Theories of reasoned action and planned behavior as models of condom use: a meta-analysis

Promoting male involvement to improve PMTCT uptake and reduce antenatal HIV infection: a cluster randomized controlled trial protocol

BACKGROUND

Despite the availability of a dual therapy treatment protocol and infant feeding guidelines designed to prevent mother to child transmission (PMTCT) of HIV, of the over 1 million babies born in South Africa each year, only 70% of those born to HIV positive mothers receive dual therapy. Similar to other resource-poor nations facing the integration of PMTCT into routine pregnancy and infant care, efforts in South Africa to scale up PMTCT and reduce transmission to < 5% have fallen far short of the United Nation's goal of 50% reductions in paediatric HIV by 80% coverage of mothers.

METHODS/DESIGN

This study proposes to evaluate the impact of combining two evidence-based interventions: a couple's risk reduction intervention with an evidence based medication adherence intervention to enhance male participation in combination with improving medication and PMTCT adherence in antenatal clinics to increase PMTCT overall reach and effectiveness. The study will use a group-randomized design, recruiting 240 couples from 12 clinics. Clinics will be randomly assigned to experimental and control conditions and effectiveness of the combined intervention to enhance PMTCT as well as reduce antenatal seroconversion by both individuals and clinics will be examined.

DISCUSSION

Shared intervention elements may decrease sexual risk and enhance PMTCT uptake, e.g., increased male participation, enhanced communication, HIV counselling and testing, adherence, serostatus disclosure, suggest that a combined sexual risk reduction and adherence intervention plus PMTCT can increase male participation, increase couples' communication and encourage adherence to the PMTCT process. The findings will impact public health and will enable the health ministry to formulate policy related to male involvement in PMTCT, which will result in PMTCT.

TRIAL REGISTRATION

PACTR201109000318329.

Taxonomy for strengthening the identification of core elements for evidence-based behavioral interventions for HIV/AIDS prevention

The concept of core elements was developed to denote characteristics of an intervention, such as activities or delivery methods, presumed to be responsible for the efficacy of evidence-based behavioral interventions (EBIs) for HIV/AIDS prevention. This paper describes the development of a taxonomy of core elements based on a literature review of theoretical approaches and characteristics of EBIs. Sixty-one categories of core elements were identified from the literature and grouped into three distinct domains: implementation, content and pedagogy. The taxonomy was tested by categorizing core elements from 20 HIV prevention EBIs disseminated by Centers for Disease Control and Prevention. Results indicated that core elements represented all three domains but several were difficult to operationalize due to vague language or the inclusion of numerous activities or constructs. A process is proposed to describe core elements in a method that overcomes some of these challenges. The taxonomy of core elements can be used to identify core elements of EBIs, strengthen the translation of EBIs from research to practice and guide future research seeking to identify essential core elements in prevention interventions.

Text messaging for HIV prevention with young Black men: formative research and campaign development

This article describes the formative research and campaign development for a pilot study to test the feasibility of using cell phone text messaging to promote HIV prevention for young African-American men. We conducted six focus groups with Black men aged 16-20 (N=43) in order to obtain feedback on the campaign content and how best to convey sexual health information via text message using cell phones. We present three main findings: (1) the participants' ideas for conducting this research and how to structure our campaign design; (2) how we broadened our theoretical perspective from an individual focus to an empowerment and social capital focus in order to best communicate a culturally relevant program; and (3) the young adult's specific suggestions for how best to operationalize theoretical constructs related to empowerment and social capital. We found that young Black men were receptive to the idea of receiving text messages for an HIV prevention campaign. As technology proliferates, this work offers specific ideas for how to capitalize on new technological modalities to deliver important communications on prevention.

Achieving Safety: Safer Sex, Communication, and Desire among Young Gay Men

Conceptualizations of safer sex practices among young gay men (YGM) are frequently structured around communication between partners and the subsequent utilization or absence of condoms in a sexual encounter. Drawing on a sample of 34 in-depth interviews with YGM, ages 18 to 24, we explore the ways in which conceptualizations and definitions of safer sex are discussed and enacted. Placing attention on their safer sex practices, we analyze the conversations that do and do not occur among YGM and their partners, including the strategies (e.g., negotiated safety, condom communication and negotiation) that are commonly perceived as most useful by YGM. We provide recommendations regarding how to craft safer sex messages for YGM by considering their competing demands.

HPV vaccination and the effect of information framing on intentions and behaviour: an application of the theory of planned behaviour and moral norm

BACKGROUND

Human papillomavirus (HPV) is a common sexually transmitted infection (STI) known to cause cervical cancer and genital warts. However, making the genital warts aspect explicit may reduce HPV vaccination intention and behaviour due to perceived stigma associated with STIs.

PURPOSE

This study investigated the effect of differential information framing on intention to receive the HPV vaccine using the Theory of Planned Behaviour (TPB) and moral norm construct.

METHOD

Female university students were randomised to receive a fact sheet describing the HPV vaccine as: (1) preventing cervical cancer only (n = 81); or (2) preventing both cervical cancer and genital warts (n = 78). A 2-month follow-up investigated relationships between vaccination intention and actual behaviour.

RESULTS

No effect of information framing was detected on intention to receive the HPV vaccine, or vaccine uptake behaviour at 2-month follow-up. The traditional TPB components predicted 54% of the variance in vaccination intention (F (3,155) = 61.580, p < 0.001), and moral norm explained an additional 6.2%. Intention predicted a significant but relatively small proportion of variation (9.6%) in behaviour.

