Download - Factors Explaining the Intention to Use Condoms Among Injecting Drug Users Participating in a Needle-Exchange Program1

Factors Explaining the Intention to Use Condoms Among Injecting Drug Users Participating in a

Needle-Exchange Program‘

DIANE B E L A N G E R ~ Department of Social and Preventive Medicine

Laval Universiry Quebec, Quebec, Canada

and Public Health Re.search Unit

CHUL-CHUQ Research Center Beauport, Quebec. Canada

MICHEL ALARY3 Department of Social and Preventive Medicine

Laval University, Quebec. Quebec. Canada and

Public Health Research Unit CHUL-CHUQ Research Centee Beauport

Quebec, Canada and

Research Cente); Saint-Sacrement Hospital Quebec, Quebec, Canada

GASTON GODIN Public Health Research Unit

CHUL-CHUQ Research Center Beauport, Quebec, Canada

and Research Group on Behavior in the Field

of Health Laval University

Quebec. Quebec, Canada

PAUL-MARIE BERNARD Department of Social and Preventive Medicine

Laval Universiw, Quebec Quebec, Canada

This study identified the psychosocial factors related to condom-use intention, based on Triandis’ (1980) theory of interpersonal behavior, among 261 injection drug users participating in a needle-exchange program. With regular partners (n = 139), condom-use intention was explained by normative beliefs, self-efficacy, length of relationship with last regular sexual partner, and taking oral contraceptives. Condom-use intention with casual partners ( n = 157) was also associated with self-efficacy and normative beliefs, on top of

‘The authors would like to thank Lina Noel, Raymond Parent, and Celine Poulin for access to the epidemiological data; Richard Bradet and Myrto Mondor, for their judicious advice concerning methods and computer processing, as well as the Point de Reperes community workers for their rigorous approach during data collection and for their support throughout the study. This study was done in collaboration with community workers at the needle-exchange program Point de Repires, Quebec, Canada

ZCorrespondence concerning this article should be addressed to Diane Belanger, Unite de recherche en sante, Centre de recherche du Pavillon CHUL-CHUQ, 2400 d’Estimauville, Beauport, Quebec GI E 7G9, Canada. E-mail: [email protected]

3Michel Alary is a senior research scholar supported by the Fonds de la recherche en sante du Quebec, Canada (Grant #13 136-399).

1047

Journal of Applied Social Psychology, 2002, 32, 5, pp. 1047-1 063. Copyright 0 2002 by V. H. Winston & Son, Inc. All rights reserved.

1048 BELANGER ET AL.

cognitive dimension with attitudes and lending used needles. Neither the perception of being HIV-positive, nor the habit of using a condom was associated with intention. It is thus suggested that interventions aimed at promoting condom use among this clientele be orientcd toward the reinforcement of personal convictions as well as toward the development of competencies needed to overcome obstacles, since both relate to the intention to adopt this behavior.

In North America, at the end of 200 1, 940,000 adults and children live with HIVIAIDS, and the main modes of transmission for adults are sexual transmission among men who have sex with men (MSM) and transmission through injecting drug use (IDUs; World Health Organization, 2001). In Canada, the cate- gory of MSM always represents the majority of AIDS cases. Nevertheless, the proportion attributable to IDUs has grown over time: Between 1989 and 1998, the proportion of all AIDS cases attributable to IDUs increased from 2.5% to 16.0% (Bureau du VIH/sida et des MTS, 1999) and, in 2000, it was 2 1.2% (Divi- sion of HIV/AIDS Epidemiology and Surveillance, 2002).

Among the risk factors for HIV transmission among IDUs, both the sharing of used needles and having unprotected sexual intercourse were noted. To date, most preventive measures have been concerned with preventing the sharing of used needles. An example of such preventive measures is the implementation of needle-exchange programs. However, few studies have been concerned with the prevention of unprotected sexual intercourse through condom use among IDUs. The present study is concerned with this latter risk factor; that is, using condoms with sexual partners.

Different factors have been associated with the use of condoms, notably seropositivity (White, Phillips, Mulleady, & Cupitt, 1993); having casual partners (Watkins, Metzger, Woody, & McLellan, 1993); and, in the context of prostitu- tion, having a high number of sexual partners (White et al., 1993). Self-efficacy was related to condom use among seronegative IDUs (Hartgers, van den Hoek, Coutinho, & van der Pligt, 1996; Kowalewski, Longshore, & Anglin, 1994), but not among seropositive IDUs (Hartgers, Krijnen, van den Hoek, Coutinho, & van der Pligt, 1992).

