I can use a condom, i just don't: the importance of motivation to prevent HIV in adolescent seeking psychiatric care

Applying the Information-Motivation-Behavioral Skills Model to Understand PrEP Intentions and Use Among Men Who Have Sex with Men

Research is needed to determine targets for interventions to increase pre-exposure prophylaxis (PrEP) uptake. The Information-Motivation-Behavioral Skills (IMB) model has not been tested for PrEP use among men who have sex with men (MSM). Men and transgender women and men were surveyed at a community event in the Midwest in 2016 (N = 476, 60% White, Mage = 35). New measures assessed PrEP knowledge, attitudes, stigma, descriptive and subjective norms, and intentions, and participants reported on PrEP use. We tested the IMB model for a subsample of HIV-negative MSM and transgender individuals (N = 357) using structural equation modeling. Only 12% of participants used PrEP. New measures performed well and were reliable (αs = 0.83-0.94). Structural models generally supported the IMB model: knowledge, stigma, and self-efficacy were directly associated with use, and attitudes, stigma, and descriptive norms had indirect effects on use via self-efficacy. The IMB model may be useful when developing PrEP interventions for MSM.

Sexual Health Risk Behavior Disparities Among Male and Female Adolescents Using Identity and Behavior Indicators of Sexual Orientation

Sexual minority adolescent sexual risk behavior studies often overlook young women, do not consider behavior- and identity-based sexual orientation indicators in combination, and focus mainly on condomless sex. We examined multiple risk behaviors in a large sample of adolescent young men and women using combined behavior- and identity-based indices. The 2015 Dane County Youth Assessment data included 4734 students in 22 high schools who had ever voluntarily engaged in sexual contact (51.7% male; 76.0% White, non-Hispanic). Items assessed having sex with unfamiliar partners, sex while using substances, using protection, and STI testing. Logistic regressions tested for disparities based on combined identity- and behavior-based sexual orientation indicators. For both young men and women, youth who reported heterosexual or questioning identities-but who had sex with same-sex partners-were at consistently greater risk than heterosexual youth with only different-sex partners. Also, for both young men and women, bisexuals with partners of both sexes more consistently reported higher risk than heterosexual youth than did bisexuals with only different-sex partners. Risk behavior for gay young men who had sex only with men mirrored those in extant literature. Risk levels differed for specific groups of sexual minority young women, thus deserving further attention. Findings underscore the need for sexual health research to consider sexual orientation in a more multidimensional manner.

The Information-Motivation-Behavioral Skills Model Revisited: A Network-Perspective Structural Equation Model Within a Public Sexually Transmitted Infection Clinic Sample of Hazardous Alcohol Users

The information–motivation–behavioral skills (IMB) model is useful for understanding sexual risk behavior, but has not been tested with hazardously-drinking sexually transmitted infection (STI) clinic patients, a subpopulation at greater HIV risk, or with a network-perspective sexual risk behavior outcome. Participants (N = 569) were STI clinic patients who screened positive for hazardous drinking and risky sexual behavior. Sexual risk behavior (SRB) was operationalized as a latent variable with three indicators: (1) number of sexual partners, (2) number of unprotected sex occasions with primary partner, and (3) number of unprotected sex occasions with non-primary partner(s). Preliminary analyses suggested SRB was best operationalized as a latent variable with two indicators, while unprotected sex with primary partners should be considered separately. In structural models with good fit, the IMB model was generally supported. The IMB model functioned differently for non-primary and multiple partners compared to primary partners in STI clinic patients with hazardous alcohol use.

