Health Beliefs and Harm Reduction
USING THE HEALTH BELIEF MODEL TO PREDICT INJECTING DRUG USERS' USE OF HARM REDUCTION
Erin E. Bonar, M.A.
Bowling Green State University
A Dissertation
Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of
DOCTOR OF PHILOSOPHY
August 2011
Committee:
Harold Rosenberg, Advisor
Molly Laflin Graduate Faculty Representative
William O‘Brien
Anne Gordon
Health Beliefs and Harm Reduction ii
ABSTRACT
Harold Rosenberg, Advisor
Based on the Health Belief Model (Rosenstock, 1966), the current study was designed to examine whether injecting drug users‘ (IDUs) beliefs about two injecting-related health conditions (i.e., non-fatal overdose and bacterial infections) and two harm reduction behaviors that prevent these conditions (i.e., injecting test shots and pre-injection skin cleaning) predicted their short-term intentions to engage in those two health behaviors. Ninety-one current IDUs recruited from needle exchange programs in Ohio and Michigan completed a series of questionnaires. Specifically, participants answered questions about their perceived susceptibility to and the perceived severity of the two health conditions, the perceived benefits and barriers of engaging in these two harm reduction behaviors, their self-efficacy to use these harm reduction behaviors, perceived social network norms regarding use of the harm reduction behaviors, and their recent use of and short-term intentions to use the behaviors in four drug-use situations (i.e., in withdrawal, not in withdrawal, alone, with others). Participants also completed a brief interview about their health promotion behaviors and perceived barriers to using the two harm reduction behaviors. Results indicated that recent past use of these two harm reduction behaviors consistently and positively predicted short-term intentions across all four situations.
Only two constructs of the Health Belief Model also predicted intentions to engage in harm reduction, depending on the drug-use situation. Specifically, perceived susceptibility to non-fatal overdose and perceived benefits of test shots were significant positive predictors of intentions to Health Beliefs and Harm Reduction iii engage in test shots, but only if injecting when not in withdrawal; perceived susceptibility was a significant positive predictor of intentions to do test shots, but only when injecting if alone.
Participants‘ rating of how often other injectors in their network use test shots was also a significant and positive predictor of doing test shots, but only if injecting with others or injecting alone. Analysis of open-ended interview responses also revealed that participants engage in behaviors to preserve their health in general and specific to injecting, and that they identify a variety of barriers to engaging in harm reduction behaviors. Based on these results, future research could evaluate whether discussing susceptibility to non-fatal overdose, listing the benefits of test shots, and encouraging IDUs to inject with others who engage in harm reduction behaviors may be valuable additions to interventions designed to increase these two harm reduction behaviors. Future research should explore whether the HBM predicts actual use of harm reduction interventions in addition to behavioral intentions and what other non-cognitive factors predict the use of harm reduction.
Health Beliefs and Harm Reduction iv
ACKNOWLEDGMENTS
I would like to express my gratitude to the following people and organizations who made it possible for me to conduct this study and complete my dissertation: Harold Frances
Rosenberg; William O‘Brien, Anne Gordon, and Molly Laflin; The Free Medical Clinic of
Greater Cleveland (Melissa Ghoston, Kalia Johnson, Chico Lewis, and Jamie Benson), The
Grand Rapids Red Project/Clean Works (Betsy Meier and Steve Alsum), and the HIV/AIDS
Resource Center (Lemont Gore); Kristen Abraham; Shane Kraus and Erica Hoffmann; The
Substance Abuse Research Group.
Finally, I wish to acknowledge the 99 participants and pilot participants from Ohio and
Michigan who took the time to participate in this project.
Health Beliefs and Harm Reduction v
TABLE OF CONTENTS
Page
INTRODUCTION ...... 1
Research Questions ...... 15
METHOD…………………………………………………………………………………… 16
Recruitment Procedure and Participant Characteristics ...... 16
The Free Medical Clinic of Greater Cleveland Mobile Needle Exchange … 16
The Grand Rapids Red Project…………………………………………...... 17
HIV/AIDS Resource Center (HARC) Mobile Needle Exchange…………… 17
Participant Demographics and Drug Use History…………………………………… 19
Measures……………………………………………………………………………... 20
Harm Reduction Health Beliefs Questionnaire (HR-HBQ)………………….. 20
Screening Measure…………………………………………………………… 22
Short-term Intentions to Use Harm Reduction……………………………….. 22
Past Use of Harm Reduction…………………………………………………. 23
Background Information……………………………………………………… 23
Interview……………………………………………………………………… 23
Data Collection Procedure…………………………………………………………… 23
Hypotheses…………………………………………………………………………… 24
RESULTS………………………………………………………………………………… .. 26
Preliminary Analyses ...... 26
Internal Consistency Reliability for the HR-HBQ Subscales ...... 26
Intercorrelations Among HR-HBQ Subscles and Social Norms Item ...... 28 Health Beliefs and Harm Reduction vi
Differences in Intentions to Engage in Harm Reduction Behaviors by
Drug-Use Situation ...... 29
Using the Health Belief Model to Predict Use of Test Shots……………………… 31
Using the Health Belief Model to Predict Skin Cleaning…………………………. . 32
Themes Represented in Participant Interviews……………………………………. . 34
Participants‘ General Health Behaviors…………………………………… . 34
Participants‘ Behaviors to Reduce Injecting-Related Risks………………. . 35
Participants‘ Reported Barriers to Utilizing Test Shots…………………… 35
Participants‘ Self-Reported Barriers to Skin Cleaning…………………….. 36
DISCUSSION………...... 37
REFERENCES………...... 45
APPENDIX A. CONSENT FORM……...... 50
APPENDIX B. MEASURES………...... 52
APPENDIX C. BACKGROUND INFORMATION……………………………………. ... 63
APPENDIX D. INTERVIEW QUESTIONS……………………………………...... 68
Health Beliefs and Harm Reduction vii
LIST OF TABLES
Table Page
1 Characteristics of Participants...... 69
2 Participants‘ Drug Use History ...... 72
3 Participants‘ Mean Scores on and Scale Reliabilities for HR-HBQ Subscales ...... 76
4 Intercorrelations Among HR-HBQ Subscales ...... 77
5 Linear Regression Analyses Predicting Intentions to Engage in Test Shots when
in Withdrawal and Not in Withdrawal…………………………………………. 78
6 Linear Regression Analyses Predicting Intentions to Engage in Test Shots when
With Others and Alone ...... 79
7 Linear Regression Analyses Predicting Intentions to Clean Skin When in
Withdrawal and Not in Withdrawal ...... 80
8 Linear Regression Analyses Predicting Intentions to Clean Skin When With
Others and Alone ...... 81
9 Themes Represented in Participants‘ Responses to Interview Health Question….. . 82
10 Themes Represented in Participants‘ Responses to Interview Injection Safety
Question………………………………………………………………… ...... 85
11 Themes Represented in Participants‘ Responses to Interview Test Shot Barriers
Question…………………………………………………………………………. 88
12 Themes Represented in Participants‘ Responses to Interview Skin Cleaning
Barriers Question………………………………………………………………… 91
Health Beliefs and Harm Reduction 1
INTRODUCTION
The 2007 National Survey on Drug Use and Health (Substance Abuse and Mental Health
Services Administration, 2008) reported that 9% (i.e., over 22 million) of the United States population aged 12 or older could be classified as abusing or dependent on substances during the previous year. Of those with diagnosable substance use disorders, a proportionally small, but numerically large, number inject drugs. A recent review of epidemiological studies reported that the estimated population prevalence of injecting drug use among individuals aged 15 to 64 in the
United States was approximately 0.67% to 1.34% in 2002 (Mathers, Degenhardt, Phillips,
Wiessing, Hickman, Strathdee, et al., 2008). Mathers and colleagues (2008) estimated that approximately 16 million individuals inject drugs worldwide.
Substance abuse and dependence are expensive and debilitating problems in the United
States and around the world that not only harm the drug user‘s health, but also cost our society more each year in the way of healthcare, treatment and prevention efforts, lost wages and productivity, and drug-related crime. A recent report from the Office of National Drug Control
Policy (2004) indicated the total economic cost of drug abuse was $180.9 billion in 2002. From
1992 through 2002, the costs of drug abuse increased an average of 5.3% per year. To the degree that we could successfully prevent and treat drug abuse and dependence, we would reduce the healthcare-, job-, and crime-related costs associated with the problem as well as preserve human lives that may have otherwise been lost to drug use.
Although thousands of drug treatment programs exist worldwide, large-scale multi-center treatment outcome evaluations have continually shown that about half of patients relapse to drug-use within six months to a year post-treatment. For example, the University of Georgia‘s
National Treatment Center Study (NTCS; Roman & Blum, 1997; Roman & Johnson, 1998) Health Beliefs and Harm Reduction 2 reported that 93% of American agencies surveyed employed an abstinence-oriented 12-step model that seeks to eliminate all illicit drug use by the client. Although abstinence-focused interventions are effective for some people, the results are not promising for all users who enter treatment. Roman and Johnson (1998) reported that only a little over half (56%) of clients in their sample of treatment agencies remained abstinent for a period of at least 6 months. The reported success rate may over-estimate actual success to the degree that it does not include clients who dropped out before they finished the program.
The National Treatment Outcome Research Study (Gossop, Marsden, & Stewart, 2001) examined drug use among clients receiving one of four treatment modalities (i.e., inpatient, rehabilitation, methadone maintenance, methadone reduction) at 54 agencies within the United
Kingdom. At 4 to 5 year follow-ups, 47% of the inpatient/residential treatment center clients were abstinent from opiates, the most commonly used type of illicit drug upon intake. Although there were reductions in drug use, the majority of participants in this study did not achieve or maintain abstinence.
The Drug Abuse Treatment Outcome Studies (DATOS) compared substance abuse treatment outcome in the United States among a nationwide sample of clients in long-term residential, short-term inpatient, outpatient drug-free, and outpatient methadone treatment programs (Hubbard, Craddock, & Anderson, 2003). Use of heroin, cocaine, or marijuana decreased from one year prior to admission to the 5-year follow-up point. However, not all
DATOS clients successfully abstained after receiving treatment. Post-treatment drug use differed depending on treatment modality and type of drug used. Combining across treatment modalities approximately 39% were still using heroin, 40% were still using cocaine, and 60% were still using marijuana at the 5-year follow-up. These results confirm the classic study by Health Beliefs and Harm Reduction 3
Hunt, Barnett, and Branch (1971) who reported fewer than 40% of individuals treated for heroin, smoking, or alcohol addiction abstained continuously during the first 12 months after treatment.
In light of the frequency with which many clients relapse or continue using drugs without undertaking traditional treatment, it is important that clinicians broaden their approach to substance abuse to address the needs of those who are unable or unwilling to abstain. Allowing clients to pursue non-abstinence outcome goals and providing services designed to preserve the health of on-going drug takers is a treatment philosophy commonly referred to as harm reduction. Harm reduction relies on prevention and educational efforts to minimize the unhealthy consequences for individuals and society resulting from drug use. In the United
States, harm reduction is considered an alternative to the two conventional approaches to drug treatment: the moral model and the disease model of addiction (Marlatt, 1996).
Rather than viewing one‘s drug use as a moral failure, those who take a harm reduction approach minimize moralizing, and instead focus on the consequences or effects of drug use both to the individual and society at large. In contrast to the disease model that advocates abstinence as the only suitable treatment goal, harm reduction promotes the idea that it is possible to preserve the health of drug users even while they continue to use drugs (Marlatt, 1996). In short, advocates for harm reduction acknowledge that abstinence is the healthiest goal, but accept the fact that many people will use drugs and that there are advantages to maintaining and improving their health even if they continue to take drugs (MacCoun, 1998; MacMaster, 2004;Marlatt,
1996).
There are many types of harm reduction interventions and programs for drug users, several of which are designed to prevent health problems among injecting drug users. Injection of drugs poses particular dangers such as increased risk of overdose, increased risk of acquiring Health Beliefs and Harm Reduction 4 and transmitting blood-borne diseases (e.g., HIV/AIDS, Hepatitis C), collapsed veins, and skin abscesses (Dolan, Clement, Rouen, Rees, Shearer, et al., 2004). For example, as part of a larger study of harm reduction self-efficacy, Phillips and Rosenberg (2008) assessed the lifetime prevalence of several biomedical health consequences of injecting drugs among a sample of 99 injecting drug users (IDUs). While some health conditions occurred infrequently in this sample
(e.g., 1% reported wound botulism, 2% reported HIV/AIDS, 3% reported tetanus, 16% reported septicemia), others were considerably more common (e.g., 61% reported at least one overdose episode, 62% reported collapsed veins, 41% reported skin abscesses, 31% reported Hepatitis A,
B, or C).
Some of the harm reduction interventions designed to prevent these health problems
(e.g., needle exchange programs, safer injecting facilities, and substitute prescribing) require either a large investment of money and professional staff or are illegal in many states. However, treatment providers may implement some harm reduction interventions quickly and inexpensively in their own offices or during outreach by educating IDUs about behaviors they may employ to reduce their risk for health problems. For example, when the potency of one‘s drugs is unknown, one may inject a small dose of the drug (i.e., a test shot) to test the potency before self-administering the entire dose. Injecting a test shot helps avoid potential overdose from substances of unknown potency. Another example is encouraging clients to clean their skin at the intended injection site with rubbing alcohol or soap and water prior to injecting. This helps reduce the chances of injection-related bacterial infections that may occur from bacteria on the skin entering the user‘s blood stream.
Although these harm reduction strategies can improve the health of IDUs, they are not employed by all injecting drug users with every injection. Examining the frequency with which Health Beliefs and Harm Reduction 5
99 injecting drug users employed 15 harm reduction behaviors (e.g., doing a test shot, cleaning skin prior to injecting), Phillips and Rosenberg (2009) found that some behaviors were more frequently employed than others. Only a little over one-third (36%) of Phillips and Rosenberg‘s sample reported sometimes or always doing a test shot before injecting all of their drugs, and
64% reported never or infrequently doing a test shot. In addition, although 60% of these IDUs reported sometimes or always cleaning their injection sites with alcohol or soap and water before and after injecting, the remaining 40% reported that they never or infrequently cleaned their skin before or after injecting.
There are several factors that may explain why some injecting drug users engage in these methods of harm reduction and others do not. For example, some IDUs may lack knowledge about behaviors that can reduce the harmful health consequences of injecting. Other IDUs may not be exposed to some of the potential risks of injecting; for example, if an IDU always uses a new, sterile needle and syringe, he or she would not need to clean his or her injecting equipment with bleach before shooting up. Similarly, an IDU who injects pharmaceutical drugs would not need to inject a test shot because the potency of pharmaceuticals is consistent.
