experimental Psychology, Universiteit Maastricht, PO Box 616, 6200 MD Maastricht and
3 Public Health Centre Maastricht, PO Box 3973, 6202 NZ Maastricht, The Netherlands
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Abstract |
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In many Western societies, drug users are accountable for heterosexual transmission of HIV. Although various studies have shown that safe sex is not a common practice among drug users, we still have little understanding of the factors that determine their use of condoms in their sexual relationships with steady or casual partners. The objective of this study is to gain more insight into the determinants of drug users' condom use with steady and casual sex partners. In a study conducted among 103 Dutch drug users, the participants indicated their intentions, vulnerability, attitude, personal norms, subjective norms, descriptive norms, self-efficacy and response efficacy regarding condom use with steady and casual partners. The results showed that some drug users had borrowed used syringes and that most drug users practise unsafe sex, especially with steady partners. Most drug users were hardly motivated to start using condoms. The study further showed that antecedents of condom use differ with regard to steady sex partners and casual sex partners. Self-efficacy and subjective norms were predictors of intentions to use condoms with steady partners; intention to use condoms with casual partners was only predicted by self-efficacy. These differences should be taken into account when designing AIDS prevention interventions to encourage use of condoms.
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Introduction |
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To date, AIDS prevention campaigns have mainly focused on sexual behavior and commitment to safer sex. Examples are interventions targeting the population of homosexual and bisexual men (Stall et al., 1988
; De Wit, 1996; Kalichman and Hospers, 1997) and adolescents (Kim et al., 1997). Interventions aimed at drug users have, however, mainly concentrated on drug-injecting behavior. Although these interventions have proved to be effective in reducing needle sharing (Coyle et al., 1998; Marsch, 1998; Vlahov and Junge, 1998), so far they have failed to reduce risk-taking sexual behavior (Gillies and Carballo, 1990; Booth and Watters, 1994). Drug users continue to practise unsafe sex to a great extent, even if they are aware of the risks of heterosexual HIV transmission (Magura et al., 1990; WHO, 1993; Carsauw et al., 1997; Berns et al., 1998). Recent data has revealed that non-drug-injecting heterosexuals are put at high risk for contracting HIV (Center for Disease Control, 1998; Dutch Aids Fund, 1998). Moreover, studies from the US and Western Europe suggest that drug users account for the majority of heterosexual HIV transmissions (Liebman et al., 1992; McKegany and Barnard, 1992; Rhodes et al., 1996; Fennema, 1997; Lukashove et al., 1998; Op de Coul et al., 1998). These findings indicate that more forceful attempts are needed to prevent further heterosexual transmission of HIV by drug users to other drug users and larger non-drug-using populations [see also (Williams et al., 1997)].
AIDS educational campaigns should comprise more than increasing knowledge of HIV/AIDS. More effective interventions have been shown to be systematically planned, and are based on theory and data (Fisher and Fisher, 1992; Schaalma et al., 1996; Kim et al., 1997).
Meta-evaluations and planning models (Green and Kreuter, 1991; Witte, 1995; Bartholomew et al., 1998) have shown that effective interventions require a needs assessment to analyze the problem, the behavior at both individual and environmental levels, as well as the determinants of such behavior. A fair amount of knowledge is available about the problem of HIV/AIDS and the risk behaviors involved. However, only a few studies have tried to identify determinants of safe and unsafe sexual behavior among drug users. Studies among drug users revealed that both knowledge of HIV/AIDS (Thornton and Catalan, 1993; Helal et al., 1995) and perceived vulnerability to HIV risk (Robles et al., 1995) were unrelated to safe sexual behaviors. Studies among (injecting) drug users (Paulussen et al., 1990; McKegany and Barnard, 1992; Bowen and Trotter, 1995; Bowen, 1996; Corby et al., 1996; Montoya, 1997) found that attitudes towards the use of condoms were moderately good predictors of condom use intentions. Furthermore, they found that self-confidence regarding the ability to use condoms and negotiate condom use is a strong predictor of condom use with both steady (Bowen, 1996; Corby et al., 1996) and casual sex partners (Paulussen et al., 1990; Bowen and Trotter, 1995; Corby et al., 1996; Montoya, 1997). With regard to the influence of the social environment of drug users, support has been rather mixed. Subjective norms were found to have little or no impact on condom use behavior (Paulussen et al., 1990; Corby et al., 1996). However, in their studies among IV drug users, Corby et al. (Corby et al., 1996) and Magura et al. (Magura et al., 1990) found that the norms of partners predicted condom use with steady partners. Other studies revealed that the safe sex behavior of other drug users was related to safer sexual intention (Abdul-Quader et al., 1990; Magura et al., 1990; Kowaleski et al., 1994).