Development and Refinement of a Targeted Sexual Risk Reduction Intervention for Women With a History of Childhood Sexual Abuse

Childhood sexual abuse (CSA) is associated with sexual risk behavior in adulthood. Traditional sexual risk reduction interventions do not meet the unique needs of women who have been sexually abused. In the current paper, we describe the four-stage process we followed to develop and refine a targeted sexual risk reduction intervention for this population. First, initial quantitative work revealed that the intervention should address how maladaptive thoughts related to traumatic sexualization, trust, powerlessness, and guilt/shame (traumagenic dynamics constructs) influence current sexual behavior. Second, qualitative interviews with 10 women who reported a history of CSA (M age = 34 years; 90% African American) as well as current sexual risk behavior provided support for targeting maladaptive thoughts associated with these traumagenic dynamics constructs. Third, based on the qualitative and quantitative results, we developed a 5-session, group-delivered intervention to address the maladaptive thoughts that occurred as a result of CSA, as well as the cognitive-behavioral determinants of sexual risk behavior. This intervention drew heavily on cognitive behavioral techniques to address cognitions associated with CSA and the links between these cognitions and current sexual risk behavior. Techniques from trauma-based therapies, as well as motivational techniques, were also incorporated into the intervention. Finally, we refined the intervention with 24 women (M age = 33 years; 79% African American), and assessed feasibility and acceptability. These women reported high levels of satisfaction with the intervention. The resultant intervention is currently being evaluated in a small, randomized controlled trial.

Do behavioral scientists really understand HIV-related sexual risk behavior? A systematic review of longitudinal and experimental studies predicting sexual behavior

Behavioral interventions to reduce sexual risk behavior depend on strong health behavior theory. By identifying the psychosocial variables that lead causally to sexual risk, theories provide interventionists with a guide for how to change behavior. However, empirical research is critical to determining whether a particular theory adequately explains sexual risk behavior. A large body of cross-sectional evidence, which has been reviewed elsewhere, supports the notion that certain theory-based constructs (e.g., self-efficacy) are correlates of sexual behavior. However, given the limitations of inferring causality from correlational research, it is essential that we review the evidence from more methodologically rigorous studies (i.e., longitudinal and experimental designs). This systematic review identified 44 longitudinal studies in which investigators attempted to predict sexual risk from psychosocial variables over time. We also found 134 experimental studies (i.e., randomized controlled trials of HIV interventions), but of these only 9 (6.7 %) report the results of mediation analyses that might provide evidence for the validity of health behavior theories in predicting sexual behavior. Results show little convergent support across both types of studies for most traditional, theoretical predictors of sexual behavior. This suggests that the field must expand the body of empirical work that utilizes the most rigorous study designs to test our theoretical assumptions. The inconsistent results of existing research would indicate that current theoretical models of sexual risk behavior are inadequate, and may require expansion or adaptation.

Effectiveness of a Peer-Assisted Multicomponent Behavioral Intervention in HIV Risk Reduction Among Female Entertainment Workers in China

This study examined the effectiveness of a behavioral intervention that combined cognitive and social influence approaches. The intervention consisted of small group sessions targeting HIV knowledge, protection motivation, behavioral skills, and social influences of risk reduction. The control was an attention-controlled HIV/STI health education and counseling. Two-group comparisons were conducted to assess the effectiveness of the intervention; risk reduction over time was analyzed to determine the sustainability of the effectiveness. The analyses revealed that the intervention was effective in reducing/increasing HIV risk/protective behaviors and the effect was sustainable. While participants in the control reported a greater reduction/increase in risk/protective behaviors 3-month post-intervention, the initial strong effect quickly faded and completely disappeared 12-month post-intervention. By contrast, the moderate initial effect of the intervention was not only sustained but actually strengthened over time. The intervention was well received by participants and holds promise for HIV risk reduction behavior change among female entertainment workers in China.

HIV-Risk Reduction with Juvenile Offenders on Probation

Youth involved in the juvenile justice system are at elevated risk for HIV as a result of high rates of sexual risk taking, substance use, mental health problems and sexually transmitted infections. Yet few HIV prevention programs exist for young offenders. This pilot study examined change in juvenile offenders' sexual activity, drug/alcohol use, HIV testing and counseling, and theoretical mediators of risk taking following participation in PHAT Life, an HIV-prevention program for teens on probation. Participants (N=54) were 13-17 year-old arrested males and females remanded to a detention alternative setting. Youth participated in a uniquely tailored HIV prevention intervention and completed a baseline and 3-month follow up assessment of their HIV and substance use knowledge, attitudes, beliefs, and behaviors. At 3-month follow up, teens reported less alcohol use, more positive attitudes toward peers with HIV, greater ability to resist temptation to use substances, and for males, improved HIV prevention self-efficacy and peer norms supporting prevention. Teens were also more likely to seek HIV counseling and males were more likely to get tested for HIV. Effect sizes revealed moderate change in sexual behavior. Findings support PHAT Life as a promising intervention to reduce HIV-risk among youth in juvenile justice.