For IDUs who know about harm reduction strategies, understand their health benefits, and are at risk for the negative health consequences of injecting, one or more psychological factors may explain why they do not employ harm reduction strategies. For example, being in a state of withdrawal or intense craving may reduce the motivation to employ one or more harm reduction behaviors before shooting up. While the definition of drug craving has been debated, it has been described as a compulsive desire that motivates the individual to obtain a drug
(Fortuna & Smelson, 2008; Tiffany & Carter, 1998; Drummond, 2001). Because some harm reduction behaviors are employed just prior to using the drug (e.g., cleaning skin or injection Health Beliefs and Harm Reduction 6 equipment, doing test shots), the compulsion to use the substance once it has been acquired may overwhelm any intention to engage in harm reduction.
Conceptualizing drug use as a stimulus-bound automatic behavior (Tiffany, 1990) may also explain why some IDUs do not engage in harm reduction. That is, stimuli associated with drug use may trigger automatic drug-seeking or drug-consumption that, with repeated practice, has become unintentional, efficient, effortless, and unconscious (Tiffany, 1990). Because automatic processes are difficult to control or inhibit, even if one has the intention of doing a test shot or cleaning his/her skin, one may have difficulty interrupting the automatic process of drug- taking.
The IDU‘s perception of the acceptance and use of harm reduction among his or her social network of drug injectors may also influence whether he/she engages in these strategies.
This hypothesis is supported by several studies showing that drug-related protective and risk behaviors are related to the behaviors of others in one‘s social network. For example, Zapka,
Stoddard, and McCusker (1993) found that IDUs who had a higher number of friends who used bleach to clean their injecting equipment were more likely to engage in the same behavior.
Hawkins, Latkin, Mandel, and Oziemkowska (1999) also found similar results among a sample of young IDUS in Baltimore; those who reported observing peers cleaning needles and avoiding needle sharing engaged in needle sharing less frequently and cleaned their needles more often.
Shaw, Shah, Jolly, and Wylie (2007) found that Canadian IDUs who had witnessed members of their network sharing syringes were more likely to inject with a syringe that had been already used by someone else. Similarly, a study of Puerto Rican IDUS in New York found that those who believed their injecting social network approved of sharing injection paraphernalia were more likely to engage in sharing (Andía, Deren, Robles, Kang, & Colón, 2008) and a study of Health Beliefs and Harm Reduction 7
Russian IDUs found that those whose peers encouraged them to share injecting equipment more often shared syringes and cookers (Gyarmathy, Li, Tobin, Hoffman, Sokolov, Levchenko, et al.,
2009).
Other factors may also influence the health behavior of IDUs, but they have been subjected to little or no research. For example, the degree to which an IDU feels he or she versus others have control over his or her health (i.e., health locus of control) may predict whether he or she engages in harm reduction. In addition, an IDU‘s beliefs about his or her susceptibility to negative health consequences of injecting, how severe he or she views those consequences, and his or her view of the costs and benefits of engaging in a health promoting behavior to avoid those consequences may also predict whether one engages in these health-preserving behaviors.
Social cognition theories have been used to explain why individuals do or do not engage in health preserving behaviors. These theoretical frameworks emphasize the influence of one‘s beliefs about one‘s health-related behavior. Cognitions are viewed as flexible and changeable and are thought to mediate the effects of other, more fixed factors (e.g., socioeconomic status, gender) on behavior (Conner & Norman, 1996). Protection Motivation Theory (PMT), the
Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB), and the Health Belief
Model (HBM) are three theoretical frameworks that have often been used to explore the impact of health beliefs on health behaviors (Conner & Norman, 1996). These three theories have origins in expectancy-value theory, which posits that behavior is influenced by a rational cognitive process that involves the subjective value placed on an outcome and the expectation that a health-related behavior will result in that outcome (Strecher, Champion, & Rosenstock,
1997). Thus, the PMT, TRA/TPB, and HBM assume that behavioral outcomes are the result of a rational decision-making process in which the individual weighs the costs and benefits of Health Beliefs and Harm Reduction 8 engaging in the behavior (Conner & Norman, 1996). Because they all emphasize the impact of social and cognitive factors, it is not surprising that each of these models includes one or more constructs that are similar to, if not the same as, constructs included in the other models.
Rogers developed the PMT to explain how educational messages designed to create or enhance fear (i.e., fear appeals) influence decisions to avoid engaging in a maladaptive behavior
(Rogers & Prentice-Dunn, 1997). This model considers the intrinsic and extrinsic rewards of engaging in a maladaptive behavior (e.g., unprotected sex or alcohol abuse), appraisals of severity and of vulnerability to an outcome resulting from the maladaptive behavior, and appraisals of one‘s ability to cope with the threat based on costs, benefits, and self-efficacy. In addition, fear is thought to affect one‘s behavior indirectly by influencing one‘s judgment about his or her vulnerability to and perceived severity of the threat (Rogers & Prentice-Dunn, 1997).
The Theory of Planned Behavior (TPB) was developed by Azjen (1985; Maddux &
DuCharme, 1997) as an extension of Fishbein and Azjen‘s Theory of Reasoned Action (TRA;
Fishbein & Azjen, 1975). The TRA/TPB assumes that one‘s intention to engage in a behavior is the strongest predictor of whether one actually engages in a behavior. Furthermore, the
TRA/TPB suggests that intentions are affected by the expected outcome, costs, and benefits of engaging in the behavior, social norms surrounding the behavior (i.e., the perception of whether important others approve or disapprove of the behavior), and how easy or difficult it would be to undertake the behavior (Maddux & DuCharme, 1997). Neither the PMT nor the TRA/TPB were specifically developed to explain health-related beliefs and cognitions.
Unlike the other social cognition theories that have been used to explore health beliefs and behaviors, the Health Belief Model (Rosenstock, 1966) was developed specifically for application to health behaviors. The HBM posits that an individual‘s engagement in a health Health Beliefs and Harm Reduction 9 behavior is related to his or her state of psychological readiness to engage in that behavior and the extent to which the individual believes the health behavior will be beneficial in avoiding a negative outcome (Rosenstock, 1966). Rosenstock proposed that one‘s state of readiness can be defined in terms of how susceptible the individual believes he or she is to the health outcome and how severe he or she perceives the health outcome to be. An individual‘s perception of both the benefits of engaging in the health behavior and the barriers to engaging in it are used to assess the extent to which the individual believes the behavior will help avoid the negative health outcome. Rosenstock also explained that cues-to-action (i.e., events that trigger the use of the health behavior) influence health-related behaviors. However, cues-to-action are difficult to measure, and have not been studied as extensively as the other constructs of the HBM (Strecher,
Champion, & Rosenstock, 1997).
Rosenstock, Strecher, and Becker (1988) added the concept of self-efficacy to the HBM, hypothesizing that an individual‘s belief in his or her confidence to engage in the health behavior is also predictive of engaging in the behavior. The expanded HBM posits that for an individual to engage in a designated health behavior designed to prevent a specific condition, he or she must perceive himself or herself as susceptible to the condition, perceive the condition as severe, believe that it is beneficial to engage in the designated health behavior, and believe that he or she is competent enough to engage in the behavior despite the barriers associated with it (Strecher,
Champion, & Rosenstock, 1997). Characteristics such as one‘s educational level are also proposed as influences on health behaviors, but are not included in the HBM. Strecher,
Champion, and Rosenstock (1997) also suggest that sociodemographic factors influence perceived susceptibility, perceived severity, benefits, barriers, and self-efficacy and therefore indirectly influence health behaviors. Health Beliefs and Harm Reduction 10
The HBM has been used to examine a variety of health behaviors, including influenza vaccinations, genetic disease screening, breast self-examinations, high blood pressure screening, seatbelt use, exercise, and compliance with medication regimens (Janz & Becker, 1984).
Although the HBM is one of the most widely employed theories of health behavior (Strecher,
Champion, & Rosenstock, 1997), the most recent literature reviews of the impact of HBM constructs on health behaviors were published 18 and 26 years ago. In their summary of the 46 studies conducted since the development of the HBM through 1984, Janz and Becker (1984) found that each of the four main HBM components (i.e., perceived susceptibility, perceived severity, benefits, and barriers) was significantly associated with a variety of health behaviors.
Beliefs about barriers to enacting the health behavior were significantly associated with the health behavior most often (89% of studies reviewed), followed by perceived susceptibility
(81%), perceived benefits (78%), and perceived severity (65%). The authors also noted that these significance ratios (i.e., the proportion of studies in which an HBM construct was significantly related to the health behavior in the hypothesized direction) were higher among prospective studies compared to retrospective studies. When they considered only those studies that assessed preventive health behaviors, significance ratios remained high for barriers (93%), perceived susceptibility (86%), and benefits (74%), but the significance ratio for perceived severity was lower (50%). Janz and Becker speculated that, when assessing preventive health behaviors, perceived severity may be a less relevant factor for individuals who are not currently experiencing symptoms, who view the health threat as something that may happen later in life, or who have had little or no experience with the health condition.
Harrison, Mullen, and Green (1992) conducted a meta-analysis of studies that evaluated the association of the HBM with health behaviors. Using stringent inclusion criteria, the authors Health Beliefs and Harm Reduction 11 analyzed the results from 16 published and unpublished studies. Of 24 calculated effect sizes, 22 were positive and statistically significant. The authors examined the four HBM constructs separately, and found that the mean effect sizes across HBM constructs ranged from r = .01 to r
= .30, accounting for only 0.1% to 9% of the variance in health behaviors. When they compared retrospective (i.e., studies that measured past behavior) to prospective (i.e., studies that measured future behavior or behavioral intentions) investigations, Harrison, Mullen, and Green (1992) found larger effect sizes in retrospective studies for benefits (r = .17 for retrospective and r = .10 for prospective) and barriers (r = -.30 for retrospective and r = -.16 for prospective) and smaller effect sizes in retrospective studies for severity (r = .01 for retrospective and r = .13 for prospective). Because investigations with negative results or non-significant results are often not published, Harrison et al. speculated that their meta-analysis overestimated strength of the relationships between HBM constructs and health behavior. However, the authors also noted that they considered the four HBM constructs separately which may have attenuated the relationship between the constructs and health behaviors. Therefore, if the association of the
HBM constructs with behavior were considered simultaneously there may have been a larger effect size.
In addition to explaining biomedical health outcomes and behaviors, the HBM has been used in research related to substance abuse and dependence with both adults and adolescents.
For example, Rees (1985) examined whether the HBM predicted compliance with alcoholism treatment; Bardsley and Beckman (1988) explored whether components of the HBM predicted entry into alcoholism treatment; and Cremeens, Usdan, Brock-Martin, Martin, and Watkins
(2008) used the HBM to guide their investigation of parent-child communication to reduce heavy drinking among first-year college students. In addition to these alcohol-related studies, Booth, Health Beliefs and Harm Reduction 12
Zhang, and Kwiatkowski (1999) used the HBM to develop a peer-based intervention to change the drug and sex risk behaviors among runaway and homeless adolescents. Of most relevance to my study, the HBM has also been applied to predict the use harm reduction by injecting drug users in three investigations (Davey, Richards, Lang, & Davies, 2006; Falck, Siegal, Wang, &
Carlson, 1995; Jamner, Corby, & Wolitski, 1996).
Falck, Siegal, Wang, and Carlson (1995) used the HBM to explore whether health beliefs regarding HIV/AIDS and safer injection practices were related to IDUs‘ use of safer injection practices (i.e., always using new injection equipment, never sharing injection equipment, re- using injection equipment but always cleaning them with bleach). Falck et al.‘s (1995) measure of barriers included two items assessing perceived social norms related to injecting (i.e., ―If a friend wanted me to shoot up with a needle he or she just used, I would find it hard to say no.‖ and ―When shooting up with other people, I feel like I have to use that same outfit that everyone else uses.‖). Using logistic regression, Falck and colleagues (1995) found that being African
American and reporting higher self-efficacy to avoid sharing injection paraphernalia was associated with safer injection practices, but perceived susceptibility and frequency of injection were negatively associated with safer injection practices. The finding that IDUs who saw themselves as more susceptible to HIV/AIDS were less likely to engage in safer injecting is counter to what the HBM would suggest regarding the construct of perceived susceptibility.
Jamner, Corby, and Wolitski (1996) used components of the HBM to explore the association of IDUs‘ health beliefs with bleach cleaning when they share needles. Using multiple regression analyses, Jamner and colleagues (1996) found that social norms (assessed in this study by asking about the IDU‘s perception that those close to him/her would want him/her to engage in bleach cleaning), self-efficacy to clean one‘s injecting equipment, perceived risk of Health Beliefs and Harm Reduction 13 sharing dirty needles (analogous to ―perceived severity‖), exposure to bleach cleaning information, and attitudes toward bleach cleaning (i.e., the degree to which the participant evaluated bleach cleaning as good/bad, pleasant/unpleasant, etc.) positively predicted intention to engage in bleach cleaning ―from now on‖ whenever sharing injecting equipment. With regard to actual behavior, regression analyses revealed that attitudes toward bleach cleaning, perceived social norms, self-efficacy, perceived risk of sharing needles, and number of days of substance intoxication in the previous month were positively correlated with participants‘ reported current frequency of bleach cleaning.
Davey and colleagues (2006) examined the role of beliefs about Hepatitis C and switching to non-injecting routes of administration in a sample of young, injecting amphetamine users in Australia. They sought to identify which, if any, of the HBM constructs (including self- efficacy) were related to IDUs‘ readiness to change from injecting to non-injecting routes of administration. To assess readiness to change, Davey and colleagues used the Stages of Change model (Prochaska, DiClemente, & Norcross, 1992). As defined by Prochaska, DiClemente, and
Norcross (1992), the Stages of Change model suggests that individuals who exhibit an addictive behavior may be classified into any one of five stages: Precontemplation (when the individual has no intention to change the behavior in question), Contemplation (when an individual is thinking about taking action toward making a change), Preparation (when an individual intends to change the behavior in the next month), Action (when an individual is making efforts to change the target behavior), or Maintenance (when an individual has succeeded in maintaining behavior change for more than six months).
Contrary to their hypotheses, Davey and colleagues (2006) found that perceived susceptibility to and perceived severity of Hepatitis C, along with beliefs that ceasing injecting Health Beliefs and Harm Reduction 14 would effectively prevent Hepatitis C and beliefs about the costs and benefits of ceasing injecting did not differ depending on whether an IDU was classified as being in the
Precontemplation, Contemplation, or Action stage of change toward ceasing injecting. However, those who were classified as being in the Action stage reported significantly higher self-efficacy to cease injecting than those in the Precontemplation and Contemplation stages. Although
Davey and colleagues found no consistent relationship between constructs of the HBM and readiness to cease injecting, they used only a single item for each construct. Therefore, this may not have been an adequate measurement of participants‘ health beliefs. Furthermore, Davey and colleagues examined only how the HBM constructs related to stage of change towards ceasing injecting; they did not examine whether the HBM constructs were related to frequency of or intentions to use non-injecting routes of administration.