CONCLUSION

The HPV vaccine does not seem to be associated with perceptions of stigma related to genital warts, and has broad acceptance among a female university population. This study demonstrates that TPB is suited to investigate HPV vaccination, and has helped clarify the role of moral norm within the TPB.

The validity of reporting willingness to use a supervised injecting facility on subsequent program use among people who use injection drugs

BACKGROUND

Innovative health programs for injection drug users (IDUs), such as supervised injecting facilities (SIFs), are often preceded by evaluations of IDUs' willingness to use the service. The validity of these surveys has not been fully evaluated. We sought to determine whether measures of willingness collected prior to the opening of a Canadian SIF accurately predicted subsequent use of the program.

METHODS

Data were derived from a prospective cohort of IDUs. The sample size for this study was 640 IDUs. Using multivariate logistic regression, it was assessed if a history of reporting willingness to use the program, were it available, was associated with subsequent use. In sub-analysis restricted to individuals who had a history of reported willingness, we used multivariate longitudinal analysis to identify factors associated with not attending the SIF.

RESULTS

Among 442 IDUs, 72% of those who reported initial willingness to use a SIF later attended the program, and a prior willingness to use a SIF significantly predicted later attendance (adjusted odds ratio = 1.67). In sub-analyses restricted to those who had a history of reporting willingness to use the SIF, not using the program was predicted by not frequenting the neighborhood where the SIF was located.

CONCLUSION

Our findings indicate that reported willingness measures collected from IDUs regarding potential SIF program participation prior to its opening independently predicted later attendance even when variables that were likely determinants of willingness were adjusted for. These data suggest that willingness measures are reasonably valid tools for planning the delivery of health services among IDU populations.

"I do what I have to do to survive": an investigation into the perceptions, experiences and economic considerations of women engaged in sex work in Northern Namibia

BACKGROUND

There is little published research investigating sex work in Namibia, particularly in rural areas. Therefore, the aim of this paper was to determine the views of women engaged in sex work in the Oshakati area of Namibia concerning the main factors influencing their use, or non-use, of male condoms during transactional sexual exchanges.

METHODS

Qualitative interviews were used to better understand the perceptions, experiences and economic considerations of female sex workers in Namibia who were involved in a Behavior Change Communication Program encouraging safer sex practices among high-risk populations in 2006 and 2007.

RESULTS

While the Behavior Change Communication Program has made significant strides in educating and empowering young women to negotiate more consistent condom use with sexual partners, the gendered economic inequalities and power imbalances within rural and semi-urban Namibian society that favor men hinder further advancement towards positive behavioral change for HIV prevention and also hinder the development of the loving relationships sought by some sex workers.

CONCLUSION

This study found that sex workers and transactional sex encounters are heterogeneous entities dependent upon the characteristics of the man (known, stranger, wealthy, attractive to the woman) and the woman (in financial need, desiring love). These features all influence condom use. The 3 E's 'education, empowerment and economic independence' are critical factors needed to encourage and facilitate consistent condom use to prevent HIV transmission. Without financial independence and occupational alternatives building on their health education and empowerment, women who engage in sex work-and transactional sex more generally-will remain largely marginalized from Namibian society, and will continue engaging in risky sexual practices that facilitate HIV acquisition and transmission throughout the community.

An expanded model of the temporal stability of condom use intentions: gender-specific predictors among high-risk adolescents

BACKGROUND

Adolescents involved with the criminal justice system are at particularly high-risk for the Human Immunodeficiency Virus and sexually transmitted infections.

PURPOSE

The purpose of this study was to longitudinally examine gender-specific models of condom use, incorporating temporal stability of intentions.

METHODS

Adolescents on probation (N=728) were recruited to complete longitudinal surveys including measures of Theory of Planned Behavior and gender-specific constructs, relationship length, and condom use.

RESULTS

Gender-specific models of condom use behavior suggested by previous research were mostly replicated. For young women, the effect of baseline intentions on subsequent condom use behavior was stronger when intentions were either stable or increasing. For young men, more stable, increasing intentions were directly associated with more condom use. There was preliminary evidence to suggest an association between temporal stability of intentions and decreasing condom use in stable relationships.

CONCLUSIONS

Intervention efforts should be tailored by gender and aim to forestall decreasing intentions and condom use over time by addressing difficulties in maintaining condom use.

A model of adolescents' seeking of sexual content in their media choices

This article reports on the extent to which adolescents report actively seeking sexual content in media, identifies from which media they report seeking, estimates the association between seeking sexual information and romantic and sexual behavior, and shows that active seeking of sexual content in media sources is explained by an intention to seek such content using the Integrative Model of Behavioral Prediction, a reasoned action approach. The data are a national sample of 810 adolescents aged 13 to 18 years. Results show that 50% of adolescents reported actively seeking sexual content in their media choices, which included movies, television, music, Internet pornography sites, and magazines. Males sought sex content more than females, and gender differences were greatest for seeking from Internet pornography sites, movies, and television. Path analysis demonstrate that seeking sexual content is well-predicted by intentions to seek, and intentions are primarily driven by perceived normative pressure to seek sexual content.