Thus, although a number of studies—mainly oriented to the US—have examined determinants of condom use among drug users, their focus on possible antecedents of condom use was limited and the evidence they provided is mixed. Furthermore, with the exception of Corby et al. (Corby et al., 1996), these studies have offered little insight into differences in antecedents of condom use between casual and steady sex partners. The present study is an attempt to broaden the insight into other cognitive antecedents of condom use and specify those for steady and casual sex partners. Its focus is based upon a core model of motivation previously identified by Abraham et al. (Abraham et al., 1998), who reviewed theoretical concepts of multiple social cognitive models, and identified several key cognitive constructs of individual motivation and behavior, i.e. attitudes, self-representations, social influence, self-efficacy and intention (see Figure 1). Intention is viewed as a construct that mediates the effect of the other variables on behavior.
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In the present study we have conceptualized the construct of attitudes in three ways. First, attitude is conceptualized as a set of beliefs about a certain behavior, i.e. condom use, as proposed by the Theory of Reasoned Action (TRA) (Fishbein and Ajzen, 1975
). In his Protection Motivation Theory, Rogers (Rogers, 1975) proposes two other attitude-related concepts that are also used in this study: an individual's perceived vulnerability to a threat (e.g. HIV) and an individual's perceived response efficacy, i.e. the belief about the efficacy of the possible preventive action (e.g. condom use). The present study conceptualizes the construct of self-representation by personal normative belief (Triandis, 1977), which covers an individual's personal feelings of responsibility to perform or refuse a certain behavior. Social influence is also likely to affect an individual's intention and is conceptualized by subjective norms as proposed within the TRA (i.e. beliefs about people's approval for one's behavior) and descriptive norms, referring to the observation of what others do (Cialdini et al., 1990; De Vries et al., 1995). The final construct examined is that of self-efficacy. This construct seems important within the context of less volitional behavior, such as condom use, and refers to an individual's perception of his or her ability to perform a specific behavior (Bandura, 1986). In addition, we will examine environmental barriers that might directly or indirectly increase the chances of contracting HIV (i.e. risky drug use behavior, traveling to AIDS-endemic areas, the costs of condoms, and the availability of condoms and clean needles).
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Method |
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Participants
A total of 103 drug users participated in the study. The studied area of Maastricht comprises approximately 400 drug users, of which 200 are assumed to inject drugs. With an estimated number of 25% of the total population, our sample therefore seems a good reflection of that community. The majority was male (82.5%) and of Dutch nationality (85.5%). The average age of the drug users was 34.
Setting
The participants were recruited in Maastricht via outreach workers and treatment centers of the Center for Alcohol and Drug Abuse over a 5-month period. The main selection criterion was that participants had used drugs during the 6 months preceding the study, other than alcohol, marihuana or methadone. A small number of people (about eight) declined to participate. The questionnaire was handed out to the participants and required about 20 min. All participants received a compensation of Dfl15 guilders (approximately US$6).
The questionnaire
The items used in the questionnaire to assess attitudes, perceived vulnerability, response efficacy, social influences, self-efficacy, intentions and barriers were based on a literature survey and interviews with outreach workers. The questionnaire was pre-tested among a small group of drug users for comprehension and completeness. The scales and items are described below. Most items were measured on five-point scales (ranging from `never' to `always'). Exceptions are indicated where applicable.