Finally, positive attitudes toward condom use of an individual and per- ceptions of important people for him about the use of condoms were associated with hidher condom-use intentions (Kasprzyk, Montano, & Fishbein, 1998). In turn, these factors also predicted the behavior of using condoms. The present study extends the scope of Kasprzyk’s research for IDUs. It is hoped that this study will provide useful information for the improvement of preventive strate- gies among the clientele participating in needle-exchange programs. The objective is to identify the psychosocial determinants of condom-use intentions with casual and regular partners, using Triandis’ (1980) theory of interpersonal behavior.

NEEDLE-EXCHANGE PROGRAM 1049

Theoretical Framework

Triandis (1 980) considered that behavior results from the sum of three factors; namely, the presence or lack of facilitating conditions to its adoption, the intention to adopt the behavior, and the strength of habit. Conditions facilitating or hampering the adoption of a behavior include circumstances that make it more or less difficult for an individual to eventually change a behavior. Intention is the expression of motivation in the adoption of behavior or, according to Fishbein and Ajzen (1979, the probability of adopting it. It is determined by the cognitive component of attitude, the affective dimension of attitude, social determinants, and personal normative beliefs. Finally, the strength-of-habit component reflects an automatic (without conscious thought) determinant of behavior in a given sit- uation and, indirectly, of the intention to adopt the behavior.

The cognitive component of attitude is the result of a subjective analysis of the advantages and disadvantages that would result from the adoption of a behavior. The individual translates into beliefs a certain number of positive and negative consequences caused by the adoption of a given behavior, and attributes a value to each of these consequences. The cognitive component is the sum of the products of probabilities of each consequence times the value of each of these consequences. The rdfective dimension is an individual’s emotional response to the idea of adopting a given behavior. Social determinants are judged by normative beliefs, pressures felt, and belief in the existence of specific social roles (de Vries, Weijts, Dijkstra, & Kok, 1992; Triandis, 1980). Normative beliefs and pressures felt refer to people or groups of people who are important to us. Social role beliejy refer to the individual’s perception of what an individual occupying a position similar to his or her own in the social structure should do with respect to the behavior under study. Personal normative beliefs, or personal convictions, measure the feeling of personal obligation in adoption of the behavior. This factor refers to the rules of personal conduct or, in other words, to moral principles. The individual determines to what extent the behavior agrees or disagrees with his or her principles. The moral norm is assumed to have been shaped (through socialization) over a long period of time, so it is distinct from the social norm, which reflects current pressures to behave.

Method

Sample and Procedure

The population studied consisted of IDUs participating in the Point de Reperes needle-exchange program, located in the downtown area of Quebec City (Canada). A total of about 19,000 user contacts, including 1,000 new contacts, are recorded each year. Prevalence of HIV has remained stable over time, and is


of the order of 10% as of 2001 (Alary, Parent, Hankins, Claessens, & the SurvUDI Working Group, 2002).

All IDUs who took part in the activities offered by the needle-exchange program were invited to participate in the study. The “snowball” technique (Morrison, 1988) was used to contact all those who did not visit the site regularly. In total, 261 IDUs were recruited and interviewed. The respondents were selected independent of their characteristics. Two training interviewers conducted data collection. The criteria for inclusion in the study were to have had sexual intercourse during the last 6 months, to have obvious needle marks, and to be able to provide coherent information at the time of the interview. Each interview (an average of 45 min) took place in a closed room at the needle-exchange site and included one questionnaire dealing with the measurement of theoretical constructs and epidemiological variables. The information (reported verbally by the JDUs) was entered by the interviewers on the questionnaires.

Development ojthe Questionnaire

The questionnaire was based on the “ctic-emic” approach (Pelto, 1970) proposed by Triandis and his collaborators (Triandis, 1980). The recommendations of Fishbein and Ajzen (1 975) allowed scales of each measure to be developed, while those of Godin and Kok (1996) gave direction to the steps followed in evaluating the psychometric qualities of the questionnaire.