Sorting through chickens and eggs: a longitudinal examination of the associations between attitudes, norms, and sexual risk behavior

OBJECTIVE

Health behavior theories posit that health-relevant attitudes, beliefs, and behavioral skills drive subsequent actions people take to protect themselves from health threats. Within the realm of HIV-related sexual risk behavior, much of the research in support of this notion is cross-sectional, rather than longitudinal, particularly in studies of gay and bisexual men. Other psychological theories (e.g., self-perception or cognitive dissonance theories) suggest that the opposite could be true--that health-relevant attitudes and beliefs might change as a function of previous risk or precautionary behavior. Appreciating the complex nature of these associations is essential for modifying theory and developing appropriate interventions.

DESIGN

Using longitudinal data from gay and bisexual men (n = 1465), we used structural equation modeling to examine three possibilities--that perceived norms and attitudes about sexual risk would be (a) related to unprotected anal intercourse cross-sectionally, (b) related to unprotected anal intercourse at a subsequent time point, and/or (c) predicted from previous instances of unprotected anal intercourse.

RESULTS

Safe-sex norms and attitudes were related to unprotected anal intercourse cross-sectionally, but did not predict unprotected sex longitudinally. Rather, perceived norms and attitudes changed as a function of previous risk behavior.

CONCLUSIONS

These results raise the possibility that modified theoretical models might be necessary to adequately describe sexual risk behavior among gay and bisexual men.

A Cultural Perspective on Sexual Health: HIV Positive and Negative Monolingual Hispanic Women in South Florida

This study explored feelings and attitudes with regard to HIV and sexual health among 82 monolingual Spanish-speaking, HIV-positive (n = 30) and at-risk women (n = 52), participating in the NOW en Español Project-a cognitive behavioral sexual risk-reduction intervention in Miami, Florida. Hispanic cultural values and beliefs, such as machismo, marianismo, and sexual silence, emerged throughout the intervention as important determinants of sexual behavior. Recommendations for integrating these culture-specific issues in sexual health interventions for Hispanic women are provided.

Predicting pediatricians' communication with parents about the human papillomavirus (hpv) vaccine: an application of the theory of reasoned action

This study examines the ability of the theory of reasoned action (TRA) and the theory of planned behavior (TPB) to predict whether or not pediatricians encourage parents to get their adolescent daughters vaccinated against the human papillomavirus (HPV). Four-hundred and six pediatricians completed a mail survey measuring attitudes, subjective norms, perceived behavioral control, intentions, and behavior. Results indicate that pediatricians have positive attitudes, subjective norms, and perceived behavioral control toward encouraging parents to get their daughters vaccinated, that they intend to regularly encourage parents to get their daughters vaccinated against HPV in the next 30 days, and that they had regularly encouraged parents to get their daughters vaccinated against HPV in the past 30 days (behavior). Though the data were consistent with both the TRA and TPB models, results indicate that perceived behavioral control adds only slightly to the overall predictive power of the TRA, suggesting that attitudes and norms may be more important targets for interventions dealing with this topic and audience. No gender differences were observed for any of the individual variables or the overall fit of either model. These findings have important theoretical and practical implications for the development of health communication messages targeting health care providers in general, and for those designed to influence pediatricians' communication with parents regarding the HPV vaccine in particular.

The World Starts With Me: a multilevel evaluation of a comprehensive sex education programme targeting adolescents in Uganda

Background

This paper evaluates the effect of the World Starts With Me (WSWM), a comprehensive sex education programme in secondary schools in Uganda. The aim of the present study was to assess the effects of WSWM on socio-cognitive determinants of safe sex behaviour (delay; condom use and non-coercive sex).

Methods

A survey was conducted both before and immediately after the intervention among students in intervention (N = 853) and comparison (N = 1011) groups. A mixed model repeated measures analysis was performed to assess the effectiveness of the WSWM programme on the main socio-cognitive determinants of safe sex behaviour at post-test. A similar post-hoc comparison was made between schools based on completeness and fidelity of implementation of WSWM.

Results

Significant positive effects of WSMW were found on beliefs regarding what could or could not prevent pregnancy, the perceived social norm towards delaying sexual intercourse, and the intention to delay sexual intercourse. Furthermore, significant positive effects of WSWM were found on attitudes, self-efficacy and intention towards condom use and on self-efficacy in dealing with sexual violence (pressure and force for unwanted sex). A reversed effect of intervention was found on knowledge scores relating to non-causes of HIV (petting, fondling and deep kissing). A follow-up comparison between intervention schools based on completeness of the programme implementation revealed that almost all significant positive effects disappeared for those schools that only implemented up to 7 out of 14 lessons. Another follow-up analysis on the basis of implementation fidelity showed that schools with a "partial" fidelity score yielded more significant positive effects than schools with a "full" fidelity of implementation score.

Conclusions

The study showed an intervention effect on a number of socio-cognitive determinants. However, the effectiveness of WSWM could be improved by giving more systematic attention to the context in which such a programme is to be implemented. Implications for the systematic development and implementation of school-based safe sex interventions in Uganda will be discussed.

