Factors contributing to inconsistent condom use among heterosexual men in Curaçao.

This study explored, from a public health perspective, factors that contribute to inconsistent condom use by men in Curaçao through semi-structured face-to-face interviews with 21 heterosexual men. The findings show that there is an important disconnect between what is considered culturally appropriate sexual behaviour for men and women and condom use, that diverging from prescribed notions of masculinity and femininity in order to use condoms consistently is difficult, and that condom use is particularly problematic in the context of concurrent partnerships and sexual economic exchanges. Participants further reported that Caribbean family structures, whereby mothers assume the role as primary caregiver and fathers contribute biologically but, to a much lesser extent socially, also have an impact on condom use. Additionally, consistent condom use was reported to be impeded by a cultural taboo on talking seriously about sex and sexual health. In their totality, findings provide important input from men for the development of sexual health promotion interventions that are cognizant of the cultural context in which inconsistent condom use occurs, and that are geared not only to the individual level but also to the interpersonal and structural levels.

Predicting having condoms available among adolescents: the role of personal norm and enjoyment.

OBJECTIVES: Having condoms available has been shown to be an important predictor of condom use. We examined whether or not personal norm and goal enjoyment contribute to predicting having condoms available in the context of cognition specified by the theory of planned behaviour (TPB). DESIGN: Prospective survey study, with a baseline and follow-up measurement (at 3 months). METHODS: Data were gathered using an online survey. In total 282 adolescents (mean age = 15.6, 74% female adolescents) completed both questionnaires. At baseline, demographics, sexual experience, condom use, TPB variables, descriptive norm, personal norm, and enjoyment towards having condoms available were measured. At T2 (3 months later) having condoms available was measured. Direct and moderating effects of personal norm and goal enjoyment were examined by means of hierarchical linear regression analyses. RESULTS: Regression analyses yielded a direct effect of self-efficacy and personal norm on condom availability. In addition, moderation of the intention-behaviour relation by goal enjoyment added to the variance explained. The final model explained approximately 35% of the variance in condom availability. CONCLUSIONS: Personal norm and goal enjoyment add to the predictive utility of a TPB model of having condoms available and may be useful intervention targets. STATEMENT OF CONTRIBUTION: What is already known about this subject? Having condoms available is an important prerequisite for actual condom use. The theory of planned behaviour has successfully been applied to explain condom availability behaviour. The theory of planned behaviour has been criticized for not adequately taking into account affective motivation. What does this study add? Personal norm and goal enjoyment add to the predictive utility of the model. Personal norm explains condom availability directly, enjoyment increases intention enactment. Personal norm and goal enjoyment therefore are useful intervention targets.

Evaluation of the Dutch AIDS STI information helpline: differential outcomes of telephone versus online counseling.

OBJECTIVE: Health information helplines have an important function in health education, prevention and counseling. Information and help services are increasingly provided online. This study focuses on the differences and similarities between online help services and telephone services. METHODS: The telephone service of the Dutch AIDS STI helpline was compared to its e-mail equivalent. After consulting the helpline service, both callers and e-mailers (N(tot) = 455) were asked to participate in a survey that evaluated their background characteristics, contacting reasons, and satisfaction with the specific service and information received. The survey also included questions regarding the advice received from the helpline. A follow-up measure 4 weeks after the baseline survey evaluated to what extent clients acted upon the advice. RESULTS: The study shows that both services are positively evaluated and are equally persuasive in their counseling. Differences between callers and e-mailers were found regarding background characteristics, content of the consultation, satisfaction, and the advice received. CONCLUSION: It can be concluded that online health information services are an important addition to, but not a replacement for, the traditional telephone helplines. PRACTICE IMPLICATIONS: In order to provide an optimal health service to a wide public, both online and telephone counseling should be offered.

Bedtime stories: the effects of self-constructed risk scenarios on imaginability and perceived susceptibility to sexually transmitted infections.

Various authors (e.g. Kahnemann, D., & Tversky, A. (1982). The simulation heuristic. In D. Kahnemann, P. Slovic, & A. Tversky (Eds.), Judgment under uncertainty: Heuristics and biases (pp. 201-208). New York, NY: Cambridge University Press) have suggested that imagining an event and its consequences influences the perceived likelihood that it might happen in reality (simulation heuristic). A scenario--a description of how a certain activity can lead to a certain outcome--may stimulate one to imagine the outcomes and may influence one's likelihood judgement. The present research studied the effect of risk scenarios on perceptions of susceptibility to sexually transmitted infections and the role of imaginability therein. In a randomised experimental study, we examined the effects of a prefabricated risk scenario and a self-constructed risk scenario against a non-message condition on perceived susceptibility to get infected with Chlamydia. Participants considered themselves more susceptible to Chlamydia after writing their own risk scenario but not after reading the prefabricated risk scenario. The imaginability of the event seemed to mediate the effect of self-constructed scenario information on perceived susceptibility. Recommendations for health education practices are discussed.

