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.

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 We distinguished between lapsed donors who had passively withdrawn by merely not responding to donation invitations and donors who had contacted the blood bank to actively withdraw.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.

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.

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.

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.

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.

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.

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.

Negotiating safe sex among women of Afro-Surinamese and Dutch Antillean descent in the Netherlands.

Safe sex negotiation and communication about sexual risks with partners is important for women to ensure sexual risk reduction. This paper describes the results of a survey on safer sex and negotiation behavior, and the correlates of negotiation with partners among 128 women from Surinamese and Dutch Antillean descent in the Netherlands. The key findings are that 50% of the participants had negotiated sexual risk reduction with their partner, yet only 40% of the women who negotiated safer sex actually claimed practicing safe sex. Participants defined safe sex with steady partners primarily as negotiated safety and monogamy, and safe sex with casual partners primarily as condom use. Intentions to negotiate safer sex with steady partners were related to positive attitudes and perceived injunctive norms towards safe sex negotiation, and educational background. Intention to discuss safe sex with casual partners were primarily related to attitudes and perceived self-efficacy. STI/HIV prevention interventions targeting these women should incorporate awareness-raising of safety in different types of relationships, deciding on the appropriateness of relation-specific sexual risk reduction strategies, and building negotiation skills to accomplish the realization of these strategies.

Careers in ecstasy use: do ecstasy users cease of their own accord? Implications for intervention development.

BACKGROUND: Ecstasy (MDMA, 3, 4-methylenodioxymethamphetamine) use is widespread in the Netherlands, with a lifetime prevalence of 4.3%, and two-thirds of dance party visitors being ecstasy users. However, research into Dutch ecstasy use patterns is lacking. In addition, recent studies suggest that ecstasy users cease their use automatically, which implies that interventions would do better to better focus on the promotion of harm reduction strategies than on inducing cessation. The current study addresses this process of ecstasy cessation. METHODS: 32 participants from the Dutch dance scene were interviewed, and the results were systematically analysed using NVivo. RESULTS: Most ecstasy users had started to use out of curiosity. During use, users applied a host of harm reduction strategies, albeit inconsistently and sometimes incorrectly. Most users appeared to cease ecstasy use automatically because of loss of interest or changing life circumstances (e.g. a new job or relationship). CONCLUSION: It appears that cessation of ecstasy use is largely determined by environmental variables and not by health concerns. This supports the idea that health promotion resources are better spent in trying to promote consistent and correct application of harm reduction practices than in trying to induce cessation.

Diagnosis of sustainable collaboration in health promotion - a case study.

BACKGROUND: Collaborations are important to health promotion in addressing multi-party problems. Interest in collaborative processes in health promotion is rising, but still lacks monitoring instruments. The authors developed the DIagnosis of Sustainable Collaboration (DISC) model to enable comprehensive monitoring of public health collaboratives. The model focuses on opportunities and impediments for collaborative change, based on evidence from interorganizational collaboration, organizational behavior and planned organizational change. To illustrate and assess the DISC-model, the 2003/2004 application of the model to the Dutch whole-school health promotion collaboration is described. METHODS: The study combined quantitative research, using a cross-sectional survey, with qualitative research using the personal interview methodology and document analysis. A DISC-based survey was sent to 55 stakeholders in whole-school health promotion in one Dutch region. The survey consisted of 22 scales with 3 to 8 items. Only scales with a reliability score of 0.60 were accepted. The analysis provided for comparisons between stakeholders from education, public service and public health.The survey was followed by approaching 14 stakeholders for a semi-structured DISC-based interview. As the interviews were timed after the survey, the interviews were used to clarify unexpected and unclear outcomes of the survey as well.Additionally, a DISC-based document analysis was conducted including minutes of meetings, project descriptions and correspondence with schools and municipalities. RESULTS: Response of the survey was 77% and of the interviews 86%. Significant differences between respondents of different domains were found for the following scales: organizational characteristics scale, the change strategies, network development, project management, willingness to commit and innovative actions and adaptations. The interviews provided a more specific picture of the state of the art of the studied collaboration regarding the DISC-constructs. CONCLUSION: The DISC-model is more than just the sum of the different parameters provided in the literature on interorganizational collaboration, organization change, networking and setting-approaches. Monitoring a collaboration based on the DISC-model yields insight into windows of opportunity and current impediments for collaborative change. DISC-based monitoring is a promising strategy enabling project managers and social entrepreneurs to plan change management strategies systematically.