Demographics and behavior
The participants were asked to state their age, gender, sexual preference, history of STDs and hepatitis, drug use history (past drug-injecting behavior), present drug use (during the 6 months preceding the study), and sexual history (past sexual relationships with a steady partner/casual partner/client). Unsafe drug-use behavior was measured by the frequency of used syringes or needles borrowed throughout the past 6 months and the frequency of dirty cotton, filters, spoons or rinsing water used throughout the past 3 months. Sexual behavior was measured separately for steady partners, casual partners and clients. In the questionnaire a steady sex partner was defined as a person with whom the participant had had a relationship for at least 3 months, whom the participant was seeing at least once a week and with whom the participant had frequent sexual intercourse. A casual sex partner was defined as a person with whom the participant had had sexual intercourse at least once, without having been paid, or having received drugs or other rewards in return, and with whom the participant did not have a relationship. Finally, a client was defined as a person with whom the participant had had sexual intercourse in return for money, drugs or other rewards.
We measured the number of partners (steady, casual and client) and estimated the frequency of sexual intercourse throughout the past 6 months as well as the number of incidences of unprotected sex. Also, we asked the respondents whether they had ever thought about using condoms with partners (steady, casual and client). Additionally, participants answered questions about the drug use history of their last sex partner (steady, casual and client) by `yes', `no' or `do not know'.
Perceived vulnerability
Vulnerability was measured by a self-assessment of respondents of their own chances of contracting HIV when having sex without a condom and their assessment of the chances of other drug users contracting HIV when having sex without a condom. Measurements were rated separately for sexual intercourse with steady and casual partners. Participants had to provide probability estimations in percentages.
Attitudes
Separate measurements were conducted for attitude towards condom use with steady partners and attitude towards condom use with casual partners. Both scales were constructed from a set of five items regarding personal consequences related to condom use. Both attitude scales include items such as: `Using condoms when having sexual intercourse with your steady/casual partner is annoying' (`disagree' to `agree'), `Using condoms with your steady/casual sex partners is a sign of distrust' and `Using condoms with your steady/casual sex partner is very pleasant'. The attitude scale for condom use with steady sex partners was reliable at Cronbach's 
= 0.71; the scale for casual sex partners was reliable at Cronbach's = 0.59.
Response efficacy
Response efficacy was measured by three items: `Condoms offer good protection against the AIDS virus', `Condoms offer good protection against STDs' and `Condoms offer good protection against pregnancy' (`never' to `always'). This scale was reliable at = 0.78.
Personal norms
Two items were used to assess personal norms toward condom use with steady partners and casual partners, respectively: `Do you permit yourself to have sex with your steady partner without using a condom?' and `Do you permit yourself to have sex with casual partners without using a condom?' (`never' to `always').
Perceived social influence
Social influence was measured using two concepts: the subjective norm and the descriptive norm. Both concepts were measured by means of a single item [subjective norm: `Do you think your steady partner expects you to use condoms when having sexual intercourse?' (`never'–`always'), cf. (Corby et al., 1996); descriptive norm: `Do you think your closest friends always use condoms?'] cf. (Kowaleski et al., 1994)].
Self-efficacy
Self-efficacy towards condom use with steady partners (Cronbach's = 0.66) and self-efficacy toward condom use with casual sex partners (Cronbach's = 0.77) were measured each with five items, such as `Suppose you want to use condoms when having sex, will you be able to do so when you are sexually aroused? (`never'–`always')' [cf. (Bowen and Trotter, 1995; Montoya, 1997)].
Intention
Measures of intention to use condoms when having sex with steady and with casual partners were each indexed with a single item: `I intend to use condoms with steady partners in the next 3 months' (`absolutely not' to `absolutely') and `I intend to use condoms with casual partners in the next 3 months'.
Barriers
Participants answered questions addressing barriers to AIDS-preventive behavior. First, they reported whether they were able to obtain new needles or syringes and condoms, and if so, where they obtained these. Second, the perceived cost of condoms was indexed on a five-point scale (`expensive' to `inexpensive') as a possible barrier to using condoms. Third, in order to estimate the possibility of transmission between highly and lowly HIV-endemic areas participants were asked to indicate if they had traveled to other HIV epicenters, and whether they had had sexual intercourse and/or drugs injected in those HIV epicenters.