The items were developed by interviewing individuals ( n = 21) who were similar to the participants in the main part of the study. These concerned the barriers or facilitating factors, the advantages or disadvantages, and the typical characteristics of an IDU who has used a condom (among men) or requested its use (among women) during vaginal/anal sexual relations with regular or casual partners. The questions were of the following type: “What would come to mind if you were to use condoms each time you had sexual intercourse with your regular partners during the next 6 months?” The content analysis of this information allowed us to operationalize Triandis’ (1980) theoretical constructs (etic aspects) while still respecting the specificity of language of the IDUs who frequent Point de Reperes (emic aspect). A pre-test of the instrument was then performed. Five community workers verified the clarity and understanding of the measurement tool. A 2-week interval test-retest was evaluated among 29 TDUs other than those who had completed the qualitative-type questionnaire.

The definition of the context of the questions covers the time interval (next 6 months), the behavior (using a condom), and the type of sexual partner (regular/ casual). Intention, a dependent variable, was defined as a composite score expressing the average response given to three questions, each of which was measured on a 5-point scale ranging from No++ ( - 2 ) to Yes++ (2). A sample item is “Do you intend to use a condom with your girlfriend?” (Cronbach’s a:


regular partners [Reg] = .91, casual partners [Cas] = .79; Kappa coefficient weighted by quadratic value, Kw2: Reg = .70, Cas = .24).

The cognitive component was evaluated using a semantic differential scale composed of the adjectives useful, intelligent, and prudent. The average value of the responses to the questions (rated on a 5-point scale ranging from -2 to 2) was kept for the purpose of analyzing this construct (a: Reg = .73, Cas = .73; Kw2: Reg = .78, Cas = .16). A second measure of the cognitive component was the average value of the sum of three positive outcomes weighted according to their respective value for the subject (rated on a 7-point scale ranging from -4 to 4). For example, the questions that measured the outcomes (a: Reg = .49, Cas = .27; Kw2: Reg = .84, Cas = .43) and their evaluation (0 = not important, 1 = of little importance, 2 = important; a: Reg = .12, Cas = .39; Kw2: Reg = .78, Cas = .19) were formulated as follows: “If you used a condom with your girlfriend, would you protect yourself against AIDS and other STDs?” and “Is it important for you to be protected against AIDS and other STDs during intercourse with your girlfriend?”

A semantic differential scale with the adjectives humiliating, ,foolish, and shameful was also used to evaluate the affective dimension. The adjectives were coded on 5-point scales ranging from -2 to 2 and were averaged (a: Reg = .79, Cas = .79; Kw2: Reg = .72, Cas < .0001). One variable related to the emotions and feelings experienced (Manstead & Parker, 1995) during condom use was also measured with the help of 10 items. An example of these items is “Are you embarrassed by the idea of using a condom with your girlfriend?” The average of the responses to these items was computed (a: Reg = .79, Cas = .70; Kw2: Reg =

.82, Cas = .68). The average of six items measuring personal normative beliefs (personal con-

victions) was computed for this variable. A sample item is “If you used a condom with your girlfriend, would you be acting responsibly?” (a: Reg = .68, Cas = .78; Kw2: Reg = .67, Cas = .23). Likewise, Triandis’ (1980) social factor (a: Reg =

.65, Cas = .78; Kw2: Reg = .54, Cas = .70) was defined by the sum of two constructs: nonnative beliefs and role beliefs. Normative beliefs were obtained from the average of the responses to four questions dealing with salient referents. These questions were presented as follows: “In your circle of friends and family, who would want you to use a condom with your girlfriend?” Social role beliefs were estimated from the average of the responses given to three questions. A sample question is “If a man has a steady girlfriend, is it right for him to use a condom with her?”

Facilitating factors, similar to Bandura’s (1977; Ajzen & Madden, 1986) self- efficacy, were evaluated from the average capacity of the participant to overcome the barriers (n = 10) to condom use. A sample item is “Would you insist on using a condom with your girlfriend even if she didn’t agree that you should use one?’ The choices offered were “never,” sometimes,” “always” (0 to 2; a: Reg = .93,


Cas = .91; Kw2: Reg = .79, Cas = .64). The term self-efficacy will be used in this text.

The habit of using a condom during the 6 months preceding the interview, with regular or casual partners, was estimated with the proportion of sexual relations protected by condoms over total number of sexual relations (KW2: Reg =

.93, Cas = .71). Finally, various external variables were collected at the time of the interview. These questions involved sociodemographic information, risk factors associated with sexual behavior, needle sharing, and self-reported HIV.