HIV-related stigma in African and Afro-Caribbean communities in the Netherlands: manifestations, consequences and coping.

HIV-related stigma in African and Afro-Caribbean diaspora communities in the Netherlands was investigated. Interviews with HIV-positive and HIV-negative community members demonstrated that HIV-related stigma manifests as social distance, physical distance, words and silence. The psychological consequences of HIV-related stigma among those diagnosed with HIV reported were emotional pain, sadness, loneliness, anger, frustration and internalised stigma. The social consequences included decreased social network size, limited social support and social isolation, and resulted from not only enacted stigma but also self-imposed social withdrawal. Also, poor treatment adherence was a health-related consequence. People living with HIV employed both problem-focused and emotion-focused coping strategies to mitigate the negative consequences of stigma. Problem-focused coping strategies included selective disclosure, disengagement, affiliating with similar others, seeking social support and, to a lesser extent, activism. Emotion-focused strategies included distraction, positive reappraisal, religious coping, external attributions, disidentification and acceptance. HIV-related stigma clearly permeates African and Afro-Caribbean communities in the Netherlands, and should be targeted for intervention.

Are lapsed donors willing to resume blood donation, and what determines their motivation to do so?

BACKGROUND: This study investigated the possibility of rerecruiting lapsed blood donors. Reasons for donation cessation, motivation to restart donation, and modifiable components of donation motivation were examined. We distinguished between lapsed donors who had passively withdrawn by merely not responding to donation invitations and donors who had contacted the blood bank to actively withdraw. STUDY DESIGN AND METHODS: A cross-sectional survey was sent to 400 actively lapsed donors and to 400 passively lapsed donors, measuring intention to restart donation and psychological correlates of restart intention. The data were analyzed using multiple regression analyses. RESULTS: The response rate among actively lapsed donors was higher than among passively lapsed donors (37% vs. 25%). Actively lapsed donors typically ceased donating because of physical reactions, while passively lapsed donors quit because of a busy lifestyle. Nonetheless, 51% of actively lapsed responders and 80% of passively lapsed responders were willing to restart donations. Multiple regression analysis showed that, for passively lapsed donors, cognitive attitude was the strongest correlate of intention to donate in the future (ß=0.605, p<0.001), with affective attitude (ß=0.239, p<0.05) and self-efficacy (ß=0.266, p<0.001) explaining useful proportions of the variance as well. For actively lapsed donors, cognitive attitude was also the strongest correlate of intention (ß=0.601, p<0.001), with affective attitude (ß=0.345, p<0.001) and moral norm (ß=-0.118, p<0.05) explaining smaller proportions of the variance. CONCLUSION: The majority of lapsed donors indicated a moderate to high intention to restart donations. Interventions focusing on boosting cognitive and affective attitudes and self-efficacy could further raise such intentions.

Psychological and social correlates of HIV status disclosure: the significance of stigma visibility.

HIV-related stigma, psychological distress, self-esteem, and social support were investigated in a sample comprising people who have concealed their HIV status to all but a selected few (limited disclosers), people who could conceal but chose to be open (full disclosers), and people who had visible symptoms that made concealing difficult (visibly stigmatized). The visibly stigmatized and full disclosers reported significantly more stigma experiences than limited disclosers, but only the visibly stigmatized reported more psychological distress, lower self-esteem, and less social support than limited disclosers. This suggests that having a visible stigma is more detrimental than having a concealable stigma. Differences in psychological distress and self-esteem between the visibly stigmatized and full disclosers were mediated by social support while differences between the visibly stigmatized and limited disclosers were mediated by both social support and stigma. These findings suggest that social support buffers psychological distress in people with HIV.

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.

Justify your love: testing an online STI-risk communication intervention designed to promote condom use and STI-testing.

The efficacy of a tailored, web-based intervention communicating the risks of sexually transmitted infections (STI) for heterosexual young adults was examined in a randomised, controlled trial. The main aims of the relationship-oriented intervention were to influence risk perceptions and to promote (maintenance of) condom use and STI-testing among young adults who reported being recently engaged in a heterosexual relationship. The intervention addressed risk perceptions, attitudes, normative beliefs, self-efficacy and skills related to condom use and STI-testing. Outcomes were compared immediately after the intervention (N = 171) and 3 months later (N = 115) to a non-tailored intervention group and to a control group. Cognitive and behavioural outcomes showed that the tailored intervention was efficacious in influencing perceived susceptibility to STI and STI-testing intentions immediately after the intervention, and in reducing rates of unprotected sex at 3 months.