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Results |
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Descriptive analyses
The educational level of the participants was generally low; most had only gone to school up to the age of 17. Most participants were heterosexually inclined (85%). One-quarter of the participants reported a history of STDs (23.3%) and about half the sample reported a history of hepatitis (40.8%). The majority of the participants (70.9%) had injected drugs at least once and started using drugs at an average age of 22. Most had used more than one drug in the 6 months preceding the study. Heroin was the most commonly used drug (62.1%). Most participants were in methadone maintenance treatment (65.0%).
Half the studied population had injected during the 6 months preceding the study (48.5%). The average age of these current drug injectors was 34.5 years. Of the current drug injectors, 20.0% had borrowed a used needle or syringe in the 6 months preceding the study and 30.0% of the participants had used old cotton, filters, spoons or rinsing water in the last 3 months.
Table I shows that 73 drug users (70.9%) had been sexually active during the 6 months preceding the study. Fifty-two of the sexually active participants had had sexual intercourse with one or more steady sex partners, the majority of them without using condoms (69.2%). About half of the drug users with a steady partner reported that their partner never injected drugs and a quarter reported that their partner never used drugs. A total of 32 participants (31.1%) had had one or more casual sex partners. Half of these participants reported that their casual sex partners had either never used condoms (37.5%) or had used condoms inconsistently (12.5%). Participants reported that most casual partners (53.1%) did not inject any drugs and that 18.8% did not use any drugs. Seven participants had had sex in exchange for drugs or money, of whom only three participants reported having always used condoms.
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Eleven participants had had sexual intercourse with both steady and casual sex partners. Of the seven participants that had reported sex in exchange for money, drugs or other things, three participants had also had sexual intercourse with casual partners and four participants has had sexual intercourse with steady partners.
Barriers
Forty-nine participants (47.6%) reported that needles or syringes were available when needed. Most participants (87.5%) obtained the needles from the Center for Alcohol and Drug Abuse. Sixty-seven (65.0%) participants reported where they obtained condoms if they needed them. Participants usually obtained condoms from the consultation Center for Alcohol and Drug Abuse (34.4%), followed by shops and drugstores (25.4%), vending machines (16.4%), relatives (4.5%), and the community health center (4.5%). Hence, both syringes and condoms seem to be readily available from various outlets.
Perceived vulnerability and attitude
The drug users estimated their chances of being infected as a result of unprotected sex with casual partners as being higher than their chances as a result of unprotected sex with steady partners (see Table II). Furthermore, drug users estimated their own chances of contracting HIV when having unsafe sex with a steady partner (M = 37) as being lower in comparison with other drug users (M = 49, t[96] = 3.4, P < 0.005). Only a marginal difference was found between their own probability estimates for contracting HIV when having unsafe sex with a casual partner (M = 63) and probability estimates of others (M = 69, t[96] = 1.9, P < 0.07).
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In general, drug users considered condoms to be a good protection against HIV, STDs and pregnancy (M = 3.8), and condoms to be relatively inexpensive (M = 3.4). However, the attitude towards the use of condoms was negative, especially attitude towards condom use with steady partners (see Table II
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Normative beliefs and self-efficacy
Both the subjective norm (M = –0.00, range –2/+2) and the descriptive norm toward the use of condoms were weakly negative (M = –0.30, range –2/+2). Furthermore, drug users reported a more negative personal norm towards sex with a condom with a steady partner than with casual partners (see Table II). Finally, drug users felt reasonably confident about their ability to use condoms, with drug users reporting lower self-efficacy towards the use of condoms with casual partners than towards the use of condoms with steady partners (see Table II).
Condom use intention
Participants' intentions to use condoms with steady partners were statistically significant lower than their intentions to use condoms with casual partners (see Table II). Both these intentions, however, were rather low. Of the 61 participants that ever had sexual intercourse with a casual partner, 73.8% had thought about using condoms with casual partners. Of the 86 participants that had had a steady partner at some point, only 44.2% had thought about using condoms with a steady partner.