Given the potential health benefits of harm reduction behaviors, and the dearth of research regarding psychological factors that might influence IDUs‘ use of harm reduction, the present study was designed to assess whether health beliefs proposed by the HBM are associated with IDUs‘ near-term intentions to use strategies that reduce the risks of injecting drug use. In this study, I explored whether the constructs of the expanded HBM (i.e., perceived susceptibility, perceived severity, benefits, barriers, and self-efficacy) predicted IDUs‘ intentions to engage in two specific harm reduction behaviors designed to prevent two specific outcomes (i.e., test shots to prevent non-fatal overdose; skin cleaning to prevent bacterial infections). The HBM was designed, and is most often used, to predict self-reported behavior, rather than intentions to engage in health behaviors. However, because it would be impractical to follow-up IDUs to assess their actual health-related behaviors, I chose to predict behavioral intentions. Health Beliefs and Harm Reduction 15
In addition, I explored whether IDUs‘ perceptions of the acceptability of and use of these harm reduction behaviors by other injectors they know was associated with their intentions to use the two harm reduction behaviors. The inclusion of ―perceived social network norms‖ was based on previous research demonstrating relationships between social network norms and injecting behaviors (e.g., Andía, et al., 2008, Gyarmathy, et al., 2009; Hawkins, et al.,, 1999; Shaw, et al.,
2007; Zapka, et al., 1993) and research reporting that IDUs who more frequently injected in groups had lower intentions to engage in bleach cleaning (Jamner et al., 1996). Furthermore, because aspects of the drug-use situation may influence injecting behavior or present different barriers to engaging in harm reduction, I also chose to examine the association of these HBM constructs with intention to employ these two harm reduction strategies in each of four drug-use situations (i.e., in withdrawal, not in withdrawal, alone, with others).
Research Questions
1. Do the constructs proposed by the expanded HBM (i.e., perceived susceptibility,
perceived severity, benefits, barriers, self-efficacy) and perceived social network norms
predict IDUs‘ short-term intention to engage in test shots to prevent non-fatal overdose in
each of four drug-use situations (i.e., in withdrawal, not in withdrawal, with others,
alone)?
2. Do the constructs proposed by the expanded HBM (i.e., perceived susceptibility,
perceived severity, benefits, barriers, self-efficacy) and perceived social network norms
predict IDUs‘ short-term intention to engage in skin cleaning with alcohol wipes or soap
and water to prevent bacterial infections in each of four drug-use situations (i.e., in
withdrawal, not in withdrawal, with others, alone)?
Health Beliefs and Harm Reduction 16
METHOD
Recruitment Procedure and Participant Characteristics
Following approval by the university human subjects review board, I sent informational emails about the study to 16 needle exchange and methadone programs in Ohio, Michigan, and
Illinois. Although five needle exchange programs and one methadone program responded to my email, I eventually received approval to collect data only from three needle exchange programs:
1) The Free Medical Clinic of Greater Cleveland‘s Mobile Needle Exchange, 2) The Grand
Rapids Red Project and 3) HIV/AIDS Resource Center Mobile Needle Exchange of Ypsilanti.
The Free Medical Clinic of Greater Cleveland Mobile Needle Exchange. The Free
Medical Clinic of Greater Cleveland is a non-profit organization that provides medical and dental services, HIV/AIDs treatment and prevention (including needle exchange), mental health services/substance abuse treatment, case management, and community education free of charge.
The Mobile Needle Exchange (called ―the van‖ by clinic staff) has been in operation for approximately 15 years and it is currently the only needle exchange in the state of Ohio. Staffed by two trained Free Clinic employees and occasional volunteers, the van provides a 1-for-1 needle exchange as well as cookers, alcohol pads, condoms, lubricant, bleach and water for needle cleaning, HIV-testing, weekly vaccination services provided by a registered nurse, educational materials, and referral to treatment services. For two and half hours each weekday morning, the van parks in a fixed location on the west side of Cleveland, and for two hours each weekday afternoon, it parks in a fixed location on the east side of the city. Van clients are not registered by name, but by a unique code number assigned to them. Van clients are given a card with the code number and possessing this card prevents clients from being arrested for possessing clean needles and syringes. Health Beliefs and Harm Reduction 17
The Grand Rapids Red Project. The Red Project is an HIV/AIDS prevention and advocacy organization that started about 10 years ago in Grand Rapids, Michigan. In addition to needle exchange (known as the Clean Works program), the Red Project provides street outreach and HIV/AIDS education. Clean Works is staffed by two trained employees and multiple volunteers. It operates two evenings a week for two hours at a time in a fixed location in downtown Grand Rapids. In addition to a 1-for-1 exchange, Clean Works provides male and female condoms, lubricant, dental dams, HIV and Hepatitis testing, safer use supplies, basic hygiene products, overdose prevention training, take-home naloxone, harm reduction counseling, and treatment referral. Similar to Cleveland‘s Mobile Needle Exchange, clients of Clean Works receive a unique identifying code and a card to carry that prevents arrest for possession of clean needles and syringes.
HIV/AIDS Resource Center (HARC) Mobile Needle Exchange. HARC is a non-profit comprehensive AIDS service organization located in Ypsilanti, Michigan. HARC‘s services include HIV/AIDS prevention, education, outreach, case management, advocacy, HIV testing, counseling and referral, and a mobile needle exchange. The needle exchange van is staffed by one trained staff member and one or two volunteers. The van operates Monday through Friday and parks for about two hours each day at different locations in the Ypsilanti/Ann Arbor area. In addition to needle exchange, the van also provides HIV and Hepatitis C testing, safer sex supplies, safer use supplies, HIV counseling, risk reduction education, and referral to other services. Clients of the HARC needle exchange also receive a unique identifying client number and card, but possession of this card may prevent a paraphernalia charge only in the city of Ann
Arbor, though not in Ypsilanti. Health Beliefs and Harm Reduction 18
At all three data collection sites, participants were recruited by overtures made by myself, a trained data collection assistant (one male and one female graduate student in clinical psychology who interviewed one and two participants, respectively), and/or needle exchange staff. Participants who completed the study were also given one or more copies of a small flyer with information about the study, were told the time, date, and location of the next data collection, and were asked to pass the information on to other IDUs. Because I was using the facilities provided by the three sites, any participants in my study had to be enrolled in the needle exchange programs (although individuals could enroll on the day they participated in my study).
At Clean Works in Grand Rapids, participants were taken to a private room to complete the study (with myself or a trained graduate student research assistant). At the two mobile needle exchanges, participants completed the study in the front passenger seat of the van while I administered the surveys from the driver‘s seat. At the Cleveland site, other staff remained in the van during the provision of the questionnaires, but the Ypsilanti van had a partition creating privacy while the study was completed. Either a research assistant or I read the informed consent to participants (see Appendix A). As part of the informed consent procedure, I asked participants if they were at least 18 years old and if they injected at least once a week for the previous 3 months, and I observed whether they spoke English clearly (all potential participants met these eligibility criteria). If they agreed to participate, we asked each question and response option aloud. However, the questionnaire packet was placed so that participants could follow along with the reader and point to response options if they preferred not to say their responses aloud. Questions were repeated or paraphrased when participants asked or when it appeared that a participant did not understand the question. To reduce concerns about socially desirable responding, participants were reminded that their responses would be kept confidential and Health Beliefs and Harm Reduction 19 would not be shared with needle exchange program staff. When staff members were present for data collection, I informed participants that the staff were busy with their responsibilities and were not intentionally paying attention to the data collection session.
Participant Demographics and Drug Use History. Participants were 91 current injecting drug users (77% male) recruited from needle exchange programs in Cleveland, Ohio (n = 74),
Grand Rapids, Michigan (n = 9), and Ypsilanti, Michigan (n = 8) between October, 2009 and
June, 2010. The sample was ethnically diverse, with 46% identifying themselves as Caucasian,
28% self-identifying as African American, and 22% self-identifying as Hispanic/Latino.
Participants had a mean age of 45.3 years (SD = 11.3). About one-third (35%) were in a committed relationship, 31% were single, 18% were divorced, 14% were married, and 2% were widowed. Nearly three-quarters (73%) had children. Just over half reported being unemployed
(51%) and half (50%) had household incomes of $10,000 or less for the past year. The vast majority reported they were HIV-Negative (87%), but 4% reported they were HIV-Positive and
9% were unsure of their HIV status. Table 1 reveals additional information about participants‘ background characteristics.
All but one of the participants had used heroin in the past 3 months, and 88% of them reported that heroin was the substance they used most often. Of participants who reported heroin as their most frequently used substance, all but one administered the drug by injecting (the other snorted). Of the remaining 12%, 6% indicated they used other opiates (e.g., Dilaudid, morphine) most often (80% by injecting, 20% by swallowing pills); 3% injected a mixture of heroin and cocaine most often; 2% drank alcohol most often; and 1% smoked marijuana most often. Nearly three-quarters (73%) had used their drug of choice on the day they participated in the study, and
69% reported typically using it more than once a day during the previous 3 months. Just over Health Beliefs and Harm Reduction 20 half (55%) reported previous overdose episodes with a mean of 0.7 (SD = 1.2) episodes in the previous year and 5.3 (SD = 6.2) episodes in participants‘ lifetimes. Table 2 reveals additional information about participants‘ drug use history.
Measures
Harm Reduction Health Beliefs Questionnaire (HR-HBQ). I developed the HR-HBQ
(Appendix B; pp. 53 and 58) for this study to assess respondents‘ health beliefs regarding two injection-related health conditions (overdose and bacterial infections) and two harm reduction behaviors that can prevent those conditions (injecting test shots and cleaning skin prior to injecting). Therefore, one section of the HR-HBQ focused on respondents‘ beliefs about bacterial infections and cleaning one‘s skin with alcohol wipes or soap and water to prevent such infections and a second section focused on respondents‘ beliefs about non-fatal overdose and injecting test shots to prevent this outcome. Each section assessed the six components of the modified expanded Health Belief Model.
Each of the two sections of the HR-HBQ included three questions designed to assess perceived susceptibility to the health outcome (Sample Item: ―How high are the chances that you will have a non-fatal overdose from injecting street drugs over the next 3 months?‖), three questions designed to assess perceived severity of the health outcome (Sample Item: ―If, in the next 3 months, you experienced a non-fatal overdose from injecting street drugs, how big of an impact would it have on your life?‖), three questions designed to assess perceived benefits of enacting the harm reduction behavior (Sample Item: ―If I did a test shot each time I inject street drugs, it would lower my chances of a non-fatal overdose.‖), three questions designed to assess perceived barriers to enacting the harm reduction behavior (Sample Item: ―It would be too much trouble to do a test shot when I inject street drugs.‖), three questions designed to assess self- Health Beliefs and Harm Reduction 21 efficacy to enact the harm reduction behavior (Sample Item: ―I am confident that I can inject a test shot whenever I am about to inject street drugs.‖), and three questions designed to assess perceived social network norms surrounding use of the harm reduction behavior (Sample Item:
―Other injectors I know would think I‘m weak if I do a test shot before injecting an entire ‗hit‘ of street drugs.‖). Participants‘ were asked to rate their responses to these items on a 5-point
Likert-type scale with answer choices that varied depending on the content of each question
(See Appendix B for response options).
I created four versions of the HR-HBQ in which the Overdose-Test Shot and Bacterial
Infection-Skin Cleaning sections and the items within each section were presented in different orders. In both the Overdose-Test Shot and Bacterial Infection-Skin Cleaning sections, the six items assessing perceived susceptibility and perceived severity were presented first, in one of four random orders, followed by the 12 items assessing the remaining four constructs, also in one of four random orders.
I developed the questions on the HR-HBQ by modeling items described in several studies using constructs of the HBM to assess beliefs related to breast cancer (Champion, 1999;
Champion, Monahan, Springston, Russell, Zollinger, Saywell, et al., 2008), stroke (Sullivan,
White, Young, Chang, Roos, & Scott, 2008), and osteoporosis (Kim, Horan, Gendler, & Patel,
1991). I drafted several items to assess each HBM construct and met with my research advisor and a group of graduate students enrolled in a substance abuse research group to obtain feedback about how well the items measured each HBM construct. After several revisions, I ultimately chose to include those 18 items that were applicable to both of the harm reduction behaviors and health conditions targeted by the HR-HBQ. Readability statistics calculated by Microsoft Word
2007 indicate that the HR-HBQ has a Flesch Reading Ease score of 74.0 and a Flesch-Kincaid Health Beliefs and Harm Reduction 22
Grade Level of 8.1. Given that 97% of participants had at least some high school education, it is likely that the majority of participants were able to comprehend the questions on the HR-HBQ.
Screening Measure. To assess whether participants could complete both sections of the
HR-HBQ (described above), participants completed a two-question screening measure
(Appendix B, p. 52). Before administering the HR-HBQ, I asked participants whether they injected only street drugs, both street drugs and pharmaceutical/prescription drugs, or only pharmaceutical/prescription drugs and whether they currently had any injecting-related bacterial infections. The one participant who injected only pharmaceutical/prescription drugs was not eligible to complete the HR-HBQ questions about Overdose-Test Shots. Therefore, 90 participants completed the subsequent HR-HBQ section. The six participants who reported that they currently had any bacterial infections from injecting were not eligible to complete the HR-
HBQ section about Bacterial Infections-Skin Cleaning. Therefore, 85 participants completed the subsequent HR-HBQ section.
Short-term Intentions to Use Harm Reduction. I developed eight questions designed to assess participants‘ intentions to engage in the two harm reduction behaviors in each of four drug-use situations (in withdrawal, not in withdrawal, with others, alone) during the next three months (e.g., Sample Item: ―In the next 3 months, how likely is it that you will inject a test shot every time you inject street drugs when you are in withdrawal?;‖ Appendix B; pp. 56 and 61).
Participants‘ rated their responses to these items on a 5-point Likert-type scale (―Not at all likely‖ to ―Extremely likely‖). To control for a possible order effect, half of the packets started with questions about injecting in withdrawal/not in withdrawal and half started with questions about injecting with others/alone. Health Beliefs and Harm Reduction 23
Past Use of Harm Reduction. I wrote eight questions to assess how often participants engaged in the two harm reduction behaviors in each of the four drug-use situations during the previous three months (Sample Item: ―During the past 3 months, how often did you inject a test shot before each time you injected street drugs when you were in withdrawal?;‖ Appendix B; pp.
57 and 62) using a 5-point Likert-type scale (from ―Never‖ to ―Always‖). To control for a possible order effect, half of the packets started with questions about injecting when in withdrawal/not in withdrawal and half started with questions about injecting with others/alone.
Table 2 displays average past-use scores for the two harm reduction behaviors in each of the four drug-use situations.
Background Information. Participants completed a series of background information questions that included demographic information, drug use history, treatment history, psychiatric history, and their current legal status (Appendix C; p. 63).
