Using the Health Belief Model to Predict Injecting Drug Users' Use of Harm Reduction
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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,