Analyses

The factors explaining the intention to use condoms with regular partners were studied independent of those evaluating the intention to use condoms with casual partners because each of these two types of partners refers to different contexts, and the same participant could have had sexual relations with both types of partners. In univariate analyses, ANOVAs and Students' t tests were applied to verify the level of association between intention and the continuous variables; while chi-square tests were used in the case of dichotomous variables (Fleiss, 198 1; Kleinbaum, Kupper, & Muller, 1988). Multivariate analyses were carried out using linear regression (Kleinbaum et al., 1988), and these results were com- pared with those derived from polytomic models (Hosmer & Lemeshow, 1989). Since these results were identical, only those identified by linear regression are reported. The statistical threshold for rejection was .05 for first-order interaction and collinearity (SAS, 1992).

Results

At the time of the interview, the mean age of the respondents (n = 261) was 30 years (95% confidence interval; 95% CI = 28.4; 30.5). The majority of respondents were male (69.5%), had completed their high school education (8 1.3%), had been in prison at least once (7 1.4%), had lived in apartments for the last 6 months (69%), and were on social welfare (66.7%). During the same period, almost all (96.9%) had used cocaine at least once, 3 1.3% injected them- selves three times or more per week, and 56.5% had shared used needles. The prevalence of self-reported HIV was 12.2%.

During the last 6 months, 139 respondents (88 men, 51 women) had had sexual relations with regular partners. Vaginal relations (98.6%) and oral relations (87.8%) were the sexual practices reported most frequently (anal relations =

15.1 %), but few of the relations were always protected by condoms (vaginal =

24.8%; anal = 28.6%; oral = 13.1%). A total of 157 respondents (120 men, 37 women) mentioned having had sexual relations with casual partners. The propor- tions of casual sexual relations that were vaginal (97.5%), oral (82.2%), and anal


(19.8%) were of the same order as with regular partners. However, condom were used more frequently in this context (vaginal = 43.7%; anal = 5 1.6%) except for oral practices, where its use remained marginal (oral = 15.5%).

Sexual Relations With Regular Partners

The intention to use condoms with regular partners during sexual relations with penetration during the 6 months following the interview was generally weak, with an average of 0.28 on a scale varying between -2 and 2. The variables with the strongest correlation with this construct were self-efficacy and personal normative beliefs (Table I ) .

Multivariate analyses corroborated the contribution of the two most important constructs, self-efficacy and personal normative beliefs, which explained 41 YO of the variance in intention to use condoms (Table 2). The length of the relationship (partial R2 = .06) and the fact that the regular partner used oral contraceptives (partial R2 = .04) were also additional elements of interest. In fact, respondents with a moderate ( n = 38) or strong ( n = 44) intention to use condoms with their regular partners had been living as part of a couple for an average of 1.5 years, whereas the other respondents had been doing so for about twice as long (p < .05). Only 16.3% (n = 44) of the respondents with a strong intention to use condoms and 25.0% ( n = 38) of those with moderate intention reported using oral contraceptives, while the proportion was 40.0% (n = 57) among the other respondents. The proportion of sexual relations protected by condoms during the last 6 months was related to intention (data not presented). The introduction of this variable nevertheless had a limited statistical contribution (partial R2 = .02, p = .04). Its influence also seems to have been mediated by self-efficacy, as indicated by the reduction in the coefficient associated with the latter construct. The proportion of sexual relations protected by condoms was therefore not retained as a factor explaining intention.

Sexual Relations With Casual Partners

The intention to use condoms during sexual relations with casual partners was positive, or 1.24 on average, on a scale varying between -2 and 2. All of the constructs were correlated with intention, but personal normative beliefs, cognitive aspect of attitude, and self-efficacy proved to have the strongest association (Table 3).