HIV status disclosure among HIV-positive African and Afro-Caribbean people in the Netherlands.

HIV status disclosure is often characterized as a dilemma. On the one hand, disclosure can promote health, social support, and psychological well-being. On the other, disclosure can lead to stigmatization, rejection, and other negative social interactions. Previous research has shown that HIV status disclosure is a reasoned process whereby the costs and benefits to oneself and to others are weighed. As such, understanding disclosure requires understanding the reasons for and against disclosure employed by people living with HIV (PLWH). In this study, disclosure among a population disproportionately affected by HIV in the Netherlands, namely African and Afro-Caribbean diaspora, was investigated. Reasons for nondisclosure were fear of stigmatization, previous negative experiences with disclosure, having observed the stigmatization of other PLWH, shame, the desire to protect others - particularly one's children and family - from stigmatization by association and/or worrying, and the belief that one's HIV status is a private matter. Participants reported disclosing because they were in a close and supportive relationship, disclosure led to emotional release, disclosure could lead to emotional or financial support, they felt a perceived duty to inform, and they had a desire to educate others about sexual risk-taking. The findings suggest that stigma plays an important role in disclosure decisions among these populations. They further point to a need for HIV-related stigma reduction interventions in African and Afro-Caribbean communities and culturally sensitive counseling for PLWH whereby caregivers do not automatically assume that disclosure is best but rather provide a safe environment in which the costs and benefits of disclosure can be weighed and strategies for disclosure can be developed, if perceived as beneficial by PLWH.

Motivating blood donors to recruit new donors: experimental evaluation of an evidence-based behavior change intervention.

OBJECTIVE: A sustainable, evidence-based intervention to motivate current blood donors to recruit new donors was evaluated using a quasi-experimental, in-service trial at three donation centers. DESIGN: Participating blood donors in three conditions (N = 734), received (1) an evidence-based leaflet designed to enhance recruitment motivation and five postcards facilitating recruitment and donor registration, (2) five postcards alone, or (3) no materials. MAIN OUTCOME MEASURES: Self-reported donor recruitment by donors was measured at 1-week and 6-week follow-up. RESULTS: At 1-week and at 6-week follow-up, donors in both intervention conditions reported talking to more people about donation and asking more people to donate than control participants. Intervention participants also reported persuading more people to register as a donor than control participants. Results indicated that postcards plus leaflet was somewhat more effective than the postcards alone. Donors' intentions to recruit at 1-week follow-up mediated the behavioral effects at 6-week follow-up. CONCLUSION: Motivating and facilitating recruitment of new blood donors through existing donors has the potential to continually replenish the donor population.

Testing implicit assumptions and explicit recommendations: the effects of probability information on risk perception.

When people underestimate a risk, often probability information is communicated because of the implicit assumption that it will raise people's risk estimates as a result of these objective facts. Also, scientific literature suggested that stressing the cumulative aspects of a risk might lead to higher susceptibility perceptions than only emphasizing the single incident probability. Empirical evidence that supports the effectiveness of these strategies, however, is lacking. In two studies, we examined whether cumulative and single incident probability information on sexually transmitted infections leads to higher perceived susceptibility for Chlamydia and HIV. Contrary to assumptions and recommendations, results showed that both types of probability information may result in people feeling less susceptible toward Chlamydia and having less intention to reduce the risk. For HIV, no effects were found. These results contradict implicit assumptions and explicit recommendations concerning the effects of probability information on risk perceptions.

The effects of scenario-based risk information on perceptions of susceptibility to Chlamydia and HIV.

The simulation heuristic of Kahnemann and Tversky (1982) suggests that the subjective ease by which a risky situation can be mentally construed, positively influences the person's perceived susceptibility to the presented threat. Assuming that a detailed outline of how a risky event can end up negatively increases the ease of imagination, we tested the hypothesis that scenario-based risk information enhances perceived susceptibility towards contracting a sexually transmitted infection (STI). In an experimental design, undergraduate students were exposed to one or two risk scenario messages or no scenario message (control). The results confirmed the hypothesis, but only when more than one risk scenario message was provided. This adds to the evidence that presenting scenario-based messages could be a feasible method to influence risk perceptions.

Standard care impact on effects of highly active antiretroviral therapy adherence interventions: A meta-analysis of randomized controlled trials.