Feasibility, acceptability, and initial efficacy of an online sexual health promotion program for LGBT youth: the Queer Sex Ed intervention

Lesbian, gay, bisexual, and transgender (LGBT) youth experience multiple sexual health inequities driven, in part, by deficits in parental and peer support, school-based sex education programs, and community services. Research suggests that the Internet may be an important resource in the development of sexual health among LGBT youth. We examined the feasibility of recruiting youth in same-sex relationships into an online sexual health intervention, evaluated intervention acceptability, and obtained initial estimates of intervention efficacy. LGBT youth (16 to 20 years old) completed Queer Sex Ed (QSE), an online, multimedia sexual health intervention consisting of five modules. The final sample (N = 202) completed the pretest, intervention, and posttest assessments. The primary study outcomes were sexual orientation identity and self-acceptance (e.g., coming-out self-efficacy), sexual health knowledge (e.g., sexual functioning), relationship variables (e.g., communication skills), and safer sex (e.g., sexual assertiveness). Analyses indicated that 15 of the 17 outcomes were found to be significant (p < .05). Effect sizes ranged from small for sexual orientation (e.g., internalized homophobia) and relationship variables (e.g., communication skills) to moderate for safer sex (e.g., contraceptive knowledge) outcomes. This study demonstrated the feasibility, acceptability, and initial efficacy of QSE, an innovative online comprehensive sexual health program for LGBT youth.

Trajectories of multiple adolescent health risk behaviors in a low-income African American population

This study examined interdependent trajectories of sexual risk, substance use, and conduct problems among 12- to 18-year-old African American youths who were followed annually as part of the Mobile Youth Study. We used growth mixture modeling to model the development of these three outcomes in the 1,406 participants who met the inclusion criteria. Results indicate that there were four distinct classes: normative, low risk (74.3% of sample); increasing high-risk takers (11.9%); adolescent-limited conduct problems and drug risk with high risky sex (8.0%); and early experimenters (5.8%) The higher risk classes had higher rates of pregnancy and sexually transmitted infections diagnoses than the normative sample at each of the ages we examined. Differing somewhat from our hypothesis, all of the nonnormative classes exhibited high sexual risk behavior. Although prevention efforts should be focused on addressing all three risk behaviors, the high rate of risky sexual behavior in the 25% of the sample that fall into the three nonnormative classes underscores an urgent need for improved sex education, including teen pregnancy and HIV/sexually transmitted infections prevention, in this community.

Predicting condom use in South Africa: a test of two integrative models

This study tested two integrative socio-cognitive models, namely the information-motivation-behavioral skills model (IMB) and the I-Change model (ICM), to assess their hypothesized motivational pathways for the prediction of condom use during last sexual intercourse. Students (N = 1066) from Cape Town, South Africa, filled out questionnaires at three different time points. Structural equation modeling demonstrated that self-efficacy did not predict behavior directly but indirectly via intention. Knowledge of how to use a condom and how STIs are transmitted directly predicted behavior when modeled as hypothesized by the IMB model, but indirectly when the factors attitude, subjective norms and self-efficacy were included as mediators, as hypothesized by the ICM. It is concluded that the ICM and IMB are similar in terms of model fit and explained variance, but that the ICM had a higher proportion of significant pathways.

Correlates of consistent condom use among female entertainment workers in Shanghai, China: a repeated measures analysis

Female entertainment workers (FEWs) in China are at increased risk of HIV and other sexually transmitted infections, but correlates of their risky sexual behaviour remain poorly understood. Using data from a series of four surveys, this paper employs repeated measures analysis to identify individual and social correlates of consistent condom use among FEWs in Shanghai. Results reveal that both individual cognitive and social influence factors are statistically significant in their bivariate relationships to consistent condom use with a stable or non-stable partner; only prevention motivation and perceived self-efficacy in condom use remain significant in the multiple regressions. When individual and social correlates are examined together, only peer support for condom use remains a significant and independent correlate of consistent condom use in sex with a non-stable partner. Behavioural intervention is urgently needed and should take a multilevel approach, emphasizing individual prevention motivation and behavioural skills training and promoting peer/social support.