Reducing AIDS-related stigma in developing countries: the importance of theory- and evidence-based interventions.

In many developing countries persons living with HIV and AIDS experience strong stigma and discrimination, and AIDS-related stigma has an enormous negative impact on their social relationships, access to resources, and psychological well being. Moreover, AIDS-related stigma hampers HIV-related health promotion, including voluntary HIV counselling and testing. In this article, we will argue that programs to reduce AIDS-related stigma are most likely to be effective if these programs are based upon thorough needs assessments, theory- and evidence-based intervention strategies and collaborative planning. A protocol for health promotion programs design is outlined. Furthermore, psychosocial correlates of AIDS-related stigma in developing countries, social-psychological theories that might be useful in designing intervention strategies to reduce stigmatisation and successful elements of previous interventions aimed at stigma reduction are discussed. It is concluded that psychological theory does provide guidelines for the development of stigma-reducing intervention programs, but that such programs can only be effective when based upon context-specific needs assessment and collaborative planning.

Effective methods to change sex-risk among drug users: a review of psychosocial interventions.

This review examines the current state of knowledge on the effectiveness of HIV prevention interventions with respect to sexual behavior among the population of drug users. The review focuses specifically on the relation between intervention methods found to be effective and the underlying theory. Electronic searches were conducted and supplemented by publications gathered through other channels. The studies were reviewed for (1) study design, (2) evident use of theory in intervention development, (3) clear targeting of determinants, (4) description of the study or studies, and (5) evaluation of the behavioral goals and targeted determinants. For each study, a description is given of: (1) the size and nature of the sample; (2) the retention rate; (3) the study design; (4) the nature of the intervention programs, including theoretical methods, practical strategies and theoretical background; (4) the measures of variability. The results show that a limited number of interventions were effective in changing sexual risk behavior among drug users. More successful programs featured several of the following elements: use of multiple theories and methods, inclusion of peers and rehearsal of skills. Moreover, the community-level interventions showed the importance of sustainability. The most successful intervention methods were modeling, skill building and social support enhancement. These methods are generally derived from the Social-Cognitive Theory or the Diffusion of Innovations Theory. Future HIV/AIDS interventions should build on the strengths discussed. Evaluations of interventions should be designed to facilitate comparison, using standardized and specific behavioral outcomes as well as standardized and preferably long-term follow-up levels, and should also evaluate the impact of programs at a psychosocial level to examine whether or not the theoretical methods on which a program was based were actually effective in changing the psychosocial factors targeted and why.

Evaluation of the Dutch AIDS information helpline: an investigation of information needs and satisfaction of callers.

AIDS telephone hotlines have an important function in AIDS education, HIV prevention and counselling. In this study, consults of the Dutch AIDS information helpline were evaluated to determine the AIDS information needs of the callers and callers' satisfaction with the telephone-delivered information and consultation. Immediately after their telephone consult, callers (N = 309) were redirected to co-workers of an independent telephone survey. They participated in an interview on content and evaluation of the telephone consult. This study shows that most telephone calls concerned questions about personal risk of HIV transmission, HIV transmission in general and HIV testing. Callers were very satisfied with the services of the helpline. Furthermore, helpline employees' counselling and conversation skills were evaluated very positively. These results are discussed within the scope of the professional organization of the Dutch AIDS information helpline.

An AIDS risk reduction program for Dutch drug users: an intervention mapping approach to planning.

This article presents the development of a theory- and evidence-based AIDS prevention program targeting Dutch drug users and aimed at promoting condom use. The emphasis is on the development of the program using a five-step intervention development protocol called intervention mapping (IM). Preceding Step 1 of the IM process, an assessment of the HIV problem among drug users was conducted. The product of IM Step 1 was a series of program objectives specifying what drug users should learn in order to use condoms consistently. In Step 2, theoretical methods for influencing the most important determinants were chosen and translated into practical strategies that fit the program objectives. The main strategy chosen was behavioral journalism. In Step 3, leaflets with role-model stories based on authentic interviews with drug users were developed and pilot tested. Finally, the need for cooperation with program users is discussed in IM Steps 4 and 5.

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.

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.

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.

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.