Interview. To assess participants‘ general health behaviors, harm reduction behaviors specifically related to injecting, and reasons for not engaging in the harm reduction behaviors every time they inject, I asked four questions in a semi-structured open-ended interview format
(Appendix D, p. 68). For each of the four questions, I first read participants‘ responses to develop a list of themes represented in the responses. I then re-read the responses and assigned one or more themes to each participant‘s response. Finally, I met with my research advisor to review and refine the themes and to recode some responses originally coded as miscellaneous.
Data Collection Procedure
After recruitment and informed consent was obtained, participants were read the screening measure, and then the sections of the HR-HBQ for which they were eligible.
Following completion of each HR-HBQ section, clients answered questions about their Health Beliefs and Harm Reduction 24 intentions to engage in the health behaviors over the next 3 months, their past use of the health behaviors, their demographics, and their drug use history. The data-gathering session concluded with the four-question interview. Finally, participants were given a copy of the consent form, a debriefing form explaining the purpose of test shots and skin cleaning, a list of local mental health/substance abuse treatment agencies, a small study flyer to give to other IDUs, and a $10 gift card to a local grocery store. Administration of the surveys and interview usually took between 20 and 30 minutes.
Hypotheses
1. Based on the modified HBM, I hypothesized that perceived susceptibility, benefits,
barriers, self-efficacy, and perceived social network norms, would be positively
correlated with intention to inject test shots after accounting for past use of test shots.
Because non-fatal overdose is a temporary condition that does not result in death, I
hypothesized that perceived severity would be uniformly low across participants and,
therefore, would not be correlated with intention to inject test shots.
2. I had no hypothesis about whether the expanded HBM constructs would predict
intentions to use test shots differently across the four drug-use situations. This was an
exploratory analysis.
3. With regard to bacterial infections, I hypothesized that perceived susceptibility, benefits,
barriers, self-efficacy, and perceived social network norms would be positively correlated
with intention to engage in skin cleaning, after accounting for past frequency of skin
cleaning. Because bacterial infections are usually non-fatal and may heal over time, I
hypothesized that there would be little variability in ratings of perceived severity and,
therefore, severity would not be related to intention to engage in skin cleaning. Health Beliefs and Harm Reduction 25
4. I had no hypothesis about whether the expanded HBM constructs would predict
intentions to engage in skin cleaning differently across the four drug-use situations. This
was an exploratory analysis.
Health Beliefs and Harm Reduction 26
RESULTS
Preliminary Analyses
Internal Consistency Reliability for the HR-HBQ Subscales. To assess the internal consistency of the HR-HBQ subscales, I calculated Cronbach‘s alpha for each three-item subscale in the Overdose-Test Shot and Bacterial Infection-Skin Cleaning sections. In the
Overdose-Test Shot section, five of the six subscales had adequate internal consistency: perceived susceptibility (α = .73), perceived severity (α = .85), perceived benefits (α = .79), perceived barriers (α = .69), and self-efficacy (α = .86). However, the three-item perceived social network norms subscale demonstrated relatively poor internal consistency (α = .50).
Next, I examined the inter-correlations between the three perceived social network norms items to assess whether any two items were correlated highly enough to be used as a subscale that would be representative of the construct I sought to assess. These inter-item correlations ranged from -.33 to .18 and thus were not high enough to suggest using two items to measure the perceived social network norms construct. Given the poor internal consistency reliability and these low inter-item correlations, I decided not to retain the Overdose-Test Shot perceived social network norms subscale for subsequent analyses.
Next, I examined the correlations between the three individual items designed to assess perceived social network norms and the criterion measures of test shot intentions in each of the four situations. Participants‘ scores on the item ―The injectors I know usually do test shots when they inject street drugs‖ correlated moderately with each of the test shot intentions items (rs range from .40 to .56, all ps < .001). Scores on another item, ―Other injectors I know would think I‘m weak if I do a test shot before injecting an entire hit of street drugs,‖ correlated significantly with test shot intentions when not in withdrawal [r(89) = .26, p < .05], when alone Health Beliefs and Harm Reduction 27
[r(88) = .29, p < .01], and when with others [r(74) = .31, p < .01]. Scores on the other item,
―Other injectors I know would want me to do a test shot each time I inject street drugs,‖ were correlated significantly with test shot intentions when in withdrawal [r(86) = .27, p < .05], when not in withdrawal [r(89) = .21, p < .05], and when injecting alone [r(88) = .36, p < .01]. Because participants‘ scores on the first item measuring IDUs‘ rating of how often other injectors in their network use test shots correlated most meaningfully with the criterion measures, and because this was the only item measuring the perceived social network norms construct that did not require participants to speculate about other injectors‘ thoughts, I decided to include just this one item as a predictor variable in the subsequent regression analyses.
In the Bacterial Infection-Skin Cleaning section, four of the six subscales demonstrated adequate internal consistency reliability: perceived susceptibility (α = .88), perceived severity (α
= .83), perceived barriers (α = .74), and self-efficacy (α = .74). The reliability of the perceived benefits subscale (α = .62), was lower but this may be explained by restriction in the range of responses (M = 4.67, SD = .62). Specifically, between 88% and 90% of participants chose Agree
Somewhat (coded as 4) or Strongly Agree (coded as 5) from the response options for each of the three questions. Once again, the three-item perceived social network norms subscale demonstrated relatively poor internal consistency (α = .46). Next, I examined the inter-item correlations between the three perceived social network norms items to assess whether any two items were correlated highly enough to comprise this subscale. These inter-item correlations ranged from -.19 to .38 and thus were not high enough to suggest using just two items to measure the perceived social network norms construct. Given the poor internal consistency reliability and these low inter-item correlations, I decided not to retain the Bacterial Infection-Skin Cleaning perceived social network norms subscale for subsequent analyses. Health Beliefs and Harm Reduction 28
Next, I examined the correlations between the three individual items designed to assess perceived social network norms and the criterion measures of skin cleaning intentions in each of the four situations. Participants‘ scores on the item ―The injectors I know usually clean their injection sites with alcohol wipes or soap and water before injecting‖ were significantly correlated with skin cleaning intentions in each of the four drug-use situations (rs ranged from
.36 to .44, all ps < .01). Participants‘ scores on another item, ―Other injectors I know would want me to clean my injection sites with alcohol wipes or soap and water each time I inject drugs,‖ were also significantly correlated with skin cleaning intentions in each of the four drug- use situations (rs range from .27 to .44, all ps < .05). Scores on the other item, ―Other injectors I know would think I‘m weak if I clean my injection sites with alcohol wipes or soap and water before injecting drugs,‖ were not significantly correlate with skin cleaning intentions in any of the four drug-use situations. Because participants‘ scores on the first item measuring IDUs‘ rating of how often other injectors in their network engage in pre-injection skin cleaning correlated most meaningfully with the criterion measures and because this is the only item measuring the perceived social network norms construct that did not require participants to speculate about other injectors‘ thoughts, I decided to include this item as a predictor variable in the subsequent regression analyses. Table 3 displays all internal consistency coefficients as well as sample means and standard deviations for each HR-HBQ section subscale and the two social norms items used as predictors.
Intercorrelations Among HR-HBQ Subscales and Social Norms Item. Next, I conducted
Pearson bivariate correlations among the HR-HBQ subscales (i.e., perceived severity, perceived susceptibility, perceived benefits, perceived barriers, and self-efficacy) and the social norms item for the Overdose-Test Shot and the Bacterial Infection-Skin Cleaning sections separately. In the Health Beliefs and Harm Reduction 29
Overdose-Test Shot section, the only significant intercorrelations were relatively small and occurred between perceived severity and perceived susceptibility [r(89) = .22, p < .05], between self-efficacy and perceived benefits [r(89) = .33, p < .01], between self-efficacy and perceived barriers [r(89) = -.24, p < .05], and between self-efficacy and the social norms item [r(89) = .23, p < .05].
There were several significant intercorrelations in the Bacterial Infection-Skin Cleaning section. Specifically, perceived susceptibility was correlated with perceived severity, perceived benefits, perceived barriers, and self-efficacy (absolute values of rs ranges from .24 to .40, ps <
.05). In addition, the self-efficacy subscale was significantly correlated with perceived benefits
[r(84) = .51, p < .001], perceived barriers [r(84) = -.38, p<.001], and the social norms item [r(84)
= .26, p < .05]. Table 4 displays the intercorrelations for all of the HR-HBQ subscale pairs by type of harm reduction intervention. Because the subscales in each section were not highly intercorrelated, and because each subscale was designed to represent a separate component of the
HBM, I retained all five individual subscales for each health condition-harm reduction intervention pair for subsequent regression analyses.
Differences in Intentions to Engage in Harm Reduction Behaviors by Drug-Use Situation.
Because I planned to use test shot intentions and skin cleaning intentions in each of the four drug-use situations (i.e., in withdrawal, not in withdrawal, with others, alone) as criterion variables for subsequent regression analyses, I first wanted to assess whether participants‘ intentions to engage in each harm reduction behavior differed as a function of situation. First, I conducted a repeated measures ANOVA, with Huynh-Feldt correction, using mean test shot intentions in each of the four drug-use situations as the dependent variable. The test statistic indicated that participants reported different levels of test shot intentions across these four Health Beliefs and Harm Reduction 30 situations, F(2.75,195.24) = 4.23, p < .01, partial η2 = .06. On average participants rated their likelihood of using test shots highest when they would be injecting alone (M = 2.39, SD = 1.35), followed by when they would not be in withdrawal (M = 2.29, SD = 1.37), when with others (M
= 2.10, SD = 1.26), and when in withdrawal (M = 1.97, SD = 1.31). Follow-up paired samples t- tests using a Bonferroni correction indicated that test shot intentions were higher for participants when not in withdrawal [t(86) = -2.99, p < .01] and alone [t(86) = -3.01, p < .01] compared to when in withdrawal.
Next, I conducted another repeated measures ANOVA, with Huynh-Feldt correction, using mean skin cleaning intentions in the four drug-use situations as the dependent variable.
The test statistic showed that participants reported varying levels of skin cleaning intentions across the four situations, F(2.69,177.33) = 19.77, p < .01, partial η2 = .23. On average, participants rated their likelihood of skin cleaning highest when they would be injecting alone (M
= 3.67, SD = 1.40), followed by when others would be present (M = 3.49, SD = 1.31), when not in withdrawal (M = 3.42, SD = 1.37), and when in withdrawal (M = 2.67, SD = 1.48). Follow-up paired samples t-tests using a Bonferroni correction indicated that skin cleaning intentions were higher for participants when not in withdrawal [t(81) = -4.38, p < .001], with others [t(66) = -
5.58, p < .001], or alone [t(81) = -5.68 p < .001] compared to when in withdrawal.
Because both of the above analyses indicate that participants, on average, reported different levels of intention to engage in the harm reduction behaviors across different situations in which they may be injecting, I decided to conduct subsequent regression analyses predicting intention to employ test shots and engage in pre-injection skin cleaning skin separately for each situation (rather than calculating a mean intention score collapsed across the four drug-use situations). Health Beliefs and Harm Reduction 31
Using the Health Belief Model to Predict Use of Test Shots
I conducted four linear regression analyses to examine whether the five components of the expanded HBM and the rating of how often other injectors in participants‘ network use test shots predicted IDUs‘ short-term intentions to use test shots in each of the four drug-use situations (i.e., in withdrawal, not in withdrawal, alone, with others). In all four analyses, I entered participants‘ scores on the following predictor variables simultaneously: recent past use of test shots in the target situation, perceived severity of and perceived susceptibility to non-fatal overdose, perceived benefits, perceived barriers, self-efficacy, and the social norms item. The criterion variables for the four analyses were the four single-item measures of participants‘ intentions to use test shots in the next 3 months while injecting in each of the four drug-use situations. Participants who reported not having injected in each situation in the previous three months were excluded from these analyses (nwithdrawal = 3, nnot withdrawal = 0, nalone = 1, nwith others =
15).
The overall model predicting short-term likelihood of injecting test shots when in withdrawal was significant, F(7,79) = 14.84, p < .001, Adj. R2 = .53. The only significant predictor was participants‘ past use of test shots when in withdrawal (β =.70), indicating that the more often one engaged in test shots in the previous three months, the more likely he/she is to engage in them during the next three months. Therefore, my hypothesis regarding the predictive relationship of the HBM constructs and social norms was not supported.
Secondly, the overall model predicting short-term likelihood of using test shots when not in withdrawal was also significant, F(7,82) = 13.71, p < .001, Adj. R2 = .50. Significant predictors of intention in this situation were past use of test shots when not in withdrawal (β
=.53), perceived susceptibility to non-fatal overdose (β =.25), and perceived benefits of test shots Health Beliefs and Harm Reduction 32
(β =.19). This indicates that, in addition to recent past use of test shots when not in withdrawal, two of the five HBM constructs also predicted short-term intentions to use test shots when not in withdrawal. Table 5 displays the results of the regression analyses predicting intentions to do test shots when in withdrawal and not in withdrawal.
Thirdly, the overall model predicting intentions to inject test shots when injecting with other people was significant (7,67) = 9.05, p < .001, Adj. R2 = .43. Significant predictors included past use of test shots (β =.42) and the item measuring perceived use of test shots by other injectors (β =.26). These results indicate that the more often one used test shots when injecting with others in the past three months and the more frequent one perceives use of test shots among other injectors, the more likely he/she is to engage in test shots when injecting with others in the next three months. In this analysis, one of the HBM constructs – perceived susceptibility to non-fatal overdose – was also marginally significant (β =.18, p = .052).
Fourthly, the overall model predicting intentions to use test shots when injecting alone was significant, F(7,81) = 14.06, p < .001, Adj. R2 = .51. Past use of test shots when injecting alone (β =.47), perceived susceptibility to non-fatal overdose (β =.19), the item measuring use of test shots by other injectors (β =.19) were significant predictors. Table 6 displays the results of the regression analyses predicting intentions to do test shots when with others and alone.
Using the Health Belief Model to Predict Skin Cleaning
I conducted four linear regression analyses to examine whether the components of the
HBM and the social norms item measuring how often other injectors in their network clean their skin predicted IDUs‘ short-term intentions to clean their skin with alcohol wipes or soap and water prior to injecting in the four drug-use situations (i.e., in withdrawal, not in withdrawal, alone, with others). In all four analyses, I entered participants‘ scores on the following predictor Health Beliefs and Harm Reduction 33 variables simultaneously: frequency of skin cleaning in the previous three months, perceived severity of and perceived susceptibility to bacterial infections, perceived benefits, perceived barriers, self-efficacy, and the social norms item. The criterion variables for the four analyses were single-item measures of participants‘ intentions to clean their skin in the next 3 months when injecting in the four target situations. Again, participants who reported not having injected in each situation in the previous three months were excluded from these analyses (nwithdrawal = 3, nnot withdrawal = 0, nalone = 1, nwith others = 15).