Correlation coefficients between intended condom use and the variables measured
Table III provides correlation matrices of the variables measured. Attitude toward condom use with steady sex partners, self-efficacy, the subjective norm and the descriptive norm showed the highest correlation coefficients with intended condom use with steady sex partners, with values ranging between 0.29 and 0.35 (P < 0.001). Self-efficacy was the only variable that was significantly related to intended condom use with casual sex partners (r = 0.43, P < 0.001). Furthermore, Table III shows that attitudes toward condom use were unrelated to condom response-efficacy ratings. This is in contrast to suggestions that these would be similar constructs (Abrahamson et al., 1998). Moreover, Table III shows that there is a low correlation between the subjective norm and the descriptive norm. Similar findings have been reported elsewhere (Schaalma et al., 1993; De Vries et al., 1995). Finally, Table III shows that the constructs of the Theory of Planned Behavior were positively related (Ajzen, 1991).
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Regression analysis of the predictors with condom use intention
A regression on intention to use condoms with steady sex partners was conducted for the antecedents of condom use discussed previously. This regression yielded a multiple correlation of 0.43 (R2 = 0.18, P < 0.001) with self-efficacy (ß =0.31, P < 0.005) and subjective norm (ß = 0.23, P < 0.05) as statistically significant predictors of the intention to use condoms with steady sex partners. The other variables did not contribute to explaining additional variance.
A similar analysis was conducted for intended condom use with casual sex partners. This regression revealed that self-efficacy (ß = 0.43, P < 0.001) was the only variable explaining a significant proportion of variance in the intention to use condoms with casual sex partners (R = 0.43, R2 = 0.19, P < 0.001). All other variables did not contribute to explaining additional proportions of variance.
Self-efficacy expectations concerning condom use
To determine which of the self-efficacy beliefs distinguished between individuals that intended to use condoms and those who did not, we divided the participants in three groups on the basis of intention scores. The first group consisted of participants who were unlikely or did not have any intention to use condoms with steady partners (`non-intenders'; n = 52). The second group was composed of participants who scored neutrally on the intention scale (n = 19). The third group consisted of participants who were sure or very likely to use condoms with steady partners (`intenders'; n = 28). Table IV shows that those with no intention expected to have more difficulties with using condoms when they are sexually aroused or when they suffer from drug withdrawal symptoms. With regard to condom availability, non-intenders were more likely to expect problems with having condoms available than intenders. A gender difference was found with regard to the self-efficacy assessment of being able to use condoms in a state of sexual arousal, with women (M = –0.41) being more likely to expect problems to use condoms than men (M = 0.81, t[98] = 3.4, P < 0.005). Female drug users also expected to have more serious problems with regard to the use of condoms when having withdrawal symptoms (M = –1.2) compared to male drug users (M = –0.15, t[95] = 2.5, P < 0.05). To assess the impact of self-efficacy on intention to use condoms with casual partners, we once again divided the participants in three groups based on their intention score: a non-intender group (n = 26), an undecided group (n = 15) and a group of intenders (n = 57). Analysis of variance showed that those with low intentions felt less capable of using condoms with casual partners and expected to have more difficulties to discuss condom use prior to having sexual intercourse than high intenders (see Table IV). Non-intenders also expected more difficulties when being aroused or having withdrawal problems than intenders. Finally, non-intenders expected to have more difficulties with having condoms available than drug users who intended to use condoms with casual partners. Women (M = 1.8) felt more capable of using condoms than men (M = 0.84, t[50] = 4.6, P < 0.001). Women (M = 1.5) also felt more capable of delaying sexual intercourse until the casual partner is convinced of the need to use condoms than men (M = 0.77, t[31] = 2.9, P < 0.01).