Multivariate analyses indicate that personal normative beliefs and the cognitive dimension of attitude were the variables explaining the largest portion of variance in intention (Table 4). Self-efficacy also contributed, but to a lesser degree. These three theoretical constructs explained 62% of the variance in intention. The lending of used needles, on the other hand, was associated with a low

Tabl

e 1

W P

b

4 $ A

rn

Var

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2 3

4 5

6 7

8 9

10

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* .1

9*

.13

.29*

* .5

7**

.47*

* .6

4**

.14

-.29*

* !-

2. C

ogni

tive

attit

ude

-

.40*

* .4

3**

.46*

* .6

5**

.47*

* .5

3**

.02

-.04

3. B

elie

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Table 2

Prediction of Intention to Use Condoms With Regular Partners: Multivariate Analyses Using Linear Regression

pi coefficients Partial

Variables Pi 95%CI pvalue R2

Model l a Personal normative beliefs .64 0.32; 0.95 <.001 .07 Self-efficacy .79 0.47; 1.11 <.001 .10

Personal normative beliefs 5 5 0.24; 0.86 <.001 .05 Self-efficacy .81 0.24; 0.86 <.001 .10 Length of relationship with last

Use of oral contraceptives (Yes = 1) -.62 -1.01; -0.23 .001 .04

Model 2b (model retained)

regular partner (quantitative) -.I2 -0.18; -0.06 .002 .06

Note. n = 139.95% CI = 95% confidence interval. aF(I) = 49.80,~ = .OOOl; adjusted R2 = .41. bF(3) = 3 4 . 6 8 , ~ = .0001; adjusted R2 = .49.

intention to use condoms with casual partners that was statistically significant (partial R2 = .02). Therefore, this last external variable was retained in the final linear regression model, which explains 64% of the variance in intention.

Discussion

The present study highlights the factors explaining the intention to use condoms with regular and casual partners among IDUs. Three psychosocial determinants proposed by the theory of interpersonal behavior (Triandis, 1980) seem very important in this regard. These determinants were personal normative beliefs, self-efficacy (a construct equivalent to that of facilitating factors; Ajzen & Madden, 1986), and the cognitive dimension of attitude, but in the context of casual partners only.

The intention to use condoms was associated with personal normative beliefs in a comparable way in each of the two contexts but, just as in the study by Corby, Schneider, and Wolitski (1 996), not with social norms. This very interest- ing observation suggests that using condoms among IDUs is modeled more on their own standards that have been shaped through socialization over a long period of time than on social norm, which reflects current pressures to behave. This is congruent with the observation reported by Abraham, Sheeran, Spears,

m

Tabl

e 3

rn.

Pear

son’

s Cor

rela

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Coe

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Betw

een

the

Theo

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.76*

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.52*

* .5

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.03

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ogni

tive

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ude

-

.24*

.5

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.30*

* .6

0**

.16*

* .3

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.29*

* .0

4

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.08

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7 .1

6 .2

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4. A

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.6

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* .0

8 .3

8**

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.07

5. E

mot

ions

and

feel

ings

ex

perie

nced

.5

1**

.02

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* .2

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6. P

erso

nal n

orm

ativ

e be

lief

.25*

* .5

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.44*

* .0

6 .2

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.48*

* -.1

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Soc

ial f

acto

r -

8. S

elf-

effic

acy

.58*

* -.0

4 9.

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it -.1

3 10

. Le

ngth

of r

elat

ions

hip

-

5 73

-

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157

. *p

valu

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twee

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nd .0

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*p <

,001

.


Table 4

Prediction of Intention to Use Condoms With Casual Partners: Multivariate Analyses Using Linear Regression

Pi coefficient

Variable Pi 95% CI p PartialR2

Model la Cognitive dimension of attitudes Personal normative beliefs

Model 2b Cognitive dimension of attitudes Personal normative beliefs Self-efficacy

Cognitive dimension of attitudes Personal normative beliefs Lending of used needles

Model 4d (model retained) Cognitive dimension of attitudes Personal normative beliefs Self-efficacy Lending of used needles

Model 3C

.40

.71

.42

.57

.22

.40

.69 -.26

.42

.58

.18 -.24

0.18; 0.60 <.001 0.58; 0.85 <.001

0.21; 0.62 <.001 0.41; 0.76 <.001 0.04; 0.39 .019

0.20; 0.61 <.001 0.55; 0.83 <.001

-0.42: -0.09 .003

0.22; 0.63 <.001 0.42; 0.75 <.001 0.01; 0.35 .041

-0.41; -0.08 .004

.03

.25

.04

. l l

.o 1

.04

.23

.02

.04

. l l

.o 1

.02 -

Note. n = 157. 95% CI = 95% confidence interval. aF(1) = 123.56, p = .0001; adjusted R2 = .61. bF(2) = 8 6 . 7 3 , ~ = .0001; adjusted R2 =

.62. cF(2) = 9 1 . 3 3 , ~ = ,0001; adjusted R2 = .64. dF(3) = 7 1 . 0 2 , ~ = .0001; adjusted R2 =

.64.

and Abrams (1992) that condom use is a private behavior that may not necessar- ily be discussed with significant others. Indeed, to be capable of conforming to other people’s expectations, one must feel connected by a relationship of interdependence (Triandis, 1980). This relationship of interdependence seems unlikely in the present context, since the other people in question are members of the soci- ety by which IDUs feel judged and marginalized (Cormier, 1993).