The overall model predicting skin cleaning when in withdrawal was significant, F(7,74) =
20.39, p < .001, Adj. R2 = .63. Past skin cleaning in withdrawal was the only significant predictor (β =.37), indicating that the more frequently participants had cleaned their skin when in withdrawal in the past three months, the greater their intention to clean their skin when in withdrawal during the next three months. Contrary to my hypothesis, none of the HBM constructs or social norms were significantly associated with short-term intention to clean one‘s skin prior to injecting when in withdrawal.
Secondly, the overall model predicting skin cleaning when not in withdrawal was also significant, F(7,77) = 12.75, p < .001, Adj. R2 = .50. In this drug-use situation, the only significant predictor was the frequency of recent skin cleaning when not in withdrawal (β =.56).
Thus, my hypothesis regarding the contributions of the HBM variables and social norms to predicting skin cleaning was not supported by this analysis. Table 7 displays the results of the regression analyses predicting skin cleaning when in withdrawal and not in withdrawal.
Thirdly, the overall model predicting skin cleaning when injecting with others was significant, F(7,62) = 18.09, p < .001, Adj. R2 = .63. Because past skin cleaning when injecting with others (β =.61) was the only significant predictor, my hypothesis regarding the relationship Health Beliefs and Harm Reduction 34 between the HBM constructs and social norms with skin cleaning was not supported by this analysis.
Fourthly, the overall model predicting skin cleaning when injecting alone was significant,
F(7,76) = 9.45, p < .001, Adj. R2 = .42. Past skin cleaning when injecting alone (β =.49) was the only significant predictor. Therefore, my hypothesis regarding the association of the HBM constructs and social norms with skin cleaning was not supported by this analysis. Table 8 displays the results of the regression analyses predicting skin cleaning with others and alone.
Themes Represented in Participant Interviews
Participants’ General Health Behaviors. Participants‘ responses to the question asking the types of behaviors they engage in to preserve their health were placed into one or more of 14 different categories. The most frequently mentioned theme (59% of responses) reflected the act of eating in general or eating a proper diet. A similar proportion of responses (53%) mentioned exercising or going to work as exercise (i.e., working a physical job). Less frequently, respondents mentioned seeking medical care either as needed or on a regular basis (27%), practicing good personal hygiene (18%), and taking vitamins (16%). The least frequently mentioned themes included doing nothing to take care of one‘s health (9%); taking prescriptions
(9%); avoiding stress, resting, or relaxing (8%); sleeping (8%); avoiding or limiting alcohol and/or tobacco (3%); seeking drug treatment or going to AA/NA meetings (3%); and getting mental health treatment (2%). Two participants (2%) responded by saying ―I don‘t know‖ and
12 responses or portions of responses (13%) did not fit in a previously noted category and were coded as miscellaneous. Table 9 provides the full list of the themes, the number of responses that reflected each theme, and exemplar quotes for each theme. Health Beliefs and Harm Reduction 35
Participants’ Behaviors to Reduce Injecting-Related Risks. Participants‘ responses to the question about the types of behaviors they engage in to reduce the health risks of injecting most often reflected the theme of using clean or new injecting supplies and/or avoiding reusing injecting supplies (49% of responses) and the theme of avoiding sharing needles or injecting supplies (43%). Almost one-third of responses reflected cleaning the injection site before or after injecting (30%). Fewer than 20% of responses contained the following themes: general cleanliness (16%), utilizing the needle exchange (4%), boiling or heating drugs (3%), reducing use or taking smaller hits (3%), testing the strength of the drug (2%), shooting with familiar people (2%), engaging in safe sex (2%). Twenty responses or portions of responses (22%) were coded as ―miscellaneous‖ and 11% said they did ―nothing‖ to reduce injecting risks. Table 10 provides the full list of the themes, the number of responses that reflected each theme, and exemplar quotes for each theme.
Participants’ Reported Barriers to Utilizing Test Shots. When asked their reasons for not using test shots or any personal barriers to using test shots, participants‘ responses most often contained references to being in a rush or a hurry and not having time for a test shot (23% of responses). A similar proportion of participants (20%) mentioned having used from the same batch of drugs before or receiving drugs from the same dealer who reportedly knew the strength of drugs. Not having enough drugs or not wanting to waste drugs (15%), not thinking about test shots or just not doing test shots (14%), and being in withdrawal (13%) were mentioned by similar proportions of respondents. Fewer than 10% of responses reflected the themes of wanting to get high (8%), the drugs not being strong enough to warrant concern (3%), having difficulty reaching a vein and getting a hit (2%), being anxious (2%), having a high tolerance
(2%), and consistent and steady use supposedly negating the need for a test shot (2%). I deemed Health Beliefs and Harm Reduction 36 seven responses or portions of responses (8%) as miscellaneous and four responses (5%) as uncodable because participants did not state a barrier or reason for not doing test shots. Table 11 provides the full list of themes, the number of responses that reflected each theme, and exemplar quotes for each theme.
Participants’ Self-Reported Barriers to Skin Cleaning. When asked to name barriers to or reasons for not cleaning their skin prior to injecting, participants most often responded that being in a hurry to use or being impatient (38%) restrained skin cleaning. Approximately one-fifth to one-quarter of responses mentioned being in withdrawal (23%), not having access to cleaning supplies (19%), and simply not thinking about skin cleaning (19%). Fewer than 10% mentioned being anxious (7%), being limited by the environment (7%), forgetting (7%), being lazy (3%), and not wanting to clean their skin (3%). Five responses (7%) were deemed uncodable because these participants responded to the interview question by saying they always clean their skin; however, checking their quantitative responses to the questions about skin cleaning in the recent past revealed that they did not always clean their skin. An additional eight responses or portions of responses (11%) were coded as miscellaneous. Table 11 provides the full list of the themes, the number of responses that reflected each theme, and exemplar quotes for each theme.
Health Beliefs and Harm Reduction 37
DISCUSSION
The present study was designed to assess whether the components of the expanded
Health Belief Model (i.e., perceived severity, susceptibility, benefits, barriers, and self-efficacy) and perceived social network norms predicted IDUs‘ short-term intentions to use test shots to prevent non-fatal overdose and to clean their skin before injecting to prevent bacterial infections in each of four drug-use situations (i.e., in withdrawal, not in withdrawal, alone, with others), after accounting for past use of these harm reduction strategies. Additionally, to further explore
IDUs‘ health behaviors and possible barriers to using harm reduction, I conducted a qualitative interview with participants. Specifically, using four open-ended questions, I asked about injecting drug users‘ engagement in health-promoting activities, ways they reduce injecting- related health risks, and perceived barriers to engaging in test shots and pre-injection skin cleaning.
Results from the sample of 91 current injecting drug users attending one of three needle exchange programs revealed that recent use of test shots and pre-injection skin cleaning was the only consistently significant predictor of intention to engage in both test shots and skin cleaning in each of the four drug-use situations. Specifically, the more often IDUs reported engaging in these two specific harm reduction behaviors in the past, the stronger their reported intentions to engage in the behaviors in the near future. My hypothesis about the predictive value of the HBM received minimal support. Specifically, perceived susceptibility to non-fatal overdose and perceived benefits of test shots were also significant positive predictors of engaging in test shots, but only if injecting when not in withdrawal; and perceived susceptibility was also a significant predictor of engaging in test shots, but only if injecting when alone. None of the HBM constructs predicted pre-injection skin cleaning in any drug-use situation. Furthermore, the item Health Beliefs and Harm Reduction 38 measuring participants‘ ratings of how often other injectors in their network use test shots was a significant positive predictor of test shot intentions, but only if injecting with others or alone.
Falck and colleagues (1995) also found perceived susceptibility to be a significant predictor of safer injection practices, but the relationship was negative indicating that IDUs who saw themselves as more susceptible to HIV were less likely to engage in safer injecting practices.
However, in the present study, there was a positive association between perceived susceptibility to non-fatal overdose and short-term intentions to use test shots (although this relationship appeared only when participants imagined injecting when not in withdrawal and when alone).
My finding is consistent the HBM and indicates that the more susceptible to non-fatal overdose my participants felt themselves to be, the more they intended to engage in test shots.
Neither Falck and colleagues (1995) nor Jamner and colleagues (1996) found significant relationships between another HBM construct, perceived benefits, and harm reduction behaviors or intentions. However, in my study, perceived benefits of doing test shots did predict test shot intentions, at least when participants imagined not being in withdrawal. Also unlike my findings, Jamner and colleagues (1996) found that participants‘ ―perceived risk‖ of sharing dirty needles (analogous to perceived severity) was positively related to one‘s intention to clean one‘s needles with bleach and current frequency of bleach cleaning. Both Falck et al. and Jamner et al. also found that self-efficacy was positively related to safer injection practices, intention to engage in bleach cleaning, and frequency of bleach cleaning; however, self-efficacy was not a significant predictor in any of my regression analyses.
The different patterns of results between my study and those of Jamner et al. (1996) and
Falck et al. (1995) may have occurred because I examined the HBM in the context of different health conditions and harm reduction behaviors. In addition, the other two studies were Health Beliefs and Harm Reduction 39 conducted 15 years ago, and it is also possible that IDUs‘ attitudes about susceptibility and severity to injection-related health conditions may have changed during this time. My study also differed from that of Falck et al. because I sought to predict behavioral intentions and Falck et al. were attempting to predict safer injection practices over the past month.
Previous research has demonstrated the value of the HBM constructs in relation to other types of health conditions and health behaviors (Harrison, Mullen, & Green, 1992; Janz &
Becker, 1984). However, based on the results of the present study and previous research using the HBM with IDUs (Falck et al., 1995; Jamner et al., 1996), it does not appear that the HBM is applicable to explaining why IDUs engage in or intend to engage in these two harm reduction behaviors. The HBM assumes that rational thought processes influence one‘s health-related behavior. However, the automaticity of drug-use and the powerful withdrawal and craving that accompany injecting drugs may inhibit IDUs from behaving consistently with their health beliefs.
Although social norms is not an element of the HBM, both Jamner and colleagues (1996) and the present study found that social norms positively predicted intention to engage in bleach cleaning and frequency of bleach cleaning. Jamner et al.‘s measure of social norms asked whether those close to an IDU would want him/her to clean his/her needles with bleach and did not specifically refer to the injecting social network as did the item that I used in my analyses
(i.e., ―The injectors I know usually do test shots when they inject street drugs‖). My study also found that the association between intention to do test shots and the rating of how often other injectors in one‘s network use test shots depended on the drug-use situation.
The present study extends previous research by demonstrating that intentions to use harm reduction varied depending on the drug-use situation and that certain HBM constructs and the Health Beliefs and Harm Reduction 40 perceived frequency with which other injectors do test shots predicted intentions differently across such situations. Specifically, past use of harm reduction behaviors consistently predicted intentions regardless of whether one would be injecting in withdrawal, not in withdrawal, alone, or with others, but perceived susceptibility, perceived benefits, and ratings of how often other injectors‘ use test shots predicted intentions in only some drug-use situations and not in others.
However, it is important to note that these four injecting situations are not mutually exclusive and that intentions to engage in harm reduction may change depending on, for example, whether one is alone and in withdrawal or with others and in withdrawal.
Results from the qualitative portion of the study indicated that, even though most participants engaged in consistent heavy drug use, many also engaged in behaviors that may promote their health. For example, they reported eating healthily or having regular meals, exercising, seeking medical care, and bathing or otherwise trying to stay clean. Although participants did not consistently engage in the two harm reduction behaviors of interest, they did report engaging in other harm reduction activities to reduce injecting-related risks, namely avoiding reuse of/using clean or new injection equipment and avoiding sharing needles or works.
The barrier to test shots cited most often (i.e., being in a rush or test shots taking too much time) in the qualitative interview was included in the perceived barriers subscale of the
HR-HBQ; however, participants also generated other barriers that were not included among the three questionnaire items. For example, many participants noted having used the same batch of drugs before or having a dealer who reportedly knows the strength of the drugs and test shots being a waste of drugs as reasons for not doing test shots regularly. Reasons or barriers generated by several participants that were not included in the perceived barriers questions on the
HR-HBQ for skin cleaning included being in withdrawal, not having access to cleaning supplies, Health Beliefs and Harm Reduction 41 and not thinking to clean one‘s skin. Perhaps including such constructs in the barriers questions would have yielded a significant relationship between perceived barriers and intentions to use harm reduction.
The results of this study should be considered in light of its limitations. First, because participants were injecting drug users, their ability to fully understand and respond to the questionnaires may have been impacted by their current level of intoxication or any cognitive damages created by long-term drug use. However, that all participants were able to complete the study, that some asked questions for further clarification of the questionnaires, and that the majority responded appropriately to the open-ended questions suggests that they were paying attention and able to comprehend the questions and response options.
Because most participants were interviewed in the proximity of program staff, social desirability or concerns about the relative privacy of their responses may have influenced how some participants answered questions. However, I designed the data collection procedure to reduce socially desirable responding. For example, participants were told that they could point to their responses rather than say them aloud and were reminded that their responses would remain confidential and would not be shared with needle exchange staff. Furthermore, that many participants gave responses that were not socially desirable (e.g., indicating that they never or rarely engaged in harm reduction behaviors) suggests that this data was not significantly altered by socially desirable responding.
It is also important to consider that participants were recruited from needle exchanges in one region of the United States and that these results may not generalize to IDUs who do not utilize needle exchanges or who live in different regions or countries. For example, IDUs who live in other areas may have more or less access to harm reduction education, needle exchange Health Beliefs and Harm Reduction 42 programs, and medical care which may influence, in part, their beliefs about the severity of and susceptibility to various injection-related health problems and the benefits of harm reduction.
It is possible that other aspects of one‘s personality or the drug-use context might be related to use of harm reduction. For example, severity of withdrawal, level of intoxication, access to safe injecting supplies, sensation seeking, health consciousness, and level of intoxication may all influence whether one engages in a harm reduction strategy to prevent the negative health consequences of injecting drugs. Although recent past use of the harm reduction behaviors was the only consistently significant predictor of short-term intentions to use harm reduction, this study was not designed to assess what factors are associated with the frequency of having used such harm reduction behaviors in the past.
That perceived susceptibility and perceived benefits were the only two components of the
HBM to emerge as significant predictors of harm reduction behaviors suggests that clinicians address these two constructs when designing interventions for injecting drug users. Such interventions might emphasize the prevalence of unhealthy injection-related outcomes to increase perceived susceptibility and list the benefits of harm reduction behaviors to encourage
IDUs to engage in these harm reduction behaviors in a variety of injecting circumstances.
Furthermore, because these two constructs were significant predictors in some injecting situations, but not others, clients may benefit from a discussion of the situational specificity of their health beliefs and intentions to perform harm reduction. Because perceived use of test shots by other injectors was also a significant predictor of test shot intentions in two drug-use situations, IDUs might also be encouraged to inject with others whom they trust and who regularly engage in harm reduction behaviors. Health Beliefs and Harm Reduction 43
That many participants reported using clean injecting equipment and avoiding sharing injecting equipment with others suggests that IDUs understand that diseases such as HIV and
Hepatitis are spread by sharing or using dirty equipment, and therefore educational interventions might shift to focus more on other health consequences of injecting (e.g., infections, overdose).