HIV information and behavioral skills moderate the effects of relationship type and substance use on HIV risk behaviors among African American youth

The HIV/AIDS epidemic is disproportionately impacting young African Americans. Efforts to understand and address risk factors for unprotected sex in this population are critical in improving prevention efforts. Situational risk factors, such as relationship type and substance use before sex, are in need of further study. This study explored how established cognitive predictors of risky sexual behavior moderated the association between situational factors and unprotected sex among low-income, African American adolescents. The largest main effect on the number of unprotected sex acts was classifying the relationship as serious (event rate ratio=10.18); other significant main effects were alcohol use before sex, participant age, behavioral skills, and level of motivation. HIV information moderated the effect of partner age difference, motivation moderated the effects of partner age difference and drug use before sex, and behavioral skills moderated the effects of alcohol and drug use before sex. This novel, partnership-level approach provides insight into the complex interactions of situational and cognitive factors in sexual risk taking.

Mediators of the relation between childhood sexual abuse and women's sexual risk behavior: a comparison of two theoretical frameworks

Childhood sexual abuse (CSA) is associated with sexual risk behavior in adulthood, but little research has investigated processes that might mediate this relation. The purpose of this study was to investigate whether constructs suggested by the traumagenic dynamics (TD) model (a theory of the effects of CSA) or constructs suggested by the information-motivation-behavioral skills (IMB) model (a theory of the antecedents of sexual risk behavior) better mediated the relation between CSA and sexual risk behavior in adulthood. Participants were 481 women attending a sexually transmitted infection clinic (66% African American) who completed a computerized survey as well as behavioral simulations assessing condom application and sexual assertiveness skills. Forty-five percent of the sample met criteria for CSA and CSA was associated with sexual risk behavior in adulthood. In multiple mediator models, the TD constructs mediated the relation between CSA and the number of sexual partners whereas the IMB constructs mediated the relation between CSA and unprotected sex. In addition, the TD constructs better mediated the relation between CSA and the number of sexual partners; the TD and IMB constructs did not differ in their ability to mediate the relation between CSA and unprotected sex. Sexual risk reduction interventions for women who were sexually abused should target not only the constructs from health behavior models (e.g., motivation and skills to reduce sexual risk), but also constructs that are specific to sexual abuse (e.g., traumatic sexualization and guilt).

Do psychiatric disorders moderate the relationship between psychological distress and sexual risk-taking behaviors in young men who have sex with men? A longitudinal perspective

Young men who have sex with men (YMSM) account for two-thirds of new HIV infections in young people in the United States. Identifying between-person and within-person correlates of sexual risk-taking provides critical information for developing behavioral prevention efforts for this group. Possible predictors of sexual-risk behavior in YMSM include major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and variation in psychological distress over time. To date, research has been equivocal with regard to the relationship between psychiatric disorders, psychological distress, and sexual risk behaviors. Participants included 119 16-20-year-old YMSM. Ethnicity/race of the participants included: black/African-American (46.2%), white (19.3%), Latino/Hispanic (12.6%), multiracial (11.8%), Asian/Pacific Islander (2.5%), and other (5.9%). Sexual risk outcomes included total number of male partners and unprotected anal sex acts across four waves of data collection (24 months). The study found that the between-person correlates, including ethnicity and age, predicted total male partners. Between-person correlates, including ethnicity, MDD, and a moderating effect of PTSD on psychological distress emerged as determinants of unprotected anal sex acts.

Predicting condom use using the Information-Motivation-Behavioral Skills (IMB) model: a multivariate latent growth curve analysis

BACKGROUND

The Information-Motivation-Behavioral Skills (IMB) model often guides sexual risk reduction programs even though no studies have examined covariation in the theory's constructs in a dynamic fashion with longitudinal data.