Determinants of condom use in Zambia: a multilevel analysis

Research on the determinants of condom use in sub-Saharan Africa has focused on the personal characteristics of individuals and, more recently, on community characteristics such as levels of development and of contraceptive availability. Two additional community characteristics, however--the restraining influence exerted by social networks and traditional community institutions (both theorized to decline with population growth) and the degree of interpersonal communication concerning HIV/AIDS--should also be factored into research. This study uses data from the 2003 Zambia Sexual Behaviour Survey and other surveys to conduct multilevel analyses to assess the influence of each of these various characteristics on condom use in Zambia. The results show that condom use increases with interpersonal communication concerning HIV/ AIDS, community infrastructural development, and access to condoms, and decreases with population growth rate and density. The findings suggest that condom-promotion efforts should be attentive to community-level social norms, population trends, and informal social relationships and interpersonal communication.

Sexual barrier acceptability among multiethnic HIV-positive and at-risk women

BACKGROUND

Sexual behavior interventions have been found to reduce sexual risk among HIV-seropositive and high-risk HIV-seronegative women.

METHODS

This study examined the influence of ethnicity and HIV serostatus on sexual barrier acceptability and use at short-term and long-term follow-up among African American and Hispanic (n=457) women participating in a gender and culturally tailored sexual risk reduction intervention. We hypothesized that sexual barrier acceptability and use would differ between ethnic groups but that this difference would dissipate after intervention participation. We further postulated that HIV-seropositive women would report greater acceptability and use of sexual barriers than seronegative women at baseline and that after participation in the intervention, acceptability and use would increase for both serostatus groups.

RESULTS

We enrolled 317 African American and 140 Hispanic women, 273 (60%) seropositive and 184 (40%)seronegative. Ethnic differences in the frequency of male and female condom use existed at baseline but were not found at 12-month follow-up. Male condom acceptability was higher among African American women than Hispanic women at baseline and 12-month follow-up. Seropositive women reported higher levels of consistent male condom use, but both ethnic and serostatus groups reported high levels (positive, 40%; negative, 52%) of inconsistent condom use. Most women had little experience with female condoms or lubricating gels and suppositories at baseline. No differences between ethnicities were identified in lubricant use.

CONCLUSIONS

Results support the use of a culturally tailored intervention among these populations to increase sexual barrier use and reduce sexual risk.

Online sexual activity experience of heterosexual students: gender similarities and differences

This study compared male and female university students' experiences with online sexual activity (OSA) and tested a model explaining gender differences in OSA. OSAs were categorized as non-arousal (e.g., seeking sexuality information), solitary-arousal (e.g., viewing sexually explicit materials), or partnered-arousal (e.g., sharing sexual fantasies). Participants (N = 217) completed measures of OSA experience, sexual attitudes, and sexual experience. Significantly more men than women reported engaging in solitary-arousal and partnered-arousal OSA and doing so more often. However, the men and women who reported having engaged in partnered-arousal activities reported equal frequencies of experience. There were no significant gender differences for engaging in non-arousal OSA experience. These results support the importance of grouping OSAs in terms of the proposed non-arousal, solitary-arousal, and partnered-arousal categories. Attitude toward OSA but not general attitudes toward or experiences with sexuality partially mediated the relationship between gender and frequency of engaging in arousal-oriented OSA (solitary and partnered OSA). This suggests that attitude toward OSA specifically and not gender socialization more generally account for gender differences in OSA experience.

Decision-making style and gender moderation of the self-efficacy-condom use link among adolescents and young adults: informing targeted STI/HIV prevention programs

OBJECTIVE

To test the moderating effects of decision-making style and gender on the relationship between condom use self-efficacy (CUSE) and condom use behavior among sexually active adolescents and young adults.

DESIGN

Cross-sectional study.

SETTING

Twenty-four continuation high schools in California.

PARTICIPANTS

Data were collected between February 2008 to June 2009 from a sample of 1304 sexually active adolescents and young adults. The mean (SD) age of the participants was 16.8 (0.9) years, 41% were female, and the ethnicity frequencies were Hispanic, 65%; mixed, 13%; white, 11%; black, 6%; and other, 5%.

MAIN EXPOSURES

The tools used were CUSE, decision-making-self-confidence, and decision-making-approach.

MAIN OUTCOME MEASURE

Condom use during the most recent sexual intercourse (termed last sex).

RESULTS

Forty-five percent of sexually active participants used condoms at last sex. Decision-making-self-confidence and decision-making-approach significantly moderated the effect of CUSE on condom use. The positive relationship between CUSE and condom use was relatively stronger for males and females reporting high vs low decision-making-self-confidence. Among females, the relationship between CUSE and condom use at last sex was weaker for those reporting high vs low decision-making-approach. Both of these effects were observed at high levels of CUSE.

CONCLUSION

Programs for sexually transmitted infection/human immunodeficiency virus prevention including CUSE content may increase adolescent and young adult condom use by targeting interventions to decision-making style and gender.

Alcohol, conscientiousness and event-level condom use

OBJECTIVES

Alcohol impairs judgement and could be causally implicated in sexual risk taking. However, meta-analytic studies do not find an association between alcohol use and unprotected sexual intercourse at the event level, where both behaviours refer to the same point in time. Associations between personality traits and sexual risk taking have been replicated across several studies. Traits may be better conceptualized as independent risk factors, where alcohol use mediates the association between personality and condom use. The objective of our study was to determine the direct and indirect effects connecting big five personality traits with condom use, potentially mediated through alcohol use during the most recent sexual encounter.

DESIGN

A sample of community-dwelling adults (N= 190) completed measures of big five personality traits and a detailed assessment of event-level sexual behaviour and alcohol use.