Interventions might also be improved if some of the barriers to engaging in harm reduction cited by IDUs in the qualitative portion of the study were addressed. For example, several IDUs mentioned there was no need to do test shots because the dealer supposedly knows the strength of the drug. Correcting potential misperceptions by educating IDUs that their dealers may not be accurate or that that strength of the drug may differ even if one uses the same dealer consistently may help encourage IDUs to use test shots more often.
Because my study predicted intentions to engage in harm reduction behaviors, it is important to consider that the relationship between health beliefs and actual behavior may be different than the relationship between health beliefs and intended behavior. As Azjen (1985) pointed out, behavioral intentions may be characterized as the intention to try or attempt to engage in a behavior and performance of the behavior relies on a person‘s control over and ability to overcome related barriers. Furthermore, intentions to engage in a behavior may change after they are assessed. Some of these concerns could be addressed by using longitudinal research assessing intentions and behavior repeatedly over a longer period of time.
Additionally, research investigating IDUs‘ reasons for engaging in harm reduction behaviors may prove as useful for helping to tailor interventions as understanding their reported barriers to engaging in harm reduction. Future research might also entail investigating the outcome of interventions designed to increase harm reduction behaviors through targeting health beliefs, such as self-efficacy to engage in harm reduction. Also, IDUs may have limited Health Beliefs and Harm Reduction 44 knowledge of the injecting behaviors of other drug injectors‘ or have limited insight into the influence of other injectors‘ behavior on their own injecting behavior. Therefore, future research could evaluate the correspondence between IDUs‘ use of specific harm reduction strategies and the actual use of such strategies by others in one‘s injecting network. Finally, it is important to recognize that no single model of health behavior or theory of addiction is likely to account for all aspects of individuals‘ drug use. Therefore additional biological, psychological, and social variables should be considered in addition to these attitudinal variables when exploring the determinants of health behavior.
Health Beliefs and Harm Reduction 45
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Health Beliefs and Harm Reduction 50
APPENDIX A
Consent Form
Injecting Drug Use Survey
Principal Investigator: Erin E. Bonar, M.A. (Graduate Student) Faculty Advisor: Harold Rosenberg, Ph.D.
INTRODUCTION You are invited to take part in an anonymous research study. This study is about injecting drug users‘ beliefs about ways to stay healthy. I am doing this research study for my doctoral degree in the Department of Psychology at Bowling Green State University.
Please read this sheet carefully. You will not be asked to sign this form. Instead, we assume you agree to take part if you want to continue after you read this form and the researcher answers any questions you may have.
PURPOSE Our main goal is to study injecting drug users‘ beliefs about some possible health effects of injecting drug use. We are also studying injecting drug users‘ beliefs about things they can do to stay healthier when injecting.
ELIGIBILITY You can take part in this study if you: o are at least 18 years old, o have injected drugs at least once per week during the past 3 months, and o speak English clearly.
PROCEDURE It is your choice to decide to take part in this study. If you choose to take part, you will be asked questions about: o The health effects of injecting drug use o Actions that could keep you healthier when injecting o Your own injecting habits o Your drug use history o Your beliefs about your health o Background information about you If you choose to take part in the study, you will also be asked to complete a short interview. These questions will be about how you take care of your health. You are free to skip any questions that you do not want to answer. We think that it will take you about 30 to 45 minutes to complete this study.
Health Beliefs and Harm Reduction 51
RISKS AND BENEFITS Taking part in this study could help treatment professionals learn more about the health practices of injecting drug users. This may help providers create programs to improve the health of injecting drug users. You could learn more about your own injection habits and health behaviors. You will get a $10 gift card to a local grocery store or restaurant if you complete the study. The risks of being in this study are not greater than you would encounter in your daily life. Answering questions about drug use can be upsetting for some people. If answering these questions becomes upsetting for you, please tell the researcher that you want to stop taking the surveys. We will give you a list of local mental health and drug treatment agencies in case you want to seek help for any discomfort you might have.
CONFIDENTIALITY Your answers will be kept private by the researcher. They will be stored in a locked office in the Psychology Department at BGSU. Your identity will not be given to anyone. We will not ask you for your full name. There is no way to connect your answers with your identity. We will not share your answers with the staff of this agency. Only the researchers will see your answers.
CONTACT INFORMATION If you have questions about this study you can contact:
o Principal Investigator: Erin E. Bonar, M.A., Psychology Department, BGSU, Bowling Green, OH 43403. Phone: 419.372.4503. Email: [email protected] o Faculty Advisor: Harold Rosenberg, Ph.D., Psychology Department, BGSU, Bowling Green, OH 43403. Phone: 419.372.7255. Email: [email protected]
If you have questions about the conduct of this study or your rights as a research participant, you may contact the Chair of Bowling Green State University‘s Human Subjects Review Board (Phone: 419.372.7716, Email: [email protected]).
INFORMED CONSENT Completing the surveys and interview questions indicates your voluntary informed consent to take part in this research study. You may keep this sheet as a record of your participation.
You may refuse to take part in this study. If you change your mind you can stop answering questions at any point. There will be no harmful results if you refuse to take part or stop after you have started the study.
Approved BGSU HSRB: ID H10D007GE7. Effective 7/21/2009. Expires 7/12/2010. Health Beliefs and Harm Reduction 52
APPENDIX B
MEASURES
Injecting Drug Use Survey – Eligibility Screener
Please check the line next to your answer for each question.
1. Street drugs are illegal drugs such as heroin, crack, or amphetamines.
Pharmaceutical or prescription drugs are drugs like vicodin, oxycontin, or methadone that come in a fixed dose and are usually obtained from a pharmacy or medical provider.
What kind of drugs do you inject?
_____ I inject only street drugs, such as heroin, crack, and amphetamines.
_____ I inject both street drugs and pharmaceutical or prescription drugs.
_____ I inject only pharmaceutical or prescription drugs.
2. Bacterial infections (not Hepatitis C, not HIV) are abscesses, sores, or open wounds at the injection site caused by injecting drugs. Bacterial infections often cause fever, swelling, discharge, and pain
Do you have a bacterial infection right now from injecting?
_____ No, I do not have a bacterial infection right now
_____ Yes, I have a bacterial infection right now
Health Beliefs and Harm Reduction 53
HR-HBQ
[Note to readers: Items are labeled for ease of identifying the construct measured. These labels did not appear on the questionnaires shown to participants. SEV = Severity, SUS = Susceptibility, BEN = Benefits, BAR = Barriers, EFF = Self-Efficacy, and NET = Social Network Norms.]
[Overdose/test shot items]
Please circle the best answer to each of the questions below about your beliefs about non- fatal overdose from injecting street drugs. What we mean by street drugs are illegal drugs such as heroin, crack, or amphetamines.
1. If, in the next 3 months, you experienced a non-fatal overdose from injecting street drugs, how big of an impact would it have on your life? [SEV]
No Small Medium Large Huge impact impact impact impact impact
2. How high are the chances that you will have a non-fatal overdose from injecting street drugs over the next 3 months? [SUS] No Low Medium High 100% chance chance chance chance chance
3. If, in the next 3 months, you had a non-fatal overdose from injecting street drugs, how scared would you be? [SEV] Not at all A little Somewhat Very Extremely scared scared scared scared scared
4. What is the risk that you will have a non-fatal overdose from injecting street drugs over the next 3 months? [SUS]
No risk A small A medium A large A huge at all risk risk risk risk
5. If, in the next 3 months, you experienced a non-fatal overdose from injecting street drugs, how big of a problem would it be for you? [SEV] Not a A small A medium A large A huge problem problem problem problem problem
6. How likely is it that you will have a non-fatal overdose from injecting street drugs over the next 3 months? [SUS]
Not at all A little Somewhat Very Extremely likely likely likely likely likely
Health Beliefs and Harm Reduction 54
Please circle how strongly you agree or disagree with the following statements about injecting a test shot when you inject street drugs. ―Test shot‖ means injecting a small amount of a street drug before injecting the entire ―hit‖ in order to test the strength of the drug. Even if you never inject test shots, we still want to know your responses if you were to inject test shots.
7. The injectors I know usually do test shots when they inject street drugs. [NET] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
8. If I did a test shot each time I inject street drugs, it would lower my chances of a non-fatal overdose. [BEN]
Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
9. I would have a hard time remembering to inject a test shot when I inject street drugs. [BAR]
Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
10. I am confident that I can inject a test shot whenever I am about to inject street drugs. [EFF] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
11. Other injectors I know would think I’m weak if I do a test shot before injecting an entire ―hit‖ of street drugs. [NET]
Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
12. I am certain that I can do a test shot each time I inject street drugs. [EFF] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
13. It would be too much trouble to do a test shot when I inject street drugs. [BAR] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
14. It would take too much time to do a test shot when I inject street drugs. [BAR] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree Health Beliefs and Harm Reduction 55
15. If I did a test shot each time I injected street drugs, I would be at a lower risk for a non-fatal overdose. [BEN] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
16. I am sure that I can do a test shot each time I inject street drugs. [EFF] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
17. Other injectors I know would want me to do a test shot each time I inject street drugs. [NET] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
18. If I did a test shot each time I inject street drugs, it could help me avoid a non-fatal overdose. [BEN] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
Health Beliefs and Harm Reduction 56
Intentions to Use Harm Reduction
[Test shot items]
Please circle your responses to the items below about test shots.
19. In the next 3 months, how likely is it that you will inject a test shot every time you inject street drugs when you are in withdrawal?
Not at all A little Somewhat Very Extremely I never inject likely likely likely likely likely when I am in withdrawal
20. In the next 3 months, how likely is it that you will inject a test shot every time you inject street drugs when you are NOT in withdrawal?
Not at all A little Somewhat Very Extremely I never inject likely likely likely likely likely when I am NOT in withdrawal
21. In the next 3 months, how likely is it that you will inject a test shot every time you are injecting street drugs with others present?
Not at all A little Somewhat Very Extremely I never inject likely likely likely likely likely with others present 22. In the next 3 months, how likely is it that you will inject a test shot every time you are injecting street drugs alone?
Not at all A little Somewhat Very Extremely I never inject likely likely likely likely likely alone
Health Beliefs and Harm Reduction 57
Past Use of Harm Reduction
[Test shot items]
Now answer these questions about the past 3 months.
23. During the past 3 months, how often did you inject a test shot before each time you injected street drugs when you were in withdrawal?
Never Rarely About half Almost all Always I never the time the time injected when I was in withdrawal in the past 3 months
24. During the past 3 months, how often did you inject a test shot before each time you injected street drugs when you were NOT in withdrawal?
Never Rarely About half Almost all Always I never the time the time injected when I was NOT in withdrawal in the past 3 months
25. During the past 3 months, how often did you inject a test shot before each time you injected street drugs with others?
Never Rarely About half Almost all Always I did not inject the time the time with others in the past 3 months
26. During the past 3 months, how often did you inject a test shot before each time you injected street drugs alone?
Never Rarely About half Almost all Always I did not inject the time the time alone in the past 3 months
Health Beliefs and Harm Reduction 58
HR-HBQ
[Bacterial infection/cleaning items]
Please circle the best answer to each of the questions below about your beliefs about bacterial infections (not Hepatitis C, not HIV) from injecting street drugs. Hep C and HIV are viral infections. These questions are about bacterial infections.
1. If, in the next 3 months, you got a bacterial infection (not HIV, not Hep C) from injecting drugs, how big of an impact would it have on your life? [SEV]
No Small Medium Large Huge impact impact impact Impact impact
2. How high are the chances that you will get a bacterial infection (not HIV, not Hep C) from injecting drugs over the next 3 months? [SUS] No Low Medium High 100% chance chance chance chance chance
3. If, in the next 3 months, you got a bacterial infection (not HIV, not Hep C) from injecting drugs, how scared would you be? [SEV] Not at all A little Somewhat Very Extremely scared scared scared scared scared
4. What is the risk that you will get a bacterial infection (not HIV, not Hep C) from injecting drugs over the next 3 months? [SUS]
No risk A small A medium A large A huge at all risk risk risk risk 5. If, in the next 3 months, you got a bacterial infection (not HIV, not Hep C) from injecting drugs, how big of a problem would it be for you? [SEV] Not a A small A medium A large A huge problem problem problem problem problem
6. How likely is it that you will get a bacterial infection (not HIV, not Hep C) from injecting drugs over the next 3 months? [SUS]
Not at all A little Somewhat Very Extremely likely likely likely likely likely
Health Beliefs and Harm Reduction 59
Please circle how strongly you agree or disagree with the following statements about cleaning your skin—where would inject— with alcohol wipes or soap and water. Even if you never clean your injection sites, we still want to know your responses if you were to clean your skin where you would inject.
7. The injectors I know usually clean their injection sites with alcohol wipes or soap and water before injecting. [NET] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
8. If I cleaned my injection sites with alcohol wipes or soap and water before each time I inject drugs, it would lower my chances of getting a bacterial infection (not HIV, not Hep C). [BEN] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
9. I would have a hard time remembering to clean my injection sites with alcohol wipes or soap and water before I inject drugs. [BAR] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
10. I am confident that I can clean my injection sites with alcohol wipes or soap and water whenever I am about to inject drugs. [EFF] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
11. Other injectors I know would think I’m weak if I clean my injection sites with alcohol wipes or soap and water before injecting drugs. [NET] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
12. I am certain that I can clean my injection sites with alcohol wipes or soap and water before each time I inject drugs. [EFF] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
13. It would be too much trouble to clean my injection sites with alcohol wipes or soap and water before I inject drugs. [BAR] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
Health Beliefs and Harm Reduction 60
14. It would take too much time to clean my injection sites with alcohol wipes or soap and water when I inject drugs. [BAR] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
15. If I cleaned my injection sites with alcohol wipes or soap and water each time I inject drugs, I would be at a lower risk for a bacterial infection (not HIV, not Hep C). [BEN] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
16. I am sure that I can clean my injection sites with alcohol wipes or soap and water each time I inject drugs. [EFF] Strongly Disagree Neither agree Agree Strongly disagree Somewhat nor disagree somewhat agree
17. Other injectors I know would want me to clean my injection sites with alcohol wipes or soap and water each time I inject drugs. [NET] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
18. If I clean my injection sites with alcohol wipes or soap and water each time I inject drugs, it could help me avoid a bacterial infection (not HIV, not Hep C). [BEN] Strongly Disagree Neither agree Agree Strongly disagree somewhat nor disagree somewhat agree
Health Beliefs and Harm Reduction 61
Intentions to Use Harm Reduction
[Cleaning items]
Please circle your responses to the items below about cleaning your injection sites.