PURPOSE

Using new developments in latent growth modeling, we explore how changes in information, motivation, and behavioral skills over 9 months relate to changes in condom use among STD clinic patients.

METHODS

Participants (N = 1281, 50% female, 66% African American) completed measures of IMB constructs at three time points. We used parallel process latent growth modeling to examine associations among intercepts and slopes of IMB constructs.

RESULTS

Initial levels of motivation, behavioral skills, and condom use were all positively associated, with behavioral skills partially mediating associations between motivation and condom use. Changes over time in behavioral skills positively related to changes in condom use.

CONCLUSIONS

Results support the key role of behavioral skills in sexual risk reduction, suggesting these skills should be targeted in HIV prevention interventions.

Prevalence and correlates of HIV unsafe sex and STIs among women working in China's entertainment industry

Female entertainment workers in China are at risk of sexually acquiring HIV, but risk factors of their unsafe sex remain understudied. Using information from a venue-based sample of 724 female entertainment workers in Shanghai, this paper examines the prevalence and risk factors of unsafe sex and STIs. While both measures of unsafe sex and history of common STIs suggest that participants in this study appear to have lower rates of unsafe sex and STIs than reported in the literature, venue-based female entertainment workers are at risk of sexually acquiring HIV. Risk factors of unsafe sex include both individual cognitive (information, motivation, and behavioral skills) and social factors. However, HIV-related information and most social factors are not directly and independently associated with unsafe sex. Behavioral intervention is needed for female entertainment workers in China. However, individual-based cognitive approach alone may be limited in effectiveness in reducing unsafe sex among female entertainment workers. Effective intervention needs to take a multi-level approach that addresses both individual cognitive and social risk factors and can particularly benefit from attention to empowering women in sexual relationships and creating a supportive social and working environment.

Factors Associated with Motivation to Change HIV Risk and Substance Use Behaviors among Homeless Youth

This study sought to identify and compare variables associated with motivation to change alcohol, drug use, and HIV risk behaviors among a sample of homeless youths. More frequent alcohol use, older age, and childhood sexual abuse was associated with greater motivation to change alcohol use; higher reported negative consequences of substance use was associated with higher motivation to reduce illicit drug use. Shorter periods of current homelessness predicted higher motivation to change HIV risk behaviors. Findings suggest these areas might be fruitful targets of intervention efforts to enhance motivation to reduce alcohol and illicit drug use and HIV risk behaviors.

The efficacy of a peer-assisted multi-component behavioral intervention among female entertainment workers in China: an initial assessment

Women working in China's entertainment industry are at increased risk of acquiring or transmitting HIV/sexually transmitted infections (STIs). Efforts to develop effective risk-reduction interventions for female entertainment workers (FEWs) remain limited. We conducted a randomized controlled trial of a theory-based risk-reduction intervention among FEWs in Shanghai. The intervention condition consisted of small group, peer-assisted sessions integrating information-motivation-behavioral skills training with social influences of behavior change. The control condition was an attention-matched HIV, health education, and counseling. At three-month post-intervention, participants in the intervention condition reported greater reductions in unprotected sex with a stable partner than participants in the control condition. However, participants in the control condition reported greater reductions in unprotected sex with a non-stable partner than participants in the intervention condition. Some aspects of the study design may have diluted the effects of the intervention. Future intervention studies need to pay more attention to social influences of behavior change and the particular challenges of risk-reduction with stable partner(s).

Predicting condom use among STD clinic patients using the Information - Motivation-Behavioral Skills (IMB) model

We assessed determinants of condom use postulated by the IMB model among STD patients (N = 1474). The model provided acceptable fit to the data (CFI = 0.99, RMSEA = .04). Information was unrelated to condom use but had a negative effect on behavioral skills. Motivation had a positive effect on behavioral skills and condom use. Behavioral skills had a positive effect on condom use. In multiple-groups analyses, stronger associations between motivation and condom use were found among participants reporting no prior STD treatment. Interventions among STD patients should include activities addressing condom use motivation and directly enhancing condom skills.