RESULTS

In regression model adjusting for known confounding factors, including oral contraceptive use, partner type, and hazardous drinking patterns, one standard deviation increase in conscientiousness was associated with a 1.14-fold increase in the odds of using a condom with most recent sexual partner (p= .04). Repeating the analysis using zero-inflated regression for estimated blood alcohol concentration (eBAC) values revealed an association between conscientiousness and eBAC (p= .002). There was no association between alcohol and condom use in either analysis.

CONCLUSIONS

The results illustrate that personality traits are strong independent risk factors for sexual risk taking and eBAC values during sexual events, and both should be incorporated into research designs. Future research should evaluate specific facets of conscientiousness, and whether eBAC mediates the association between personality and condom use in other samples. The possibility of tailoring interventions to personality traits is discussed.

Attributional processes underlying imagined contact effects

Recent research has demonstrated that mentally simulating positive intergroup encounters can promote tolerance and more positive intergroup attitudes. We explored the attributional processes underlying these effects. In our study participants who imagined intergroup contact subsequently reported greater intentions to engage in future contact, a relationship that was mediated by participants’ attribution, to themselves, of a more positive attitudinal orientation towards outgroup contact. Consistent with this attributional account, the perspective taken when imagining the encounter qualified this effect. Participants who imagined the encounter from a third-person perspective reported heightened intentions to engage in future contact relative to control participants, while this was not the case when the encounter was imagined from a first-person perspective. These findings suggest that attributional processes are key to observing the benefits that accrue from imagining intergroup contact. We speculate that these attributions may distinguish the approach from extended and actual forms of contact and help researchers to further capitalize on the benefits of mental imagery for improving intergroup relations.

Toward an information-motivation-behavioral skills model of microbicide adherence in clinical trials

Unless optimal adherence in microbicide clinical trials is ensured, an efficacious microbicide may be rejected after trial completion, or development of a promising microbicide may be stopped, because low adherence rates create the illusion of poor efficacy. We provide a framework with which to conceptualize and improve microbicide adherence in clinical trials, supported by a critical review of the empirical literature. The information-motivation-behavioral skills (IMB) model of microbicide adherence conceptualizes microbicide adherence in clinical trials and highlights factors that can be addressed in behavioral interventions to increase adherence in such trials. This model asserts that microbicide adherence-related information, motivation, and behavioral skills are fundamental determinants of adherent microbicide utilization. Specifically, information consists of objective facts about microbicide use (e.g., administration and dosage) as well as heuristics that facilitate use (e.g., microbicides must be used with all partners). Motivation to adhere consists of attitudes toward personal use of microbicides (e.g., evaluating the consequences of using microbicides as good or pleasant) as well as social norms that support their use (e.g., beliefs that a sexual partner approves use of microbicides). Behavioral skills consist of objective skills necessary for microbicide adherence (e.g., the ability to apply the microbicide correctly and consistently). Empirical evidence concerning microbicide acceptability and adherence to spermicides, medication, and condom use regimens support the utility of this model for understanding and promoting microbicide adherence in clinical trials.

Toward a new methodological paradigm for testing theories of health behavior and health behavior change

OBJECTIVE

Traditional theory testing commonly applies cross-sectional (and occasionally longitudinal) survey research to test health behavior theory. Since such correlational research cannot demonstrate causality, a number of researchers have called for the increased use of experimental methods for theory testing.

METHODS

We introduce the multi-methodological theory-testing (MMTT) framework for testing health behavior theory.

RESULTS

The MMTT framework introduces a set of principles that broaden the perspective of how we view evidence for health behavior theory. It suggests that while correlational survey research designs represent one method of testing theory, the weaknesses of this approach demand that complementary approaches be applied. Such approaches include randomized lab and field experiments, mediation analysis of theory-based interventions, and meta-analysis.

CONCLUSION

These alternative approaches to theory testing can demonstrate causality in a much more robust way than is possible with correlational survey research methods. Such approaches should thus be increasingly applied in order to more completely and rigorously test health behavior theory.

PRACTICE IMPLICATIONS

Greater application of research derived from the MMTT may lead researchers to refine and modify theory and ultimately make theory more valuable to practitioners.

Community norms for HIV risk behaviors among men in a South African township

We investigated alcohol-related sexual risk behavior from the perspective of social norms theory. Adults (N = 895, 62% men) residing in a South African township completed street-intercept surveys that assessed risk and protective behaviors (e.g., multiple partners, drinking before sex, meeting sex partners in shebeens, condom use) and corresponding norms. Men consistently overestimated the actual frequency of risky behaviors, as reported by the sample, and underestimated the frequency of condom use. Relative to actual attitudes, men believed that other men were more approving of risk behavior and less approving of condom use. Both behavioral and attitudinal norms predicted the respondents' self-reported risk behavior. These findings indicate that correcting inaccurate norms in HIV-risk reduction efforts is worthwhile.