19. In the next 3 months, how likely is it that you will clean your injection sites with alcohol wipes or soap and water every time you inject drugs when you are in withdrawal?
Not at all A little Somewhat Very Extremely I never inject likely likely likely likely likely when I am in withdrawal 20. In the next 3 months, how likely is it that you will clean your injection sites with alcohol wipes or soap and water every time you inject drugs when you are NOT in withdrawal?
Not at all A little Somewhat Very Extremely I never inject likely likely likely likely likely when I am NOT in withdrawal
21. In the next 3 months, how likely is it that you will clean your injection sites with alcohol wipes or soap and water every time you inject drugs with others present?
Not at all A little Somewhat Very Extremely I never inject likely likely likely likely likely with others present
22. In the next 3 months, how likely is it that you will clean your injection sites with alcohol wipes or soap and water every time you inject drugs alone?
Not at all A little Somewhat Very Extremely I never inject likely likely likely likely likely alone
Health Beliefs and Harm Reduction 62
Past Use of Harm Reduction
[Cleaning items]
Now answer these questions about the past 3 months.
23. During the past 3 months, how often did you clean your injection sites with alcohol wipes or soap and water when you injected when you were in withdrawal?
Never Rarely About half Almost all Always I never the time the time injected when I was in withdrawal in the past 3 months
24. During the past 3 months, how often did you clean your injection sites with alcohol wipes or soap and water when you injected when you were NOT in withdrawal?
Never Rarely About half Almost all Always I never the time the time injected when I was NOT in withdrawal in the past 3 months
25. During the past 3 months, how often did you clean your injection sites with alcohol wipes or soap and water when you were injecting with others?
Never Rarely About half Almost all Always I did not inject the time the time with others in the past 3 months
26. During the past 3 months, how often did you clean your injection sites with alcohol wipes or soap and water when you were injecting alone?
Never Rarely About half Almost all Always I did not inject the time the time alone in the past 3 months Health Beliefs and Harm Reduction 63
APPENDIX C
BACKGROUND INFORMATION
Please complete the following questions about yourself.
Remember that all of your responses are confidential and will not be connected to your name.
Please place a checkmark on the line next to your answer.
Please mark only one answer per question, unless asked to mark more than one.
1. Gender: _____ Male _____Female
2. Race/Ethnicity: _____ Caucasian/White _____ African American _____ Asian/Pacific Islander _____ Hispanic/Latino(a) _____ American Indian/Native American _____ Biracial/Multiracial _____ Other—Please fill in: ______
3. Age (please fill in): ______years
4. Education: _____ Some high school _____ Some college or trade school _____ Completed high school _____ College degree
5. Current Relationship Status: _____ Married _____ Not in a relationship _____ Divorced _____ In a committed relationship, _____ Widowed but not married
6. Do you have children? _____Yes _____No
7. Living situation (check only one): _____ Live alone _____ Live with parents or other family members _____ Live with partner/spouse and/or children _____ Live with friend(s) _____ Homeless _____ Other—Please fill in: ______8. Employment: There may be more than 1 answer. Check all that apply.
_____ Regular, full-time _____ Occasional/casual jobs _____ Regular, part-time _____ Social Security or Disability Health Beliefs and Harm Reduction 64
_____ Full-time student benefits (SSI/SSDI) _____ Part-time student _____ Unemployed _____ Other—Please fill in: ______
9. Legal Status: Do you have any legal problems related to your drug use right now?
_____Yes _____No
Are you on probation or parole right now for drug offenses?
_____Yes _____No
10. Sexual Orientation: _____ Heterosexual/Straight _____ Homosexual/Gay/Lesbian _____ Bisexual
11. Approximate household income in the last year (please check the one answer that includes all your total household income from legal and illegal sources):
_____ $0-10,000 _____ $50,001— 75,000 _____ $10,001—25,000 _____ $75,001—100,000 _____ $25,001—50,000 _____ $100,001 or more
12. Health: Overall, how much do you value your physical health?
_____ I do not value my health at all _____ I value my health a little bit _____ I value my health somewhat _____ I value my health a lot
13. HIV Status: _____ Unknown _____ HIV-Positive (infected) _____ HIV-Negative (not infected)
14. What substances have you taken recently and in the past? Please circle your responses.
Have you used this in Substance Have you ever used this? the last 3 months?
Alcohol Yes No Yes No Heroin Yes No Yes No Prescription Opiates not Yes No Yes No prescribed to you (for example, methadone, oxycontin, vicodin, dilaudid, buprenorphine/Subutex) Health Beliefs and Harm Reduction 65
Crack cocaine Yes No Yes No Cocaine powder Yes No Yes No Cannabis/Marijuana Yes No Yes No Other (Fill In): Yes No Yes No Other (Fill In): Yes No Yes No Other (Fill In): Yes No Yes No Other (Fill In): Yes No Yes No
Answer the following questions about the drug you currently use most often.
15. What is the drug you currently use most often? Please do not list prescribed medications such as methadone or benzos unless abused. ______
16. How do you typically use this drug? Please check. _____ Smoke _____ Inject _____ Swallow it _____ Snort _____ Other—please fill in: ______
17. When was your last use of your this drug?
Please check only one.
_____ Have not used for over 2 weeks _____ 2 days ago _____ About 1 week ago _____ Yesterday _____ 5-6 days ago _____ Today _____ 3-4 days ago
18. How often during the last 3 months have you used this drug? Please check only one.
_____ Not at all _____ 1-2 times per week _____ Less than monthly _____ 3-6 times per week _____ Once per month _____ Once a day _____ 2-3 times per month _____ More than once a day
Please answer the next two questions about drug overdose.
19. Have you ever overdosed on any injected drug? _____ Yes _____ No
20. If yes, how many times have you overdosed on an injected drug?
______times in the past year
______times in my lifetime Health Beliefs and Harm Reduction 66
Have you ever been diagnosed with any of the following psychiatric conditions by a mental health worker?
21. Depression………………………………_____ Yes _____ No
22. Bipolar Disorder or Manic Depression…………………...... _____ Yes _____ No
23. Schizophrenia…………………………..._____ Yes _____ No
24. Anxiety Disorder……………………...... _____ Yes _____ No (including: Posttraumatic Stress Disorder or PTSD, Obsessive- Compulsive Disorder or OCD, Generalized Anxiety Disorder, or Panic Disorder/Panic Attacks)
25. List any other mental disorders you have been told you have by a mental health worker: ______
26. Are you currently experiencing any physical symptoms of withdrawal RIGHT NOW (such as feeling sweaty, nauseous or sick, having cramps or achy muscles, having diarrhea, being tired, chills)? _____ Yes _____ No
Answer the following questions about injecting drugs.
27. How old were you when you first injected drugs? _____ years
28. How confident are you that you could keep yourself from shooting up if you wanted to? Please circle one. Not at all A little Somewhat Very Completely confident confident confident confident confident
Drug Treatment:
29. Are you currently in treatment for drug or alcohol use right now? _____ Yes _____ No
30. Have you ever gone through treatment for any type of drug or alcohol abuse in the past?
_____Yes _____No
Health Beliefs and Harm Reduction 67
31. What is the total number of times you have been in treatment for drug or alcohol use?
_____ 1 time _____ 2-4 times _____ 5–10 times _____ More than 10 times
32. How often do you inject with others who are also injecting drugs? Please circle one.
Never Rarely About half the Almost all the Always time time
33. If you inject with others, how often do people you inject with do a test shot before injecting an entire hit?
Does not Never Rarely About half Almost all Always apply to me/ the time the time I don’t inject with others
34. When you inject with others, how often do people you inject with wash and clean their injection sites with alcohol wipes or soap and water before injecting?
Does not Never Rarely About half Almost all Always apply to me/ the time the time I don’t inject with others
Do not answer this question if you only came here to be in the study and are not getting treatment or services here.
35. How long have you been coming to this agency where you have been filling out these forms?
Please indicate months or years. ______
Health Beliefs and Harm Reduction 68
APPENDIX D
INTERVIEW QUESTIONS
1. What kinds of things do you do to take care of your health?
2. You may know that injecting drugs carries certain health risks. What kinds of things do you do to reduce the health risks of injecting drugs?
3. Many people who inject drugs do not do a ―test shot‖ every time they inject drugs. What types of things get in the way of you doing a test shot every time you inject drugs?
4. Many people who inject drugs do not wash and clean their injection sites with alcohol wipes or soap and water before they inject every time. What types of things get in the way of you cleaning your injecting sites every time you inject drugs?
Health Beliefs and Harm Reduction 69
Table 1
Characteristics of Participants
Demographic Characteristic Percent or Mean (SD)
Sex
Male 77% Female 23
Age 45.3 (11.3)
Under 30 years old 16% 31 to 40 years old 18 41 to 50 years old 24 51 to 60 years old 38 Over 60 years old 3
Ethnicity
Caucasian 46% African American 28 Hispanic/Latino 22 Other 4
Education
Quit before high school 3% Some high school 31 Completed high school 42 Some college or trade school 19 College degree 5
Sexual Orientation
Heterosexual/Straight 96% Homosexual/Gay/Lesbian 2 Bisexual 2
Relationship Status
Married 14% Divorced 18 Widowed 2 Health Beliefs and Harm Reduction 70
Not in a relationship 31 In a committed relationship, 35 unmarried
Parent Status Has children 73% Does not have children 28
Living Situation
Alone 29% With parents or other family 18 With partner/spouse and/or children 39 With friends 10 Homeless 5 Other 1
Employmenta
Regular, full-time 16% Regular, part-time 6 Full-time student 1 Part-time student 1 Occasional/casual jobs 0 Social Security or Disability 23 Unemployed 51 Other (e.g., Veteran‘s Benefits) 4
Household income over previous year
$0-10,000 50% $10,001-25,000 22 $25,001-50,000 14 $50,001-75,000 4 $75,001-100,000 2 $100,001 or more 2
Any current drug-related legal problems
Yes 17% No 84
Currently on probation/parole for drugs
Yes 17% No 84 Health Beliefs and Harm Reduction 71
Overall, how much do you value your physical health?
Not at all 2% A little bit 10 Somewhat 20 A lot 68
HIV Status
Positive 4% Negative 87 Unknown 9
Any current injection-related bacterial infections
Yes 7% No 93
Previous Psychiatric Diagnosesb
Depression 45% Bipolar Disorder/Manic Depression 21 Schizophrenia 10 Anxiety Disorders 25 Other (e.g., ADHD, multiple 6 personalities) Note. Proportions may add up to more than 100% due to rounding. aProportions add up to more than 100% because participants could choose more than one response. bProportions add up to more than 100% because participants could have more than one psychiatric diagnosis.
Health Beliefs and Harm Reduction 72
Table 2
Participants’ Drug Use History
Drug Use History Characteristic Percent or Mean (SD)
Age of first drug injection 24.9 (9.2)
Under 18 years old 21% 18 to 25 years old 40 26 to 35 years old 26 Over 35 years old 13
Length of time attending needle exchange 3.8 years (4.3 years)
First day 15% More than 1 day, but less than a year 14 1 to 5 years 45 6 to 10 years 13 More than 10 years 10
Type of drugs injected
Only street drugs (e.g., heroin, 95% cocaine) Street drugs and pharmaceuticals 4 Only pharmaceuticals 1
Substance used most often
Heroin 88% Other opiates 6 Heroin and cocaine mixed 3 Marijuana 1 Alcohol 2
Last use of frequent substance
Have not used for over 2 weeks 1% About 1 week ago 1 5-6 days ago 0 3-4 days ago 2 2 days ago 0 Yesterday 23 Today 73 Health Beliefs and Harm Reduction 73
How often used frequent drug in last 3 months
Less than monthly 0% Once per month 0 2-3 times per month 3 1-2 times per week 7 3-6 times per week 12 Once a day 9 More than once a day 69
Substances ever trieda
Alcohol 99% Heroin 99 Prescription opiates 74 Crack cocaine 73 Cocaine powder 86 Cannabis/marijuana 93 Other (e.g., ecstasy, PCP, LSD/acid, 48 methamphetamines, benzodiazepine, barbiturates)
Substances used in previous 3 monthsa
Alcohol 62% Heroin 99 Prescription Opiates 55 Crack cocaine 37 Cocaine powder 40 Cannabis/marijuana 45 Other (e.g., ecstasy, PCP, LSD/acid, 12 methamphetamines, benzodiazepine, barbiturates)
Ever overdosed and number of overdoses
Yes 55% Number in past year 0.7 (1.2) Number in lifetime 5.3 (6.2)
Currently experiencing withdrawal symptoms Yes 11% No 89 Health Beliefs and Harm Reduction 74
Confidence in keeping self from shooting up, if wanted to
Not at all confident 21% A little confident 21 Somewhat confident 35 Very confident 18 Completely confident 6
Currently in drug/alcohol treatment
Yes 12% No 88
Previous drug/alcohol treatment
0 times 12% 1 time 11 2-4 times 42 5-10 times 30 More than 10 times 6
Frequency of injecting test shots in previous 3 monthsb
In withdrawal 1.74 (1.16) Not in withdrawal 1.76 (1.15) With others 1.73 (1.07) Alone 1.82 (1.16)
Frequency of pre-injection skin cleaning in previous 3 monthsb
In withdrawal 2.87 (1.55) Not in withdrawal 3.29 (1.49) With others 3.16 (1.52) Alone 3.32 (1.51)
Frequency of injecting with others
Never 14% Rarely 33 About half the time 26 Almost all the time 21 Always 6
Health Beliefs and Harm Reduction 75
When injecting with others, others‘ frequency of test shot
Never 59% Rarely 32 About half the time 9 Almost all the time 0 Always 0
When injecting with others, others‘ frequency of washing/cleaning with alcohol/soap
Never 28% Rarely 34 About half the time 21 Almost all the time 8 Always 9
Note. Proportions may add up to more than 100% because of rounding. aProportions total more than 100% because participants could endorse more than one drug used in the past. b Response options ranged from 1 (Never) to 5 (Always).
Health Beliefs and Harm Reduction 76
Table 3
Participants’ Mean Scores on and Scale Reliabilities for HR-HBQ Subscales Bacterial Infections-Skin Overdose-Test Shot Cleaning
Mean (SD) α Mean (SD) α
Severity 3.17 (1.11) .85 3.27 (1.03) .83
Susceptibility 2.41 (0.87) .73 2.35 (0.92) .88
Benefits 3.99 (1.19) .79 4.67 (0.62) .62
Barriers 2.91 (1.27) .69 2.16 (1.21) .74
Self-Efficacy 3.03 (1.42) .86 4.44 (0.90) .74
Social Norms Item 2.27 (1.54) - 2.87 (1.65) -
Note. Response options for each subscale/item ranged from 1 to 5. Higher scores on each subscale indicate higher levels of perceived severity, perceived susceptibility, perceived benefits, perceived barriers, and self-efficacy. Higher scores on the Social Norms item indicate that other injectors that participants know are more likely to engage in test shots/skin cleaning.