Social influence and individual risk factors of HIV unsafe sex among female entertainment workers in China

Female entertainment workers in China are at increased sexual risk of HIV, but causes of their unprotected sex remain poorly understood. We develop a model that integrates information-motivation-behavioral skills (IMB) with social influences and test the model in a venue-based sample of 732 female entertainment workers in Shanghai. Most IMB and social influence measures are statistically significant in bivariate relationships to condom use; only HIV prevention motivation and behavioral self-efficacy remain significant in the multiple regressions. Self-efficacy in condom use is the most proximate correlate, mediating the relationship between information and motivation and condom use. Both peer and venue supports are important, but their influences over condom use are indirect and mediated through prevention motivation and/or self-efficacy. Behavioral intervention is urgently needed and should take a multilevel approach, emphasizing behavioral skills training and promoting a supportive social/working environment.

Evaluating a two-step approach to sexual risk reduction in a publicly-funded STI clinic: rationale, design, and baseline data from the Health Improvement Project-Rochester (HIP-R)

BACKGROUND

Sexually transmitted infection (STI) clinics provide an opportune setting for HIV prevention efforts. This randomized controlled trial evaluated a unique, two-step approach to sexual risk reduction at a publicly-funded STI clinic.

METHODS

During an initial visit, patients completed an audio-computer assisted self-interview (ACASI), were randomized to and received one of two brief interventions, obtained medical care, and completed a post-assessment. Next, two-thirds of the patients were assigned to attend an intensive sexual risk reduction workshop. At 3, 6, and 12 months, patients completed additional ACASIs and provided urine specimens to assess behavior change and incident STIs.

RESULTS

During a 28-month interval, 5613 patients were screened, 2691 were eligible, and 1483 consented to participate and were randomized; the modal reason for declining was lack of time (82%). Consenting patients included 688 women and 795 men; 64% of participants were African-American. The sample was low-income, with 57% reporting an annual income of less than $15,000; most participants (62%) had a high school education or less, and 51% were unemployed. Sexual risk behavior was common, as indicated by multiple sexual partners (mean=32.8, lifetime; mean=2.8, past 3 months), unprotected sex (mean=17.3 episodes, past 3 months), and prior STIs (mean=3.3, lifetime; 23% at baseline). Bivariate analyses confirmed our prediction that HIV-related motivation and behavioral skills would be related to current sexual risk behavior. All patients received a brief intervention; patient satisfaction ratings were uniformly high for both interventions (all means >or=3.7 on 4-point scales). Fifty-six percent of invited patients attended the intensive workshop, and attendance did not differ as a function of brief intervention. Patient satisfaction ratings were also uniformly positive for the workshop interventions (all means >or=3.6). Return to follow-up assessments exceeded 70%.

CONCLUSIONS

Results demonstrate that implementing an HIV preventive program in a busy, public clinic is feasible and well-accepted by patients. Ongoing evaluation will determine if the interventions reduce sexual risk behavior and lower incident STIs.

Interventions and Patterns of Risk in Adolescent HIV/AIDS Prevention

Mid-way through the third decade of experience in preventing HIV/AIDS among adolescents, behavioral interventions and outcomes for high risk subgroups have generated evidence extremely instructive for navigating future priorities in reducing transmission risk behavior. Youth who abuse alcohol or drugs, who are detained or incarcerated, or have mental health co-morbidity such as externalizing disorders, represent the most significant challenge to current and future efforts to control the epidemic among the adolescent population. Although there is no unambiguous, standard intervention approach with adolescents, patterns of risks and outcomes with these subgroups are instructive in the critical priority of creating more sustainable gains with our HIV prevention resources. This article provides a synthesis of the evidence with these subgroups, discusses important limitations and difficulties in the current intervention science and highlights promising directions for the next generation of effort in reducing adolescent HIV-related sexual risk behavior. Because individual-level interventions have had only modest effects, a key current emphasis within the field is to develop multilevel interventions with a more ecological or contextual focus. We review various pragmatic responses that acknowledge this priority and the debt owed to individual-level intervention work with adolescents.