Effects of a theory-based audio HIV/AIDS intervention for illiterate rural females in Amhara, Ethiopia

In Ethiopia the level of illiteracy in rural areas is very high. In this study, we investigated the effects of an audio HIV/AIDS prevention intervention targeted at rural illiterate females. In the intervention we used social-oriented presentation formats, such as discussion between similar females and role-play. In a pretest and posttest experimental study with an intervention group (n = 210) and control group (n = 210), we investigated the effects on HIV/AIDS knowledge and social cognitions. The intervention led to significant and relevant increases in HIV/AIDS knowledge, self-efficacy, perceived vulnerability to HIV/AIDS infection, response efficacy of condoms and condom use intention. In the intervention group, self-efficacy at posttest was the main determinant of condom use intention, with also a significant contribution of vulnerability. We conclude that audio HIV/AIDS prevention interventions can play an important role in empowering rural illiterate females in the prevention of HIV/AIDS.

Connect: an effective community-based youth suicide prevention program

Youth suicide prevention is an important public health issue. However, few prevention programs are theory driven or systematically evaluated. This study evaluated Connect, a community-based youth suicide prevention program. Analysis of pre and posttraining questionnaires from 648 adults and 204 high school students revealed significant changes in knowledge and attitudes about suicide, increased belief in the usefulness of mental health care, and reduction of stigma associated with seeking help. Adults' preparedness to help also increased significantly as did the likelihood that youth participants would seek adult assistance if they were concerned about a peer. Implications of findings are discussed.

A pilot programme using mobile phones for HIV prevention

We explored the feasibility of engaging young black men in a 12-week text messaging programme about HIV prevention. There were two non-randomized groups of 30 young men each. The participants were aged 16–20 years, self-identifying as black or African-American, sexually active, who owned a mobile phone and lived in Philadelphia. They received three text messages per week for 12 weeks. People in the intervention group received text messages about HIV prevention, while those in the control group received text messages about nutrition. The intervention participants showed trends in increased monogamy at follow-up compared to controls. Awareness of sexual health was significantly higher in the intervention group. Condom norms were significantly higher for the control group. There were no differences in the proportion of protected sex acts. The participants embraced the project, and were enrolled and retained in numbers that suggest such an intervention is worth examining for efficacy.

Integrating social identity theory and the theory of planned behaviour to explain decisions to engage in sustainable agricultural practices

The present research integrates core aspects of social identity theory with the theory of planned behaviour to investigate factors influencing engagement in sustainable agricultural practices. Using a two-wave prospective design, two studies were conducted with samples of farmers (N = 609 and N = 259, respectively). At Time 1, a questionnaire survey assessed theory of planned behaviour variables in relation to engaging in riparian zone management (a sustainable agricultural practice). In addition, intergroup perceptions (i.e. relations between rural and urban groups), group norms and group identification were assessed. At Time 2, self-reported behaviour was measured. There was support for the integrated model across both studies. As predicted, past behaviour, attitudes and perceived behavioural control were significant predictors of intentions, and intentions significantly predicted self-reported behaviour. Group norms and intergroup perceptions were also significant predictors of intentions providing support for the inclusion of social identity concepts in the theory of planned behaviour. More supportive group norms were associated with higher intentions, especially for high-group identifiers. In contrast, more negative intergroup perceptions were associated with lower intentions and, unexpectedly, this effect only emerged for low-group identifiers. This suggests that in the context of decisions to engage in riparian zone management, an important sustainable agricultural practice, high identifiers are influenced predominantly by in-group rather than out-group considerations, whereas low identifiers may attend to cues from both the in-group and the out-group when making their decisions.

Alcohol-Related Social Gatherings with Coworkers: Intentions to Behave and Intentions to Not Behave

Two studies are reported using the theory of planned behaviour (TPB) to examine Koreans' intentions and self-reported behaviour of joining and not joining alcohol-related social gatherings with work colleagues after work hours. Study 1 showed that group-related attitudes and perceived behavioural control of the TPB components regarding joining were significantly associated with intentions to join. Study 2 examined TPB components regarding not joining and intentions to not join. Study 2 found that although none of the TPB components was directly related to intentions, subjective norms from work colleagues moderated the effect of group-related attitudes on intentions to not join. The TPB components and intentions were not significantly related to self-reported behaviour of joining. The findings indicate that the relationships between the TPB components and intentions can be different for engaging and not engaging in a behaviour.

College students and condom attitude: validation of the Multi-Factor Attitude toward Condoms Scale (MFACS)

OBJECTIVE

Sexually transmitted infections and the human immunodeficiency virus incidence rates remain high among college-aged individuals. This study examined the validity and reliability of the Multi-Factor Attitude toward Condoms Scale (MFACS).

PARTICIPANTS

Participants were recruited from a large midwestern university during February and March 2009.

METHODS

Data were collected using in-class data collection with a test-retest design from undergraduate courses. A total of 442 surveys were collected during initial testing and 421 during retesting.

RESULTS

Reliability assessments indicated a sufficient Cronbach's alpha for the total scale (α = .805) and each subscale: affective (α = .790), perceived effectiveness (α = .795), and manageability (α = .751). Further analyses provide evidence of construct validity.

CONCLUSIONS

The study reaffirmed the psychometric properties of the MFACS among a sample of college students. The MFACS provides a contemporary way to examine condom attitudes as sexual health research is moving beyond only disease prevention efforts.