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Discussion |
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The data presented show that drug users in Maastricht run the risk of contracting HIV and STDs, and transmitting HIV/STD to other parts of society. The low rates of condom use with casual and steady partners—of whom a considerable number does not inject or even use drugs—make actual transmission quite likely. Finally, due to the finding that quite a few drug users in the study sample injected drugs (20.4%) or had sexual intercourse (28.2%) in other AIDS epicenters in the Netherlands, it is very likely that HIV and STD are transmitted from high-prevalence areas to low-HIV prevalence areas (see Figure 2
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The participating drug users acknowledged the risk of contracting the HIV infection and were convinced that the use of condoms is an effective protection against from HIV, STDs and unwanted pregnancy.
Perceived self-efficacy seemed to be an important determinant in explaining consistent condom use intention, both in steady sexual relationships and in sexual encounters with casual partners. Drug users with a higher perceived self-efficacy were more likely to intend to use condoms with both steady and casual partners. Low perceived efficacy seems to be related to having self-management problems, with drug users not being able to anticipate risk situations in which sexual encounters may happen or to anticipate difficult situations that should be avoided.
The gender differences in self-efficacy expectations regarding the use of condoms with casual and steady sex partners seem to indicate that mainly women determine whether or not to aim for safe sex. We found lower self-efficacy expectations for female drug users in comparison with male drug users regarding the use of condoms within steady sexual relationships. This seems to indicate a difficulty to resist pressure to have unprotected sex or a difficulty to insist to a lesser extent upon condom use when experiencing psychological or physical barriers [cf. (Cabral et al., 1998)].
The results further suggest that norms are an important predictor of condom use within steady relationships. Drug users who perceived their steady partner to feel positive about the use of condoms were more likely to intend using condoms with steady partners. This finding is not entirely surprising as condom use is usually based upon mutual commitment with a partner. Although descriptive norms did not predict condom use, we found that the perceived behavior of what others do was clearly related to intention to use condoms with steady sex partners.
In contrast to other studies (Paulussen et al., 1990; McKegany and Barnard, 1992; Bowen and Trotter, 1995; Bowen, 1996; Corby et al., 1996; Montoya, 1997), attitudes did not predict condom use intention. However, the results presented show that attitudes towards condom use are negative, particularly within steady relationships. Moreover, drug users hold the personal normative belief that sex without a condom is okay when having sex with steady partners. Furthermore, we found a clear relation between attitude toward using condoms with steady sex partners and intention to use condoms, with respondents with lower intentions towards condom use with steady sex partners finding condoms less necessary than respondents with a higher intention (M = –0.71 versus M = 0.11, t[93] = 2.5, P < 0.01), and for casual sex partners, people with a low intention to use condoms found condoms more unpleasant (M = –0.45 versus M = 0.22, t[91] = 2.2, P < 0.05) and unnecessary (M = 0.86 versus M = 1.8, t[52] = 4.0, P < 0.001) than people with a high intention. These findings are worrying and should be given serious attention.
The results further showed that most drug users did not use condoms when having sexual intercourse with a steady partner and that most had never even thought about using condoms with steady partners. A majority of drug users had thought about using condoms with casual sex partners and most of the participating drug users who had had sex with casual partners had actually used condoms. In terms of a Stage-of-Change approach (Prochaska et al., 1997), it may be argued that drug users are in a different stage of using condoms with casual partners than with their main partners. In accordance with the expectations of the Transtheoretical Model, which assumes that self-efficacy rises along the stages as people become more motivated (DiClemente et al., 1991; Maibach and Cotton, 1995; Montoya, 1997), we found self-efficacy to be most important for condom use with casual partners. In line with the stages approach we also found that norms and attitudes were most important in the context of steady sexual relationships, where people are not or less motivated to use condoms.
The data presented have important implications for the planning of interventions to promote the use of condoms among drug users. First, it seems important to make a distinction in motivational stages for condom use with steady partners and condom use with casual partners, as also psychosocial determinants may differ in those contexts. The most important step in the promotion of condom use with steady partners seems to be a change in risk perception, attitude and social influence. For the promotion of condom use with casual sex partners it seems to be most important to enhance self-efficacy regarding the communication about and use of condoms.