BACKGROUND: Poor adherence to medication limits the effectiveness of treatment for human immunodeficiency virus. Systematic reviews can identify practical and effective interventions. Meta-analyses that control for variability in standard care provided to control groups may produce more accurate estimates of intervention effects. METHODS: To examine whether viral load and adherence success rates could be accurately explained by the active content of highly active antiretroviral therapy (HAART) adherence interventions when controlling for variability in care delivered to controls, databases were searched for randomized controlled trials of HAART adherence interventions published from 1996 to January 2009. A total of 1342 records were retrieved, and 52 articles were examined in detail. Directly observed therapy and interventions targeting specific patient groups (ie, psychiatric or addicted patients, patients <18 years) were excluded, yielding a final sample of 31 trials. Two coders independently retrieved study details. Authors were contacted to complete missing data. RESULTS: Twenty studies were included in the analyses. The content of adherence care provided to control and intervention groups predicted viral load and adherence success rates in both conditions (P < .001 for all comparisons), with an estimated impact of optimal adherence care of 55 percentage points. After controlling for variability in care provided to controls, the capacity of the interventions accurately predicted viral load and adherence effect sizes (R(2) = 0.78, P = .02; R(2) = 0.28, P < .01). Although interventions were generally beneficial, their effectiveness reduced noticeably with increasing levels of standard care. CONCLUSIONS: Intervention and control patients were exposed to effective adherence care. Future meta-analyses of (behavior change) interventions should control for variability in care delivered to active controls. Clinical practice may be best served by implementing current best practice.

Standard care quality determines treatment outcomes in control groups of HAART-adherence intervention studies: implications for the interpretation and comparison of intervention effects.

OBJECTIVE: Clinical trials of behavioral interventions seek to enhance evidence-based health care. However, in case the quality of standard care provided to control conditions varies between studies and affects outcomes, intervention effects cannot be directly interpreted or compared. The objective of the present study was to examine whether standard care quality (SCQ) could be reliably assessed, varies between studies of highly active antiretroviral HIV-adherence interventions, and is related to the proportion of patients achieving an undetectable viral load ("success rate"). DESIGN: Databases were searched for relevant articles. Authors of selected studies retrospectively completed a checklist with standard care activities, which were coded to compute SCQ scores. The relationship between SCQ and the success rates was examined using meta-regression. MAIN OUTCOME MEASURES: Cronbach's alpha, variability in SCQ, and relation between SCQ and success rate. RESULTS: Reliability of the SCQ instrument was high (Cronbach's alpha = .91). SCQ scores ranged from 3.7 to 27.8 (total range = 0-30) and were highly predictive of success rate (p = .002). CONCLUSIONS: Variation in SCQ provided to control groups may substantially influence effect sizes of behavior change interventions. Future trials should therefore assess and report SCQ, and meta-analyses should control for variability in SCQ, thereby producing more accurate estimates of the effectiveness of behavior change interventions.

HIV-related stigma and psychological distress: the harmful effects of specific stigma manifestations in various social settings.

OBJECTIVES: Recent research has shown that experiences of stigmatization have an adverse impact on the psychological well being of people living with HIV/AIDS (PLWHA). Most studies investigating this relationship employ an aggregate measure of stigma. Although this approach provides useful information about the psychological implications of HIV-related stigma in general, it neglects to acknowledge the possibility that some manifestations in specific settings may be psychologically more detrimental than others. The present study examines which specific stigma experiences are most strongly related to psychological distress across a number of social settings. METHODS: A cross-sectional survey was administered to 667 PLWHA in the Netherlands. We examined participants' experiences of 11 manifestations of HIV-related stigma in six social settings. Linear regression analyses were conducted to determine which setting-specific manifestations best predict psychological distress after controlling for marital status, education and health status. RESULTS: Three manifestations in family settings, namely receiving advice to conceal one's status, being avoided and being treated with exaggerated kindness, and one manifestation in healthcare settings, namely awkward social interaction, best predicted psychological distress in PLWHA. CONCLUSION: Manifestations of HIV-related stigma vary according to setting. Certain manifestations in specific social settings impact the psychological well being of PLWHA more than others. In this study, certain experiences of stigmatization with PLWHA's families and in healthcare settings were more strongly related to psychological distress than experiences occurring in other social settings. These findings suggest that stigma reduction interventions focusing on these influential settings may benefit the psychological well being of PLWHA.

HIV/STI risk communication: the effects of scenario-based risk information and frequency-based risk information on perceived susceptibility to chlamydia and HIV.