Beliefs Underlying the Decision to Eat Breakfast: The Role of Theory-based Behavioral Analysis in the Development of Policy, Communication and Educational Interventions for Healthy Eating

Policy, communication, and education efforts to influence any social or health outcome are more effective if based on an understanding of the underlying behaviors and their determinants. This conceptual paper outlines how behavioral theory can help design interventions for one healthy eating behavior, eating breakfast. More specifically, the paper illustrates how a prominent health behavior theory, the Reasoned Action Approach, can be used to guide formative research to identify factors underlying people's decisions. Select findings are presented from three studies of beliefs underlying eating breakfast: online surveys with 1185 undergraduates from a large university in Indiana; in-depth interviews with 61 adults from four Indiana worksites; and 63 in-depth interviews with students from three middle schools in rural Indiana. Analyses of data from the undergraduates demonstrated the role of self-efficacy. Analyses of data from the working adults revealed the importance of normative beliefs about what employers believed. Analyses comparing consequences perceived by adults with those perceived by middle school students found that both groups believed that eating breakfast would provide energy but only middle school students believed that eating breakfast would improve alertness. For each finding, the theory is presented, the finding is described, implications for interventions are suggested, and the need for additional research is outlined. In sum, theory-based behavioral research can help develop interventions at intrapersonal, interpersonal, and environmental levels that are warranted to encourage healthy eating.

Can safer-sex promotion leaflets change cognitive antecedents of condom use? An experimental evaluation

An experimental evaluation of a safer sex promotion leaflet was undertaken to assess its capacity to change antecedent cognitions of condom use. The leaflet was identified in a previous study as addressing research-based cognitive antecedents of condom use. A pre-post-test experimental study including three conditions was conducted: (a) presentation of the leaflet; (b) presentation of the leaflet plus incentive for systematic processing; (c) no-leaflet control. The leaflet was evaluated in terms of its capacity to change eight cognitive correlates of condom use identified in a recent meta-analysis. The sample consisted of 230 tenth-grade students. Following baseline assessments, leaflet-induced change was measured immediately following the intervention and at a follow up 4 weeks post-intervention. The target leaflet alone did not result in significant changes in the cognitive antecedents of condom use compared with the control condition. However, in combination with an incentive for systematic processing, the target leaflet had a greater impact on cognitive antecedents than the no-leaflet control condition. The findings are discussed with regard to the development and evaluation of research-based health-promotion materials.

First- and higher-order models of attitudes, normative influence, and perceived behavioural control in the theory of planned behaviour

The present study examined the validity of an augmented version of Ajzen's (1991) theory of planned behaviour (TPB), adopting second-order latent factors to explain relationships between the differentiated components of the theory constructs. This model was tested on data from two independent samples, for exercise and dieting behaviours, respectively. The affective and instrumental attitude, injunctive and descriptive norms, and perceived controllability and self-efficacy constructs all exhibited discriminant validity in the first instance. First- and second-order confirmatory factor analyses exhibited satisfactory fit with the observed data from both samples. There were no substantial differences in the fit indices across the first- and second-order models, and the second-order models exhibited the most optimal parsimony-corrected fit indices. The higher-order models could therefore not be rejected on the grounds of inferior fit or parsimony. First- and second-order structural equation models accounted for significant variance in intentions and behaviour. These results corroborate Ajzen's (2002a) and Bagozzi, Lee, and van Loo's (2001) premise that recent augmentations of the TPB that differentiate the model components can be subsumed by global, higher-order factors while still making the distinction at the subordinate level.

Theory of planned behavior and smoking: meta-analysis and SEM model

To examine if the theory of planned behavior (TPB) predicts smoking behavior, 35 data sets (N = 267,977) have been synthesized, containing 219 effect sizes between the model variables, using a meta-analytic structural equation modeling approach (MASEM). Consistent with the TPB's predictions, 1) smoking behavior was related to smoking intentions (weighted mean r = 0.30), 2) intentions were based on attitudes (weighted mean r = 0.16), and subjective norms (weighted mean r = 0.20). Consistent with TPB's hypotheses, perceived behavioral control was related to smoking intentions (weighted mean r = -0.24) and behaviors (weighted mean r = -0.20) and it contributes significantly to cigarette consumption. The strength of the associations, however, was influenced by the characteristics of the studies and participants.

A network-individual-resource model for HIV prevention

HIV is transmitted through dyadic exchanges of individuals linked in transitory or permanent networks of varying sizes. A theoretical perspective that bridges key individual level elements with important network elements can be a complementary foundation for developing and implementing HIV interventions with outcomes that are more sustainable over time and have greater dissemination potential. Toward that end, we introduce a Network-Individual-Resource (NIR) model for HIV prevention that recognizes how exchanges of resources between individuals and their networks underlies and sustains HIV-risk behaviors. Individual behavior change for HIV prevention, then, may be dependent on increasing the supportiveness of that individual's relevant networks for such change. Among other implications, an NIR model predicts that the success of prevention efforts depends on whether the prevention efforts (1) prompt behavior changes that can be sustained by the resources the individual or their networks possess; (2) meet individual and network needs and are consistent with the individual's current situation/developmental stage; (3) are trusted and valued; and (4) target high HIV-prevalence networks.

A framework for incorporating dyads in models of HIV-prevention

Although HIV is contracted by individuals, it is typically transmitted in dyads. Most efforts to promote safer sex practices, however, focus exclusively on individuals. The goal of this paper is to provide a theoretical framework that specifies how models of dyadic processes and relationships can inform models of HIV-prevention. At the center of the framework is the proposition that safer sex between two people requires a dyadic capacity for successful coordination. According to this framework, relational, individual, and structural variables that affect the enactment of safer sex do so through their direct and indirect effects on that dyadic capacity. This dyadic perspective does not require an ongoing relationship between two individuals; rather, it offers a way of distinguishing between dyads along a continuum from anonymous strangers (with minimal coordination of behavior) to long-term partners (with much greater coordination). Acknowledging the dyadic context of HIV-prevention offers new targets for interventions and suggests new approaches to tailoring interventions to specific populations.