Perceived self-efficacy was more important in predicting intention to use condoms with regular partners than with casual partners. IDUs thus have greater difficulty overcoming obstacles related to the adoption of this behavior with their regular partners. The prevailing contexts during these sexual relations are


probably sufficiently constraining to attenuate their capacity to manage stress and to mobilize the personal resources needed to maintain their motivation (Bandura, 1977). Some of these contexts, such as exclusivity and the degree of confidence in the longevity of the sexual relationship (Sheeran, Abraham, & Orbell, 1999), explicitly differentiate the steady relationships from the casual. Use of oral contraceptives and the lending of used needles are two other examples that suggest similar relations. In fact, it is possible that condom use is related to avoiding contraception between regular partners, but to prevent both pregnancy and infection between casual partners. The risk of sexual infection could threaten the relationship of tiust that regular partners develop over time. The exchange of used needles (including borrowing) between regular partners is rather perceived like an intimate behavior, while the lending of used needles with casual partners could be an indicator of barter situations involving the exchange of body fluids (one needle for one act of sexual relations without a condom). Consequently, to help increase condom use, it would be important that the messages designed to prevent risky behaviors conducive to the spread of HIV emphasize the mutual respect that regular partners develop over time, the effectiveness of condoms as a method of contraception (Sheeran et al., 1999), and the capacity of an TDU to say “No” in barter situations.

The affective dimension of attitude as well as the emotions and feelings experienced were not associated with the development of intention in a statistically significant way. According to the data from the present study, these two constructs were related more to perceived self-efficacy. Their respective influence on intention was thus filtered by the capacity to overcome barriers preventing adoption of the behavior, as proposed by Bandura (1977). These results diverge from those reported by Kasprzyk et al. ( 1 998), who observed a strong relationship between the intention to use condoms and the overall measure of attitudes, con- sisting mainly of an important affective dimension. Similarly, they do not support the remarks of Manstead and Parker ( I 995), who recommend measuring affective advantages and disadvantages independently. Before drawing a definitive conclusion on this question, however, it would be useful to clarify, through further research, the relationship between these different constructs and their influence on the intention to use condoms.

The cognitive dimension of attitude proved very significant, but with casual partners only. We noted that such partners do not as a rule have a relationship based on love, which in turn allows them to consider the advantages ofusing a condom. This result also suggests that there is good reason to maintain interventions that promote the advantages related to this behavior. To do this, however, it is very important to be clear about the definition of a casual partner, which seems to vary in a very selective way in the context of IDUs. The manager of a shooting gallery who exchanges needles for sexual relations and the client who becomes a casual partner because of a friendship that has developed over


time (Bonenfant, 1996) are good illustrations of this observation. From another standpoint, we note that the direct measure of attitudes toward condom use may be more helpful than belief-based attitudes (Sheeran et al., 1999; Trafimow & Sheeran, 1998).

Neither the perception of being HIV-positive nor the habit of using a condom was associated with intention. These results are in keeping with Triandis’ (1 980) theory in which the perception of illness is considered as a variable external to the theory, whereas habit is understood more as a variable that defines behavior (Sheeran et al., 1999) or the affective dimension of attitudes. Thus, the perception of illness would contribute indirectly to the definition of intention through its links with other determinants, as suggested by the correlation between perception of illness and personal normative beliefs ( r = -. 16,p = .09) or between perception of illness and the overall measure of attitudes (r = -. 16, p = .09), two variables that explained the intention to use a condom with casual partners. Furthermore, an IDU can have the intention to use condoms independent of his or her habit of doing so. In the opposite case, an IDU would have to have used a condom quite often if the emotions felt just at the thought of using it would automatically lead to its use. This is unlikely, given that condom use was low during the 6 months preceding the interview, particularly with regular partners, and that the affective dimension was not associated with intention in a significant way.