Health Beliefs and Harm Reduction 77
Table 4
Intercorrelations Among HR-HBQ Subscalesa Severity Susceptibility Benefits Barriers Self- Social efficacy Norms
Severity .30** -.19 -.04 -.14 .18
Susceptibility .22* -.24* .40** -.37** .06
Benefits .03 .06 -.08 .51** .03
Barriers -.06 .04 .15 -.38** -.03
Self-efficacy .04 .03 .33** -.24* .26*
Social Norms .15 .14 -.06 .02 .23* aIntercorrelations for Overdose-Test Shot section presented below the diagonal and intercorrelations for Bacterial Infection-Skin Cleaning section presented above the diagonal. *p < .05 **p<.01
Health Beliefs and Harm Reduction 78
Table 5
Linear Regression Analyses Predicting Intentions to Engage in Test Shots when in Withdrawal and Not in Withdrawal Target Situation In Withdrawal Not in Withdrawal
ΔR2 Adj. R2 B SEB β ΔR2 Adj. R2 B SEB β
Full Model .57** .53** .54** .50** Past use of test shots in .81 .12 .70** .66 .13 .53** target situation Perceived severity to overdose -.05 .09 -.04 .02 .10 .02 Perceived susceptibility to overdose .21 .12 .14 .41 .13 .25** Perceived benefits of test shots -.04 .10 -.04 .23 .11 .19* Perceived barriers to test shots .02 .08 .01 -.16 .09 -.14 Self-efficacy to do test shots .09 .08 .09 -.01 .09 -.01 Social norms item .04 .09 .05 .07 .09 .08 *p < .05 **p<.01
Health Beliefs and Harm Reduction 79
Table 6
Linear Regression Analyses Predicting Intentions to Engage in Test Shots when With Others and Alone Target Situation With Others Alone
ΔR2 Adj. R2 B SEB β ΔR2 Adj. R2 B SEB β
Full Model .49** .43** .55** .51** Past use of test shots in .49 .15 .42** .57 .12 .47** target situation Perceived severity to overdose .01 .11 .01 .01 .10 .01 Perceived susceptibility to overdose .26 .13 .18 .31 .13 .19* Perceived benefits of test shots .00 .12 .00 .17 .11 .14 Perceived barriers to test shots -.09 .10 -.09 -.02 .09 -.02 Self-efficacy to do test shots .03 .09 .03 .15 .09 .15 Social norms item .22 .10 .26* .17 .09 .19*
*p < .05, **p<.01
Health Beliefs and Harm Reduction 80
Table 7
Linear Regression Analyses Predicting Intentions to Clean Skin When in Withdrawal and Not in Withdrawal Target Situation In Withdrawal Not in Withdrawal
ΔR2 Adj. R2 B SEB β ΔR2 Adj. R2 B SEB β
Full Model .66** .63** .54** .50** Past skin cleaning in .67 .08 .67** .53 .09 .56** target situation Perceived severity to bacterial infection .09 .11 .06 .13 .12 .09 Perceived susceptibility to bacterial -.14 .14 -.09 .10 .14 .07 infection Perceived benefits of skin cleaning .26 .20 .11 .22 .21 .10 Perceived barriers to skin cleaning -.10 .11 -.08 -.17 .11 -.15 Self-efficacy to engage in skin cleaning -.01 .16 -.01 .26 .16 .17 Social norms item .14 .07 .15 .03 .08 .03
*p < .05, **p<.01
Health Beliefs and Harm Reduction 81
Table 8
Linear Regression Analyses Predicting Intentions to Clean Skin When With Others and Alone Target Situation With Others Alone
ΔR2 Adj. R2 B SEB β ΔR2 Adj. R2 B SEB β
Full Model .67** .64** .47** .42** Past use of test shots in .53 .08 .60** .45 .10 .49** target situation Perceived severity to overdose .08 .11 .06 .04 .13 .03 Perceived susceptibility to overdose .04 .14 .03 .12 .15 .08 Perceived benefits of test shots -.30 .22 -.11 .02 .23 .01 Perceived barriers to test shots -.19 .10 -.17 -.12 .12 -.10 Self-efficacy to do test shots .27 .15 .17 -.22 .18 .14 Social norms item .08 .07 .10 .15 .08 .18 *p < .05, **p<.01 Health Beliefs and Harm Reduction 82
Table 9
Themes Represented in Participants’ Responses to Interview Health Question
Theme Number of responses Exemplar quotes including theme Eating/Eating well 53 ―Eat right, eat a lot of fruits and vegetables…‖
―…Eat Cap N Crunch.‖
―Eat.‖
Exercise/Going to Work 48 ―Exercise, run, walk.‖
―I got to the gym twice a week. Do a lot of walking. Try to go to the gym when I can.‖
―Work. [I] do landscaping so that‘s pretty healthy.‖
Seeking Medical Care 24 ―I‘m diabetic, so I always go to my doctor every month…‖
―I try to keep up at least every 3-6 months going to the doctor, when I can, but I have no insurance.‖
―…I get tested for Hepatitis every 6 months.‖
Practicing Good Hygiene 16 ―…Personal hygiene.‖
―I try to stay – I bathe, stay clean…‖
―I got dentures and I keep [my] dentures clean as much as possible. Brush my tongue and mouth. Keep my clothes clean as much as I can.‖
Health Beliefs and Harm Reduction 83
Taking Vitamins 14 ―…Take my vitamins.‖
―Try to take vitamins because smoking depletes my body of vitamins, so [I] take vitamins.‖
Take 8 ―Take prescribed Medications/Prescriptions medications.‖
―I have a blood clot disorder, so I take my medications everyday.‖
―Aspirin.‖
Nothing 8 ―Nothing, really.‖
―I‘m a drug user, I‘m not taking care of myself.‖
―I don‘t do anything. I don‘t go to the doctor or the dentist. I just live to live.‖
Avoid Stress/Rest/Relax 7 ―Go Bingo – a relaxing hobby.‖
―Avoid stressors.‖
―I get proper rest.‖
Getting Proper Sleep 7 ―Sleep.‖
―Sleep good.‖
Avoid/Limit Alcohol or 3 ―Try not to smoke too much a Tobacco day. Use less than a whole pack a day.‖
―Watch what I drink; try not to drink alcohol.‖
Health Beliefs and Harm Reduction 84
Drug Abuse 3 ―Go to meetings.‖ Treatment/AA/NA Meetings ―Methadone.‖
―Go to rehab twice a year.‖
Mental Health Treatment 2 ―Go to…mental health doctor.‖
―Go to a mental health facility.‖
I don‘t know 2 ―I haven‘t been to the doctor in a while, so I don‘t know.‖
Miscellaneous 12 ―…Don‘t take care of my health like I should.‖
―The only thing I do bad is put this crap [drugs] in myself.‖
―Home remedies.‖
―Take care of myself.‖
Note. Number of definitions coded = 90 because one participant declined participation in the interview.
Health Beliefs and Harm Reduction 85
Table 10
Themes Represented in Participants’ Responses to Interview Injection Safety Question Theme Number of responses Exemplar quotes including theme Using Clean or New 44 ―I don‘t use my works more Works/Avoiding Reusing than 2-3 times.‖ Works ―Clean my rigs with bleach when [I‘m] done or before I use someone else‘s.‖
―I use fresh water, fresh everything; every time I use, I use new things‖
Avoid Sharing Needles or 39 ―I don‘t use other people‘s Works cottons, cookers, needles.‖
―Use my own needle, no one else‘s.‖
―Try not to share.‖
Clean Injection Site 27 ―First of all, I clean with Before/After Injecting alcohol and whenever I‘m done I clean with alcohol.‖
―Wash my arm, make sure it‘s clean.‖
―Cleaning site before, I rarely do it. When I‘m done I will clean off with alcohol wipes, peroxide, or soap and water. Use antibiotic ointment, used to use vitamin E.‖
Health Beliefs and Harm Reduction 86
Cleanliness Not Specific to 14 ―Try to be as clean as possible Using Clean Works when I use.‖
―Very precautious, sanitary, cleanliness.‖
―Just use hot water to keep bacteria out.‖
―Keep wounds wrapped.‖
Nothing 10 ―Nothing.‖
―I take care of myself, start doing like it says, clean myself off. [Interviewer: Do you do anything now?] No.‖
Use Needle Exchange 4 ―Try to come here and get new needles.‖
―Try not to get abscesses by coming here and getting clean works…‖
Boil/Heat the Drugs 3 ―…Boil the dope…‖
―Putting heat to drugs…‖
―I cook everything and that helps reduce it somewhat.‖
Reducing Use/Taking Smaller 3 ―Use a little more often Hits instead of a lot at one time.‖
―Don‘t do it often.‖
Testing Strength of Drugs 2 ―I test the dope before I inject it – see if I can handle it or not.‖
―Test shots.‖
Health Beliefs and Harm Reduction 87
Shoot with People You Know 2 ―Know the people I shoot up with.‖
―Be with my boyfriend, by ourselves.‖
Engage in Safe Sex 2 ―Protect myself, have sex with one person.‖
―Always have safe sex.‖
Miscellaneous 12 ―Drink a lot of water.‖
―Try not to do it with other people, stay safe.‖
―Try to stay mentally positive.‖ Note. Number of definitions coded = 90 because one participant declined participation in the interview.
Health Beliefs and Harm Reduction 88
Table 11
Themes Represented in Participants’ Responses to Interview Test Shot Barriers Question
Theme Number of responses Exemplar quotes including theme Rushing/Hurrying/Time 20 ―Too much in a hurry.‖
―…In a rush.‖
―Cuz I usually just want to get it over with.‖
Used Same Batch or Dealer 17 ―I deal with the same folks, so Before/Dealer Knows Strength I know what it is.‖
―They, the people I‘m getting it from, usually have the same stuff, they basically know what I‘m getting.‖
―If I bought it and it‘s the same, if it‘s something different, I will test it out.‖
Not Enough Drugs/Wasting 13 ―It‘s not enough to feel Drugs/Not Enough to Get anything.‖ High ―I don‘t have enough to test it.‖
―You‘re just testing it out and you don‘t get high from it. It would be stupid and detrimental.‖
―Don‘t want to waste a dime when you‘re doing a quarter.‖
Doesn‘t Think To/Just Don‘t 12 ―Nothing would stop me from Do It/I Don‘t Know doing it, I just never thought of it before.‖
―I just don‘t do it.‖
Health Beliefs and Harm Reduction 89
Withdrawal 11 ―If I was sick, that would get in the way, just want to hurry up and feel right or normal.‖
―Dope sick.‖
―If I‘m feeling bad in a late state of withdrawal.‖
Just Want to Get High 7 ―I don‘t know, I just want to use it and do it.‖
―Cuz I wanna get high.‖
The Drugs Are Not Strong 3 ―Drugs here are not strong Enough enough. Don‘t warrant concern. That‘s my sole reason.‖
―They don‘t have that kind of dope anymore.‖
Bad Veins/Hard to Get a Hit 2 ―Because it‘s hard for me to get a hit, I don‘t have any veins. Need to take advantage of it or I might not get any at all.‖
Anxious/Anticipation 2 ―Just the anticipation of getting the drug in your arm.‖
―Being anxious…‖
Tolerance for Drugs 2 ―…And I know I have a high tolerance, so I can handle more than what I‘m doing, but that can be dangerous, too. I black out a lot and that‘s scary.‖
―I have a huge immunity to heroin, high tolerance.‖
Health Beliefs and Harm Reduction 90
Consistent/Steady Use 2 ―If I‘m steady using it everyday I don‘t, but if I haven‘t used in a while I‘ll test it because I‘ve overdosed before.‖
―…I would only do a test shot if I hadn‘t used for a long time, like 6 months.‖
Miscellaneous 7 ―Usually when I do a test shot it‘s when I mix heroin and cocaine, or if it‘s coke alone. But if it‘s heroin alone, I know the strength, but I‘m taking a risk.‖
―I don‘t see no use in it, if you‘re going to do it, just do it.‖
―My boyfriend tastes it and he thinks he knows how strong it is. The more bitter the stronger it is.‖
Uncodable Response 4 ―Don‘t have the right supplies, the alcohol wipes, bleach water, etc.‖
―Why would I test it? It‘s mine already.‖
Note. Number of definitions used for coding = 86 because one participant declined participation in the interview and four participants reported always doing test shots, so the barriers question was irrelevant to them. An additional 4 participants responded to the interview question, but their answers did not make sense and were noted as uncodable in the table above.
Health Beliefs and Harm Reduction 91
Table 12
Themes Represented in Participants’ Responses to Interview Skin Cleaning Barriers Question
Theme Number of responses Exemplar quotes including theme In a Hurry/Time/Impatience 28 ―Time consuming, it takes time, and you know, I should, I have swabs.‖
―Time. If I‘m in a hurry, going somewhere.‖
―Basically impatient, rushing…‖
Withdrawal 17 ―Sometimes you don‘t wanna wait. If you‘re withdrawing or feel kinda bad…‖
―If I‘m going in withdrawal, if I‘m real sick I don‘t do it. If not in withdrawal, I do it.‖
No Supplies Present/No 14 ―Not having them present Access when I inject.‖
―Usually I‘m getting high in the car so I don‘t have access. Don‘t have a way to clean it.‖
―Just if I‘m not near the proper stuff, soap and water or alcohol pads.‖
Doesn‘t Think To/Just Don‘t 14 ―Nothing stops me. Just don‘t Do It/I Don‘t Know do it.‖
―It just never comes to mind. If your body‘s clean there is no risk.‖
―…Not being conscious.‖
Health Beliefs and Harm Reduction 92
Anxious/Anticipation 5 ―Actually I suppose the anticipation of instant gratification.‖
―Anxious to get high.‖
Environment 5 ―When people are present. The pride. Thinking that I‘m weak or something.‖
―Nothing would stop me from being able to. At work, sometimes the time frame, other people would walk in and catch me. If I‘m in the bathroom and my kid‘s banging on the door I need to hurry up.‖
Forgetting 5 ―…And I forget.‖
―Just remembering; if it dawned on me I might do it some of the time.‖
Lazy 2 ―Lazy.‖
―Just laziness…‖
Does Not Want To/See 2 ―I don‘t know, I don‘t want Necessity to…‖
―Don‘t think it‘s necessary.‖
Miscellaneous 8 ―…I forget.‖
―Not being home, being with somebody else.‖
―Not much, do it most of the time.‖
Uncodablea 5
Health Beliefs and Harm Reduction 93
Note. Number of definitions coded = 73 because one participant declined participation in the interview and 15 participants reported always cleaning their skin before injecting, so the barriers question was irrelevant to them. aFive respondents answered this questions by saying that they ―always‖ clean their injection sites before injecting. However, inspecting their quantitative responses to questions about frequency of past skin cleaning, revealed that respondents did not ―always‖ engage in this behavior.