An initial step in promoting the use of condoms within steady sexual relationships could be risk identification and acknowledgement. However, it has been shown that often this is not enough to convince people to use condoms (Flowers et al., 1997) and that other factors may be more important. Maibach and Cotton (Maibach and Cotton, 1995) state that besides personalizing risk, the positive attributes of alternative behavior should be emphasized and a re-evaluation of the beliefs that include the new information should be encouraged. The focus should not only be on personal risk identification, but also on the vulnerability of the sex partner and on a certain responsibility to protect that partner.
Furthermore, it seems important to make condom use more acceptable in society by changing the current unsafe sexual norm. Community-level interventions designed to change community norms might be effective in dealing with unsafe sexual behaviors. For example, Kegeles et al. (Kegeles et al., 1996) proved the effectiveness of a community-level intervention targeting gay men, based on a process of informal communication and modeling by peers within interpersonal networks (Kegeles et al., 1996; Kelly et al., 1992). Jamner et al. (Jamner et al., 1997) also showed that an approach of peer outreach to deliver persuasive mass-media material, by means of role model stories together with condoms, can be effective in changing norms and behaviors.
Finally, self-efficacy to use condoms should be enhanced. People should feel able to talk about and practise the use of condoms. Effective methods to enhance self-efficacy have been derived from Social Cognitive Theory (Bandura, 1997), such as modeling, vicarious learning and by means of role model stories [e.g. (Maibach and Cotton, 1995; Jamner et al., 1997)]. Other methods that enhance self-efficacy are communication or self-management skills training.
Caution is warranted in interpreting the findings. The low variance of the antecedents of condom use behavior for both casual and steady partners shows that we still lack understanding of other cognitive, affective and behavioral factors predicting condom use among drug users. More psychosocial determinant studies have to be conducted among drug users, to decrease gaps in our understanding of the safe and unsafe sexual behavior of drug users with both steady and casual sex partners. Also, insights into the effect of psychopathology in relation to HIV risks and motivational principles might further improve our understanding of how condom use could be promoted. For example, Hartgers et al. (Hartgers et al., 1992) have shown psychopathology to be related to current HIV risk-taking behavior.
Furthermore, one could criticize the reliability of self-reports of drug users. However, several studies have shown that drug users' self-reports of drug use and sexual behavior are reliable (McElrath et al., 1994; Needle et al., 1995). Moreover, studies have shown that self-administered questionnaires show a high level of agreement in comparison with face-to-face interviews, but have shown to lead to less underreporting of drug use (McElrath, 1994). Also, DesJarlais et al. (DesJarlais et al., 1999) report that socially sensitive behaviors are less likely to be underreported when using self-administered questioning—in this case via computer-assisted self-interviewing—rather than face-to-face interviews.
Also, one could doubt the appropriateness of analyzing the whole sample with not all participants having been sexually active in the last 6 months. Analyses, however, revealed that there were no differences on any of the determinants measured between the sexually active participants and the ones who had not been sexually active in the last 6 months. Moreover, all participants reported having had sexual experiences in the past. On the basis of these arguments we think it is appropriate to have included the entire sample.
Finally, one could argue the use of a single item to measure intention. However, the item was stated as explicit as possible, with a precise operationalization of the target, i.e. condom use with steady sex partners or condom use with casual sex partners. The confidence within this measurement is further enhanced by the reasonable correlations between the intention measurement and the actual behavior (respectively, r = 0.58, P < 0.001 for steady sex partners and r = 0.42, P < 0.05 for casual sex partners). Moreover, similar kinds of operationalizations have been reported elsewhere [e.g. (Paulussen et al., 1990; Kowalewski et al., 1994)].
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Acknowledgments |
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The authors wish to thank the local health center, GGD Maastricht, for its participation and especially John Deckers for collecting the data. The authors also thank Nicole van Kesteren and the reviewers of an earlier version of the paper for their helpful comments. This project was supported by funds from the Dutch Aids Fund (grant no. 2166).
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Received on February 8, 2000; accepted on September 26, 2000
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