Social-level correlates of shooting gallery attendance: a focus on networks and norms

The purpose of this study was to examine the association between social network characteristics and peer norms related to sharing needles and shooting gallery use. Multivariate logistic regression modeling was used to identify factors that were independently associated with shooting gallery use among a sample of injection drug users recruited in Baltimore, Maryland. Of 842 study participants, 35% reported attending a shooting gallery in the past 6 months. Social networks of shooting gallery users were larger, had a greater number of injectors and crack smokers, were younger and less dense with fewer kin members compared to networks of non-gallery attenders. A greater proportion of those who used a gallery perceived that their peers shared needles and that peers would not disapprove if they used a dirty needle. Future research is needed to understand how social networks and peer norms are specific to behavioral settings and how this may impede adoption of preventive behaviors.

Social representations of HIV/AIDS in five central European and eastern European countries: a multidimensional analysis

Cognitive processing models of risky sexual behaviour have proliferated in the two decades since the first reporting of HIV/AIDS, but far less attention has been paid to individual and group representations of the epidemic and the relationship between these representations and reported sexual behaviours. In this study, 494 business people and medics from Estonia, Georgia, Hungary, Poland and Russia sorted free associations around HIV/AIDS in a matrix completion task. Exploratory factor and multidimensional scaling analyses revealed two main dimensions (labelled 'Sex' and 'Deadly disease'), with significant cultural and gender variations along both dimension scores. Possible explanations for these results are discussed in the light of growing concerns over the spread of the epidemic in this region.

Identifying the psychosocial correlates of condom use by female sex workers in Hong Kong

This study examined factors affecting condom use by Hong Kong female sex workers when they have sex with their clients and steady partners. Our respondents consisted of 109 active female sex workers, mainly streetwalkers or sex workers who worked in villas. During a 30-minute interview, respondents were interviewed individually and were asked questions regarding their condom use practice. These questions were designed to measure various factors affecting their condom use practice, including attitudes toward condom use, normative pressure, perceived behavioural control, perceived AIDS risks, past condom use behaviour, and future condom use intentions with respect to the two types of partners. Multiple regression analyses reveal that perceived behavioural control is the most important factor associated with these respondents' future condom use across the two types of partners. Perceived AIDS risk is the additional predictor for condom use with clients, while normative pressure is the additional predictor for condom use with steady partners. Past condom use behaviour also provided significant additional prediction for both types of partners, implying the habitual nature of condom use among our respondents. These results have significant implications for designing intervention programmes targeting at increasing condom use by female sex workers in Hong Kong.

Determinants of intention to use condoms among clients of female sex workers in Haiti

A cross-sectional survey was conducted to examine factors influencing intention of condom use among 378 clients of female sex workers (FSWs) visiting commercial sex sites in St-Marc and Gonaives, Haiti. Mean age of the study participants was 24 years. A structured questionnaire was used to collect data on socio-demographic characteristics, behaviors, and the theory of planned behavior (TPB) constructs. Seventy-four percentage of clients reported having used condoms with a FSW the last time they had had sexual intercourse. The majority (81.7%) firmly intended to use condoms during the next sexual encounter with a FSW. Multivariate logistic models revealed that subjective norms (odds ratio (OR)=1.75; 95% confidence interval (CI): 1.06-2.88), perceived behavioral control (OR=1.34; 95% CI: 1.09-1.63) and attitudes (OR=1.23; 95% CI: 1.04-1.44) were predictors of intention to use condoms, with norms being more important. Clients having used condoms the last time they had a sexual intercourse with a FSW, were more likely to have the intention to use them in the future (OR=3.17; 95% CI: 1.65-6.10), indicating an adopted behavior. Lastly, having had a previous sexually transmitted infection was associated with intention, suggesting that a negative experience can influence a future behavior. In conclusion, intention to use condoms among the clients of Haitian FSWs was well predicted by TPB constructs. Our findings provide evidence for designing interventions targeted at reducing risky sex behaviors in this population.

Initial commitment to pre-exposure prophylaxis and circumcision for HIV prevention amongst Indian truck drivers

Studies of HIV prevention interventions such as pre-exposure prophylaxis (PREP) and circumcision in India are limited. The present study sought to investigate Indian truck-drivers initial commitment to PREP and circumcision utilizing the AIDS Risk Reduction Model. Ninety truck-drivers completed an in-depth qualitative interview and provided a blood sample for HIV and HSV-2 testing. Truck-drivers exhibited low levels of initial commitment towards PREP and even lower for circumcision. However, potential leverage points for increasing commitment were realized in fear of infecting family rather than self, self-perceptions of risk, and for PREP focusing on cultural beliefs towards medication and physicians. Cost was a major barrier to both HIV prevention interventions. Despite these barriers, our findings suggest that the ARRM may be useful in identifying several leverage points that may be used by peers, health care providers and public health field workers to enhance initial commitment to novel HIV prevention interventions in India.