Health risk judgments are not merely based on risk statistics but also on the ease with which hypothetical events are imagined. We explored the effects of scenario information as opposed to frequency information on susceptibility perceptions regarding Chlamydia and HIV. Results showed that participants felt more susceptible to Chlamydia after reading frequency information. Scenario information only seemed to affect feelings of susceptibility in participants with no intimate relationship. No effects on perceived susceptibility for HIV were found. Results are discussed in terms of severity of the disease and defensive reactions.

Uma Tori! Evaluation of an STI/HIV-prevention intervention for Afro-Caribbean women in the Netherlands.

OBJECTIVE: This study describes the effectiveness of 'Uma Tori', an STI/HIV-prevention intervention for women of Afro-Surinamese and Dutch Antillean descent in the Netherlands, aimed at increasing awareness of sexual risk and power in relationships and improving sexual decision-making skills. METHODS: Intervention effects were evaluated in a pre-post-test design, using self-report questionnaires among a sample of 273 women. Data were analysed using intention-to-treat, MANOVA with repeated measures and Bonferroni correction for multiple comparisons. Additionally, a qualitative process evaluation, using logbooks and interviews, was conducted to assess fidelity and completeness of intervention implementation. RESULTS: The results showed positive effects on participants' knowledge, risk perceptions, perceived norms and sexual assertiveness. In addition, after the programme, participants had stronger intentions to negotiate and practice safe sex. Furthermore participants communicated more with their partners about safe sex. CONCLUSION: The effects of 'Uma Tori' are promising and the intervention seems to support attempts to reduce sexual-risk behaviour among Afro-Caribbean women. PRACTICE IMPLICATION: The evaluation of the programme suggests that this interactive, multiple session, multi-faceted small-group intervention is successful in increasing participants' awareness, sexual assertiveness, intentions to negotiate safe sex, and communication about sexual behaviour with partners. This programme is applicable in practice, provided that it is gender specific and culturally appropriate.

Social and cognitive variables predicting voluntary HIV counseling and testing among Tanzanian medical students.

OBJECTIVE: The present study aimed to predict Tanzanian medical students' Voluntary Counseling and Testing (VCT) participation intention using the Health Belief Model (HBM) as a theoretical framework. Further, differences between respondents who had previously participated in VCT and respondents who had not were assessed. METHODS: Cross-sectional data were gathered from 186 Tanzanian medical students using a self-administered questionnaire. RESULTS: Almost half of the respondents (43.3%) reported having been tested for HIV. A prediction model containing HBM and demographic variables explained 31% of the variance in VCT-participation intention. Self-efficacy, fear of being HIV-positive, and perceived susceptibility contributed significantly to the final regression model. In addition, respondents who had previously participated in VCT expressed less fear of being stigmatized and being HIV-positive than respondents who had not. CONCLUSION: Fear of being HIV-positive, self-efficacy, perceived susceptibility and fear of being stigmatized were associated with either VCT-participation intention or previous participation. Further, the HBM accounted for a limited proportion of the explained variance in Tanzanian students' intention to participate in VCT. This suggests that the validity of the HBM in explaining HIV-preventive behavior in Sub-Saharan Africa should be questioned. PRACTICE IMPLICATIONS: Interventions promoting VCT should incorporate program elements targeting self-efficacy, fear of being HIV-positive, perceived susceptibility and fear of being stigmatized.

Fear of stigmatization as barrier to voluntary HIV counselling and testing in South Africa.

OBJECTIVE: The objective of this qualitative study was to identify psychosocial correlates of HIV voluntary counselling and testing (VCT), with an emphasis on the association between fear of AIDS-related stigma and willingness to have an HIV test. METHODS: The study was executed in Limpopo Province at University of Limpopo, Polokwane, South Africa. Focus group interviews were held among 72 students, divided over 10 groups. RESULTS: Results showed that participants had different levels of knowledge about HIV/AIDS and VCT, and that AIDS was still strongly associated with 'death'. Results further demonstrate that HIV/AIDS related stigma is still a very serious problem in South Africa. Lack of HIV/AIDS related knowledge, blaming persons with HIV/AIDS for their infection, and the life-threatening character of the disease were seen as the most important determinants of AIDS-related stigma. The main benefit to go for VCT was 'knowing your HIV status', whereas main barriers for testing were 'fear of being stigmatised' and 'fear of knowing your HIV positive status'. CONCLUSION: Fear of stigmatization is an important barrier to HIV testing and has negative consequences for AIDS prevention and treatment. Interventions to reduce HIV-related stigma are needed in order to foster voluntary HIV counselling and testing in South Africa