The principal limitation of the present study is that the behavior of using condoms was not evaluated 6 months after the measurement of intention. This limitation might be attenuated by the fact that intention is considered sufficiently stable for predicting upcoming behavior in a very satisfactory way (Bagozzi, 1981; Bentler & Speckart, 1979; Godin & Kok, 1996), particularly in the context of regular partners (Sheeran & Orbell, 1998). This observation does not exclude the potential contribution of habit or factors preventing adoption of the behavior, which, in the same way as intention, could explain future behavior (Triandis, 1980). For habit to contribute significantly at the theoretical level, the IDUs would have had to use condoms a sufficiently large number of times under the same conditions and context for the behavior to have become automatic. However, the possibility that IDUs would develop the habit of using condoms is low, particularly in the context of casual partners, since some relationships are characterized by spon- taneity. However, the hypothesis of the influence of barriers to condom use is likely to be supported. In fact, certain conditions make adoption of this behavior extremely difficult for IDUs, particularly the possibility of having used drugs excessively at the time of the sexual relations. Therefore, it would be important to explore the respective contributions of intention and of factors preventing adoption of the behavior by means of other studies dealing with this clientele.

Another aspect to consider concerns the psychometric qualities of the instrument of measure. In general, Cronbach’s alpha coefficients indicate good internal coherence. However, the coefficients of test-retest reliability were satisfactory in

1060 BtLANGER ET AL.

the context of regular partners, but weak in the case of casual partners. These results highlight the very selective character of sexual relations with casual partners, as reported earlier. This makes the definition of this context imprecise, particularly among IDUs. On the basis of these methodological considerations, the determinants associated with intention to use condoms with casual partners could therefore be different from those observed at the time of analysis. The statistical and theoretical importance of the determinants that were retained, particularly those dealing with perceived self-efficacy, nonetheless reduces the plausibility of such a hypothesis. In fact, these results cast further doubt on the pertinence of using measures of reliability for studying the accuracy of data-collection instru- ments among the IDU clientele, at least when the definition of the “context” of adoption of a behavior cannot be defined in a stable way.

In the present study, a great deal of the variance of intention had been explained. Although encouraging, we must also recognize that part of it remains unexplained. The refinement of the operational measure of certain constructs such as those dealing with personal normative beliefs and the exploration of the potential usefulness of other determinants such as self-monitoring (Snyder, 1974; Triandis, 1980) might fill in these gaps. Research efforts in this direction are therefore necessary.

On a practical level, it would be desirable for interventions promoting condom use among IDUs participating in needle-exchange programs to address the personal normative beliefs relating to the adoption of this behavior as well as the development of the competencies needed to overcome obstacles that could prevent its adoption. It would be equally important that such interventions stress the advantages related to condom use, but especially in the context of sexual relations with casual partners. Community workers in needle-exchange programs can develop various interventions. For example, certain contacts between community workers from the site and IDUs, either at the time of needle-exchange or on the street, might reach the necessary level of trust for values and personal norms relating to sexuality to be discussed (Eagly & Chaiken, 1993; Godin, Fortin, Michaud, Bradet, & Kok, 1997). Role-playing, considered more persuasive than just the transfer of knowledge (Eagly & Chaiken, 1993; Godin et al., 1997; Mann & Janis, 1968), could also facilitate the development of personal skills for condom use; while messages about the advantage of its use, designed to prevent sexually risky behaviors, could be posted in strategic locations frequented by IDUs. As well, prisons could be an important location for the development of preventive interventions aimed at behavioral change, since three out of four IDUs reported having already spent time there.

The establishment of apartments where prostitutes can go to rest, or even shooting galleries where the norms would be consistent with the messages con- veyed by public health authorities, are two other options that merit examination. However, these innovative interventions as a whole should be supported by


public health organizations, since this is the only way that it will be possible to work in close collaboration with community workers in needle-exchange programs. This implies that health professionals working in intervention and research must help community workers in such programs when appropriate interventions to prevent HIV risky behaviors are being developed. They must also evaluate these interventions rigorously and scientifically and transmit the main results to the community workers in the milieu with the goal of improving the content of and means used for such interventions. Developing such a procedure is a long-term project that will require additional financial and human resources in public health, but also within the programs offered to IDUs, including needle- exchange programs.

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